Anesthetic management of the hybrid stage 1 procedure for hypoplastic left heart syndrome (HLHS)

Introduction: Despite advances in the surgical and perioperative management of patients with hypoplastic left heart syndrome (HLHS), outcomes for this high‐risk group of patients remains suboptimal. The hybrid approach [bilateral pulmonary artery (PA) banding, ductal stenting, balloon atrial septostomy], is an emerging alternative therapy for the management of HLHS, which defers the risks of a major surgical repair until the infants are older. This article will describe our experience providing the anesthetic management of patients undergoing the hybrid procedure. Methods: After Institutional Review Board approval, we retrospectively reviewed the records of 77 patients who underwent the hybrid procedure as neonates between July 2002 and August 2008. We reviewed both the anesthetic and intensive care records. Results: The hybrid procedure was performed in 77 patients (31 female and 46 male). The average age of the patients was 11.8 days with an average weight of 2.98 kg. Fentanyl was used for analgesia at an average dose of 5.7 mcg·kg^?1. The average increase in the systolic blood pressure after placement of the right and left PA bands was 11.3 mmHg. The average drop in the systemic saturation after placement of the bands was 7%, with an average postband and stent SaO₂ of 82%. Twenty‐one patients received blood transfusion (27.3%) at an average dose of 43.5 ml (14.5 ml·kg^?1). Forty patients received albumin during the case (51.9%) at an average dose of 23.2 ml (7.7 ml·kg^?1). Seventeen patients arrived at the hybrid suite already intubated, and no attempt was made to extubate these patients at the end of the case. Thirty‐six patients were extubated at the end of the procedure, and a total of 64.9% of patients were extubated within the first 24 h postoperatively. Patients had notably stable hemodynamics throughout the first 24 h in the intensive care unit. Discussion: Patients undergoing the hybrid procedure have relatively stable intraoperative and early postoperative hemodynamics. The procedure is performed without cardiopulmonary bypass (CPB) and with minimal narcotic and anesthetic exposure. Patients typically do not require blood transfusions or inotropic support and are extubated at either the end of the procedure or within 24 h of ICU admission. In our experience, the anesthetic management of patients undergoing the hybrid procedure is straightforward and requires relatively few interventions when compared to traditional neonatal surgical repairs. Deferring the risks of anesthesia, CPB, hypothermic circulatory arrest, and prolonged postoperative sedation may yield developmental advantages to patients born with HLHS.     

Management of surgical procedures common in men. Part 1: genitourinary procedures

Common genitourinary surgical procedures in the male population have seen a dramatic rise in frequency as the percentage of men aged greater than 50 years old increases in the United States. Accompanying the advanced age of many men undergoing these procedures is the presence of one or more co-existent medical conditions. This article explores the surgical and anesthetic implications of transurethral resection of the prostate (TURP), radical prostatectomy (RP), transurethral resection of a bladder tumor (TURBT), cystoscopy, and extracorporeal shock wave lithotripsy (ESWL) and the considerations necessary when one or more coexistent illnesses are present. Each procedure will be considered from the surgical, anesthetic, pre-operative and postoperative perspective.     

International Federation of Nurse Anesthetists' Anesthesia Program Approval Process

The International Federation of Nurse Anesthetists is improving anaesthesia patient care through a voluntary Anesthesia Program Approval Process (APAP) for schools and programmes. It is the result of a coordinated effort by anaesthesia leaders from many nations to implement a voluntary quality improvement system for education. These leaders firmly believe that meeting international education standards is an important way to improve anaesthesia, pain management and resuscitative care to patients worldwide. By 2013, 14 anaesthesia programmes from France, Iceland, Indonesia, Philippines, Sweden, Switzerland, Netherlands, Tunisia and the USA had successfully completed the process. Additional programmes were scheduled for review in 2014. Faculty from these programmes, who have successfully completed APAP, show how anaesthesia educators throughout the world seek to continually improve education and patient care by pledging to meet common education standards. As national governments, education ministers and heads of education institutions work to decrease shortages of healthcare workers, they would benefit from considering the value offered by quality improvement systems supported by professional organizations. When education programmes are measured against standards developed by experts in a profession, policy makers can be assured that the programmes have met certain standards of quality. They can also be confident that graduates of approved programmes are appropriately trained healthcare workers for their citizens.     

Surface Stimulation to Determine Needle Direction and Angle When Performing an Infraclavicular Brachial Plexus Block

Abstract:   The infraclavicular approach to the brachial plexus is a safe and reliable technique for surgery of the upper extremity. When performing the block, the anesthesiologist must appreciate three variables: needle direction, needle angle to the chest wall, and needle depth. Surface stimulation is an easy technique that can reliably predict both needle direction and needle angle.