A&A practice最新文献

We describe a 69-year-old man in septic shock undergoing an emergent endoscopic retrograde cholangiopancreatography (ERCP) whose narrow-complex supraventricular tachycardia (SVT, 180-200 bpm) persisted despite synchronized cardioversion, vagal maneuvers, adenosine, esmolol, and amiodarone. Changing vasopressors from norepinephrine to phenylephrine and angiotensin II aided in rate control. Noting transient reversion during maneuvers provoking vagal stimulation, when SVT reoccurred we titrated intravenous neostigmine in 0.5 to 1.0 mg increments (3.5 mg total), achieving a stable sinus rhythm at 80 bpm without adverse effects. This case illustrates neostigmine's value as an off-label vagomimetic rescue when guideline-directed therapies fail, and vagal stimulation appears beneficial. .

False lumen perfusion is a potentially catastrophic complication of femoral artery cannulation for cardiac surgery that can occur even when transesophageal echocardiography (TEE) suggests correct guidewire placement. We experienced this complication after initiation of cardiopulmonary bypass in one patient with a Stanford type A aortic dissection and another with an iatrogenic dissection. Both were successfully salvaged by switching rapidly to another perfusion route. TEE alone is insufficient confirmation of guidewire placement. Life-saving intervention was achieved by combining TEE with multipoint arterial pressure monitoring, allowing rapid detection of false lumen perfusion. This multimodal approach is crucial for preventing irreversible organ ischemia.

Background: Enhanced recovery after surgery (ERAS) is a perioperative multimodal approach aimed at improving post-surgery functional outcomes. Its implementation in patients with intracranial aneurysms undergoing craniotomy is insufficient. Hence, we aimed to investigate whether the ERAS protocol is better than the conventional protocol in terms of favorable outcomes. The primary outcome of the study was postoperative hospital length of stay (LOS). The secondary outcomes included intraoperative fentanyl consumption, postoperative pain assessment and analgesic requirement, length of intensive care unit (ICU) stay, postoperative complications, functional recovery, and patient satisfaction.

Methods: American Society of Anesthesiologists (ASA) grade I or II patients with anterior circulation aneurysms (18-65 years) with World Federation of Neurosurgical Societies (WFNS) grade 1 were enrolled and randomized into 2 groups: ERAS group (group E) or conventional group (group C) using computer-generated sequence numbers. Exclusion criteria included nonconsenting patients, posterior circulation aneurysms, WFNS grades 2, 3, 4, and 5, age <18 or >65 years, ASA grade III, IV, V, pregnant patients, patients requiring postoperative ventilation, history of brain surgery, preoperative cognitive dysfunction, and body mass index (BMI) >40. Quantitative data underwent analysis via t test or Mann-Whitney U test, while qualitative data were subjected to χ2 test or Z test of proportions. The value of P < .05 was considered significant.

Results: A total of 46 patients were analyzed for the study, 23 in each group. Demographics and baseline characteristics were comparable between the groups. The mean ± standard deviation (mean ± SD) of LOS in group E was 8.0 ± 2.4 days and those were in group C was 8.9 ± 2.7 days, which were comparable (difference 0.9 [95% confidence interval {CI}, -2.32 to 0.67; P = .28]). The duration of the mean ICU stay was shorter in group E in comparison to those in group C (20.9 ± 6.8 hours vs 28.9 ± 9.0 hours; difference 8; 95% CI, 12.7 to -3.37; P = .001). The additional intraoperative fentanyl requirement was significantly lower in group E in comparison to those in group C (132 ± 40 vs 183 ± 39 µg; difference 51, 95% CI, -73.8 to -27.0; P < .001). The median (interquartile range [IQR]) patient satisfaction scores were significantly higher in group E in comparison to group C (4 [3-5] vs 3 [2-4]; difference 1; 95% CI, 0-2; P < .001).

Conclusions: ERAS protocol within the domain of intracranial aneurysm surgery results in early ICU discharge, augmented patient satisfaction, improved postoperative pain scores, and a potentially higher score in functional recovery.

Background: Complex Regional Pain Syndrome (CRPS) is a chronic pain condition with a complex pathophysiology, significantly affecting patients' quality of life. Effective patient education is crucial for managing CRPS, but available resources often lack readability and accessibility, leading to the persistence of myths. This study evaluates the accuracy, readability, completeness, emotional tone, and myth-debunking capabilities of AI-generated patient education materials (PEMs) compared to traditional online sources.

Methods: A comparative design was employed to assess PEMs generated by three AI chatbots (ChatGPT, Google's Gemini, and Meta's Llama) against traditional online materials from Cleveland Clinic and Mayo Clinic. Readability was evaluated using the Flesch Reading Ease, Gunning Fog Index, Flesch-Kincaid Grade Level, and SMOG Index. Accuracy and completeness were assessed by a panel of five pain experts using a Likert scale (1-5). Sentiment analysis measured emotional tone, and the AI chatbots' ability to debunk 15 common CRPS myths was compared with expert evaluations using sensitivity, specificity, and other performance metrics.

Results: Cleveland Clinic PEMs demonstrated the highest accuracy (4.8 ± 0.40 expressed as mean ± standard deviation, significantly outperforming Gemini (3.4 ± 0.49, P = .004) and Llama (3.6 ± 0.49, P = .014). Completeness was also higher for Cleveland Clinic (4.8 ± 0.40), vs Gemini (3.8 ± 0.40, P = .031) and vs Llama (3.6 ± 0.49, P = .008). Gemini had superior readability (Flesch score 62 as compared to Traditional PEMs and other AI generated PEMs all scoring <52) but lower specificity (66.67%) in debunking myths. ChatGPT had the highest specificity (100%). The sentiment analysis showed that Gemini produced the most positive content (sentiment score 83), while the Cleveland Clinic's tone was neutral (sentiment score -8.0).

Conclusion: AI-generated PEMs show promise as effective tools for patient education in CRPS, offering accurate and readable content. However, traditional online resources from prestigious institutes still provide more comprehensive information. The study highlights the potential of AI in complementing traditional online educational materials, but further validation and improvements are needed to optimize their use in clinical practice.

We report a rare case of congenital esophageal atresia (EA) associated with bronchoesophageal fistula (BEF) identified intraoperatively in a neonate initially presumed to have tracheoesophageal fistula (TEF). Intraoperative fiberoptic bronchoscopy facilitated the localization and confirmation of the fistula prior to surgical ligation. The BEF was ligated via open thoracotomy. Esophageal repair was deferred due to a long gap between proximal and distal esophagus pouches. This case underscores the importance of comprehensive airway evaluation in neonates with suspected TEF/EA.

Neuromuscular monitoring in patients with cerebral palsy (CP) is technically challenging due to limb contractures and muscle atrophy. We report a case of a 28-year-old male with CP who underwent surgery under general anesthesia. Intraoperative recovery from neuromuscular block was successfully monitored using an electromyography-based neuromuscular monitor. Due to finger deformities, the abductor digiti minimi muscle was selected for monitoring. The onset of rocuronium 0.65 mg/kg was delayed and its duration markedly prolonged. Adequate recovery of neuromuscular function was confirmed with a train-of-four ratio ≥ 0.9, demonstrating the feasibility and clinical utility of TetraGraph in CP patients.