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- Immune Thrombocytopenia and Type 1 von Willebrand Disease in a Patient With a Femoral Fracture: A Case Report.Publication . Ferreira, André; Roberto, AndréThis article describes the case of a complex medical patient with immune thrombocytopenia (ITP) and von Willebrand disease (vWD), among other comorbidities, who underwent urgent orthopedic surgery and discusses the specificities of the perioperative anesthetic management of these bleeding disorders. Immune thrombocytopenia is an acquired autoimmune condition characterized by a diminished platelet count due to immune destruction. vWD is the most common inherited bleeding disorder, in which there is a defect of von Willebrand factor, a fundamental component of the hemostatic process. By compromising primary hemostasis, both conditions carry an important hemorrhagic risk in surgical patients, which is compounded by their coexistence.
- Is Sleep a Neglected Cornerstone in Brain Health and Perioperative Medicine?Publication . Martins, Ana Margarida
- Sex Dependence of Postoperative Pulmonary Complications - A Post Hoc Unmatched and Matched Analysis of LAS VEGAS.Publication . Vermeulen, Tom D; Hol, Liselotte; Swart, Pien; Hiesmayr, Michael; Mills, Gary H; Putensen, Christian; Schmid, Werner; Serpa Neto, Ary; Severgnini, Paolo; Vidal Melo, Marcos F; Wrigge, Hermann; Hollmann, Markus W; Gama de Abreu, Marcelo; Schultz, Marcus J; Hemmes, Sabrine N; van Meenen, David MStudy objective: Male sex has inconsistently been associated with the development of postoperative pulmonary complications (PPCs). These studies were different in size, design, population and preoperative risk. We reanalysed the database of 'Local ASsessment of Ventilatory management during General Anaesthesia for Surgery study' (LAS VEGAS) to evaluate differences between females and males with respect to PPCs. Design, setting and patients: Post hoc unmatched and matched analysis of LAS VEGAS, an international observational study in patients undergoing intraoperative ventilation under general anaesthesia for surgery in 146 hospitals across 29 countries. The primary endpoint was a composite of PPCs in the first 5 postoperative days. Individual PPCs, hospital length of stay and mortality were secondary endpoints. Propensity score matching was used to create a similar cohort regarding type of surgery and epidemiological factors with a known association with development of PPCs. Main results: The unmatched cohort consisted of 9697 patients; 5342 (55.1%) females and 4355 (44.9%) males. The matched cohort consisted of 6154 patients; 3077 (50.0%) females and 3077 (50.0%) males. The incidence in PPCs was neither significant between females and males in the unmatched cohort (10.0 vs 10.7%; odds ratio (OR) 0.93 [0.81-1.06]; P = 0.255), nor in the matched cohort (10.5 vs 10.0%; OR 1.05 [0.89-1.25]; P = 0.556). New invasive ventilation occurred less often in females in the unmatched cohort. Hospital length of stay and mortality were similar between females and males in both cohorts. Conclusions: In this conveniently-sized worldwide cohort of patients receiving intraoperative ventilation under general anaesthesia for surgery, the PPC incidence was not significantly different between sexes. Registration: LAS VEGAS was registered at clinicaltrial.gov (study identifier NCT01601223).
- Association of Preoperative Smoking With the Occurrence of Postoperative Pulmonary Complications: A Post Hoc Analysis of an Observational Study in 29 Countries.Publication . Dorland, Galina; Saadat, W; van Meenen, David M P; Neto, Ary Serpa; Hiesmayr, Michael; Hollmann, Markus W; Mills, Gary H; Vidal Melo, Marcos F; Putensen, Christian; Schmid, Werner; Severgnini, Paolo; Wrigge, Hermann; de Abreu, Marcelo Gama; Schultz, Marcus J; Hemmes, Sabrine N T; Appleton, SofiaIntroduction: While smoking has been consistently identified as a significant contributor to postoperative complications, the existing literature on its association with postoperative pulmonary complications remains conflicting. Aim: We examined the association of preoperative smoking with the occurrence of postoperative pulmonary complications (PPCs). Methods: Post hoc analysis of an observational study in 146 hospitals across 29 countries. We included patients at increased risk of PPCs, according to the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score (≥ 26 points). The primary endpoint was the occurrence of one or more predefined PPCs in the first five postoperative days, including unplanned postoperative need for supplementary oxygen, respiratory failure, unplanned need for invasive ventilation, ARDS, pneumonia and pneumothorax. Secondary endpoints included length of hospital stay and in-hospital mortality. We performed propensity score matching to correct for factors with a known association with postoperative outcomes. Results: Out of 2632 patients, 531 (20.2 %) patients were smokers and 2102 (79.8 %) non-smokers. At five days after surgery, 101 (19.0 %) smokers versus 404 (19.2) non-smokers had developed one or more PPCs (P = 0.95). Respiratory failure was more common in smokers (5.1 %) than non-smokers (3.0 %) (P = 0.02), while rates of other PPCs like need for supplementary oxygen, invasive ventilation, ARDS, pneumonia, or pneumothorax did not differ between the groups. Length of hospital stay and mortality was not different between groups. Propensity score matching did not change the findings. Conclusion: The occurrence of PPCs in smokers is not different from non-smokers. Funding: This analysis was performed without additional funding. LAS VEGAS was partially funded and endorsed by the European Society of Anaesthesiology through their Clinical Trial Network and the Amsterdam University Medical Centers, Amsterdam, The Netherlands. Registration: LAS VEGAS was registered at Clinicaltrials.gov (NCT01601223). Prior presentation: Preliminary study results have been presented at the Euroanaesthesia 2024 International Congress, in Munich, Germany.
- Ketodex: A Game-Changer in Pediatric Sedation for Challenging Airway.Publication . Baptista, Lidia Sofia; Pelicano Paulos, Jorge; Pinto Carneiro, AnaManaging sedation in pediatric patients with complex facial anomalies and airway challenges requires careful consideration of safety and efficacy. This case report presents the use of the Ketodex sedation protocol, combining ketamine (NMDA receptor antagonist) and dexmedetomidine (alpha-2-agonist), for a child with a large cervical/facial mass undergoing a diagnostic magnetic resonance imaging (MRI). Ketodex provides effective sedation with minimal need for manipulation of the airway and side effects, making it ideal for cases involving difficult airways. Our protocol allows spontaneous ventilation without compromising airway reflexes and reduces airway hyperreactivity, ensuring safety in high-risk pediatric cases. Initiating sedation in a controlled environment enhances safety before moving to remote locations. The Ketodex protocol is a safe and effective choice for managing pediatric patients with challenging airways. Its use should be prioritized in controlled settings, with adaptations for individual patient needs.
- Estágios de Grupo I do Internato de Anestesiologia: Uma Perspetiva AtualPublication . Roxo, M; Mamede, M; Vieira, I; Chen, JIntrodução: A especialidade de Anestesiologia prima pela prática baseada na evidência e cuidado com a formação. Os estágios de grupo I são a mais recente alteração ao programa formativo da especialidade, tendo-se realizado pela primeira vez em janeiro de 2020. Material e Métodos: Realizou-se um estudo observacional transversal descritivo com base num inquérito on-line com o objetivo de definir, segundo a perceção dos Médicos Internos, a qualidade, utilidade e recursos logísticos do estágio. O inquérito era composto por 14 questões, divididas em dois grupos: um bloco relativo à componente formativa e laboral e um bloco relativo à componente logística do estágio. Resultados: De um universo de 160 Internos de Formação Especializada em Anestesiologia foram obtidas 75 respostas (46,9%). Os estágios de grupo I demonstraram ser uma mais-valia no Internato de Anestesiologia. Os médicos internos, na sua grande maioria, apresentam um elevado grau de satisfação com o estágio, autonomia e variedade de funções desempenhadas, que culminam na vontade de exercer futuramente funções em hospitais distritais. Conclusão: Esta análise dos dois primeiros anos do estágio de grupo I pode servir de base para uma discussão alargada que poderá conduzir a um processo de contínua melhoria de condições e eventual introdução de novos elementos num estágio que já demonstrou ser vantajoso para os elementos envolvidos.
- Perioperative Ultrasound-Guided Continuous Caudal Epidural Analgesia in Newborns: A Case Series in a Tertiary Medical CenterPublication . Portela, F; Costa, G; Cenicante, TBackground Caudal epidural anesthesia technique is a relevant method for postoperative analgesia in newborns, allowing for the reduction of drug-induced respiratory depression. The threading of a catheter is, however, uncommon in clinical practice. Our main purpose was to describe our experience regarding caudally inserted epidural catheters in neonates undergoing major abdominal surgery. Methods We included every full-term neonate undergoing surgery under combined caudal epidural-general anesthesia from 2017 to 2022 in our institution. After induction of general anesthesia, an ultrasound-guided caudal epidural injection was performed, and an epidural catheter was inserted for perioperative analgesia. An epidural bolus of ropivacaine was administered to every patient before the surgical incision, and an epidural infusion of ropivacaine 0.05% was administered for 24 hours. Results Retrospectively obtained data included six full-term neonates with American Society of Anesthesiologists (ASA) physical status II to IV. Intraoperatively, good analgesia was achieved without hemodynamic instability or need for additional systemic opioids after induction. At the end of surgery, five of the six neonates were extubated without adverse respiratory events. Postoperatively, effective analgesia was achieved in four cases with an epidural infusion of ropivacaine 0.05%, at a rate between 0.2 and 0.4 mg/kg/h, and intravenous paracetamol. Epidural pain control was not successful in one neonate, and thus an intravenous fentanyl infusion was added. The sixth neonate remained intubated for prolonged mechanical ventilation due to surgical complications, and thus an intravenous fentanyl infusion was introduced for sedation in the neonatal intensive care unit (NICU), not allowing to evaluate the effectiveness of the epidural infusion alone. No other complications related to the epidural catheters were reported. Conclusion Continuous caudal epidural analgesia may be a valuable technique with a low risk of complications, decreasing the incidence of respiratory adverse events in this patient population. Although more cases are needed for a stronger conclusion, it has become a useful analgesic strategy for major abdominal surgery in neonates in our institution.
- Kawasaki-Like Syndrome as an Emerging Complication of SARS-CoV-2 Infection in Young AdultsPublication . Germano, N; Pelicano Paulos, J; Botelho Cardoso, F; Ferreira, AT; Burgi Vieira, CBackground: Kawasaki-like syndrome occurring in children during the COVID-19 pandemic has been labelled multisystem inflammatory syndrome in children (MIS-C) by the CDC and paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 infection (PIMS-TS) by the ECDC. Case report: We report the case of an 18-year-old male patient presenting with a 72-hour history of abdominal pain, fever, erythematous skin rash, vomiting and diarrhoea. Examination showed he also had shock and he was first thought to have oedematous cholecystitis. SARS-CoV-2 infection was also diagnosed. He was admitted to the ICU, and echocardiography showed cardiac dysfunction, with a low ejection fraction and low cardiac index. High-sensitivity troponin serum levels were elevated. The patient received inotropic and vasopressor support. As he fulfilled several criteria for MIS-C/PIMS-TS, he was administered acetylsalicylic acid, corticosteroids and immunoglobulin, with a good clinical response. Conclusion: This case emphasizes how this severe presentation of COVID-19 can easily be misdiagnosed if the clinician is less aware of this syndrome in younger patients. Learning points: SARS-CoV-2 infection is a diagnostic challenge in some patients with atypical clinical presentations, who may have MIS-C/PIMS-TS.Physicians should be aware of this condition when evaluating teenagers and young adults with COVID-19.
- Unexpected Presentation of Tracheoesophageal Fistula During Intubation in a Pediatric PatientPublication . Telo, M; Morais, L; Ferreira, R; Coelho, AP; Peixer, ITracheoesophageal fistula (TEF) is an abnormal connection between the trachea and esophagus. This report presents a rare case of a pediatric patient who developed a TEF due to battery ingestion, which was diagnosed during intubation and resulted in cardiac arrest. A 4-year-old child with a two-year history of battery ingestion presented with severe dehydration, weight loss, and recurrent respiratory tract infections. Chest X-ray revealed a radiopaque foreign body in the esophagus. During general anesthesia for central venous line insertion and after endotracheal intubation, some difficulties in ventilation occurred, characterized by the inability to reach tidal volume, absence of capnography, and stomach distention which led to hypoxia and ultimately to cardiac arrest. Prompt resuscitation (CPR) was initiated, and selective right bronchial intubation during CPR improved the patient's condition. Subsequent bronchofibroscopy performed in the ICU confirmed the TEF, which was surgically corrected during the hospital stay. TEF poses challenges in anesthesia and airway management, particularly when positive pressure ventilation is used. In this case, the TEF was diagnosed during intubation, highlighting the critical role of clinical expertise and prompt intervention in managing this unexpected pediatric critical event.