A&A practice最新文献

Bleeding is common after cardiac surgery and is associated with increased morbidity and mortality. The etiology of coagulopathy after cardiopulmonary bypass is complex, involving systemic inflammation, hemodilution, residual heparin effect, platelet activation, hypothermia, and hyperfibrinolysis. Antifibrinolytic agents such as aprotinin and lysine analogs are used to mitigate hyperfibrinolysis. Although epsilon-aminocaproic acid (EACA) is generally considered safe, dosing regimens vary, and thrombotic complications are underreported in national registries. We describe a case of acute intracardiac thrombosis shortly after EACA administration during mitral valve repair in a patient with no known hematologic or hypercoagulable conditions. .

A 22-year-old female patient, who had lost 44 kg after sleeve gastrectomy, underwent combined mammoplasty and abdominoplasty for postbariatric skin redundancy. Bilateral modified thoracoabdominal nerve block through perichondrial approach (M-TAPA) was performed for perioperative analgesia. The 250-minute surgery was completed without additional analgesics. Postoperative pain scores (Numerical Rating Scale [NRS] ≤3) remained low, no opioids were required, and no complications were observed. The Quality of Recovery-15 (QoR-15) score at 24 hours was 143. This case may suggest that the M-TAPA block is a safe and effective analgesic option in extensive aesthetic surgeries involving both thoracic and abdominal regions.

High-grade gliomas, including glioblastoma multiforme, represent some of the most prevalent and aggressive malignant brain tumors. Awake craniotomy is preferred for resecting tumors involving eloquent areas of the brain (motor, language, and executive function). Hyperfibrinolysis during these surgeries is rare, though hemorrhage is not uncommon. We report the management of hyperfibrinolytic coagulopathy and hemorrhage in a 59-year-old man undergoing an awake craniotomy for the World Health Organization (WHO) grade IV glioblastoma. This case underscores the importance of goal-directed coagulation management, using point-of-care viscoelastic testing and time-critical intervention such as tranexamic acid and fibrinogen concentrate when treating hemorrhagic complications during tumor resection.

General anesthesia (GA) is often preferred for cervical spine surgeries; however, it may pose risks for patients with severe comorbidities. This case report describes management of cervical decompression laminectomy using continuous thoracic spinal anesthesia (TSA) with hypobaric levobupivacaine in a high-risk elderly patient. This technique provided an effective alternative to GA.

Background: Acute kidney injury (AKI) is a frequent complication after major surgery and has significant implications for long-term outcomes. This study aimed to evaluate the incidence and impact of postoperative AKI (PO-AKI) in adults who underwent major abdominal surgeries in 2019 at Hospital Clínico de la Universidad de Chile. The primary focus was on the association between PO-AKI and 2-year mortality, along with other postoperative complications and hospital-related outcomes.

Methods: A descriptive observational study was conducted with approval from the Local Ethical Committee. Patients aged 18 years and older who underwent major abdominal surgeries were included, excluding those with incomplete records or preoperative renal failure. Data were collected from electronic medical records (TiCares) and included demographics, comorbidities, and surgical details. Postoperative complications, including PO-AKI [defined by kidney disease: improving global outcomes (KDIGO) criteria or clinical diagnosis], in-hospital myocardial infarction, pulmonary thrombosis, pneumonia, sepsis, in-hospital mortality, and 2 years mortality, were recorded. The primary outcome was 2-year mortality, while secondary outcomes included in-hospital mortality and hospital stay length. Multivariable analysis was used to explore the relationship between PO-AKI and these outcomes.

Results: In 214 patients analyzed, PO-AKI occurred in 13.6% of patients and was associated with advanced age (P = .003), high American Society of Anesthesiologists physical status (ASA-PS) scores (P = .02, between ASA-PS 1-2 vs 3-higher), and longer surgical durations (mean [standard deviation {SD}] 282.6 [144.3] vs 227.4 [108.5] min; P = .02). Individual preoperative creatinine and baseline renal function did not significantly differ between those with and without PO-AKI (P = .82 and P = .22, respectively). PO-AKI was associated with a relative risk of 1.4 [95% confidence interval [CI], 1.2-1.8] for 2-year mortality and stayed in the hospital twice as long as those without PO-AKI (median (min - max) 14 (2-67) vs 7 (0-53) P < .0001). Multivariate analysis identified PO-AKI (odds ratio [OR] = 4.1 [95% CI, 2.5-6.5]; P = .003) as an independent predictor of 2-year mortality. Overall, 20.1% of the cohort died within 2 years, and 3.7% experienced in-hospital mortality. Additional complications included sepsis (12.6%), pulmonary thromboembolism (3.7%), and pneumonia (2.8%).

Conclusions: PO-AKI was found to be an independent predictor of 2-year mortality. These findings highlight postoperative renal function impairment as a key marker of poor long-term prognosis. Acute renal deterioration may reflect systemic damage from surgery and/or increased vulnerability in this population, underscoring the need for targeted preventive strategies and early interventions.

Background: Deep learning can automate nerve identification by learning from expert-labeled examples to detect and highlight nerves in ultrasound images. This study aims to evaluate the performance of deep-learning models in identifying nerves for ultrasound-guided nerve blocks.

Methods: A total of 3594 raw ultrasound images were collected from public sources-an open GitHub repository and publicly available YouTube videos-covering 9 nerve block regions: Transversus Abdominis Plane (TAP), Femoral Nerve, Posterior Rectus Sheath, Median and Ulnar Nerves, Pectoralis Plane, Sciatic Nerve, Infraclavicular Brachial Plexus, Supraclavicular Brachial Plexus, and Interscalene Brachial Plexus. Of these, 10 images per nerve region were kept for testing, with each image labeled by 10 expert anesthesiologists. The remaining 3504 were labeled by a medical anesthesia resident and augmented to create a diverse training dataset of 25,000 images per nerve region. Additionally, 908 negative ultrasound images, which do not contain the targeted nerve structures, were included to improve model robustness. Ten convolutional neural network-based deep-learning architectures were selected to identify nerve structures. Models were trained using a 5-fold cross-validation approach on an Extended Video Graphics Array (EVGA) GeForce RTX 3090 GPU, with batch size, number of epochs, and the Adam optimizer adjusted to enhance the models' effectiveness. Posttraining, models were evaluated on a set of 10 images per nerve region, using the Dice score (range: 0 to 1, where 1 indicates perfect agreement and 0 indicates no overlap) to compare model predictions with expert-labeled images. Further validation was conducted by 10 medical experts who assessed whether they would insert a needle into the model's predictions. Statistical analyses were performed to explore the relationship between Dice scores and expert responses.

Results: The R2U-Net model achieved the highest average Dice score (0.7619) across all nerve regions, outperforming other models (0.7123-0.7619). However, statistically significant differences in model performance were observed only for the TAP nerve region (χ² = 26.4, df = 9, P = .002, ε² = 0.267). Expert evaluations indicated high accuracy in the model predictions, particularly for the Popliteal nerve region, where experts agreed to insert a needle based on all 100 model-generated predictions. Logistic modeling suggested that higher Dice overlap might increase the odds of expert acceptance in the Supraclavicular region (odds ratio [OR] = 8.59 × 10⁴, 95% confidence interval [CI], 0.33-2.25 × 10¹⁰; P = .073).

Conclusions: The findings demonstrate the potential of deep-learning models, such as R2U-Net, to deliver consistent segmentation results in ultrasound-guided nerve block procedures.

Surgical interventions involving the face, particularly in elderly or medically complex patients, present unique anesthetic challenges. We report the case of a 70-year-old woman with multiple comorbidities who underwent excision of a midline frontal basal cell carcinoma (2.5 cm × 2 cm) under regional anesthesia and sedation. Bilateral supraorbital, supratrochlear, and zygomaticotemporal nerve blocks were performed. Sedation was maintained with intravenous bolus fentanyl and propofol infusion. The procedure was completed without complications, with excellent analgesia and hemodynamic stability. Scalp nerve blocks may offer a safe and effective alternative to general anesthesia for forehead surgeries, particularly in high-risk patient populations.

The American Society of Anesthesiologists (ASA) most recently released guidelines for preoperative fasting in 2023, which aim to minimize the risk of aspiration in healthy patients undergoing elective procedures. Although these nil per os (NPO) guidelines are intended to be comprehensive for this patient population, they leave significant room for interpretation. To address this, we created modified pediatric anesthesia NPO guidelines within our institution based on existing published evidence and anesthesiology faculty consensus. Implementing these guidelines has provided a more consistent approach to preoperative care for patients, families, and providers.