Anesthetic Management for Paraesophageal Hernia Repair.

Paraesophageal hernia repairs are complex surgical cases frequently performed on patients of advanced age with multiple comorbidities, both of which create difficulties in the anesthetic management. Preoperative evaluation is challenging because of overlapping cardiopulmonary symptoms. The patient's symptoms and anatomy lead to an increased aspiration risk and the potential need for a rapid sequence induction. Depending on the surgical approach, lung isolation may be required. Communication with the surgeon is vital throughout the case, especially when placing gastric tube and bougies. Multimodal analgesia should include regional and/or neuraxial techniques, in addition to the standard intravenous and oral pain medications.

Perioperative management of obstructive sleep apnea in bariatric surgery: a consensus guideline.

BACKGROUND: The frequency of metabolic and bariatric surgery (MBS) is increasing worldwide, with over 500,000 cases performed every year. Obstructive sleep apnea (OSA) is present in 35%-94% of MBS patients. Nevertheless, consensus regarding the perioperative management of OSA in MBS patients is not established. OBJECTIVES: To provide consensus based guidelines utilizing current literature and, when in the absence of supporting clinical data, expert opinion by organizing a consensus meeting of experts from relevant specialties. SETTING: The meeting was held in Amsterdam, the Netherlands. METHODS: A panel of 15 international experts identified 75 questions covering preoperative screening, treatment, postoperative monitoring, anesthetic care and follow-up. Six researchers reviewed the literature systematically. During this meeting, the "Amsterdam Delphi Method" was utilized including controlled acquisition of feedback, aggregation of responses and iteration. RESULTS: Recommendations or statements were provided for 58 questions. In the judgment of the experts, 17 questions provided no additional useful information and it was agreed to exclude them. With the exception of 3 recommendations (64%, 66%, and 66% respectively), consensus (>70%) was reached for 55 statements and recommendations. Several highlights: polysomnography is the gold standard for diagnosing OSA; continuous positive airway pressure is recommended for all patients with moderate and severe OSA; OSA patients should be continuously monitored with pulse oximetry in the early postoperative period; perioperative usage of sedatives and opioids should be minimized. CONCLUSION: This first international expert meeting provided 58 statements and recommendations for a clinical consensus guideline regarding the perioperative management of OSA patients undergoing MBS.

Epidural chloroprocaine bolus in emergency cesarean section-lessons learned from a near mishap.

Administration of a large bolus of epidural chloroprocaine to hasten the spread of anesthesia is an accepted practice during emergency cesarean section. Occasionally, this practice can result in a very high block that can compromise patient's safety. We describe a case of epidural chloroprocaine administration in a 4 point position resulting in a high dermatomal block requiring respiratory assistance. Events surrounding the case are discussed, with a view to warn the reader about the pitfalls of such a practice.

Peroral endoscopic myotomy-initial experience with anesthetic management of 24 procedures and systematic review.

BACKGROUND: Peroral endoscopic myotomy (POEM) is a novel method of treating achalasia of the esophagus. Very little data are available to guide the anesthesia providers caring for these patients. The anesthetic challenges are primarily related to the risk of pulmonary aspiration. There is also a potential risk of pneumomediastinum, pneumoperitoneum, subcutaneous, or submucosal emphysema, as a result of carbon dioxide tracking into the soft tissues surrounding the esophagus and lower esophageal sphincter. METHODS: In this retrospective study, electronic charts of 24 patients who underwent POEM over 18 months were reviewed. Demographic data, fasting status, relevant aspiration risks, anesthetic technique, and postoperative care measures were extracted. RESULTS: Fasting times for both solids and liquids were variable. None of the patients underwent preprocedural esophageal emptying. Standard induction and intubation were performed in 16, rapid sequence induction (RSI) with cricoid pressure in seven, and modified rapid sequence without application of cricoid pressure in one of the patients. One of the patients aspirated at induction, and the procedure was aborted. However, the procedure was performed successfully after a few weeks, this time a RSI with cricoid pressure was chosen. CONCLUSION: As there are no guidelines for the perioperative management of patients presenting for POEM presently, certain recommendations can be made. Preprocedural esophageal emptying should be considered in patients considered as high-risk, although cultural factors might preclude such an approach. Induction and intubation in a semi-reclining position might be useful. Although debatable, use of RSI with cricoid pressure should be strongly considered.

Are we operating too late? Mortality Analysis and Stochastic Simulation of Costs Associated with Bariatric Surgery: Reconsidering the BMI Threshold.

BACKGROUND: Present guidelines recommend bariatric surgery at BMI ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with obesity-related morbidity. METHODS: Evidence for cost and mortality/morbidity risk of bariatric surgery and obesity-related diseases was evaluated determining equivalency point of absolute incremental mortality risk by BMI and risks associated with bariatric surgery. A stochastic model was developed evaluating costs related to surgical procedure at a given BMI. RESULTS: Bariatric surgery produces significant lifetime cost savings associated with diabetes, gallstones, hypertension, high cholesterol, colon cancer, heart disease, and stroke in men at BMI 30 kg/m2 for laparoscopic gastric bypass. For women, laparoscopic gastric bypass saves cost at BMI 32 kg/m2 and laparoscopic gastric banding at BMI 37 kg/m2. In white men, relative to single-year mortality risks by BMI, surgical intervention becomes risk-beneficial at BMI 25 kg/m2 for laparoscopic gastric banding, BMI 27 kg/m2 for laparoscopic gastric bypass procedure and open gastric banding, and BMI 37 kg/m2 for open gastric bypass. Risk benefit for African-American men by procedure occurs at BMI <25 kg/m2, BMI 27 kg/m2, and BMI 42 kg/m2, respectively. In white women, surgical intervention is beneficial at BMI 25.5 kg/m2 (laparoscopic gastric banding), BMI 28.5 kg/m2 (laparoscopic gastric bypass procedure), and BMI 45 kg/m2 (open gastric banding). Risk benefit for black women by procedure occurs at BMI 27.5 kg/m2, BMI 33.5 kg/m2, and BMI 50+ kg/m2, respectively. CONCLUSION: Risk and cost benefit suggest surgical guidelines should be reconsidered. Threshold for bariatric surgery should be redefined to BMI 35 kg/m2 or BMI 30 kg/m2 with comorbidities.

Aprepitant for postoperative nausea and vomiting: a systematic review and meta-analysis.

Postoperative nausea and vomiting (PONV) is an important clinical problem. Aprepitant is a relatively new agent for this condition which may be superior to other treatment. A systematic review was performed after searching a number of medical databases for controlled trials comparing aprepitant with conventional antiemetics published up to 25 April 2015 using the following keywords: 'Aprepitant for PONV', 'Aprepitant versus 5-HT3 antagonists' and 'NK-1 versus 5-HT3 for PONV'. The primary outcome for the pooled analysis was efficacy of aprepitant in preventing vomiting on postoperative day (POD) 1 and 2. 172 potentially relevant papers were identified of which 23 had suitable data. For the primary outcome, 14 papers had relevant data. On POD1, 227/2341 patients (9.7%) patients randomised to aprepitant had a vomiting episode compared with 496/2267 (21.9%) controls. On POD2, the rate of vomiting among patients receiving aprepitant was 6.8% compared with 12.8% for controls. The OR for vomiting compared with controls was 0.48 (95% CI 0.34 to 0.67) on POD1 and 0.54 (95% CI 0.40 to 0.72) on POD2. Aprepitant also demonstrated a better profile with a lower need for rescue antiemetic and a higher complete response. Efficacy for vomiting prevention was demonstrated for 40 mg, 80 mg and 125 mg without major adverse effects. For vomiting comparison there was significant unexplainable heterogeneity (67.9% and 71.5% for POD1 and POD2, respectively). We conclude that (1) aprepitant reduces the incidence of vomiting on both POD1 and POD2, but there is an unexplained heterogeneity which lowers the strength of the evidence; (2) complete freedom from PONV on POD1 is highest for aprepitant with minimum need for rescue; and (3) oral aprepitant (80 mg) provides an effective and safe sustained antivomiting effect.

Controversies in perioperative anesthetic management of the morbidly obese: I am a surgeon, why should I care?

Over the last four decades, as the rates of obesity have increased, so have the challenges associated with its anesthetic management. In the present review, we discuss perioperative anesthesia management issues that are modifiable by the early involvement of the surgical team. We sum up available evidence or expert opinion on issues like patient positioning, postoperative analgesia, and the effect of continuous positive airway pressure (CPAP) ventilation on surgical anastomosis. We also address established predictors of higher perioperative risk and suggest possible management strategies and concerns of obese patients undergoing same day procedures. Finally, a generalized pharmacological model relevant to altered pharmacokinetics in these patients is presented.

Comparison between continuous non-invasive estimated cardiac output by pulse wave transit time and thermodilution method.

AIMS AND OBJECTIVES: Cardiac output (CO) measurement is essential for many therapeutic decisions in anesthesia and critical care. Most available non-invasive CO measuring methods have an invasive component. We investigate "pulse wave transit time" (estimated continuous cardiac output [esCCO]) a method of CO measurement that has no invasive component to its use. MATERIALS AND METHODS: After institutional ethical committee approval, 14 adult (21-85 years) patients undergoing surgery and requiring pulmonary artery catheter (PAC) for measuring CO, were included. Postoperatively CO readings were taken simultaneously with thermodilution (TD) via PAC and esCCO, whenever a change in CO was expected due to therapeutic interventions. Both monitoring methods were continued until patients' discharge from the Intensive Care Unit and observer recording values using TD method was blinded to values measured by esCCO system. RESULTS: Three hundred and one readings were obtained simultaneously from both methods. Correlation and concordance between the two methods was derived using Bland-Altman analysis. Measured values showed significant correlation between esCCO and TD ( r = 0.6, P < 0.001, 95% confidence limits of 0.51-0.68). Mean and (standard deviation) for bias and precision were 0.13 (2.27) L/min and 6.56 (2.19) L/min, respectively. The 95% confidence interval for bias was - 4.32 to 4.58 L/min and for precision 2.27 to10.85 L/min. CONCLUSIONS: Although, esCCO is the only true non-invasive continuous CO monitor available and even though its values change proportionately to TD method (gold standard) with the present degree of error its utility for clinical/therapeutic decision-making is questionable.

Changing trends of hemodynamic monitoring in ICU - from invasive to non-invasive methods: Are we there yet?

Hemodynamic monitoring in the form of invasive arterial, central venous pressure and pulmonary capillary wedge pressure monitoring may be required in seriously ill Intensive care unit patients, in patients undergoing surgeries involving gross hemodynamic changes and in patients undergoing cardiac surgeries. These techniques are considered the gold standards of hemodynamic monitoring but are associated with their inherent risks. A number of non-invasive techniques based on various physical principles are under investigation at present. The goal is to not only avoid the risk of invasive intervention, but also to match the gold standard set by them as far as possible. Techniques based on photoplethysmography, arterial tonometry and pulse transit time analysis have come up for continuous arterial pressure monitoring. Of these the first has been studied most extensively and validated, however it has been shown to be substandard in patients with gross hemodynamic instability. The other two still need further evaluation. While the non-invasive methods for arterial blood pressure monitoring are based on diverse technologies, those for measurement of central venous and pulmonary pressures are mostly based on imaging techniques such as echocardiography, Doppler ultrasound, computed tomography scan and chest X ray. Most of these techniques are based on measurement of the dimensions of the great veins. This makes them operator and observer dependent. However, studies done till now have revealed adequate inter-observer agreement. These techniques are still in their incipience and although initial studies are encouraging, further research is needed on this front.

The association of gender and body mass index with postoperative pain scores when undergoing ankle fracture surgery.

BACKGROUND: Intraoperative administration of opiates for postoperative analgesia requires a dosing strategy without clear indicators of pain in an anesthetized patient. Preoperative patient characteristics such as body mass index (BMI), gender, age, and other patient characteristics may provide important information regarding opiate requirements. This study intends to determine if there is an association between gender or BMI and the immediate postoperative pain scores after undergoing an open reduction and internal fixation (ORIF) of an ankle fracture with general anesthesia and morphine only analgesia. MATERIALS AND METHODS: Using a retrospective cohort design, the perioperative records were reviewed at a university healthcare hospital. One hundred and thirty-seven cases met all inclusion and no exclusion criteria. Postanesthesia care unit (PACU) records were reviewed for pain scores at first report and 30 min later as well as PACU opiate requirements. T-test, chi-square, and Mann-Whitney tests compared univariate data and multivariate analysis was performed by linear regression. RESULTS: There were no statistically significant PACU pain score group differences based on gender or BMI. Post hoc analysis revealed that in the setting of similar pain scores, obese patients received a similar weight based intraoperative morphine dose when using adjusted body weight (ABW) compared to nonobese subjects. A further finding revealed a negative correlation between age and pain score (P = 0.001). CONCLUSION: This study did not find an association between obesity or gender and postoperative pain when receiving morphine only preemptive analgesia. This study does support the use of ABW as a means to calculate morphine dosing for obese patients and that age is associated with lower immediate pain scores.

Significantly reduced hypoxemic events in morbidly obese patients undergoing gastrointestinal endoscopy: Predictors and practice effect.

BACKGROUND: Providing anesthesia for gastrointestinal (GI) endoscopy procedures in morbidly obese patients is a challenge for a variety of reasons. The negative impact of obesity on the respiratory system combined with a need to share the upper airway and necessity to preserve the spontaneous ventilation, together add to difficulties. MATERIALS AND METHODS: This retrospective cohort study included patients with a body mass index (BMI) >40 kg/m(2) that underwent out-patient GI endoscopy between September 2010 and February 2011. Patient data was analyzed for procedure, airway management technique as well as hypoxemic and cardiovascular events. RESULTS: A total of 119 patients met the inclusion criteria. Our innovative airway management technique resulted in a lower rate of intraoperative hypoxemic events compared with any published data available. Frequency of desaturation episodes showed statistically significant relation to previous history of obstructive sleep apnea (OSA). These desaturation episodes were found to be statistically independent of increasing BMI of patients. CONCLUSION: Pre-operative history of OSA irrespective of associated BMI values can be potentially used as a predictor of intra-procedural desaturation. With suitable modification of anesthesia technique, it is possible to reduce the incidence of adverse respiratory events in morbidly obese patients undergoing GI endoscopy procedures, thereby avoiding the need for endotracheal intubation.

Effectiveness of high dose remifentanil in preventing coughing and laryngospasm in non-paralyzed patients for advanced bronchoscopic procedures.

BACKGROUND: Anesthesia for bronchoscopy presents unique challenges, as constant stimulus due to bronchoscope needs to be obtunded using drugs with a minimal post-procedure residual effect. Remifentanil for maintenance is an ideal choice, but optimal doses are yet to be determined. MATERIALS AND METHODS: Bronchoscopic procedures were prospectively evaluated for 4 months studying the frequency of complications and anesthesia techniques. Anesthesia was maintained on remifentanil/propofol infusion avoiding neuromuscular blockers. Laryngeal mask airway was used for the controlled ventilation (with high oxygen concentration) that also served as a conduit for bronchoscope insertions. Anesthesiologists were blinded to the study (avoiding performance bias) and the Pulmonologist was blinded to the anesthesia technique (to document unbiased procedural satisfaction scores). Procedures were divided into 2 groups based on the dose of remifentanil used for maintenance: Group-H (high dose -0.26 to 0.5 µg/kg/min and Group-NH (non-high dose ≤0.25 µg/kg/min). RESULTS: Observed 75 procedures were divided into Group-H (42) and Group-NH (33). Number of statistical difference was found in demography, procedural profile, hemodynamic parameters and total phenylephrine used. Chi-square test showed Group-NH had significantly higher frequency of laryngospasm (P = 0.047) and coughing (P = 0.002). The likelihood ratio of patient coughing and developing laryngospasm in Group-NH was found to be 4.56 and 10.97 times respectively. Minimum pulse-oximeter saturation was statistically higher in Group-H (98.80% vs. 96.50% P = 0.009). Pulmonologist satisfaction scores were significantly better in Group-H. CONCLUSIONS: High dose of remifentanil infusion is associated with a lower incidence of coughing and laryngospasms during bronchoscopy. Simultaneously, it improves Pulmonologist's satisfaction and procedural conditions.

Postoperative analgesia in morbid obesity.

Morbidly obese patients due to high incidence of obstructive sleep apnea (OSA) are predisposed to opioid induced airway obstruction and thus frontline high ceiling analgesics (opioids) have concerns based on safety in their liberal use. Although surgical techniques over the last two decades have seen a paradigm shift from open to laparoscopic procedures for morbidly obese patients; optimally titrated yet safe analgesic management still remains a challenge. The present review sums up the analgesic options available for management of morbidly obese patients undergoing surgery. We highlight the utility of multimodal approach for analgesia with combinations of agents to decrease opioids requirements. Pre-emptive analgesia may be additionally used to improve the efficacy of postoperative pain relief while allowing further reductions in opioid requirements.

Aprepitant's prophylactic efficacy in decreasing postoperative nausea and vomiting in morbidly obese patients undergoing bariatric surgery.

BACKGROUND: Postoperative nausea and vomiting is a major cause of patient dissatisfaction towards surgery. For bariatric surgery, increased vomiting/retching is detrimental to surgical anastomosis. The present study evaluated the efficacy of aprepitant (neurokinin-1 inhibitor) as a prophylactic antiemetic in morbidly obese patients for laparoscopic bariatric surgery. METHODS: After institutional review board approval, 125 morbidly obese patients were recruited into this double-blind placebo-controlled trial. On random division, the patients received a tablet of aprepitant (80 mg) in group A, or a similar-appearing placebo in group P, an hour prior to surgery. All patients received intravenous ondansetron (4 mg) intraoperatively. Postoperatively, the patients were evaluated for nausea and vomiting by a blinded evaluator at 30 min, 1, 2, 6, 24, 48, and 72 h. RESULTS: Both groups were evenly distributed for age, body mass index, type, and length of surgery. Cumulative incidence of vomiting at 72 h was significantly lower in group A (3%) compared to group P (15%; p = 0.021). Odds ratio for vomiting in group P compared to group A was 5.47 times. On Kaplan-Meier plot, time to first vomiting was also significantly delayed in group A (p = 0.019). A higher number of patients showed complete absence of nausea or vomiting in group A compared to group P (42.18 vs. 36.67%). On the other hand, nausea scores were unaffected by aprepitant, and no significant difference between groups was found at any of the measured time points. CONCLUSIONS: In morbidly obese patients undergoing laparoscopic bariatric surgery, addition of aprepitant to ondansetron can significantly delay vomiting episodes simultaneously lowering the incidence of postoperative vomiting.