Posts by Dr. Clemens | Anesthesia Experts

About Dr. Clemens

Here are my most recent posts

SEE Question

September 26, 2024 by Dr. Clemens Leave a Comment

A 70-year-old patient with aortic stenosis and no other notable medical history is undergoing a transcatheter aortic valve replacement (TAVR) procedure. According to a recent study comparing outcomes at three years between TAVR and surgical aortic valve replacement (SAVR) in patients at low surgical risk, which of the following outcomes was MOST likely with TAVR?

□ (A) Lower likelihood of a permanent pacemaker
□ (B) Lower rate of death or disabling stroke
□ (C) Higher mean gradients on the three-year follow-up transthoracic echocardiogram

Trials of TAVR started in patients deemed to be at prohibitive surgical risk. Over time, patients at lower surgical risk have been enrolled in these trials comparing TAVR with SAVR. Since transcatheter valves are being placed in healthier patients with presumably longer lifespans, study of the longevity and outcomes associated with the valves is even more important.

The Evolut Low Risk trial, a multinational, prospective, randomized study, evaluated low-risk patients with aortic stenosis undergoing either TAVR or SAVR. The three-year outcomes for this trial were recently published, which included the primary end point of all-cause mortality or disabling stroke at three years. The study was conducted at 86 sites in seven countries from March 2016 to May 2019 and included 730 TAVR patients and 684 SAVR patients. Overall, patients who received a TAVR had a lower rate of death or disabling stroke compared with SAVR at three years (7.4% TAVR vs. 10.4% SAVR; hazard ratio, 0.70; 95% CI, 0.49-1.00). In addition to this benefit, the transcatheter valves performed well compared with the surgical valves. The mean gradients on the three-year follow-up transthoracic echocardiogram were lower for TAVR and had higher effective orifice areas compared with SAVR. The authors attributed this finding to the supra-annular position of the valve. No differences were found in valve reoperations between TAVR and SAVR, with comparable thrombosis and infection rates, although this metric needs to be tracked for a longer period.

The disadvantages of TAVR continue to be the increased risk for permanent pacemaker and paravalvular leak. Patients undergoing TAVR were 2.8 times more likely to need a pacemaker than those undergoing SAVR (23.2% TAVR vs. 9.1% SAVR; 95% CI, 2.08-3.79). However, as the technology evolves, there are structural changes being made to the valves that may decrease the risk of heart block and paravalvular leak. Additionally, as seen in the primary composite outcome, the presence of a paravalvular leak or pacemaker does not seem to increase the risk of stroke or death.

Overall, this study demonstrated that the TAVR procedure had a lower risk of death or disabling stroke in low-risk patients at three years compared with SAVR. This population will continue to be followed by the study authors through the 10-year mark to provide longer-term data on the performance of these valves.

Answer: B

Understanding and Treating Laryngeal Mask Airway-Induced Intraoperative Hiccups

September 26, 2024 by Dr. Clemens Leave a Comment

Authors: Khatri S, et al

Cureus 16(9): e69782.

Abstract

The laryngeal mask airway (LMA) has gained popularity as an airway management device in the perioperative setting due to its ease of use, reduced invasiveness compared to endotracheal intubation, and lower incidence of complications. However, hiccups, though relatively uncommon, can pose a significant challenge during the perioperative period when an LMA is in place. Abrupt movement because of hiccups can lead to delay in surgery as well as interfere with surgical instrumentation. This discussion presents a case where perioperative hiccups occurred with LMA use and explores the management strategies employed.

Introduction

Hiccups or singultus are sudden, involuntary contractions of the diaphragm and external intercostal muscles, followed by the abrupt closure of the glottis, producing the distinctive “hic” sound [1]. In recent scenarios, the laryngeal mask airway (LMA) has gained popularity as an airway device for spontaneous and controlled ventilation, as it helps avoid complications associated with endotracheal intubation. Acute hiccup during sedation or general anesthesia after the use of LMA is a minor yet notable complication that can have several disruptive effects. It may disturb the surgical field, making it difficult for the surgeon to perform precise procedures. Additionally, it can interfere with lung ventilation, potentially compromising the patient’s oxygenation and ventilation status [2]. This condition can also hinder diagnostic procedures, particularly those requiring steady or controlled conditions, such as imaging or endoscopic examinations. While generally not severe, managing acute hiccups promptly is important to prevent these potential complications. This case suggests that using an LMA device may trigger hiccups, with the incidence of LMA-related hiccups being approximately 1%-14% [3].

Case Presentation

We hereby present a case of a 30-year-old female with a height of 160 cm and 55 kg weight, diagnosed with fibroadenoma in her right breast, scheduled for elective excision surgery under general anesthesia. Classic LMA was decided to be used as an airway adjunct. She had no other significant history, chronic medical conditions, prior surgeries, artificial dentures, or drug allergies.

She was physically fit, with a respiratory rate of 18 breaths/minute, pulse rate of 70 beats/minute, and blood pressure of 110/70 mmHg in the sitting position. On auscultation, breath sounds in both lung fields were normal, and no cardiac murmurs were present. Her airway assessment was Mallampati class I, and she was classified under the American Society of Anesthesiologists (ASA) physical status grade I.

All routine laboratory investigations, including complete blood count, renal function test, liver function test, prothrombin time, and international normalized ratio, were normal with normal ECG and chest X-ray. An informed and written consent was obtained from the patient. The patient was kept nil by mouth for 8 hours preoperatively.

All ASA standard monitors in the operating room were connected, showing a body temperature of 36.8°C, pulse rate of 80 beats/minute, noninvasive blood pressure of 110/70 mmHg, and pulse oximeter saturation of 100%. An intravenous cannula of 20G was taken from the left hand, and 500 mL of Ringer’s lactate solution was started.

Premedication with 0.2 mg intravenous glycopyrrolate, 1 mg midazolam, and 2 μg/kg of fentanyl intravenously was done. An oxygen mask was attached at a flow rate of 8 L/minute, and the patient was induced with 2 mg/kg of propofol. A classic LMA of size 3 was inserted, and 20 mL of air was used for inflating the cuff. Anesthesia was maintained with sevoflurane, nitrous oxide, and oxygen. The patient was kept on controlled ventilation, and intraoperative analgesia was achieved with intravenous paracetamol (1 g). The oxygen saturation and pulse rate were continuously monitored. Noninvasive blood pressure was recorded at five-minute intervals during the intraoperative period.

After 20 minutes of induction, the patient suddenly developed hiccups. They continued despite administering 40 mg of propofol in repeated 10 mg boluses. These hiccups disturbed the surgeon’s instrumentation during the procedure. Next injection, 0.5 mg atropine was given intravenously but was not effective. Subsequently, 50 μg of dexmedetomidine was administered intravenously over a 10-minute period, which successfully resolved the hiccups. Following the administration of dexmedetomidine, there was a noted decrease in both heart rate and blood pressure, though this did not exceed 20% of the patient’s baseline values. The surgery then proceeded without further complications for another 25 minutes.

At the end of surgery, a thorough oral suction was performed, and inhalational agents were discontinued. Once the patient was awake and all airway reflexes were restored, the cuff was deflated, and LMA was removed. She was transferred to the recovery room for further observation. Hiccups did not recur for the next three days while she stayed in the hospital.

Discussion

Hiccups can significantly disrupt surgery, so addressing them promptly is crucial. The hiccup reflex arc consists of two limbs: afferent and efferent limbs. The afferent limb consists of vagal, sympathetic chains from T6 to T12 and phrenic nerves that travel to the hiccup center located at the posterolateral part of the medulla oblongata. The efferent pathway is through the motor fibers of the phrenic nerve and the accessory nerve to the diaphragm. Any stimulation along the reflex pathway leads to a hiccup. It also increases the risk of aspiration by creating a pressure gradient across the lower esophageal sphincter, enabling reflux.

Various etiologies of intraoperative hiccups are excessive food and carbonated beverages preoperatively [2] and various anesthetic drugs and techniques used during general anesthesia like methohexital, thiopentone, midazolam, and opioids [4,5]. Propofol is also one of the causes of hiccups, which can be treated with intravenous lidocaine [6]. However, since propofol is usually given with lidocaine for ameliorating pain during injection, it is rarely found to be the causative agent (Table 1) [7].

Pharmacological management	Nonpharmacological management
Dexmedetomidine	Stomach deairing
Atropine	Lubrication of nasal airway with lignocaine
Midazolam	CPAP of 25-30 H₂O
Metoclopramide	Acupuncture
Nifedipine	Stellate ganglion block
Proton pump inhibitors	–
Chlorpromazine	–

Table 1: Management of intraoperative hiccups

Pharmacological and nonpharmacological methods used for treating intraoperative hiccups are displayed [8]

Bag mask ventilation before induction has pros and cons. On the one hand, it leads to preoxygenation, and on the other, it leads to stomach insufflation, which can cause hiccups due to vagus nerve stimulation. Patients with preexisting conditions like gastroesophageal reflux disease (GERD) and central nervous disorders are also more prone to hiccups.

Patients induced with LMA cause hiccups due to the stimulation of mechanoreceptors. The distal end of a well-seated LMA lies over the proximal esophagus, and the sudden and rapid stretch of mechanoreceptors in the proximal esophagus leads to hiccups. The stimulus for hiccups in intraoperative settings can also be pain at the surgical site and decreased depth of anesthesia [9].

Treatment guidelines are unclear because the reflex arc is incompletely understood, and various possible etiologies exist. The main goal is to disrupt the reflex arc using pharmacological or nonpharmacological methods.

As a lighter plane of anesthesia is one reason for hiccups, we deepened the plane of anesthesia by giving boluses of propofol, but still, hiccups were present.

Acetylcholine is one of the neurotransmitters triggering the reflex arc. Therefore, giving anticholinergics like atropine 0.5 mg intravenously blocks the vagally mediated reflex from LMA insertion and abolishes the efferent arc from the hiccup center [2]. It additionally decreases intraesophageal pressure [3]. In our case, 0.5 mg atropine was unsuccessful in terminating the reflex arc.

In a study by Koteswara and Dubey, dexmedetomidine, a selective alpha-2 adrenergic receptor agonist, was found to abolish hiccups in a similar scenario, implying that sympatholytic drugs abolish intraoperative hiccups [10]. Since atropine was ineffective, we gave dexmedetomidine 1 μg/kg, and the hiccups ceased. There was a slight decrease in heart rate and blood pressure.

Various other modalities can be used in addition to these drugs. For anesthetic agent-induced hiccups, metoclopramide, through its dopamine antagonism and serotonin agonism, seems to be a potent agent for terminating hiccups [8].

Dexmedetomidine offers several advantages over metoclopramide in the management of hiccups. While metoclopramide was traditionally used for treating hiccups due to its dopamine antagonist properties, dexmedetomidine presents unique benefits that may make it preferable.

Sedative, analgesic, and anxiolytic properties

Stimulating presynaptic receptors in sympathetic nerve endings and central postsynaptic receptors inhibits sympathetic activity. Analgesia is achieved by stimulating α2 adrenoreceptors in the spinal cord. This inhibition of sympathetic activity (one of the pathways of the reflex arc in the hiccups pathway), along with analgesic and sedative properties, may have been the reason for suppressing intraoperative hiccups [10].

Reduced risk of adverse neurological effects

Metoclopramide is known to carry risks of extrapyramidal symptoms, especially in young adults who are at higher risk for developing dystonic reactions [11]. Dexmedetomidine, by contrast, lacks these dopamine-blocking effects, which is a significant advantage in younger patients who are more susceptible to these adverse reactions.

GERD patients are, in general, more prone to hiccups, which, in turn, leads to a higher risk of aspiration, so prophylactically proton pump inhibitors should be used. The only Food and Drug Administration-approved treatment is chlorpromazine (25-50 mg) intravenously [12].

Nonpharmacological stomach desiring and nasal airway lubrication with lidocaine lead to pharyngeal stimulation opposite to C2 C3 and terminate hiccups. Lung recruitment, application of 25-30 cm of H₂O continuous positive airway pressure [2], and suboccipital release technique all reduce pressure on the vagus and interrupt reflex arc [2]. Deliberate hypoventilation, where the end-tidal carbon dioxide is targeted at 48 mmHg, also halts hiccups [13]. Stellate ganglion block is a recent technique for intractable hiccups [14].

Conclusions

Intraoperative hiccups are a nuisance for both anesthetists and surgeons. Using classic LMA heightens the chance of aspiration, especially in the absence of a nasogastric tube. Hence, strategies to reduce gastric insufflation, early detection of the cause, and effective management using various drug modalities are the key points to prevent any complications.

Numerous interventions have been suggested for managing hiccups during anesthesia. However, perioperative treatment remains largely based on empirical evidence, with no approach being “evidence-based.” As a result, no definitive recommendations can be made to treat hiccups. In our case, conventional medications and techniques for multimodal management were ineffective, so dexmedetomidine was administered, successfully controlling the hiccups.

References

Musumeci A, Cristofori L, Bricolo A: Persistent hiccup as presenting symptom in medulla oblongata cavernoma: a case report and review of the literature. Clin Neurol Neurosurg. 2000, 102:13-7. 10.1016/s0303-8467(99)00058-x
Mathew J, Shen S, Liu H: Intraoperative laryngeal mask airway-related hiccup: an overview. Transl Perioper Pain Med. 2020, 7:145-51. 10.31480/2330-4871/103
Kanaya N, Nakayama M, Kanaya J, Namiki A: Atropine for the treatment of hiccup after laryngeal mask insertion. Anesth Analg. 2001, 93:791-2. 10.1097/00000539-200109000-00047
Marhofer P, Glaser C, Krenn CG, Grabner CM, Semsroth M: Incidence and therapy of midazolam induced hiccups in paediatric anaesthesia. Paediatr Anaesth. 1999, 9:295-8. 10.1046/j.1460-9592.1999.00378.x
Liu CC, Lu CY, Changchien CF, Liu PH, Perng DS: Sedation-associated hiccups in adults undergoing gastrointestinal endoscopy and colonoscopy. World J Gastroenterol. 2012, 18:3595-601. 10.3748/wjg.v18.i27.3595
Krishnakumar M, Srinivasaiah B, Naik SS, Goyal A: Propofol-induced hiccups in MRI suite treated with dexmedetomidine. Saudi J Anaesth. 2023, 17:450-1. 10.4103/sja.sja_816_22
Landers C, Turner D, Makin C, Zaglul H, Brown R: Propofol associated hiccups and treatment with lidocaine. Anesth Analg. 2008, 107:1757-8. 10.1213/ane.0b013e3181853605
Prakash S, Sitalakshmi N: Management of intraoperative hiccups with intravenous promethazine. J Anaesthesiol Clin Pharmacol. 2013, 29:561-2. 10.4103/0970-9185.119131
Nwagwu CC, Ebirim LN: Postoperative hiccup induced by LMA—a case report with literature review. Open J Anesthesiol. 2014, 4:236-9. 10.4236/ojanes.2014.410035
Koteswara CM, Dubey JK: Management of laryngeal mask airway induced hiccups using dexmedetomedine. Indian J Anaesth. 2013, 57:85. 10.4103/0019-5049.108583
Fink FM, Bognar M, Hengl P, Paulmichl M, Nofziger C: Case report: metoclopramide induced acute dystonic reaction in adolescent CYP2D6 poor metabolizers. Front Pharmacol. 2023, 14:1201566. 10.3389/fphar.2023.1201566
Polito NB, Fellows SE: Pharmacologic interventions for intractable and persistent hiccups: a systematic review. J Emerg Med. 2017, 53:540-9. 10.1016/j.jemermed.2017.05.033
Obuchi T, Shimamura S, Miyahara N, Fujimura N, Iwasaki A: CO(2) retention: the key to stopping hiccups. Clin Respir J. 2018, 12:2340-5. 10.1111/crj.12910
Lopez DJ, Kumar S: Stellate ganglion block for intractable hiccups secondary to a motor vehicle collision. Cureus. 2023, 15:e37030. 10.7759/cureus.37030

A Comparative Study of Infusion of Ephedrine and Phenylephrine on Hemodynamic Stability After Spinal Anesthesia in Elderly Patients Undergoing Lower Limb Orthopedic Surgeries

September 26, 2024 by Dr. Clemens Leave a Comment

Authors: Ibrahim S et al

Cureus 16(9): e69977

Background

Hypotension during spinal anesthesia occurs due to sympathetic nervous system blockade, resulting in decreased systemic vascular resistance and reduced cardiac output. Due to reduced sympathetic tone, peripheral arterial vasodilatation and blood pooling in lower limbs due to venodilatation occur, reducing preload to the heart and stroke volume. The elderly patients have reduced cardiovascular compensatory mechanisms, increasing the frequency and severity of hypotension due to sympathetic blockade after spinal anesthesia significantly. Vasopressors correct hypotension during the intraoperative period to maintain organ perfusion. Fluids can be administered, and if given excessively, can cause fluid overload and urinary retention. This study aimed to compare the effectiveness of vasopressors, phenylephrine, and ephedrine in maintaining hemodynamic stability intraoperatively through prophylactic infusion after spinal anesthesia in elderly patients for lower limb orthopedic surgeries.

Methodology

A total of 174 elderly patients aged 60 years and above with American Society of Anesthesiologists (ASA) Classification I and II, undergoing lower limb orthopedic surgeries, enrolled in a randomized comparative study, were allocated into three groups: Group P (phenylephrine, n=58) received 250 mcg phenylephrine in 30 ml normal saline using infusion syringe pump, Group E (ephedrine, n=58) received 30 mg ephedrine in 30 ml normal saline using infusion syringe pump, and Group C (control group, n=58) received mephentermine I/V (6 mg bolus) when the fall in blood pressure was below 30% of baseline without any placebo infusion. Hemodynamic parameters (systolic and diastolic blood pressure, mean arterial pressure (MAP), heart rate) at 15, 10, and 5-minute intervals before spinal anesthesia, and at 3, 6, 9, 12, 15, 20, 25, and 30-minute intervals after spinal anesthesia. The need for rescue doses to treat hypotension after spinal anesthesia was recorded.

Result

At all time intervals following spinal anesthesia, Group E reported heart rate and systolic blood pressure better than Groups P and C, significantly. At 3, 6, 9, 12, 15, and 25-minute intervals following spinal anesthesia, the diastolic blood pressure in Group E was enhanced significantly than Groups P and C. The MAP in Group E was substantially higher than in other groups at 3, 6, 15, and 20-minute intervals following spinal anesthesia, which was statistically significant. Compared to Groups P and C, Group E required lesser rescue doses to treat intraoperative fall in hypotension 30% below baseline and lesser events of bradycardia.

Conclusion

Following spinal anesthesia, the preload to the heart is to be maintained with intravenous (crystalloid or colloidal) solutions to maintain cardiac output adequately. Intraoperative use of phenylephrine and ephedrine as a low-dose prophylactic infusion can be used, as it increases both systemic vascular resistance and preload without cardiac stimulation along with intravenous solutions to maintain hemodynamic parameters such as systolic and diastolic blood pressure, MAP, heart rate effectively but preferably ephedrine in elderly patients.

Introduction

Hypotension is frequently observed after induction of spinal anesthesia which is a commonly used regional technique in elderly patients undergoing lower limb orthopedic procedures [1]. It occurs due to reduced cardiac output and peripheral vascular resistance, which raises the possibility of myocardial ischemia. Impaired cerebral auto-regulation during the perioperative period decreases middle cerebral artery velocity [2]. Reducing the spinal dose and the extent of anesthetic spread to the necessary dermatomes decreases the incidence of adverse effects [3]. As crystalloids are frequently ineffective in ameliorating blood pressure, their administration can soon result in circulatory overload and congestive cardiac failure [4].

The elderly are more likely to have comorbid diseases, which increases their risk of hypoperfusion, which is due to hypotension, the primary risk factor for which is hypovolemia [4,5]. Vasopressors such as phenylephrine and ephedrine can be immediately infused into elderly people to prevent hemodynamic abnormalities following spinal anesthesia [6]. More research is to be done to study the efficacy and minimal dose requirement of vasopressors as a prophylactic infusion to maintain hemodynamics in the elderly population.

The objective of this study was to determine the effectiveness of vasopressors such as phenylephrine and ephedrine as a low-dose prophylactic intravenous infusion to study hemodynamic variations in elderly patients immediately after spinal anesthesia and to prevent hypotension and the need for rescue doses to maintain vital parameters in patients aged 60 years and above undergoing lower limb orthopedic surgeries.

Materials & Methods

This study was registered at Clinical Trials Registry-India with link https://ctri.nic.in/Clinicaltrials/login.php under the CTRI/2023/04/051451 registration number. The study time was from May 2023 to August 2024. The study was conducted after receiving approval from the institutional ethical committee of Bijapur Lingayat District Education (BLDE) (Deemed to be University), Shri BM Patil Medical College, Hospital and Research Centre with ethical clearance number BLDE(DU)/IEC/787/2022-23. A total of 174 patients aged 60 years and above belonging to American Society of Anesthesiologists (ASA) grades I and II [7], scheduled for elective lower limb orthopedic surgical procedures under spinal anesthesia, were included in the study. The study excluded patients with infection at the site of injection, uncontrolled hypotension, allergic or hypersensitivity to vasoconstrictors, coagulopathies, sepsis, fixed cardiac output states, uncontrolled hypertension, hypothyroidism, uncontrolled diabetes, untreated or uncontrolled heart failure, pheochromocytoma, on monoamine oxidase inhibitors, tricyclic antidepressants, phenothiazine compounds, recent myocardial ischemia/infarction.

During the pre-anesthetic evaluation, a detailed history and general and systemic examinations were carried out the previous day. A history of any significant medical illness was elicited and medication history was taken. The airway, respiratory system, and cardiovascular system were assessed. Written informed consent was obtained. Routine investigations such as complete blood profile, bleeding time and clotting time, random blood sugar, serological tests, chest X-ray, and 2D echocardiography were performed.

On the day of the surgery, nil per oral status was confirmed. An 18G IV cannula was secured and preloading with Ringer lactate solution (15 ml/kg) was infused. On the operating table, vital monitors such as non-invasive blood pressure (NIBP), electrocardiography (ECG), and pulse oximetry were attached to record baseline heart rate, blood pressure, and SpO2. The patients were positioned in a sitting posture. Using a 25G Quincke spinal needle, a lumbar puncture was done at the L3-4 or L4-L5 interface following skin disinfection and 2% lignocaine infiltration. Premedication was given with midazolam 0.5 mg I/V to alleviate the anxiety of the patients. The groups were intrathecally administered with 0.5% hyperbaric bupivacaine 15 mg I/V. Subsequently, patients were supined and oxygen (5 L/min) was delivered with a face mask. Five minutes after intrathecal injection, sensory blockade of spinal anesthesia was assessed using ice cubes or pinpricks.

Patients were split randomly into three groups. Group P received a low-dose continuous infusion of 30 ml 0.9% normal saline with 250 mcg of phenylephrine for 30 minutes (8.3 mcg/min) immediately following spinal anesthesia using an infusion syringe pump. Group E received a continuous infusion of 30 ml 0.9% normal saline with 30 mg of low-dose ephedrine for 30 minutes (1 mg/min) immediately following spinal anesthesia using an infusion syringe pump. Group C (control) received a bolus of mephentermine 6 mg I/V after spinal anesthesia when required without any placebo infusion. The infusion of treatment medication in Group P and Group E was started immediately after spinal anesthesia at an infusion rate of 60 ml/hour, and infusion was stopped after 30 mins (study period) following induction of spinal anesthesia. NIBP, heart rate, ECG, and percentage of oxygen saturation (SpO2) were monitored. Incidence of hypotension and bradycardia were noted. Hemodynamic parameters were recorded at 15, 10, and 5 minutes prior to spinal anesthesia and for 0, 3, 6, 9, 12, 15, 20, 25 and 30-minute intervals after spinal anesthesia.

The rescue treatment protocol to treat intraoperative hypotension was followed. If the reduction in systolic blood pressure was greater than 30% below baseline, then a bolus dose of phenylephrine 50 mcg I/V or ephedrine 5 mg I/V was given in respective groups. Atropine 0.6 mg I/V was given if the heart rate was less than 50 beats per minute. In the case of hypertension, the ongoing infusion was stopped.

Statistical analysis

Using G*Power Version 3.1.9.4 (Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany) for sample size calculation, the mean arterial pressure (MAP) for control (mean=90, SD=12), phenylephrine (mean=85, SD=12), and ephedrine (mean=84, SD=9) were obtained. This study required a total sample size of 174 (for each group 58, assuming equal group sizes) to achieve a power of 80% for detecting a difference means [7].

The data was entered into a Microsoft Excel sheet and statistical analysis was performed using IBM SPSS Statistics for Windows, Version 20 (IBM Corporation, New York, US). The findings were evaluated using basic statistics, including mean and standard deviation of numerical variables and percentages for categorical variables. To compare categorical variables between the two groups, the chi-square test was used. For groups that were not normally distributed, the Kruskal-Wallis test was performed. All analyses were two-tailed, with a p-value of <0.05, which was considered to be statistically significant.

Results

In the present study, constituting 174 elderly patients aged 60 years and above, 58 in each group were posted for all elective lower limb orthopedic surgeries (such as open reduction and internal fixation of fractures, tendon repairs, soft tissue procedures, arthroplasty, arthroscopic knee surgeries, etc.) to assess the impact of phenylephrine or ephedrine infusion administered intravenously as a prophylactic measure to prevent hypotension and its effect on heart rate. The present study followed The Consolidated Standards of Reporting Trials (CONSORT) guidelines (Figure 1). There was no statistically significant difference in all groups with demographic characteristics such as age (p=0.496), sex (p=1), ASA grades (p=0.197), and body mass index (p=0.271).

Figure 1: CONSORT flow diagram

CONSORT: Consolidated Standards of Reporting Trials; n: Number of patients

The mean systolic blood pressure at different time intervals was plotted for each group (Figure 2). The mean systolic blood pressure at induction (0 mins) of spinal anesthesia was superior in Group P compared to Group E and the control group. It was enhanced in Group E when compared to other groups at 6 (p=0.001), 9 (p=0.001), 12 (p=0.01), 15 (p=0.02), 20 (p=0.001), 25 (p=0.001) and 30 (p=0.002) minute time intervals after spinal anesthesia, which was statistically significant (p<0.05).

Figure 2: Comparison of SBP before and after SA

SBP: Systolic blood pressure; SA: Spinal anesthesia

The mean diastolic blood pressure at different time intervals was plotted for each group (Figure 3). The mean diastolic blood pressure at induction (0 min) of spinal anesthesia was superior in Group P compared to Group E and the control group. It was enhanced in Group E with reference to other groups at 3 (p=0.002), 6 (p=0.002), 9 (p=0.001), 12 (p=0.02), 15 (p=0.001) and 25 (p=0.01) minute time intervals after spinal anesthesia, which was statistically significant (p<0.05).

Figure 3: Comparison of DBP before and after SA

DBP: Diastolic blood pressure; SA: Spinal anesthesia

The mean values of MAP at different time intervals were plotted and the mean MAP was superior in the control group compared to other groups (Figure 4). The mean MAP was enhanced in the ephedrine group in comparison to Group P at 3 (p=0.02), 6 (p=0.017), 15 (0.007), and 20 (0.006) minute time intervals after spinal anesthesia, which was statistically significant (p<0.05).

Figure 4: Comparison of MAP before and after SA

MAP: Mean arterial pressure; SA: Spinal anesthesia

The mean heart rate at different time intervals was plotted for each group (Figure 5). The mean heart rate was superior in Group E in comparison to other groups and was statistically significant (p<0.05) at 3 (p=0.013), 6 (p=0.014), 12 (p=0.001), 15 (p=0.001), 20 (p=0.001), 25 (p=0.001), and 30 (p=0.001) minute time intervals after spinal anesthesia.

Figure 5: Comparison of heart rate before and after SA

SA: Spinal anesthesia

The number and percentage of rescue doses of vasopressors to treat hypotension if it falls below 30% of baseline, given among all groups, were evaluated using the chi-square test and tabulated (Table 1). The obtained p-value of 0.297 was observed to be statistically insignificant.

Rescue Doses	Group P		Group E		Control		Chi-Square Test	p-Value
Rescue Doses	No.	%	No.	%	No.	%	Chi-Square Test	p-Value
0	48	82.80%	53	91.40%	45	77.60%	4.911	0.297
1	9	15.50%	5	8.60%	11	19.00%
2	1	1.70%	0	0.00%	2	3.40%

Table 1: Number and percentage of rescue doses given in all groups

The number and percentage of atropine I/V to treat bradycardia (heart rate less than 50 beats/min) given among all groups was tabulated and it was observed to be statistically insignificant (Table 2). The atropine I/V required to treat bradycardia was less in Group E than in Group P and the control group.

Atropine	Group P		Group E		Control		Chi-Square Test	p-Value
Atropine	No.	%	No.	%	No.	%	Chi-Square Test	p-Value
0	54	93.10%	56	96.60%	55	94.80%	0.703	0.704
1	4	6.90%	2	3.40%	3	5.20%	0.703	0.704

Table 2: Number and percentage of atropine doses given in all groups

Discussion

The present study observed the hemodynamic variations after spinal anesthesia. Results showed that the mean systolic blood pressure (Group E>Group P>Group C), diastolic blood pressure (Group E>Group P>Group C), MAP (Group E=Group P=Group C), and heart rate were better maintained in Group E compared to Groups P and C above baseline blood pressure before induction. Elderly patients with untreated sympathetic block after spinal anesthesia have lower systolic blood pressure, systemic vascular resistance, and mean venous pressure due to decompensated state. Restoring preload to the heart during spinal block should be accomplished by administering sufficient intravenous fluids (8-10 ml/kg). Adequate preloading precludes a decrease in cardiac output and unanticipated cardiac arrests, but excessive fluid administration can lead to fluid overload [8]. A vasopressor should be administered if the systolic blood pressure declines by 25 to 30% baseline value or less than 90 mmHg. Vasopressors are known to cause vasoconstriction by increasing systemic vascular resistance to prevent spinal-induced hypotension (SIH) eventually, thus they are a better choice for maintaining hemodynamics in elderly patients [9]. The alpha-adrenergic agonist phenylephrine is typically linked to reflex bradycardia [10]. It raises blood pressure due to venoconstriction and arterial vasoconstriction. It increases venous tone, venous return (preload), and systemic vascular resistance.

Ephedrine, a mixed-action (alpha and beta) adrenergic agonist, increases the cardiac output and prevents a decrease in heart rate as it causes greater venoconstriction than arteriolar constriction and results in increased venous return (preload) and enhances cardiac output, blood pressure, and heart rate [11].

As per the observed results in the present study, phenylephrine 250 mcg/30 ml and ephedrine 30 mg/30 ml, were both effective in maintaining hemodynamic stability after subarachnoid block. The systolic blood pressure was well maintained in Group E>Group P>Group C following induction of spinal block. The attenuation of systolic blood pressure due to sympathetic blockade was more pronounced within the initial 15 minutes after spinal anesthesia and well optimized by Group E compared to Groups P and C.

The diastolic blood pressure was enhanced in Group E>Group P>Group C. The MAP was observed to be equally maintained above and at baseline in all groups (Group P=Group E=Group C). However, the initial drop in MAP following the spinal block was better optimized in the ephedrine group. Zunic et al. reported the impact of phenylephrine or ephedrine infusion following spinal anesthesia on hemodynamics in elderly patients for orthopedic surgeries. They observed that cardiac index, MAP, and heart rate were better in Group E than in Groups P and C [7]. Conversely, Abbasivash et al. found that the MAP, systolic and diastolic blood pressures, and the frequency of hypotension were all considerably reduced in the phenylephrine group after spinal anesthesia, with no apparent difference in heart rate among phenylephrine and ephedrine groups. Less vasopressor use was observed in the phenylephrine group [12]. In this study, less vasopressor rescue dose was required to treat hypotension in Group E compared to Groups P and C. Mon et al. demonstrated that Groups P and E achieved good systolic blood pressure, but ephedrine increased cardiac output in comparison to phenylephrine in parturients [13]. Asokan et al. concluded that ephedrine 6 mg and phenylephrine 100 mcg did not differ in their effectiveness in treating hypotension during subarachnoid block for cesarean section. However, maternal bradycardia was more in the phenylephrine group, with equal incidence of fetal acidosis in the study groups [14]. In this study, both ephedrine and phenylephrine were effective in maintaining hemodynamics and considerably better in the ephedrine group. The incidence of bradycardia was also less in the ephedrine group compared to other groups.

The heart rate in the present study was maintained better in Group E>Group C>Group P. Four patients in the phenylephrine group were given atropine 0.6 mg I/V in response to bradycardia, whereas in the Ephedrine group, only two patients had bradycardia. The rescue doses (phenylephrine 50 mcg/ephedrine 5 mg) to maintain systolic blood pressure after a fall of more than 30% below baseline, were required more in the phenylephrine group than in the ephedrine group. Sinha et al. conducted a study and concluded that following subarachnoid block for cesarean delivery, the three vasopressors efficiently preserved arterial blood pressure. When compared to ephedrine and mephentermine, phenylephrine significantly lowered heart rate [15].

Limitations

A larger sample size is required and a multi-centric study is preferred. Invasive blood pressure (IBP) monitoring provides precise monitoring of blood pressure, which was not done in the present study. Cardiac output is not measured which is crucial in determining the effectiveness of vasopressors among the elderly population.

Conclusions

Hypotension following spinal anesthesia, caused by a reduction in stroke volume can be treated with crystalloid or colloidal solutions. Administration of vasopressor agents increases stroke volume and preload by increasing systemic vascular resistance without heart stimulation. Hence, both vasopressors (ephedrine and phenylephrine) can be used along with crystalloid solutions to correct hypotension post-subarachnoid block in elderly patients. Consequently, prophylactic low-dose infusion of ephedrine (0.4-0.5 mg/kg) could be a better vasopressor agent of choice than phenylephrine in maintaining hemodynamic stability in elderly patients aged 60 years and above for lower limb orthopedic surgeries under spinal anesthesia.

References

Tarkkila PJ, Kaukinen S: Complications during spinal anesthesia: a prospective study. Reg Anesth. 1991, 16:101-6.
Ferré F, Marty P, Bruneteau L, et al.: Prophylactic phenylephrine infusion for the prevention of hypotension after spinal anesthesia in the elderly: a randomized controlled clinical trial. J Clin Anesth. 2016, 35:99-106. 10.1016/j.jclinane.2016.07.020
Brull R, Macfarlane AJR, Chan VWS: Spinal, epidural, and caudal anaesthesia. Miller RD, Cohen NH, Erikson LI, Fleisher LA, Wiener JP, Young WL. Miller’s Anaesthesia. 8th ed. United States of America. Elsevier, 2014. 8:1684-720.
Tarkkila P, Isola J: A regression model for identifying patients at high risk of hypotension, bradycardia and nausea during spinal anesthesia. Acta Anaesthesiol Scand. 1992, 36:554-8. 10.1111/j.1399-6576.1992.tb03517.x
Hartmann B, Junger A, Klasen J, et al.: The incidence and risk factors for hypotension after spinal anesthesia induction: an analysis with automated data collection. Anesth Analg. 2002, 94(6):1521-1529. 10.1213/00000539-200206000-00027
Minville V, Fourcade O, Grousset D, et al.: Spinal anesthesia using single injection small-dose bupivacaine versus continuous catheter injection techniques for surgical repair of hip fracture in elderly patients. Anesth Analg. 2006, 102:1559-63. 10.1213/01.ane.0000218421.18723.cf
Žunić M, Krčevski Škvarč N, Kamenik M: The influence of the infusion of ephedrine and phenylephrine on the hemodynamic stability after subarachnoid anesthesia in senior adults – a controlled randomized trial. BMC Anesthesiol. 2019, 19:207. 10.1186/s12871-019-0878-4
Critchley LA: Hypotension, subarachnoid block and the elderly patient. Anaesthesia. 1996, 51:1139-43. 10.1111/j.1365-2044.1996.tb15051.x
Biricik E, Ünlügenç H: Vasopressors for the treatment and prophylaxis of spinal induced hypotension during caesarean section. Turk J Anaesthesiol Reanim. 2021, 49:3-10. 10.5152/TJAR.2020.70
Rivera R, Antognini JF: Perioperative drug therapy in elderly patients. Anesthesiology. 2009, 110:1176-81. 10.1097/ALN.0b013e3181a10207
Becker DE: Basic and clinical pharmacology of autonomic drugs. Anesth Prog. 2012, 59:159-68. 10.2344/0003-3006-59.4.159
Abbasivash R, Sane S, Golmohammadi M, Shokuhi S, Toosi FD: Comparing prophylactic effect of phenylephrine and ephedrine on hypotension during spinal anesthesia for hip fracture surgery. Adv Biomed Res. 2016, 5:167. 10.4103/2277-9175.190943
Mon W, Stewart A, Fernando R, et al.: Cardiac output changes with phenylephrine and ephedrine infusions during spinal anesthesia for cesarean section: a randomized, double-blind trial. J Clin Anesth. 2017, 37:43-8. 10.1016/j.jclinane.2016.11.001
Asokan A, Muthalu A, Ananthy V, et al.: Comparison of intravenous bolus doses of phenylephrine vs ephedrine along with crystalloid co-loading in the prevention of hypotension during spinal anesthesia for caesarean section. Indian J Clin Anaesth. 2021, 8(4):537-542. 10.18231/j.ijca.2021.116
Sinha G, Hemalatha S, Gurudatt C L: Effectiveness of intravenous boluses of phenylephrine, ephedrine and mephentermine as vasopressors for management of perioperative hypotension in elective lower segment caesarean section under spinal anaesthesia – a prospective comparative study. Indian J Clin Anaesth. 2020, 7(1):46-53. 10.18231/j.ijca.2020.009

Complex Management of a Migrating Inhaled Metallic Foreign Body in a Child

September 26, 2024 by Dr. Clemens Leave a Comment

Authors: Id El Haj N et al

Cureus 16(9): e70023.

Abstract

Foreign body (FB) inhalation in children is a common and potentially life-threatening occurrence encountered in pediatric emergency medicine. A wide range of clinical presentations including often delayed onset of symptoms make it challenging to identify and provide a timely diagnosis. This increases the risk of complications and leads to suboptimal outcomes. For instance, inhalation of sharp objects may lead to perforations and migrations to surrounding structures making it difficult to retrieve the FB as seen in this case. Additionally, the onset of symptoms can vary, making it difficult to diagnose based on a patient’s history alone. An unusual case of an inhaled sharp metallic object (dental bur) in a 13-year-old boy that migrated from the left lower thorax to the right perihilar and finally to the gastric lumen is presented a week after the incident. A 13-year-old boy presented to the emergency department with mild symptoms. He was stable with normal chest findings. Previous rigid bronchoscopy failed to localize and remove the FB and the thoracotomy. A post-operative X-ray was done, and the migration of the FB to the right middle lobe was revealed. A flexible bronchoscopy was then performed, again with no positive results. It was finally the abdominopelvic CT scan followed by the gastroduodenal esophagoscopy that allowed us to visualize and remove the FB from the gastric lumen.
In this case, we review the literature to emphasize the diagnostic challenges of FB inhalation in children, focusing on key diagnostic clues that assist clinicians in managing this condition.

Introduction

Foreign body (FB) inhalation in children is a common and potentially life-threatening occurrence encountered in pediatric emergency medicine. Children are at a heightened risk of inhaling foreign objects, leading to respiratory obstruction and subsequent complications.

The epidemiology of FB inhalation in children reveals a notable prevalence, with studies indicating a higher incidence among toddlers and preschool-aged children, typically between one and three years old [1]. According to Chen et al., the infant mortality rate from FBA has decreased significantly, despite FB inhalation remaining one of the main causes of infantile deaths [2].

Sharp FBs (e.g., bones, safety pins, and needles) can cause perforation and migrate to surrounding structures, causing further injuries.

Clinical presentation varies depending on the nature of the FB, its location within the respiratory tract, and the duration since inhalation. Saki et al. showed that common signs and symptoms include sudden onset of coughing, choking, wheezing, stridor, dyspnea, or respiratory distress [3]. However, in some cases, the presentation may be subtle, with nonspecific symptoms such as persistent cough, recurrent respiratory infections, or unexplained fever, making diagnosis challenging.

Managing a migrating FB inhalation in children presents significant challenges due to the difficulty in localizing the object, which can move unpredictably within the respiratory tract, complicating diagnosis. The ultimate challenge lies in pinpointing its exact location through imaging and endoscopy. Removal procedures are fraught with risks, including the potential for airway damage, obstruction, or accidental displacement of the FB into more sensitive areas. These complications can lead to severe respiratory distress, infections, or long-term pulmonary issues if not promptly and effectively addressed.

Case Presentation

A 13-year-old boy without any pertinent medical history initially presented to the emergency department a week after inhaling a metallic FB, presenting mild symptoms: recurrent cough and nausea. The incident occurred during a dental appointment when the dental bur fell and was accidentally inhaled by the patient.

He was initially taken to a local hospital in his hometown, where a chest X-ray revealed an FB in the left lower thorax with no evidence of air or fluid pleural effusion (Figure 1).

Figure 1: Chest X-ray showing a FB in the left base of the thorax (06/05/2024)

FB, foreign body

A gastroduodenal esophagoscopy was performed, but no FB was visualized or removed. A subsequent thoracic CT scan showed that the dental bur was in the inferior lung lobe (Figure 2).

Figure 2: Chest CT scan showing a FB in the left basal lung (10/05/2024)

FB, foreign body

One week later, the patient was referred to our hospital for further management. Laboratory investigation (Table 1) and rigid bronchoscopy were performed, but the procedure failed to visualize the FB. The patient was then admitted to the pediatric intensive care unit, intubated and ventilated due to complications during the bronchoscopy, where he experienced severe bronchospasm and alveolar hemorrhage.

	16/05/2024	19/09/2024
White cell count (per μL)	22020	14000
Neutrophil count (per μL)	18390	7300
Lymphocyte count (per μL)	1300	1250
Platelet count (per μL)	403000	380000
Hemoglobin (g/dL)	12.7	13.1
Hematocrit (%)	39.6	40
CRP (mg/L)	12.40	6.1
PCT (ng/mL)	1.90	0.2
Sodium (mEq/L)	140	139
Potassium (mEq/L)	3.5	3.4
Alkaline reserve (mEq/L)	22	22
Prothrombin ratio (%)	95.9	96
INR	1.02	1.03

Table 1: Laboratory investigation report (main assessments)

The patient was extubated the day after his admission. A second chest X-ray (Figure 3) showed the migration of the FB, which was still in the inferior left lobe; thoracic surgeons were involved in surgical removal. Initially, video-assisted thoracoscopic surgery (VATS) was planned, but when the FB could not be located, the procedure was converted intraoperatively to a thoracotomy. All segments were palpated, but the FB was not found.

Figure 3: Chest X-ray showing a right perihilar FB (16/05/2024)

FB, foreign body

A third chest X-ray was done and visualized a migration of the FB to the right middle lobe. A flexible bronchoscopy was performed for one hour following the X-ray, again with no positive result. Immediately afterward, an abdominopelvic CT scan (Figure 4) revealed that the FB had migrated to the gastric lumen. The gastroenterology team was then requested to perform a gastroduodenal esophagoscopy, which successfully removed the FB (Figure 5).

Figure 4: Abdominopelvic CT scan showing a FB in the gastric lumen

Figure 5: Removal of the metallic FB from the gastric lumen during the gastroduodenal esophagoscopy procedure

The child was discharged from the hospital the day after the removal.

Discussion

Foreign body inhalation represents a significant challenge in emergency pediatric care, with the potential for serious morbidity and mortality especially when rapid migration occurs [4].

In this case of a 13-year-old boy who inhaled a metallic dental bur, we will discuss the complexities involved in diagnosing and locating foreign bodies that migrate post-inhalation, as well as the therapeutic challenges encountered in its management. The shape and chemical nature of the FB are two important factors in evaluating the risk of migration [5]. Most inorganic foreign bodies, such as the dental drill in this case, do not result in any prominent symptoms [6].

Diagnostic challenges

The diagnosis of inhaled FBs can be particularly challenging. While chest radiography remains the initial diagnostic modality of choice, its sensitivity is limited, particularly for non-radiopaque objects or those that have migrated. The study by Kripa et al. stated that for the chest X-rays performed in all 98 patients, 54.1% of patients had normal chest X-rays, radiopaque FB was seen for 24% of the patients, atlectasis in 11%, and consolidation in 7% [7]. This is similar to the studies done by Eren et al. who also found that two-thirds of their patients had normal chest X-rays [8].

In this case, the initial chest X-ray identified the FB in the left lower lung lobe, yet subsequent procedures failed to visualize it. This highlights the need for a high index of suspicion and the use of advanced imaging modalities when initial diagnostic efforts are inconclusive. CT is recommended as it offers superior resolution and can help in accurately localizing FBs, especially when they migrate within the thoracic cavity or beyond. Studies indicate that CT has a higher diagnostic yield compared to standard radiography in cases of suspected FB aspiration.

Utilization of bronchoscopy

Bronchoscopy remains the gold standard for diagnosing and managing migrating foreign bodies. It allows direct visualization of the airways, precise localization of the FB, and immediate intervention if extraction is warranted. Early bronchoscopic examination is crucial in cases where clinical suspicion remains high despite inconclusive imaging results. However, the nature of some FB makes them migrate easily, which complicates the extraction by endoscopy and thereby leads to thoracotomy [9]. Failure of rigid bronchoscopy combined with flexible bronchoscopy can occur, which is the case here [9].

Complications of bronchoscopy

Bronchoscopy is the gold standard for both diagnosis and removal of inhaled FBs. However, it is not without risks, particularly in pediatric patients who are more susceptible to complications such as bronchospasm, hypoxemia, and airway trauma. Kaur et al. have reported hypoxia complication rate to be 10% of bronchoscopy’s complications [10]. In this case, the patient experienced a severe bronchospasm during the bronchoscopy procedure, necessitating intubation and mechanical ventilation in the intensive care unit. The presence of a skilled multidisciplinary team, including anesthesiologists and pediatric intensivists, is crucial to managing such complications effectively.

Multidisciplinary approach and surgical intervention

The management of this case necessitated the involvement of multiple specialties. Initial rigid bronchoscopy failed to visualize or retrieve the FB, leading to the involvement of thoracic surgeons. The decision to convert from video-assisted thoracoscopic surgery (VATS) to an open thoracotomy reflects the complexity and unpredictability of FB management. Although VATS is less invasive and generally preferred, it may not always be feasible, particularly when the FB is not readily visible or accessible. The conversion to open surgery, while more invasive, allows for thorough exploration and palpation of all thoracic segments, a critical step when other methods fail. To avoid unnecessary pulmonary resections, it is mandatory to confirm the precise location of an intrapulmonary FB; the aforementioned especially holds true in the case of inorganic and simple-shaped airway foreign bodies because of the possibility of an unexpected migration. The presumption that a bronchoscopically irremovable airway FB is firmly fixed in the bronchial tree and does not migrate intraoperatively is incorrect.

Migration of the foreign body

Although rare, migration of FBs has been documented in the literature [11]. The spontaneous movement of the FB underscores the dynamic nature of the pediatric respiratory and gastrointestinal systems. This phenomenon necessitates a comprehensive and adaptable diagnostic approach. The follow-up abdominopelvic CT was instrumental in identifying the new location of the FB, highlighting the importance of repeated and varied imaging studies in complex cases.

Endoscopic retrieval

Endoscopic retrieval of gastrointestinal FBs is well-documented as an effective and minimally invasive approach. The eventual successful removal of the FB via gastroduodenal esophageal fibroscopy aligns with best practices. Endoscopic techniques are preferred for their high success rates and lower risk profiles compared to surgical interventions. The literature supports the use of flexible endoscopy for FB retrieval in the gastrointestinal tract due to its ability to reach and remove objects with minimal patient discomfort and rapid recovery times [12].

Conclusions

This case underscores the complexity and multidisciplinary nature of managing inhaled foreign bodies in pediatric patients. It illustrates the major diagnostic challenge to precisely determine the localization of the FB due to its unpredictable migration (from the chest to the gastric lumen in this case). Therefore, just like in other cases and studies, the patient had to undergo several imaging and intervention techniques such as repeated bronchoscopy (rigid and flexible), thoracotomy, and gastroduodenal esophagoscopy to finally visualize and remove the FB. This leads us to question the indications at each intervention as well as the patient risk-benefit balance. The case reported here shows that in order to avoid unnecessary interventions, it is crucial to confirm the precise location of the FB and always consider possible migration in case of failed visualization of the FB.

References

1b] K. Dongol, Y. Neupane, H. Das Dutta, B.R. Gyawali, B. Kharel: Prevalence of foreign body aspiration in children in a tertiary care hospital. JNMA J. Nepal Med. Assoc. 59:2021.
Chen X., Zhang C: Foreign body aspiration in children: Focus on the impact of delayed treatment. Int. J. Pediatr. Otorhinolaryngol. 2017;96: 111-115. 10.1016/j.ijporl.2017.03.013. [PubMed] [CrossRef] [Google Scholar
Saki N., Nikakhlagh S., Rahim F., Abshirini H: Foreign body aspirations in Infancy: A 20-year experience 2009. Int. J. Med. Sci. 20096, 322-328. 10.7150/ijms.6.322. [PMC free article] [PubMed] [CrossRef] [Google Scholar
Hitter A., Hullo E., Durand C., Righini C.A: Diagnostic value of various investigations in children with suspected foreign body aspiration: Review. Eur. Ann. Otorhinolaryngol. Head Neck Dis. 2011;128: 248-252. 10.1016/j.anorl.2010.12.011. [PubMed] [CrossRef] [Google Scholar
G.P Conners: Pediatric Foreign Body Ingestion: Complications and Patient and Foreign Body Factors. Sci. 2022, 4:20.
Rafanan AL, Mehta AC: Adult airway foreign body removal. What’s new?. Clin Chest Med. 2001, 22:319-330. 10.1016/s0272-5231(05)70046-0
Dongol K, Neupane Y, Das Dutta H, Raj Gyawali B, Kharel B: Prevalence of Foreign Body Aspiration in Children in a Tertiary Care Hospital. 2021. 10.31729/jnma.5393
Eren S, Balci AE, Dikici B, Doblan M, Eren MN: Foreign body aspiration in children: experience of 1160 cases. Ann Trop Paediatr. 2003;23(1): 31-7. 10.1179/000349803125002959. [PubMed] [CrossRef] [Google Scholar
[The surgical extraction of foreign bodies after the inhalation of a scarf pin: two cases]. 2009, 65:293-6. 10.1016/j.pneumo.2009.02.004
Kaur K, Sonkhya N, Bapna AS: Foreign bodies in the tracheobronchial tree: A prospective study of fifty cases. Indian J Otolaryngol Head Neck Surg. 2002, 54:30-4. 10.1007/BF02911002
Foncannon F: Migrating foreign body. Am. J. Surg. 1942;55: 600-601. 10.1016/S0002-9610(42)90932-2. [CrossRef] [Google Scholar
Ferrari D, Aiolfi A, Bonitta G, et al.: Flexible versus rigid endoscopy in the management of esophageal foreign body impaction: systematic review and meta-analysis. World J Emerg Surg. 2018, 13:42. 10.1186/s13017-018-0203-4

Regular painkillers more effective than new migraine drugs: Study

September 26, 2024 by Dr. Clemens Leave a Comment

Author: Alexandra Murphy

Becker’s Hospital Review

A new study suggests that some recently marketed migraine medications may not be more effective than standard painkillers for treating acute migraine episodes.

The study analyzed 137 trials with 89,445 adults, testing 17 different migraine drugs. Researchers then compared how well these treatments relieved pain within two hours and sustained relief for up to 24 hours, according to the analysis published Sept. 18 in The BJM.

The results showed that traditional pain medications like ibuprofen and certain triptans (eletriptan, rizatriptan, sumatriptan and zolmitriptan) were more effective in providing pain relief within two hours and sustaining relief for up to 24 hours. By comparison, newer migraine medications like lasmiditan, rimegepant and ubrogepant were found to be less effective and associated with side effects like dizziness and nausea.

Researchers concluded that the more established triptans remain the best option for acute migraine treatment.

Uncover A Great CRNA and Anesthesiologist Opportunity in Lubbock TX

September 25, 2024 by Dr. Clemens Leave a Comment

We are seeking a dedicated anesthesia care team to join our new anesthesia care team contract at Lubbock Heart and Surgery Hospital in Lubbock TX.

Position Highlights:

Anesthesiologist call is 1:3
Competitive salary of $575,000 plus benefits.
8 weeks of vacation.
CRNA call is 1:6
Competitive salary of $280,000 plus benefits.
8 weeks of vacation.

Interested? Please contact me at 660-596-2224 or drrob@anesthesiaexperts.com if you or anyone you know would like to apply.

Note: Agencies, please do not contact us as we do not use your service

Discover The Best Anesthesiologist Opportunity in New Mexico

September 25, 2024 by Dr. Clemens Leave a Comment

We are seeking a dedicated anesthesiologist to join our all-anesthesiologist group. Our team will consist of 4 full-time providers and 1 for vacation relief, managing 3 operating rooms.

Position Highlights:

Zero call for 3 weeks, followed by 1 week of call without daytime work only call after 7 PM therefore you may not work the entire week.
Competitive salary of $500,000 plus benefits.
8 weeks of vacation.

This is the best job on GasWork #370670

Interested? Please contact me at 660-596-2224 or drrob@anesthesiaexperts.com if you or anyone you know would like to apply.

Note: Agencies, please do not contact us as we do not use your service

The Use of Point-of-Care Ultrasound (POCUS) in Anesthesiology

September 25, 2024 by Dr. Clemens Leave a Comment

Authors: Gohad R et al

Cureus 16(9): e70039.

Abstract

Point-of-care ultrasound (POCUS) has become an essential tool in modern anesthesiology, offering real-time imaging that aids in diagnosis, treatment, and procedural guidance. Its applications have expanded significantly, from routine assessments to complex perioperative management, enhancing patient care across various domains. This study aimed to review and summarize the current literature on the applications of POCUS in anesthesiology, focusing on its utility in airway management, cardiac assessment, lung ultrasound (LUS), and abdominopelvic evaluations. Additionally, it discusses the challenges and strategies for overcoming barriers to its widespread adoption. A narrative literature review was conducted, encompassing studies on using POCUS in anesthesiology. Key databases were searched for relevant articles (“Point-of-care ultrasound,” “Focused cardiac ultrasound,” “Lung ultrasound“), and studies were selected based on their relevance to the main topics of interest: airway management, cardiac ultrasound, LUS, and abdominopelvic and gastric ultrasound. Both observational studies and randomized controlled trials were included. POCUS improves the safety and accuracy of regional anesthesia and airway procedures, enhancing patient outcomes by providing real-time visualization. Focused cardiac ultrasound is valuable in preoperative, intraoperative, and postoperative care, allowing for tailored anesthesia plans and timely interventions based on cardiac function. The US is an effective diagnostic tool for assessing pulmonary conditions, with specific signs and artifacts aiding in identifying pathologies such as pneumothorax, pleural effusions, and pulmonary congestion. Despite its benefits, POCUS faces barriers such as limited access to training, the need for standardized protocols, and the high equipment cost, especially in low-resource settings. While its integration into clinical practice continues to grow, overcoming challenges related to training, standardization, and equipment access is essential to realize its full potential. Continued efforts in education and research are needed to support the widespread adoption of POCUS in anesthesiology.

Introduction & Background

For more than 50 years, doctors have used ultrasonography, a comparatively safe, portable, affordable, and easily accessible imaging method, for diagnostics [1]. Point-of-care ultrasound (POCUS) is the concept of performing imaging studies immediately at the patient’s bedside, which helps in the assessment, management, and intervention that may be required. POCUS should be used in general when it can be used to accomplish particular objectives in a short time and when the patients’ outcome improves correspondingly. The POCUS is just one of the many assessment techniques employed in routine patient examinations, and it has also experienced a remarkable transformation within the past few years. These ultrasound devices have become smaller, cheaper, and capable of achieving higher image quality, which has increased the use of such equipment during physicians’ perioperative patient evaluations [2]. Bedside ultrasound is currently the standard of care in anesthesiology for nerve blocks and vascular access. However, there has been an increasing interest in how to incorporate whole-body POCUS into the daily practice of contemporary anesthesiologists. This includes but is not limited to using it for procedural purposes and supplementing traditional assessment and management of the patient’s care [3].

High-frequency sound waves above human hearing, or more than 20,000 Hz (20 kHz), are referred to as ultrasounds. Diagnostic ultrasound operates at millions of hertz, with lower frequency probes typically operating between 2 and 5 MHz and higher frequency probes operating between 6 and 13 MHz [1]. The three most popular varieties are phased array, linear, and curvilinear probes. The frequency of each probe varies, affecting image resolution but having an inverse relationship with probe penetration depth. Although the high frequency of linear probes enables superior resolution of surface structures, the low penetration prevents the visualization of deeper structures. Thus, linear probes work best for superficial structures like vascular access or a more thorough assessment of the lung pleura.

On the other hand, curvilinear and phased array probes operate at lower frequencies. Still, they penetrate deeply, making it possible to see deeper structures, like those for the abdomen and heart examinations. The probe on the phased array has a smaller footprint than the curved probe, making it simpler to get sufficient views between the ribs when performing cardiac or pulmonary examinations [4]. Additionally, a growing number of recent clinical research studies have shown that, in comparison to other initial bedside assessment tools, ultrasound is more cost-effective and has better diagnostic sensitivity and specificity [2]. POCUS is a more effective initial diagnostic tool for the cardiovascular assessment of non-ST segment elevation chest pain than the electrocardiogram (EKG). POCUS offers immediate visualization of the heart’s anatomy and function, allowing clinicians to identify wall motion abnormalities, estimate ejection fraction, and assess for pericardial effusion. This capability not only aids in the diagnosis of acute coronary syndromes but also facilitates the detection of other potential causes of chest pain, such as pulmonary embolism or aortic dissection [5]. Furthermore, POCUS is more accurate in detecting main stem bronchial intubation than chest auscultation [6]. POCUS is more effective, faster, and more accurate for detecting pneumothorax, pleural effusions, and consolidation in critical care settings than chest auscultation or chest radiograph [7].

Review

Applications of POCUS in anesthesia

Airway Management

A review of the literature was conducted by Hurtado et al. to assess the function of POCUS in regional anesthesia for airway management. According to the author, POCUS is used to evaluate the upper airway, which is important for efficient airway care. This entails recognizing anatomical landmarks and making sure that instruments are properly visible. It also highlights the importance of visualizing the needle placement during airway blocks in real time. This method improves patient outcomes by increasing the accuracy of regional anesthetic techniques. Specific methods for performing translaryngeal blocks are described, such as using a linear probe with a focus at 1 cm and a depth setting of 3-4 cm. Conclusions drawn from the paper emphasize the significance of POCUS in improving the safety and efficacy of regional anesthesia and airway management, advocating for individualized, less-invasive techniques while highlighting the necessity of proper training and anatomical knowledge [8].

Arumugam et al. reviewed the literature to discuss the application of POCUS in regional anesthesia and its broader implications in perioperative care. The paper emphasizes the analysis of POCUS applications specifically related to airway management, assessment of gastric contents, and trauma evaluation. The authors found that integrating POCUS into regional anesthesia practice is a significant advancement that can improve patient care. POCUS can help avoid delays or cancellations of surgeries by facilitating immediate and accurate assessments of airway anatomy. With real-time imaging, anesthesiologists can identify potential challenges related to airway structure, such as anatomical variations or obstructions, before the induction of anesthesia. This proactive assessment allows for early planning of alternative strategies, such as specialized intubation techniques, which can be crucial in managing difficult airways. This capability can lead to improved operational efficiency and better patient experiences. The paper concludes with a call for more anesthesiologists to embrace POCUS in their practice [9].

Wu and Li did an observational study that advocates for using POCUS as a fast, convenient, and noninvasive alternative to traditional imaging methods such as computed tomography (CT), magnetic resonance imaging, and conventional ultrasound. It enables immediate bedside assessments, reducing wait times and minimizing patient discomfort compared to these more invasive or time-consuming approaches. POCUS can effectively visualize the placement of bronchial blockers (BBs) by detecting ultrasonic signs indicative of one-lung ventilation. The study concludes that POCUS is a promising and effective method for confirming the placement of BBs in pediatric patients. It highlights that POCUS can provide real-time visualization of lung isolation, which is crucial for ensuring the safety and efficacy of one-lung ventilation during thoracoscopic surgeries [10].

POCUS in anesthesia enhances clinical decision-making, particularly in endotracheal tube (ETT) placement. Anesthesiologists utilize POCUS to assess ETT positioning airway size and to predict the appropriate diameter of ETTs, ensuring accurate placement and reducing the risk of complications [11,12]. POCUS can differentiate between tracheal, esophageal, and endobronchial intubation, aiding in preventing airway-related issues. Additionally, ultrasound of the upper airway can accurately locate the cricothyroid membrane for emergency airway access and identify tracheal rings for ultrasound-guided tracheostomy, further improving patient safety and procedural success. Using POCUS in ETT placement showcases the versatility and effectiveness of ultrasound technology in optimizing anesthesia practices and patient outcomes [13].

Cardiac (Focused Cardiac Ultrasound)

Pallesen et al. did a randomized controlled trial to investigate the effects of preoperative focused cardiac ultrasound (FOCUS) in high-risk patients undergoing noncardiac surgery. The study focused on high-risk patients scheduled for noncardiac surgery. Participants in the intervention group underwent preoperative FOCUS. This technique provides valuable information about the cardiac status of patients and can reveal previously unknown cardiac issues. The ultrasound findings were used to tailor the anesthesia plan for each patient, potentially improving outcomes. The primary outcomes measured were the proportion of patients admitted to the hospital for more than 10 days or who died within 30 days after surgery. The study hypothesized that preoperative FOCUS would lead to a decrease in the number of patients who were either admitted to the hospital for more than 10 days or who died within 30 days after surgery. By utilizing FOCUS, the treatment and anesthesia plans could be customized based on the cardiac status of each patient [14].

Numerous studies have demonstrated the effectiveness and practicality of integrating FOCUS into preoperative, intraoperative, and postoperative care for elective and emergency cases. This technique offers critical insights that can substantially impact patient management [15]. It enables rapid assessment of biventricular function, detection of gross valvular abnormalities, identification of pericardial effusions, recognition of wall motion abnormalities indicative of ischemia, and evaluation of a patient’s volume status through measures like inferior vena cava collapsibility and ventricular size. There are multiple reports of bedside cardiac ultrasound proving invaluable for prompt diagnoses and adjustments in intraoperative management. For example, it has been used to detect left ventricular inferior wall akinesis in a patient who experienced sudden, severe hypotension after a procedure, even in the absence of EKG changes that would typically indicate acute ischemia [16].

Sheth et al. reviewed the study that evaluated the impact of FOCUS on management decisions. It was noted that in 94% of cases, there was a change in management based on the findings from FOCUS. This assessment was crucial in determining how FOCUS influenced clinical outcomes. The study included the use of FOCUS both intraoperatively and postoperatively. This allowed for the real-time evaluation of patients’ conditions and facilitated timely interventions based on the ultrasound findings. The study concludes that FOCUS is an excellent clinical adjunct during the perioperative period. It enhances the anesthesiologist’s ability to make informed management decisions, particularly for patients undergoing noncardiac surgery who may be at higher risk due to underlying cardiovascular conditions. A critical finding is that FOCUS led to a change in management in 94% of the cases examined. This indicates that using FOCUS significantly influences clinical pathways and can improve patient outcomes by allowing for timely interventions based on ultrasound findings [17]. A phased array probe is well suited for this type of examination due to its lower frequency and deeper penetration, which allow for effective visualization of cardiac structures while maintaining a small “footprint” for accessing intercostal windows. The heart’s oblique position within the chest, surrounded by ribs and lungs that ultrasound waves cannot penetrate, can make obtaining clear images challenging. While patients can be examined in the supine position, the left lateral decubitus position is preferable for parasternal and apical views, as it brings the heart’s structures closer to the chest wall for better imaging [18].

Lung Ultrasound

Basumatary et al. did an observational study on 70 patients. Only those undergoing elective extrathoracic surgeries lasting over three hours under general anesthesia were selected for the study. A preoperative, intraoperative, and postoperative lung ultrasound (LUS) was performed on all patients to establish a baseline for lung conditions before surgery. The study monitored the volume of intraoperative fluid administered to each patient and the appearance of three or more “B” lines on the ultrasound, which was used as the criterion for diagnosing lung congestion. The findings emphasize the need for careful fluid management during surgeries, particularly those of longer duration, to minimize the risk of postoperative pulmonary congestion. The study advocates for using LUS as a noninvasive method for early detection of pulmonary congestion, which can help guide postoperative care [19].

Bedside LUS for evaluating pulmonary diseases is not a new technique, having been employed in critical care since the early 1990s [20]. It later gained traction in emergency medicine and, more recently, in perioperative settings by anesthesiologists. LUS is a valuable, efficient, and precise goal-directed diagnostic tool for real-time assessment of respiratory symptoms. Due to the high ultrasound reflectivity at the air-tissue interface, air-filled lungs cannot be directly visualized, making it impossible to assess normal pulmonary parenchyma with ultrasound. Interestingly, this limitation is diagnostically advantageous, as LUS depends on recognizing specific signs, artifacts, and patterns linked to certain pathologies, which are distinct and easily identifiable. A high-frequency linear probe, which can visualize structures up to 4 cm deep, is ideal for examining the superficial pleural line and lung parenchyma. It provides the best resolution for assessing abnormal pleural surfaces, making it the preferred probe for evaluating conditions like pneumothorax or edema. Lower frequency probes are better suited for examining deeper, subpleural artifacts, such as effusions [21].

Abdominopelvic and Gastric Ultrasound

Focused assessment with sonography for trauma (FAST) plays a crucial role in abdominopelvic anesthesia by aiding in the rapid and accurate detection of intra-abdominal injuries, especially in trauma patients. Studies have shown that FAST has reasonable sensitivity, specificity, and accuracy in detecting free fluid in traumatic renal injuries [22]. Additionally, FAST has been widely accepted and integrated into trauma management protocols, demonstrating high specificity and negative likelihood ratio in pediatric patients with blunt torso trauma [23]. Its use allows for the timely identification of intra-abdominal pathology, potentially reducing the need for more time-consuming imaging modalities like CT. Understanding the diagnostic accuracy of FAST, including its strengths and limitations, is essential for informed decision-making and optimal patient management in abdominopelvic anesthesia [24].

The use of POCUS in the FAST procedure has been effectively incorporated into emergency medicine, critical care, and surgery. Rabbani et al. did a cross-sectional study to evaluate the diagnostic accuracy of FAST in detecting renal injuries compared to CT. The findings indicate that FAST has a reasonable sensitivity of 85% for detecting renal injuries. This suggests that FAST is effective in identifying a significant majority of cases where renal injuries are present, making it a useful tool in trauma settings. The overall diagnostic accuracy of FAST was reported to be 83.61%. This level of accuracy indicates that FAST can be a valuable initial assessment tool in trauma patients, particularly for detecting free fluid associated with renal injuries. The study concludes that FAST can be a beneficial first-line imaging modality in trauma cases, especially in emergency settings where rapid assessment is crucial [22].

For anesthesiologists, the principles and views used in the FAST exam can be similarly applied in the postoperative period for patients who experience decompensation after abdominal surgeries. Whether in the operating room, recovery unit, or intensive care unit, elements of the FAST exam can assist providers in quickly determining if a patient’s worsening hemodynamic instability is due to intra-abdominal hemorrhage or ruptured viscera. Additionally, ultrasound can swiftly identify potentially life-threatening intra-abdominal fluid and guide its drainage when necessary. To achieve sufficient tissue penetration, a low-frequency probe such as the phased array or curvilinear probe is utilized [25].

Gastric POCUS plays a crucial role in anesthesiology by assessing gastric contents, essential for reducing the risk of pulmonary aspiration during general anesthesia. Studies have shown that gastric POCUS can help identify high-risk situations for aspiration, guide anesthetic management, and optimize patient safety by determining gastric emptying and volume [26,27]. This technique is particularly valuable when patients’ fasting status is uncertain or delayed gastric emptying is suspected. Additionally, gastric POCUS is reliable and accurate in various clinical settings, including pediatric anesthesia, where it can assist in confirming nasogastric tube placement and diagnosing conditions like hypertrophic pyloric stenosis. Integrating gastric POCUS into anesthesiology practice through proper training and equipment can enhance patient care and outcomes [28].

Maseri et al. did a cross-sectional survey to gather data on POCUS’s clinical recognition and use among anesthesiologists in Belgium. Only 20.8% of the surveyed anesthesiologists identified the risk of a full stomach based on the patient’s medical history. This indicates a significant gap in recognizing high-risk situations for gastric aspiration among practitioners. A mere 13.08% of respondents reported having received training in gastric POCUS. This highlights a critical need for enhanced educational programs to improve the knowledge and skills of anesthesiologists in this area. The survey revealed that 80.17% of participants had access to adequate ultrasound equipment. This availability is crucial for effectively implementing gastric POCUS in clinical settings. The findings underscore the importance of appropriate training and equipment to ensure gastric POCUS’s safe and effective use in anesthesia practice. The study calls for additional efforts to enhance training and encourage the integration of gastric POCUS into daily clinical routines [26].

Disadvantages

POCUS in anesthesiology, while highly beneficial, does come with certain disadvantages. Challenges in low-resource settings include constrained healthcare budgets, initial equipment costs, and maintenance barriers [29]. Additionally, the vast array of applications and possibilities of POCUS can be overwhelming for novices, leading to difficulties in training and gaining proficiency. The need for ongoing quality control, standardization, and training in POCUS remains a significant hurdle, especially in ensuring minimum standards in residency programs. Despite its advantages in providing quick diagnostic data and enhancing patient outcomes, the complexity and breadth of POCUS applications require continuous education and training to maximize its potential while overcoming the associated challenges in anesthesiology [30].

Overcoming challenges

Overcoming training challenges in POCUS for anesthesiology involves standardizing training, defining credentialing/privileging protocols, and establishing billing guidelines. Anesthesiologists are integrating diagnostic POCUS into their practice to enhance patient care, necessitating a minimum level of training for competence and addressing variability in training across specialties [31]. To promote POCUS competency, anesthesiology departments should incorporate POCUS into curricula, offer training programs, and support ongoing professional development activities at a national level. The evolution of POCUS technology, its portability, and the potential for automated image analysis through artificial intelligence present opportunities to streamline training and enhance diagnostic accuracy in anesthesiology practice. By overcoming challenges through standardized training, credentialing, and ongoing education, anesthesiologists can successfully incorporate POCUS into routine practice, improving patient outcomes and diagnostic capabilities at the point of care [32]. Table 1 includes a summary of a few studies included in the study.

Study	Study type	Study description	Conclusion
Hurtado et al. [8]	Literature review	The chapter synthesizes existing knowledge about POCUS in the context of regional anesthesia and airway management	Conclusions drawn from the paper emphasize the significance of POCUS in improving the safety and efficacy of regional anesthesia and airway management, advocating for individualized, less-invasive techniques while highlighting the necessity of proper training and anatomical knowledge
Arumugam et al. [9]	Literature review	The study involves an analysis of specific applications of POCUS, a discussion of its benefits and limitations, an emphasis on skill development, and a call for increased adoption among anesthesiologists. These methods collectively aim to enhance the understanding and application of POCUS in regional anesthesia and perioperative care	POCUS in regional anesthesia, highlighting its benefits in patient care, the necessity for skill development, and the potential for improved surgical efficiency. The authors encourage anesthesiologists to adopt these techniques to enhance their practice and patient outcomes
Wu and Li [10]	Observational study	The study highlights the transition from traditional methods like fiberoptic bronchoscopy to more innovative approaches like POCUS for the effective placement of bronchial blockers in children, aiming to enhance safety and efficiency in anesthetic airway management during thoracic surgeries	The study concludes that POCUS is a valuable tool for the placement of bronchial blockers in children, offering significant advantages over traditional methods and supporting its potential for broader clinical application in surgical settings
Pallesen et al. [14]	Randomized controlled trial	The study utilized a randomized controlled trial design, focused on high-risk surgical patients, implemented preoperative cardiac ultrasound as an intervention, and measured significant postoperative outcomes to evaluate the effectiveness of the intervention. This structured approach aims to provide robust evidence regarding the benefits of preoperative cardiac assessment in improving surgical outcomes	The study focused on preoperative-focused cardiac ultrasound, which may play a crucial role in improving outcomes for high-risk surgical patients by enabling tailored anesthesia and reducing the incidence of adverse postoperative events. The study highlights the need for further research to validate these findings and integrate FOCUS into standard preoperative assessments
Sheth et al. [17]	Review article	The study collected clinical and demographic information from the database. This included details such as age, gender, and the American Society of Anesthesiologists classification, which helped in understanding the patient population undergoing noncardiac surgery. The researchers identified the specific indications for performing FOCUS in patients	The paper underscores the importance of FOCUS as a transformative tool in perioperative medicine, enhancing diagnostic capabilities and management strategies for patients undergoing noncardiac surgery
Basumatary et al. [19]	Observational study	Seventy participants were included in the study. The study employed a prospective, observational design to investigate the incidence of postoperative pulmonary congestion diagnosed by lung ultrasound in patients undergoing surgeries under general anesthesia	Conclusions underscore the importance of monitoring fluid administration and surgical duration to improve patient outcomes in the postoperative setting
Rabbani et al. [22]	Cross-sectional study	The study included 139 patients, and both FAST and CT scans were performed on them. FAST is a rapid ultrasound examination used in trauma settings to detect free fluid, whereas CT is considered the gold standard for diagnosing renal injuries	The study highlights the potential of FAST as an effective initial diagnostic tool for renal injuries in trauma patients while also recognizing its limitations that warrant further investigation through more definitive imaging methods
Maseri et al. [26]	Cross-sectional survey	Methods used in this study were designed to effectively assess the knowledge, recognition, and utilization of gastric POCUS among anesthesiologists, highlighting areas for improvement in training and practice	The survey highlights critical areas for improvement in the recognition and utilization of gastric POCUS among anesthesiologists in Belgium, emphasizing the need for better training, education, and integration into clinical practice

Table 1: A summary of few articles included in the study

POCUS: point-of-care ultrasound; FOCUS: focused cardiac ultrasound; FAST: focused assessment with sonography for trauma; CT: computed tomography

Discussion

The incorporation of POCUS in anesthesiology has led to significant advancements in clinical practice, with various studies highlighting its effectiveness across multiple domains, including airway management, cardiac assessment, LUS, and abdominopelvic evaluations. While the benefits are clear, comparing different studies reveals both the potential and the challenges associated with the widespread use of POCUS. In airway management, studies by Hurtado et al. and Arumugam et al. emphasize the value of POCUS in enhancing the precision and safety of regional anesthesia techniques. Hurtado et al. underscore the importance of real-time visualization in improving needle placement accuracy during airway blocks, which directly translates to better patient outcomes. Similarly, Arumugam et al. highlight POCUS’s broader implications in perioperative care, particularly its role in reducing surgery delays and improving operational efficiency. However, these studies also highlight the need for rigorous training to ensure that anesthesiologists can fully leverage POCUS’s capabilities, as the technique’s complexity may pose a barrier to novices [8,9].

In the realm of cardiac assessment, the studies by Pallesen et al. and Sheth et al. illustrate the profound impact of FOCUS on patient management, particularly in high-risk surgical patients. Pallesen et al. demonstrate that preoperative FOCUS can identify previously undetected cardiac issues, allowing for tailored anesthesia plans to improve outcomes. Sheth et al. further reinforce this by showing that FOCUS leads to management changes in a significant proportion of cases, enhancing intraoperative and postoperative decision-making. These findings collectively highlight the transformative potential of FOCUS in anesthesiology. Yet, they also underscore the necessity for proper training and the challenges of obtaining high-quality cardiac images in certain patient populations [14,17].

LUS, as examined in studies by Basumatary et al. and others, has proven to be a valuable tool for assessing pulmonary conditions, particularly in the perioperative setting. Basumatary et al. emphasize the role of LUS in monitoring intraoperative fluid management, identifying early signs of pulmonary congestion, and guiding postoperative care. The ability to detect specific lung pathologies through ultrasound artifacts further supports LUS’s utility in critical care and emergency medicine. However, relying on artifact recognition rather than direct visualization presents a diagnostic challenge that requires a deep understanding of ultrasound physics and pathology, again highlighting the importance of specialized training [19].

The use of POCUS in abdominopelvic evaluations, particularly through the FAST, has become integral to trauma management, as noted in studies by Rabbani et al. and others. FAST’s ability to rapidly detect intra-abdominal injuries and guide immediate interventions has been well-documented, making it a cornerstone in trauma care. The application of FAST principles in the perioperative setting, as discussed in various studies, further extends its utility to anesthesiology, where it can help manage patients with postoperative complications. However, the variability in diagnostic accuracy, as noted in the literature, underscores the need for careful interpretation of ultrasound findings and the limitations of FAST in certain clinical scenarios [22].

Conclusions

The integration of POCUS into anesthesiology has marked a significant shift in the way anesthesiologists approach patient care. POCUS has proven a versatile and powerful tool, from enhancing the precision of airway management and guiding cardiac assessments to improving lung evaluations and abdominopelvic trauma detection. The studies reviewed demonstrate that POCUS augments traditional techniques and provides real-time, noninvasive insights that can lead to more informed and timely clinical decisions. However, the effectiveness of POCUS is closely tied to the practitioner’s expertise. The benefits observed in various studies underscore the importance of comprehensive training and continuous education to ensure that anesthesiologists can fully leverage the technology’s potential. Moreover, the challenges associated with image acquisition and interpretation, particularly in complex clinical scenarios, highlight the need for ongoing research and the development of standardized protocols. While POCUS has already profoundly impacted anesthesiology, its future success will depend on addressing the current training, standardization, and quality control challenges. By continuing to refine these aspects, POCUS can be further integrated into anesthetic practice, ultimately leading to better patient outcomes and more efficient perioperative care.

References

Moore CL, Copel JA: Point-of-care ultrasonography. N Engl J Med. 2011, 364:749-57. 10.1056/NEJMra0909487
Kendall JL, Hoffenberg SR, Smith RS: History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Crit Care Med. 2007, 35:S126-30. 10.1097/01.CCM.0000260623.38982.83
Mahmood F, Matyal R, Skubas N, et al.: Perioperative ultrasound training in anesthesiology: a call to action. Anesth Analg. 2016, 122:1794-804. 10.1213/ANE.0000000000001134
Ihnatsenka B, Boezaart AP: Ultrasound: basic understanding and learning the language. Int J Shoulder Surg. 2010, 4:55-62.
Muscholl MW, Oswald M, Mayer C, von Scheidt W: Prognostic value of 2D echocardiography in patients presenting with acute chest pain and non-diagnostic ECG for ST-elevation myocardial infarction. Int J Cardiol. 2002, 84:217-25. 10.1016/s0167-5273(02)00144-4
Ramsingh D, Frank E, Haughton R, et al.: Auscultation versus point-of-care ultrasound to determine endotracheal versus bronchial intubation: a diagnostic accuracy study. Anesthesiology. 2016, 124:1012-20. 10.1097/ALN.0000000000001073
Xirouchaki N, Magkanas E, Vaporidi K, et al.: Lung ultrasound in critically ill patients: comparison with bedside chest radiography. Intensive Care Med. 2011, 37:1488-93. 10.1007/s00134-011-2317-y
Hurtado EDM, de Luis Cabezón N, Vaquero MÁF, Merchante MS: PoCUS and regional anesthesia for airway management . Advances in Regional Anesthesia – Future Directions in the Use of Regional Anesthesia. IntechOpen, United Kingdom; 2024. 10.5772/intechopen.1003842
Arumugam S, Kolli S, Brakoniecki K, et al.: Point-of-care ultrasound (POCUS) for the regional anesthesiologist. Curr Anesthesiol Rep. 2024, 14:231-48. 10.1007/s40140-024-00622-3
Wu J, Li Z: Point-of-care ultrasound (POCUS): a new promising approach for the position of bronchial blockers in children. J Clin Ultrasound. 2022, 50:1399-400. 10.1002/jcu.23297
Makris A, Tileli M, Moka E: Sp41 indicators that pocus is here to stay for anaesthesiologists too!. Region Anes Pain Med. 2022, 47:49-50.
Chelikam N, Vyas A, Desai R, et al.: Past and present of point-of-care ultrasound (PoCUS): a narrative review. Cureus. 2023, 15:e50155. 10.7759/cureus.50155
You-Ten KE, Siddiqui N, Teoh WH, Kristensen MS: Point-of-care ultrasound (POCUS) of the upper airway. Can J Anaesth. 2018, 65:473-84. 10.1007/s12630-018-1064-8
Pallesen J, Bhavsar R, Fjølner J, et al.: The effects of preoperative focused cardiac ultrasound in high-risk patients: a randomised controlled trial (PREOPFOCUS). Acta Anaesthesiol Scand. 2022, 66:1174-84. 10.1111/aas.14134
Augoustides JG, Hosalkar HH, Savino JS: Utility of transthoracic echocardiography in diagnosis and treatment of cardiogenic shock during noncardiac surgery. J Clin Anesth. 2005, 17:488-9. 10.1016/j.jclinane.2005.04.001
Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ: Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013, 26:567-81. 10.1016/j.echo.2013.04.001
Perioperative focused cardiac ultrasound: a brief report. (2024). Accessed: August 11, 2024: http://medcraveonline.com/JACCOA/perioperative-focused-cardiac-ultrasound-a-brief-report.html.
Naji A, Chappidi M, Ahmed A, Monga A, Sanders J: Perioperative point-of-care ultrasound use by anesthesiologists. Cureus. 2021, 13:e15217. 10.7759/cureus.15217
Basumatary K, Dey S, Neema PK, Mujahid OM, Arora P, Kalbande J: Incidence of postoperative pulmonary congestion as diagnosed by lung ultrasound in surgeries performed under general anaesthesia: a prospective, observational study. Indian J Anaesth. 2023, 67:628-32. 10.4103/ija.ija_598_22
Lichtenstein DA, Mezière GA: Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008, 134:117-25. 10.1378/chest.07-2800
Gargani L, Volpicelli G: How I do it: lung ultrasound. Cardiovasc Ultrasound. 2014, 12:25. 10.1186/1476-7120-12-25
Rabbani N, Anjum H, Iftikhar S: Comparative analysis of focused assessment with sonography for trauma (fast) and computed tomography (CT) for renal injury detection in trauma patients. J Gandhara Med Dent Sci. 2024, 11:20-9. 10.37762/jgmds.11-2.531
Inci O, Altuncı YA, Can O, Akarca FK, Ersel M: The efficiency of focused assessment with sonography for trauma in pediatric patients with blunt torso trauma. J Emerg Trauma Shock. 2024, 17:8-13. 10.4103/jets.jets_137_22
Sabry AA, Fathy HA, Mostafa KS, Mohamed AMB: Diagnostic accuracy of extended focused assessment sonography in penetrating abdominal trauma. Alexmed Eposters. 2024, 6:37-8. 10.21608/alexpo.2024.272852.1794
Sharma A, Bhattarai P, Sharma A: eFAST for the diagnosis of a perioperative complication during percutaneous nephrolithotomy. Crit Ultrasound J. 2018, 10:7. 10.1186/s13089-018-0088-1
Maseri A, Delhez Q, Dincq AS, Lacrosse D: Clinical recognition of a potentially full stomach and use of point-of-care gastric ultrasound (POCUS) by anesthesiologists: a Belgian survey. Res Square. 2024, 3:1-8. 10.21203/rs.3.rs-3721487/v1
Putte PVD: Sp67 pocus gastric ultrasound. Reg Anesth Pain Med. 2022, 47:78. 10.1136/rapm-2022-ESRA.73
Valla FV, Tume LN, Jotterand Chaparro C, et al.: Gastric point-of-care ultrasound in acutely and critically ill children (POCUS-ped): a scoping review. Front Pediatr. 2022, 10:921863. 10.3389/fped.2022.921863
Zewdie A: POCUS as an adjunct to clinical examination and management in resource-limited emergency and critical care setting. Pan Afr J Emerg Med Crit Care. 2023, 1:1-8. 10.58904/2023/68
Coppens S, Hoogma DF, Dreelinck R, Loon PV: SP18 pocus: pick the lit. Well and less well studies from the scene. Reg Anesth Pain Med. 2022, 47:14-5. 10.1136/rapm-2022-ESRA.19
Bronshteyn YS, Blitz J, Hashmi N, Krishnan S: Logistics of perioperative diagnostic point-of-care ultrasound: nomenclature, scope of practice, training, credentialing/privileging, and billing. Int Anesthesiol Clin. 2022, 60:1-7. 10.1097/AIA.0000000000000369
McCormick TJ, Miller EC, Chen R, Naik VN: Acquiring and maintaining point-of-care ultrasound (POCUS) competence for anesthesiologists. Can J Anaesth. 2018, 65:427-36. 10.1007/s12630-018-1049-7

Epidural Analgesia in a Parturient for Labor Analgesia After Surgical Correction of Spina Bifida

September 25, 2024 by Dr. Clemens Leave a Comment

Authors: Washburn N Rmet al

Cureus 16(9): e69676.

Abstract

This case report details the successful management of labor pain using epidural analgesia in a 22-year-old primigravid patient with a history of spina bifida and extensive surgical repair. Spina bifida, a congenital neural tube defect, presents unique challenges for neuraxial anesthesia due to altered spinal anatomy and potential neurological deficits. Despite these complexities, effective pain relief was achieved through careful patient counseling, comprehensive pre-procedural planning, and meticulous technique. Upon admission for labor induction due to preeclampsia, a physical examination revealed significant lumbar scarring with obscure anatomical landmarks. Despite these challenges, informed consent was obtained, and an epidural catheter was successfully placed using palpable bony prominences above the presumed T12-L1 interspace. A standard midline approach with saline loss of resistance technique was employed, epidural space was confirmed at a depth of 5 cm, and a catheter was placed. Continuous patient-controlled epidural analgesia (PCEA) comprising fentanyl and ropivacaine provided consistent pain relief throughout a 17-hour labor period, maintaining a dermatome level of T10. Post-delivery, neurosurgical evaluation confirmed successful catheter removal without complications, and the patient exhibited normal neurological function. This case underscores the importance of individualized pain management strategies in patients with spina bifida, necessitating thorough risk-benefit assessment, detailed patient education, and interdisciplinary collaboration for optimal outcomes. Despite the inherent challenges, epidural analgesia can be a viable option with careful planning and execution, contributing to improved maternal comfort and satisfaction during labor and delivery for patients with a history of spina bifida.

Introduction

This case report discusses the successful management of labor pain in a patient with a history of extensive surgical repair of spina bifida using epidural analgesia. Spina bifida is a congenital neural tube defect that can lead to various neurological and musculoskeletal complications. Effective neuraxial analgesia in such patients can be challenging due to altered anatomical and physiological considerations. In these circumstances, it is common that the spinous process of multiple vertebrae, which are classic landmarks for the guidance of placement of an epidural catheter, is significantly altered or absent. Even if these landmarks are patent, the underlying epidural space may be completely obliterated. This case highlights the importance of including the patient in pain management planning, taking a thorough patient history, and weighing the risks and benefits of treatment options to achieve optimal outcomes.

Spina bifida is characterized by congenital incomplete closure of the neural tube during embryonic development. This process can result in a wide range of abnormalities, including neurological and orthopedic problems such as motor deficits, musculoskeletal defects, and sensory disturbances. Neuraxial techniques for the management of labor pain in these patients pose a particular challenge due to a multitude of possible complicating factors, including altered internal spinal anatomy, missing anatomic landmarks, pre-existing neurologic deficits, and post-surgical changes, amongst others. Epidural analgesia is a well-established technique for providing adequate relief of typical labor pains. When patients with a prior diagnosis of spina bifida are identified, anesthesiologists must carefully assess whether this modality is appropriate or feasible and have a frank and truthful discussion with the parturient. Risks associated with this technique, including inadvertent dural puncture, no relief or “patchy” relief, as well as risks of worsening neurologic deficits, must be discussed. The totality of these factors, both from the standpoint of risks associated with difficult placement and possible failure, epidural analgesia, remains a controversial topic. Despite these challenges, this case demonstrates that a successful labor epidural without complications is possible using a cautious technique combined with a thorough discussion and an eager patient.

Case Presentation

A 22-year-old, G2, term 0, preterm 0, abortion 1, living 0, 97 kg female with a history of spina bifida, extensive surgical repair in infancy, and subsequent tethered cord syndrome requested epidural analgesia for labor analgesia. There was no prior history of neuraxial anesthesia. This term singleton pregnancy was complicated by preeclampsia leading to induction of labor; she was experiencing irregular contractions upon admission. Upon initial presentation, no imaging was available. A physical exam revealed extensive scarring with no palpable landmarks in the lumbar region. A bony process presumed to be a spinous process was palpable at an estimated T12 level. Neurological exam and history revealed no sensory or motor deficits.

The patient was counseled that epidural catheter placement carries a significantly greater risk for the spina bifida patient population. Additional or increased risks discussed were failure to access the epidural space, inadvertent dural picture with accompanying headache, incomplete or “patchy” pain relief, high epidural blockade, nerve damage, and increased length of time for placement. The patient acknowledged the risks, displayed full understanding, and elected to proceed.

After palpation of remaining anatomic landmarks, the decision was made to proceed with epidural catheter placement just above the level of the surgical scar and at the first palpable bony prominence, which was presumed to be the T12-L1 interspace. The patient was placed in the sitting position, and the procedure was performed with standard sterile precautions, a 17 g Tuohy needle, and a 19 g epidural catheter. From a midline approach, the loss of resistance to saline technique was utilized. The epidural space was accessed at a depth of 5 cm, and 3 cm of the catheter was left in the epidural space via the Touhy needle. A test dose was administered through the catheter of 3 mL of 1.5% lidocaine and 1:200,000 epinephrine. Following a negative test dose, patient-controlled epidural analgesia (PCEA) dosing was initiated using a solution containing fentanyl 2 mcg/mL and ropivacaine 0.125% at a basal rate of 8 mL/hour with a PCEA bolus of 3 mL and interval lockout of 15 minutes and a one-hour dose limit of 30 mL. No bolus was given due to the perceived risk of a high epidural. Patients, family members, and nursing staff received extensive education on the signs and symptoms of a high epidural blockade. The pain was well controlled with a dermatome level of T10 throughout labor, and vaginal delivery was completed after approximately 17 hours. The epidural catheter was removed with the tip intact without complications. A prior computed tomography scan of the abdomen was discovered after our procedure. Upon review, the epidural space appears to be completely scarred below the T12-L1 interspace. A small patent epidural space can be identified in Figures 1–2 at the T11-T12 interspace.

Figure 1: Sagittal computerized tomography scan of abdomen, arrow indicates possible epidural space

Figure 2: Transverse computerized tomography scan of abdomen, arrow indicates potential epidural space

Effective pain management was achieved throughout labor. On postpartum day 1, the patient was found to have normal neurologic function marked by normal ambulation and return of bowel and urinary function. The patient denied headaches or any signs and symptoms of secondary complications of epidural catheter placement.

Discussion

Spina bifida occulta may be present in up to 5-10% of the population [1,2]. Spina bifida patients are more likely to require a cesarean section, and traditionally, neuraxial techniques have been avoided due to concerns of secondary complications [3]. Additionally, previous spinal surgery has been considered a relative contraindication to the use of neuraxial anesthetic techniques. The anatomy of the epidural space at the level of the spinal lesion following surgical correction remains unclear. It has been described as “lobules of fat lying in the midline adherent to fascia and surrounding tissues or entirely obliterated” [4,5]. An attempt at epidural placement at the level of the defect significantly increases the risk of incidental dural puncture. A blood patch as a treatment for an inadvertent dural puncture presents similar technical difficulties and may be ineffective. Even if neuraxial needle placement is successful, then the spread of local anesthetic is rather unpredictable and may produce an incomplete block. Despite this, multiple case reports exist in the literature describing the successful use of epidural analgesia in patients with spina bifida both with and without corrective surgery [6,7]. There are no definitive guidelines in place for epidural analgesia in spina bifida patients after spine surgery.

Daley et al. [8] reviewed the experience of 18 patients for a total of 21 separate attempts at epidural analgesia for obstetric patients with previous spinal surgery. Continuous labor analgesia was established in 20 out of 21 cases reviewed. However, only 10 of them were placed easily on the first attempt, leaving the remaining 11 with higher requirements of local anesthetic and/or an incomplete block. Hubbert [9] attempted epidural analgesia in 17 laboring patients with a history of Harrington rod fusion and was successful in nine. It is noted that in only four (23%) was epidural analgesia easily obtained, two patients had inadvertent spinal anesthesia from a dural puncture, and 11 required multiple attempts at various levels. Tidmarsh [10] attempted 10 epidural catheter placements for labor analgesia in a parturient with known neural tube defects, of which four had prior corrective surgery. A similar approach was taken as in our case with a midline approach just above the level of defect at first palpable normal spinous process. Out of the 10 epidurals placed, six received normal symmetrical block at or below low thoracic dermatome levels. Of the four remaining, one block was asymmetric, one excessively high blockade, and two were inadequate analgesia below the level of spinal defect. Notably, of the four epidurals placed in patients with a history of corrective surgery, two received normal sensory blockade, one had an excessively high level (T3) of block, and one had inadequate analgesia at a level below the defect. Therefore, in this case series, 50% of those with corrective surgery had complications or inadequate labor analgesia.

It is worth discussing alternative techniques used to place epidural catheters, which include fluoroscopic and ultrasound-guided techniques. Fluoroscopic guided technique has been shown to have a “higher success rate than traditional landmark technique as it can accurately identify anatomical structures and epidural spaces using imaging devices” [11]. However, due to the difficulty of using fluoroscopy in daily practice and the burden of radiation exposure, the practical use is rather limited, especially in the obstetric population. The role of ultrasound guidance in placing epidural catheters is relatively new, but the evidence regarding its practical application and efficacy continues to grow. Chin et al. performed a thorough literature review regarding the benefits and limitations of ultrasound-guided thoracic and lumbar neuraxial blockades. They discovered the evidence suggests ultrasound guidance could improve neuraxial success rate, quality of epidural analgesia, ease of performance, identification of required needle depth, and identification of intervertebral levels [12]. However, the ultrasound-guided technique has displayed limitations in obese and elderly patients, and its use in those with prior spinal surgery remains unknown [12]. Also, extensive experience with ultrasound-guided techniques may be required before competence is attained [12]. In this case, an anesthesiologist with this experience was not readily available.

Our case is unique in that inadequate imaging was available prior to the placement of the epidural catheter and using a surgical scar as a landmark for a potentially patent epidural space proved to be a successful approach. Additionally, it is unusual given the extent of her post-surgical scarring that a continuous epidural space would retain the patency necessary for successful labor analgesia to be achieved.

Conclusions

Effective pain management for patients with a history of spina bifida requires a personalized approach due to their unique anatomic and physiologic factors. A clear discussion about the potential complications and the challenges of effective pain control even with safe epidural placement must be had with this patient population. Despite these challenges, epidural catheter placement can be a safe and effective means of achieving labor analgesia. Collaborating with specialists and considering various imaging modalities may enhance the precision of epidural placement and improve overall outcomes.

References

Eubanks JD, Cheruvu VK: Prevalence of sacral spina bifida occulta and its relationship to age, sex, race, and the sacral table angle: an anatomic, osteologic study of three thousand one hundred specimens. Spine (Phila Pa 1976). 2009, 34:1539-43. 10.1097/BRS.0b013e3181a98560
McGrady EM, Davis AG: Spina bifida occulta and epidural anaesthesia. Anaesthes. 1988, 43:867-9. 10.1111/j.1365-2044.1988.tb05602.x
O’Neal MA: A pregnant woman with spina bifida: need for a multidisciplinary labor plan. Front Med (Lausanne). 2017, 4:172. 10.3389/fmed.2017.00172
Bromage PR: Epidural Analgesia. WB Sanders Company, Philadelphia; 1978. 707-8.
Ingraham FD, Hamlin H: Spina bifida and cranium bifidum. N Engl J Med. 1948, 228:10.1056/NEJM194305202282001
Vaagenes P, Fjaerestad I: Epidural block during labour in a patient with spina bifida cystica. Anaesthes. 1981, 36:299-301. 10.1111/j.1365-2044.1981.tb10205.x
Bajaj P: Regional anaesthesia in the patient with pre-existing neurological dysfunction. Indian J Anaesth. 2009, 53:135-8.
Daley MD, Rolbin SH, Hew EM, Morningstar BA, Stewart JA: Epidural anesthesia for obstetrics after spinal surgery. Reg Anesth. 1990, 15:280-4.
Hubbert CH: Epidural anesthesia in patients with spinal fusion. Anesth Analg. 1985, 64:843.
Tidmarsh MD: Epidural anesthesia and neural tube defects. Int J Obstet Anesth. 1998, 7:111-14.
Parra MC, Washburn K, Brown JR, et al.: Fluoroscopic guidance increases the incidence of thoracic epidural catheter placement within the epidural space: a randomized trial. Reg Anesth Pain Med. 2017, 42:17-24. 10.1097/AAP.0000000000000519
Chin KJ, Karmakar MK, Peng P: Ultrasonography of the adult thoracic and lumbar spine for central neuraxial blockade. Anaesthes. 2011, 114:1459-85. 10.1097/ALN.0b013e318210f9f8

Technology in Anesthesia

September 25, 2024 by Dr. Clemens Leave a Comment

ASA Monitor September 2024, Vol. 88, 30.

First Allia IGS pulse electrophysiology lab in the US for minimally invasive cardiovascular procedures

Heart Hospital of New Mexico at Lovelace Medical Center (HHNM) and GE HealthCare announced HHNM as the first location in the United States to install GE HealthCare’s latest Allia Image Guided System (IGS) Pulse, which was designed for the diagnosis and treatment of cardiovascular diseases. HHNM will use the Allia IGS Pulse system in its cardiac electrophysiology lab to plan, guide, and monitor the outcomes of electrophysiological procedures, such as cardiac ablations, cardiac catherizations, transcatheter aortic valve replacements, balloon, and coronary angioplasties and more.

Dr. Sean Mazer, electrophysiologist and president of the New Mexico Heart Institute/Lovelace Medical Group said, “We can accommodate patients of any size and the system provides us with a personalized workspace that meets our specific needs and preferences, resulting in shorter surgical time and better outcomes for our patients.”

The Allia IGS Pulse system provides imaging at the right dose for visible impact in complex cardiology interventions regardless of patient size, including large and bariatric patients with a BMI of greater than 30.

Researchers build first-ever molecular atlas of blood vessel pathways in the human brain

An international consortium of researchers led by University Health Network (UHN) in Toronto and University of Zurich have built the first-ever molecular atlas of the human brain vasculature at single-cell resolution, spanning from early development to adulthood and through disease stages such as brain tumors and brain vascular malformations.

In this study, researchers isolated blood vessels from human early developing brains, adult brains, brain tumors, and brain vascular malformations. They found that endothelial cells, which line the blood vessels and regulate interactions between the bloodstream and surrounding tissues, behave differently across various stages of brain development, and may have a more important role than previously understood within the brain’s neurovascular signaling networks.

Noted in the team’s findings:

Researchers found that the vasculature in an adult healthy brain stops growing almost completely over time, but a brain tumor or a brain vascular malformation can reactivate blood vessel growth in the brain tissue, like the blood vessel growth in an early developing brain. This finding has never been described before.
The research team also showed for the first time how the human brain vasculature differs from the vasculature of organs outside the brain, both during early brain development and in adulthood – and when disease arises, the brain vasculature becomes more like that of a peripheral organ.
In disease, the typical features of the human brain vasculature are partially altered. One example is the endothelial cells of the blood-brain barrier, which act as the brain’s “filter” and gatekeeper for substances, toxins, and drugs. Endothelial cells can also affect interactions with the body’s immune system. When disease occurs, these cells help to upregulate immune-specific properties, meaning that endothelial cells can evolve into “antigen-presenting cells,” triggering an immune response.

The hope is that if clinicians can one day combine these therapies targeting the vasculature with immunotherapies, they may be able to inhibit vascular growth and prolong patients’ survival.

Source: asamonitor.pub/4bGeL2R

« Previous Page

About Dr. Clemens

Abstract

Introduction

Case Presentation

Discussion

Table 1: Management of intraoperative hiccups

Sedative, analgesic, and anxiolytic properties

Reduced risk of adverse neurological effects

Conclusions

References

Background

Methodology

Result

Conclusion

Introduction

Materials & Methods

Statistical analysis

Results

Figure 1: CONSORT flow diagram

Figure 2: Comparison of SBP before and after SA

Figure 3: Comparison of DBP before and after SA

Figure 4: Comparison of MAP before and after SA

Figure 5: Comparison of heart rate before and after SA

Table 1: Number and percentage of rescue doses given in all groups

Table 2: Number and percentage of atropine doses given in all groups

Limitations

Conclusions

References

Introduction

Case Presentation

Figure 1: Chest X-ray showing a FB in the left base of the thorax (06/05/2024)

Figure 2: Chest CT scan showing a FB in the left basal lung (10/05/2024)

Table 1: Laboratory investigation report (main assessments)

Figure 3: Chest X-ray showing a right perihilar FB (16/05/2024)

Figure 4: Abdominopelvic CT scan showing a FB in the gastric lumen

Figure 5: Removal of the metallic FB from the gastric lumen during the gastroduodenal esophagoscopy procedure

Discussion

Diagnostic challenges

Utilization of bronchoscopy

Complications of bronchoscopy

Multidisciplinary approach and surgical intervention

Migration of the foreign body

Endoscopic retrieval

Conclusions

References

Abstract

Introduction & Background

Review

Applications of POCUS in anesthesia

Disadvantages

Overcoming challenges

Table 1: A summary of few articles included in the study

Discussion

Conclusions

References

Abstract

Introduction

Case Presentation

Figure 1: Sagittal computerized tomography scan of abdomen, arrow indicates possible epidural space

Figure 2: Transverse computerized tomography scan of abdomen, arrow indicates potential epidural space

Discussion

Conclusions

References

First Allia IGS pulse electrophysiology lab in the US for minimally invasive cardiovascular procedures

Researchers build first-ever molecular atlas of blood vessel pathways in the human brain

Testimonials

Add a Testimonial