The Use of Virtual Reality to Reduce Pain and Anxiety in Surgical Procedures of the Oral Cavity: A Scoping Review.

PURPOSE: Virtual reality (VR) is considered a nonpharmacological intervention to manage pain and anxiety for different procedures. We aimed to review the literature about the role of VR in reducing pain and anxiety in surgical procedures performed in the oral cavity. METHODS: A literature review was conducted using Medline and Embase with no restrictions on language or publication date. Our inclusion criteria were articles related to the use of VR to manage perioperative pain and anxiety on procedures in the oral cavity. RESULTS: Twenty-seven articles met the inclusion criteria. The number of publications increased significantly from 2 studies between 2000-2010 to 25 between 2011 and 2021. Of the 27 included studies, 22 (81.4%) studied patients undergoing dental procedures, and 5 (18.5%) in oral and maxillofacial surgery (OMS). There was heterogeneity in the VR software used in the different studies. Thirteen studies (41.9%) evaluated self or observational assessments of pain and anxiety. Pain alone was evaluated in 9 studies (29%) and anxiety alone in 8 studies (25.8%). Also, 6 studies (19.3%) evaluated physiological parameters such as heart rate and respiratory rate as objective measures of pain and anxiety. In oral surgery studies, VR was effective at reducing acute pain, fear, and anxiety levels. CONCLUSIONS: There is a paucity of research in OMS compared to dentistry. Given that this specialty involves highly stimulating and anxiety-provoking procedures, OMS could benefit from VR intervention for improved patient care.

Efficacy of Intraventricular Sponge Placement to Capture Debris in Aortic Valve Replacement.

Objective: Surgical aortic valve replacement (SAVR) carries the known risk of shedding debris into the left ventricle during valve leaflet excision and annulus debridement. Embolization of this debris may have devastating effects for the patient. Although surgeons have developed methods to mitigate this risk, no data exist as to their efficacy. Herein, we present the first study that evaluates the efficacy of a technique for capturing debris during SAVR. Methods: Our group conducted a prospective case series of 20 patients who underwent SAVR using the insertion of an intraventricular surgical sponge prior to valve leaflet excision and annulus debridement to capture debris. Surgical sponges were grossly, radiographically, and histologically examined for the presence of cellular and acellular debris to determine the efficacy of this technique. Results: Of the 20 surgical sponges analyzed, 15 specimens (75%) registered positivity for cellular and/or acellular debris. Seven sponges (35%) were grossly positive, 15 sponges (75%) were radiographically positive, and 4 sponges (20%) were histologically positive for calcified debris on examination. Conclusions: This is one of the few studies to objectively evaluate a method used to capture debris in SAVR procedures. Our results demonstrate a high frequency of debris captured within intraventricular surgical sponges and confirms the efficacy of this technique. While these data are promising, numerous additional approaches exist to capture debris, and a best practice standard should exist across the specialty.  In addition, this study does not address the clinical outcomes associated with this technique. To these ends, additional data and multicenter collaboration are required.

Anesthetic Considerations for Minimally Invasive, Off-Pump, HeartMate III Implantation.

OBJECTIVE: The authors developed and utilized an anesthetic protocol for the management of an off-pump approach for minimally invasive Heartmate III (HM3) implantation. Their goal was to determine if this method was safe and feasible for patients with in-situ mechanical support. DESIGN: The authors performed a retrospective study of consecutive patients undergoing off-pump HM3 implantation via bilateral minithoracotomies. SETTING: This was a single-institution study at the University of Rochester Medical Center, using the same cardiac anesthesiologist and cardiac surgeon pair. PARTICIPANTS: The authors studied 8 consecutive patients undergoing off-pump HM3 implantation from June 2019 to July 2020. INTERVENTIONS: The authors developed an anesthetic management protocol for off-pump HM3 implantation via bilateral minithoracotomies. MEASUREMENTS AND MAIN RESULTS: As a result, the authors evaluated 88% of men with a mean age of 55.0 ±13.0 years. The median time to extubation was 19.7 hours, with a median intensive care unit length of stay of 6.5 days. Fifty percent of patients required blood transfusions during the first 24 hours after surgery (postoperative), and 63% of patients were free from all postoperative complications. No patients required a right ventricular assist device. The mean hospital stay was 26.3 ± 11.3 days, with an 88% survival to discharge. CONCLUSION: In this single-center study, the authors have described the anesthetic consideration for the implantation of the HM3 left ventricular assist device using a complete sternal-sparing technique without the use of cardiopulmonary bypass. Their results have shown, in a case series of 8 patients, that this is a safe and feasible alternative to traditional techniques in patients with existing mechanical support.

Perioperative Management of Ehlers-Danlos Type III Syndrome Associated With Postural Orthostatic Tachycardia in Patients Undergoing General Anesthesia.

Ehlers-Danlos syndrome (EDS) is an autosomal dominant inherited disorder of connective tissue with common clinical features of skin hyperelasticity, joint hypermobility, and easy bruising. Postural orthostatic tachycardia syndrome (POTS) refers to more than three months of a sustained increase in heart rate of more than 30 beats per minute and symptoms of orthostatic intolerance within 10 minutes of assuming a standing position without associated hypotension. These medical conditions can be associated with each other, potentially creating significant perioperative challenges. This paper describes two cases of young women with POTS and EDS hypermobility type (III) who presented for surgery under general anesthesia. The anesthesiologist performed an extensive preoperative evaluation, provided adequate preoperative hydration, ensured careful positioning during anesthetic induction, and avoided neck hyperextension during intubation. Gentle emergence and extubation were practiced with vigilance towards complications of cervical subluxation and airway mucosal injury. Robust communication between postoperative caregivers was prioritized. All these considerations facilitated the achievement of good outcomes. Here, a literature review and subsequent flow diagram of the anesthetic management and perioperative considerations for these patients is purposed.

Venous Gas Embolism During Radical Robotic Prostatectomy: A Case Report and Evidence-Based Management Algorithm.

Robotic-assisted radical prostatectomy (RARP) has gained rapid popularity in the last two decades after early reports of excellent survival rates, quick learning curves, and minimal invasion or tissue damage. Given the anatomical location of surgical prostatectomies and the utilization of intra-abdominal gas during laparoscopy, there is a risk of developing venous air embolism (VAE). We present a case of a 62-year-old male with hypothyroidism and benign prostatic hyperplasia who underwent robotic suprapubic prostatectomy under general anesthesia. One hour after incision the ETCO2 suddenly dropped (40 mmHg to 25 mmHg) as did the SpO2 (98% to 90%). There were no other vital sign changes, nor was there significant blood loss. The surgical team was notified, which prompted the surgeon to inform us that he had just been dissecting around the pelvic venous plexus. At this point, with the clinical suspicion of VAE, abdominal insufflation pressure was lowered, and inspired oxygen was increased to 100%. After 10 minutes, SpO2 and ETCO2 normalized. A debrief and literature review inspired us to develop a laparoscopic-specific VAE management algorithm, with attention to robotic-case management issues. To the best of our knowledge, this is a rare case report describing a clinical VAE during RARP.

Early Outcomes of Isolated Aortic Valve Replacement Through Right Anterior Minithoracotomy Using the Latest-Generation Biological Prosthesis.

OBJECTIVE: The aim of this study is to evaluate early and intermediate outcomes and hemodynamics of the latest-generation Trifecta valve implanted using right anterior minithoracotomy. METHODS: We performed a single-center, retrospective, observational study including 175 individuals who underwent isolated minimally invasive aortic valve replacement with the latest-generation Trifecta valves through a right anterior minithoracotomy between January 2016 and January 2019. Exclusion criteria for follow-up echocardiographic study included concomitant procedures, conversion to median sternotomy, and nonsurvival during the index admission. Analyses addressed implantation safety, 30-day and intermediate-term survival and hemodynamic performance of the valves. RESULTS: Overall, patients were followed with duration ranging from 0.5 to 3 years. Early (<30 days) mortality occurred in 2 patients (1.1%), and there were 9 (5.1%) late (>30 days) deaths. Early thromboembolic events and postoperative bleeding requiring reoperation occurred at a rate of 4.0% (n = 7) and 6.2% (n = 11), respectively. Overall in 175 patients who met inclusion criteria for the follow-up echocardiography study, mean gradients across all valve sizes were 41.3 ± 14.9 (standard deviation) mm Hg preoperatively and remained low at 7.2 ± 3.9 mm Hg with mean effective orifice area of 1.8 ± 0.5 cm2 on the last follow-up echo. There was 1 case of infective prosthetic endocarditis, which did not require valve explant. There were no reoperations due to valve-related problems during the study period. CONCLUSIONS: This is the largest series reporting on outcomes of the latest-generation Trifecta valve implanted using right anterior minithoracotomy. Our results demonstrate that this valve can be safely implanted via a minimally invasive approach with excellent early and intermediate outcomes and hemodynamic performance.

Routine Placement of Temporary Epicardial Pacing Leads Is Not Required After Minimally Invasive Aortic Valve Replacement.

OBJECTIVE: Our objective is to identify the incidence of urgent transvenous (TV) pacing wire placement following minimally invasive aortic valve replacement (mini-AVR). METHODS: This is a single-center, retrospective, observational study including 359 individuals who underwent isolated mini-AVR through right anterior mini-thoracotomy between January 2015 and September 2019. Patients were grouped according to avoidance or insertion of epicardial pacing wires, and further subdivided based on the requirement for postoperative emergent temporary TV pacing or permanent pacemaker (PPM) placement during the index admission. RESULTS: Two hundred forty-two (67.4%) had acceptable rate and no high-degree atrioventricular (AV) block prior to chest closure and did not have insertion of epicardial pacing wires. Of those patients, only 3 (1.2%) required emergent TV pacing and 6 (2.5%) required nonemergent TV pacing with or without PPM placement during the index admission. Sixty-two (17.3%) patients received only atrial epicardial pacing leads secondary to sinus bradycardia or junctional rhythm and 3 (4.8%) of those patients required PPM placement due to sick sinus syndrome and 1 (1.6%) patient required nonemergent TV pacing and PPM due to high-grade AV heart block. Fifty-five (15.3%) patients received ventricular leads due to high-grade AV heart block and 7 (12.7%) of those patients required PPM placement during the index admission. CONCLUSIONS: Temporary epicardial lead insertion is not routinely required in mini-AVR in patients with normal rate and acceptable AV conduction prior to chest closure. In the absence of epicardial ventricular lead insertion, the chance of requiring urgent TV pacing wire placement during the index admission is 0.99%.