Nimma, Sindhuja

Pain management after thoracotomy is particularly complex in lung transplant recipients on extracorporeal membrane oxygenation (ECMO), where anticoagulation significantly limits available treatment options. Coagulopathy constitutes a contraindication to neuraxial and deep peripheral nerve blocks due to hemorrhagic complications. Uncontrolled thoracotomy pain, hypoxia due to increasing opioid use, and hemodynamic instability can delay successful weaning from ECMO. We present the case of a patient on bivalirudin after undergoing a thoracotomy for a right lung transplantation. This case highlights the successful use of a serratus anterior plane block (SAPB) as an alternative approach to neuraxial anesthesia in an anticoagulated patient, optimizing analgesia and facilitating recovery postthoracotomy.

Suzetrigine is a unique, nonopioid oral analgesic that selectively inhibits voltage-gated sodium channels in peripheral nerves. The Food and Drug Administration (FDA) recently approved it, and we present the first successful use of suzetrigine in a 16-year-old boy with hereditary neuropathy who underwent foot reconstruction surgery. His postoperative pain management plan included a sciatic nerve catheter, a 14-day course of suzetrigine, opioids, and home medications. His pain was well controlled with no side effects. Within 24 hours of stopping suzetrigine, the patient’s pain rapidly intensified, suggesting suzetrigine’s effectiveness in postoperative pain management in an adolescent patient with neuropathy.

BACKGROUND: The use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) has significantly increased in recent years. GLP-1 RAs delay gastric emptying, resulting in early satiety and weight loss. This may increase the risk of pulmonary aspiration of residual gastric contents (RGC) during anesthesia delivery. Evidence is urgently needed to guide perioperative anesthesia management for patients taking GLP-1 RAs. This study evaluated preoperative factors that may be associated with high RGC. METHODS: Adult patients who were taking GLP-1 RAs and scheduled to receive anesthesia at 3 hospitals between June 30, 2023, and August 15, 2024, were evaluated via preoperative point-of-care gastric ultrasonography (GUS). The primary outcome was high RGC, defined by the presence of solids food or >1.5 mL/kg of clear liquids on GUS, and its association with preoperative factors (eg, existing medical conditions, indication and route of taking GLP-1 RAs, length of taking GLP-1 RAs, days of withholding GLP-1 RAs before surgery, and preoperative fasting periods). Data are presented as median (interquartile range [IQR]). RESULTS: Among the 316 patients (60.9 years [52.1–68.9] of age; 167 [52.8%] females) included in the study, 113 (35.8%) had high RGC. A higher percentage (5.3%; 6/113) of patients in the high RGC group had an opioid prescription for pain management within 3 months of the GUS assessment compared to the low RGC group (1.0%; 2/203; P = .027). No statistical difference was found between the groups in other existing medical conditions, indication and route of taking GLP-1 RAs, and length of taking GLP-1 RAs. Of the 294 patients taking weekly injections, there were 187 (63.6%) with low RGC and 107 (36.4%) with high RGC. Patients with low RGC withheld their GLP-1 RAs for 8 days [5–10], while patients with high RGC withheld for 6 days [3–9] ( P = .003). Receiver operating characteristic (ROC) analysis found ≤7.5 days of withholding the medication as cutoff for increased prevalence of high RGC in patients taking GLP-1 RA injections. Patients with low RGC fasted from solid food for 20.0 hours [14.8–40.8], and patients with high RGC fasted from solid food for 15.0 hours [12.8–19.0] ( P < .001). ROC found ≤21.3 hours of fasting from solid food as the cutoff for increased prevalence of high RGC. CONCLUSIONS: GLP-1 RA usage may delay gastric emptying. In preoperatively fasting adults, ≤7.5 days of withholding injections and ≤21.3 hours of fasting from solid food are associated with high RGC.

A woman in her 40s presented to the emergency department (ED) with a 3-week history of nausea, vomiting and diarrhoea. Blood cultures were positive for Serratia and Pantoea agglomerans spp. One month before her ED visit, she underwent targeted uterine artery embolisation with particles by an interventional radiologist. Uterine artery embolisation is considered a safe alternative to surgical removal of fibroids or hysterectomy. The patient was initially treated with targeted antibiotics for a large infected uterine fibroid but ultimately required a hysterectomy for source control. To our knowledge, this is the first documented case of P. agglomerans infecting a uterine fibroid.

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease involving the upper and lower motor neurons. Perioperative management of patients with ALS can be challenging due to the risk of hemodynamic instability, aspiration, and ventilatory failure. We discuss a 58-year-old male patient with ALS who underwent open abdominal surgery under regional anesthesia utilizing a remimazolam infusion for sedation. While various sedation agents have been used successfully in patients with ALS, remimazolam, a new short-acting benzodiazepine with unique pharmacologic properties and reversible anxiolysis, provides amnesia while avoiding ventilatory depression.

Purpose of review To summarize recent evidence that discusses the clinical, financial, and logistical implications of a 23 h stay postsurgical stay unit in an ambulatory surgical center (ASC). Recent findings Twenty-three-hour stays in ambulatory surgery centers are safe, but proper patient selection and optimization are key to maintaining a high level of safety. The financial implications of overnight stays in ASCs rely heavily on payment structures and comparative costs at hospital-based outpatient surgery centers. The establishment of pathways and protocols for clinical care are key to the success of a 23 h stay at an ASC Summary A concurrent concern with the recent increase in outpatient surgery and medical complexity of cases performed in an ambulatory surgical center (ASC) is the possibility that patients may need overnight stay. Further, whether certain patients would benefit from anticipated 23 h observation rather than same-day discharge is an emerging topic. Overnight stays in ASCs may have financial advantages and decrease the risk of unanticipated admission with proper patient selection. The use of protocols and established pathways is key to the success of this model.