Bronchoscopic procedures are increasingly performed with shape-sensing robotic-assisted bronchoscopy under general anaesthesia, allowing biopsy of small and distal pulmonary lesions. We performed a retrospective cohort study at a single centre of patients undergoing robotic bronchoscopy to describe the peri-operative care. The primary outcome measure was post-procedural length of hospital stay, with secondary outcomes including complication rates and diagnostic success of biopsy. A total of 200 patients were recruited over a 12-month period. Median ([IQR] range) post-procedural length of stay was 4 h ([2.5-24.5] 0.5-75) with 106/200 (53%) of patients performed as a day case. Cardiorespiratory comorbidities were common, 65% of patients had an ASA physical status 3 or 4. Higher ASA physical status and chronic obstructive pulmonary disease were associated with increased post-procedural admission rate. All patients underwent general anaesthesia with target-controlled infusion of propofol. Neuromuscular blocking agents were used in 194/200 (97%) and remifentanil was used for 185/200 patients (93%). Median PEEP was 10 cmH2O (range 5-15 cmH2O). The incidence of peri-procedural complications requiring intervention was 6%. Our findings suggest that robotic-assisted bronchoscopy could be delivered safely as a day case procedure in a population with a high incidence of comorbidities, with low peri-procedural complication rates.
Post-anaesthesia shivering (PAS) occurs in 33%-56.7% of spinal anaesthesia patients and is associated with cold exposure, patient factors, and prolonged surgical and anaesthesia duration. Physiological changes may heighten the risk of postoperative problems, especially in vulnerable patients, and often cause considerable discomfort. This study reports four cases of women having scheduled caesarean sections while under spinal anaesthesia (lignocaine and bupivacaine). Following surgery in the postoperative ward, they had fever, raised blood pressure (170/110 mm Hg), and shivering for 1.5 min while receiving their intravenous medications. Proper perioperative monitoring of caesarean patients receiving spinal anaesthesia is crucial to minimise complications. Prompt action is made possible by early detection of adverse events like fever, shaking, and changes in blood pressure. Both patient safety and postoperative outcomes are improved by this approach.
Patients with obstructive sleep apnoea face increased risk of peri-operative pulmonary complications and prolonged hospital stay. While post-operative continuous positive airway pressure use has proven to be beneficial, less is known about its peri-operative benefits, particularly in procedural settings where deep sedation without an advanced airway is used, including total knee arthroplasty. This retrospective cohort study compared postoperative respiratory outcomes of patients with diagnosed or suspected obstructive sleep apnoea who received intra-operative nasal continuous positive airway pressure vs. standard oxygen mask during total knee arthroplasty under spinal anaesthesia with deep sedation between January 2020 and December 2023. The primary outcome comprised the incidence of oxygen desaturation in the post-anaesthesia care unit. Exploratory outcomes included failure rate of breathing air trial, time to care completion and respiratory support at post-anaesthesia care unit discharge, postoperative pulmonary complication and 2-week unanticipated hospital re-admission rates. Post hoc multivariate regression and 1:1 propensity score matching analyses were performed; p < 0.05 was considered statistically significant. Among 1516 patients, 386 (25%) patients received nasal continuous positive airway pressure, while 1130 (75%) patients received simple oxygen mask intra-operatively. The nasal continuous positive airway pressure group had a higher body mass index (36.8 versus 36.1, p = 0.04) and a higher rate of pre-existing obstructive sleep apnoea diagnosis (66.8% versus 39.7%, p < 0.001). After propensity score matching, post-anaesthesia care unit oxygen desaturation (4.5% nasal continuous positive airway pressure, 4.2% simple oxygen mask, p = 0.86) and breathing air trial failure rates remained similar. Median (IQR) time to care completion was shorter in the nasal continuous positive airway pressure group [59 (48, 60) versus 60 (47, 66) min, p = 0.005]. Two-week unanticipated hospital re-admission rate was less in the nasal continuous positive airway pressure group (1.3% versus 4.0%, p = 0.023). Intra-operative nasal continuous positive airway pressure was not associated with improved postoperative pulmonary outcomes compared to simple oxygen mask use among a cohort of high-risk patients with obstructive sleep apnoea who underwent total knee arthroplasty under spinal anaesthesia and deep sedation. Randomised trials are needed to comprehensively understand the peri-operative benefits of intra-operative nasal continuous positive airway pressure in the setting of spinal anaesthesia with deep sedation.
Machine learning (ML) tools are increasingly integrated into various sectors, including healthcare, where they have demonstrated disruptive potential. While anaesthesia is a specialty historically shaped by technological innovation, the precise clinical impact of ML remains poorly defined. Furthermore, despite a decade of prolific model development, the systematic translation of these computational tools into routine, everyday clinical workflows has stagnated. A systematic literature review was conducted using the PubMed/Medline and EBSCO databases, supplemented by an analysis of Food and Drug Administration (FDA)-approved medical ML applications. To ensure methodological rigour, the selection process followed the PRISMA 2020 guidelines. Eligible peer-reviewed publications were restricted to those focusing primarily on the development, validation, or implementation of machine learning applications within the field of anaesthesia. Out of 6,425 screened publications, 1,021 were included in a datasheet. These included 302 reviews or opinion pieces, 5 case reports, and 714 articles focused on tool development or clinical evaluation. Although research topics were highly diverse, the vast majority of studies focused on the prediction of perioperative complications and patient prognosis. Machine learning represents a highly active and debated domain in anaesthesia, characterised by a substantial volume of published research. However, exceptionally few algorithmic models have successfully translated into practice-changing clinical tools. This persistent gap indicates that technical innovation alone is insufficient, as translation is severely hindered by inherent model limitations, software interoperability constraints, and socio-technical challenges within the clinical environment. Addressing the scarcity of hybrid clinician-developer profiles and establishing robust, external field validation are critical pre-requisites for meaningful clinical integration.
This scoping review aims to map and evaluate the current body of literature on the use of extended reality (XR), including virtual reality (VR), augmented reality (AR) and mixed reality (MR), in the field of knee arthroplasty. There is a high global prevalence of knee osteoarthritis, and the frequency of knee replacement surgeries is increasing. The integration of XR technologies with surgery has the potential to improve patient care, surgical precision and medical education. This review seeks to understand the current landscape of XR applications in knee arthroplasty and identify gaps in knowledge to guide future research and clinical innovation. A systematic search of four databases-PubMed, Cochrane Central Register for Controlled Trials, National University of Singapore Libraries and Google Scholar-was conducted in December 2023 and updated in April 2024. Only English-language articles published from 2004 onwards were included. Editorials, case reports and articles not related to the knee joint were excluded. Eligible studies involved the use of XR/VR/AR/MR technologies specifically in the context of knee arthroplasty. Included articles were categorised under three major themes: (1) Clinical Practice (encompassing surgery, anaesthesia and rehabilitation), (2) Education (targeting both surgeons and nursing staff) and (3) Research (including applications in artificial intelligence and robotic-assisted surgery). Data from each study were extracted and summarised in a thematic table. Out of 236 articles retrieved from databases and 5 identified through reference screening, 54 articles met the inclusion criteria. VR was the most commonly studied modality (n = 42), followed by AR (n = 21), MR (n = 5), and XR (n = 2), with some overlap (n = 9) across technologies. Most articles focused on clinical practice (n = 45), while fewer addressed educational uses (n = 9) and research applications (n = 2). Two studies were classified under multiple themes. XR technologies were applied across preoperative training, intraoperative surgical navigation, anaesthesia techniques and postoperative rehabilitation. XR technologies in knee arthroplasty are diverse and show promising applications across clinical, education and research domains. While surgery, anaesthesia and education-related applications appear practical and beneficial, rehabilitation-related studies report mixed outcomes. Further high-quality research is needed to evaluate effectiveness and support broader clinical implementation across all identified subthemes. Level V.
Small bowel herniation through a Caesarean section wound is exceedingly rare and may present with erythema and induration clinically indistinguishable from superficial wound infection, risking dangerous diagnostic delay. A case is reported here of a 39-year-old woman with one prior Caesarean section and a body mass index of 30 kg/m2 who underwent elective lower segment Caesarean section at 39 weeks of gestation, complicated by intraoperative adhesiolysis and decompression of a uterovesical fatty cyst. On postoperative day 3, the patient re-presented with right iliac fossa pain, vomiting, and extensive blanching erythema extending to the right anterior superior iliac spine. The wound appeared clean and intact; the patient remained apyrexial with markedly elevated inflammatory markers. Initial assessment suggested cellulitis. Computed tomography of the abdomen and pelvis revealed herniation of the small bowel through the Caesarean section wound with early obstructive features. Examination under anaesthesia confirmed small bowel herniating through a rectus divarication with proximal distension. Hydrodissection and adhesiolysis enabled complete reduction; colorectal inspection confirmed viable bowel throughout; no resection was required. Omental patching and layered fascial repair were performed. The patient was discharged on postoperative day 4 without complications. The authors could find only four reports of similar cases of small bowel herniation through a Caesarean section wound; a structured series of all five reported cases is presented. Postoperative wound erythema accompanied by gastrointestinal symptoms warrants urgent computed tomography imaging to exclude bowel herniation. Early operative intervention before ischaemia develops avoids the need for bowel resection. Multidisciplinary management encompassing obstetrics, radiology, and colorectal surgery is essential; later presentations in the existing literature are consistently associated with bowel necrosis and the need for resection.
Although inadvertent intrathecal injection of medications is rare, it often leads to catastrophic neurological complications. This report describes a case of accidental intrathecal injection of high-dose magnesium sulphate combined with a local anaesthetic during anaesthesia for orthopaedic surgery, aiming to raise clinical awareness of safety regarding drug administration routes. An 80-year-old female patient underwent emergency spinal anaesthesia for surgical repair of a left femoral neck fracture. Due to the inadvertent addition of magnesium sulphate to bupivacaine for intrathecal administration, the patient developed acute hypotension and bradycardia, requiring vasopressor support to maintain circulation. Postoperatively, she exhibited lethargy, persistent hypotension, fever, decreased upper limb muscle strength, and complete paralysis of both lower limbs. Following symptomatic management, her condition gradually improved: hemodynamic stability was restored within 24 hours, and complete recovery of consciousness, motor, and sensory functions to preoperative baseline levels was achieved within 39 hours. The patient was discharged on postoperative Day 8 and showed no neurological sequelae during the two-week follow-up period. This case report demonstrates that inadvertent intrathecal injection of magnesium sulphate during anaesthesia can lead to severe complications. Local pharmaceutical manufacturers are advised to modify ampoule appearance, optimize internal risk-based segregation of high-risk medications, and enforce double-check protocols to reduce the recurrence of similar incidents.
Open total abdominal hysterectomy is associated with substantial postoperative pain. We compared ultrasound-guided transversus abdominis plane block with ilioinguinal-iliohypogastric nerve block for postoperative analgesia. We conducted a randomised, parallel-group trial in patients undergoing elective open total abdominal hysterectomy under general anaesthesia, allocating participants 1:1 to bilateral transversus abdominis plane block or ilioinguinal-iliohypogastric nerve block. The primary outcome was time from end of surgery to first rescue nalbuphine within 24 hours. Secondary outcomes included 24-hour nalbuphine consumption, pain scores at rest (0-10 numerical rating scale), haemodynamics, postoperative nausea and vomiting and complications. Forty-two participants were randomised (21 per group). Time to first rescue nalbuphine did not differ significantly between groups (log-rank p = 0.87; hazard ratio [95% CI] 1.06 [0.45-2.50], p = 0.89). Rescue nalbuphine was required by 11/21 (52%) versus 10/21 (48%) participants (p = 1.00). Total 24-hour nalbuphine consumption did not differ significantly between groups (median difference [95% CI] 0 [0-3] mg; p = 0.63). Cumulative pain burden over 24 hours was lower with transversus abdominis plane block (median difference [95% CI] -15.3 score [-21.7 to -8.6]; p = 0.0006). Haemodynamic differences were limited to the end of surgery and 5 minutes in the post-anaesthesia care unit; no significant difference was found in postoperative nausea and vomiting, and no block-related complications were observed. In summary, transversus abdominis plane block and ilioinguinal-iliohypogastric nerve blocks did not differ in time to first rescue nalbuphine; the study was likely underpowered for this endpoint, and equivalence cannot be inferred. A secondary analysis suggested lower cumulative pain burden with transversus abdominis plane block.
Background: Cryoablation is a minimally invasive technique that is being investigated as an alternative to surgery for early-stage breast cancer. Its potential advantages include outpatient treatment under local anaesthesia, favourable cosmetic outcomes, and possible immunologic synergy. However, its oncologic efficacy and long-term effectiveness are yet to be determined. Methods: We conducted a systematic review in accordance with PRISMA 2020 and the Cochrane Handbook, registered on PROSPERO (CRD420251137549). Databases searched were PubMed/MEDLINE, Scopus, and CENTRAL, from inception to August 2025. Eligible studies included women with unifocal, node-negative invasive ductal carcinoma ≤ 2 cm treated with percutaneous cryoablation. Outcomes of interest were residual disease, ipsilateral breast tumour recurrence, procedural and late complications, and cosmetic or patient-reported outcomes. Results: From 1074 records, 15 unique studies (17 reports) were included, comprising cryoablation-only studies (n = 7), treat-and-resect studies (n = 6), and comparative studies versus surgery (n = 2). Studies containing overlapping pathology validation and comparative components were classified within a single category to avoid duplication. Across treat-and-resect cohorts, complete tumour necrosis was reported in 88-95% of cases, with residual invasive carcinoma (RIC) ranging from 5% to 12%. In cryoablation-only cohorts, IBTR rates ranged from 0% to 4.3%, with follow-up durations spanning 2 months to 8 years. The largest study (ICE3, n = 194) reported a 5-year recurrence rate of 4.3%. Procedural complications were infrequent and self-limiting, most commonly bruising, oedema, or superficial frostbite. No major adverse events were reported. Validated quality-of-life instruments reported high patient satisfaction, with favourable results in selected comparative domains. Most included studies were of moderate methodological quality. Conclusions: Cryoablation appears technically feasible, safe, and cosmetically favourable in well-selected low-risk early-stage breast cancers. Oncologic outcomes are encouraging, with reported local recurrence rates in carefully selected low-risk populations being low, although direct comparison with breast-conserving surgery remains limited by the small number of comparative studies and substantial heterogeneity across the evidence base. Rigorous multicentre randomised trials with long-term follow-up and validated patient-reported outcomes are needed before cryoablation can be considered for routine clinical adoption.
Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA, or Bland-White-Garland syndrome) is a rare congenital anomaly associated with a high risk of ischaemic cardiomyopathy and sudden cardiac death. Non-cardiac surgery in patients with uncorrected anomaly is exceedingly rare and standardised peri-operative risk models are lacking. This case report highlights the complex physiological considerations and tailored anaesthetic management of a 13-year-old girl with uncorrected ALCAPA undergoing general anaesthesia for dental extractions. Pre-operative echocardiography demonstrated left ventricular dilatation (52.2 mm) with a preserved ejection fraction (68%) and mild mitral regurgitation. Cardiac magnetic resonance imaging revealed extensive subendocardial scarring and inducible stress perfusion defects, indicating ongoing ischaemic and arrhythmogenic risk. Following a multidisciplinary consensus, the procedure was performed under strict haemodynamic control. General anaesthesia was carefully titrated to maintain the balance between myocardial oxygen supply and demand, and to prevent the exacerbation of coronary steal, with advanced ischaemia monitoring and immediate defibrillator availability. The patient remained haemodynamically stable throughout the peri-operative period. This case demonstrates that by integrating detailed anatomic and functional imaging data, anaesthetic strategies can be precisely tailored to manage the severe physiological vulnerabilities of patients with uncorrected ALCAPA.
Electricity consumed during robot-assisted radical prostatectomy (RARP) generates greenhouse-gas emissions that vary with local grid carbon intensity, yet existing environmental reports are mostly single-centre or single-country and therefore cannot separate procedure electricity demand from jurisdictional electricity context. In this cross-sectional modelling study, a standardised intraoperative plug-load model for RARP was linked to publicly available electricity carbon-intensity data from 208 jurisdictions. The base-case demand was 6.5 kW over a reference operative-time distribution with a median of 170 min (IQR 140-180), corresponding to 18.42 kWh per case, with uncertainty propagated to 12.24-20.48 kWh. Structural sensitivity analyses examined robot-only incremental load, low-resource, infrastructure-conditioning, and high plug-load upper-bound settings, together with counterfactual grid-decarbonisation scenarios. Electricity carbon intensity in the archived analytical extraction ranged from 23.8 to 738.8 gCO2eq/kWh, yielding 0.44-13.61 kgCO2eq per case in the base case (median 6.41; IQR 4.19-8.83). Across scenarios, power-demand assumptions changed absolute values, while jurisdictional grid carbon intensity remained the main source of cross-jurisdiction variation within this electricity-only model. Achieving an electricity-related footprint of < 1 kgCO2eq per case required a grid carbon intensity of < 54.3 gCO2eq/kWh and was achieved by 10 jurisdictions in the archived dataset. Within the defined intraoperative plug-load electricity boundary, using life-cycle grid-intensity factors, these results support location-specific reporting and indicate where electricity decarbonisation or operating-theatre energy management can reduce the electricity component of RARP. The analysis is not a full life-cycle assessment of RARP and should be interpreted alongside non-electricity sources such as consumables, sterilisation, anaesthesia, building services, and hospital stay.
Sialolithiasis is a common condition affecting the salivary glands, typically presenting with pain and swelling, typically during meals. giant sialoliths (>15mm) are rare and usually symptomatic, often requiring surgical intervention. We report the case of a patient who remained completely asymptomatic despite harbouring a 35 x 20mm ovoidal sialolith in the submandibular gland. the patient presented to the emergency department with sudden onset of submandibular pain during the night prior to admission. Clinical examination and imaging confirmed the presence of a large, well-defined, spherical calculus. Remarkably, the stone was manually removed by an otolaryngologist without the need of surgical intervention or anaesthesia. This case is notable for the unusually large size and spherical shape of the sialolith, the absence of prior symptoms, and the successful non-surgical removal. such presentations are extremely rare and highlight the importance of considering sialolithiasis even in atypical clinical scenarios. This case contributes to the limited literature on asymptomatic giant sialoliths and supports the feasibility of non-invasive management in select cases.
A 1939 German publication on a search for novel synthetic atropine substitutes reported that 'Substanz III', named Dolantin (now generically known as pethidine and meperidine), was found coincidentally to also have morphine-like, albeit markedly weaker, analgesic properties. With a chemical structure not obviously related to morphine, it was thus an 'accidental opioid' and was soon successfully marketed in many countries for pain relief. By the 1970s, continuing advances in analytical chemistry were enabling pharmacokinetic studies of countless drugs. Among opioid analgesic agents, pethidine's larger dosing requirements made it suitable for such research, which was performed in healthy volunteers and patients with various doses and routes of administration, with some reports also including pharmacological responses. Standard postoperative intramuscular pethidine administration revealed steep and unpredictable plasma concentration-analgesic response relationships characterised by marked variability between patients. Novel computer-designed intravenous infusions based on typical pethidine pharmacokinetic data were trialled to replace intramuscular injections. These infusions improved the reliability of postoperative pain management but could not overcome the variability in individual patient requirements. This limitation accelerated the development of empirical 'patient-controlled analgesia' techniques, initially with pethidine, and subsequently with other opioid analgesic agents, thereby enabling personalised pain management. The 1970s' discovery of spinal opioid receptors and mechanisms led to neuraxial pethidine administration being investigated and subsequently integrated into standard clinical practice. Although pethidine has now been superseded in many countries, it served as an important 'model' drug to investigate how to improve the use of opioid analgesic agents for the management of severe pain.
Despite strong evidence, implementing Patient Blood Management (PBM) in routine practice remains challenging. This work describes the method we used at Grenoble Alpes University Hospital for producing quality reports using data from a graph-based clinical data warehouse (CDW).
International clinical practice guidelines recommend discontinuing sodium-glucose cotransporter-2 inhibitors (SGLT2i) 3-4 days before surgery to prevent euglycemic diabetic ketoacidosis, chiefly on the basis of case reports/series. Whether SGLT2i discontinuation may increase the risk of postoperative cardiovascular complications is unclear. In a secondary analysis of the Basel-PMI (NCT02573532) and PMI-Vital (NCT05866874) prospective cohort studies in major noncardiac surgery, the exposure of interest was continuing, or stopping, SGLT2i in participants receiving chronic SGLT2i therapy. The primary outcome was an ordinal composite of acute heart failure hospitalisation and cardiovascular death within 90 days of surgery, adjusting for prespecified covariates. Secondary outcomes included the incidence of euglycemic diabetic ketoacidosis within 7 days. Among 451 study participants receiving SGLT2i (mean age 72 (range: 47-86) yr; 22% women), 404/451 (89.6%) had diabetes mellitus, and 166/451 (36.9%) had chronic heart failure. SGLT2i were discontinued before surgery in 393/451 (87.1%) participants (39.2% for 1 day, 34.4% for 2 days, 13.5% for ≥3 days). Cardiovascular complications occurred in 1/58 (1.7%) participants who continued SGLT2i, compared with 10/177 (5.7%) stopping for 1 day, 13/155 (8.4%) stopping for 2 days and 7/61 (11.5%) stopping for ≥3 days (P=0.011; adjusted odds ratio: 1.58 [95% confidence interval: 1.08-2.30] per discontinued day). Euglycemic diabetic ketoacidosis occurred in 1/451 participants after SGLT2i discontinuation. Perioperative SGLT2i discontinuation was associated with a substantially increased risk of 90-day cardiac complications. This suggests potential harm in current guideline recommendations; randomised controlled trials are needed to confirm these findings. NCT02573532, NCT05866874.
Epidural catheters are commonly used to provide effective postoperative analgesia and are usually removed without difficulty. We report a case of unexpected resistance during removal of an epidural catheter in an obese adolescent patient. After several unsuccessful manoeuvres, including positional changes and saline flushing, further blind traction was avoided to reduce the risk of catheter fracture or neurological injury. Imaging was done to identify the aetiology, which revealed looping of the catheter in the paraspinal muscular plane. After multidisciplinary discussion, the clinical team adopted a carefully planned and minimally invasive approach with surgical backup. The catheter was successfully removed under local infiltration anaesthesia without complications. This case demonstrates the importance of careful evaluation when resistance is encountered and highlights how imaging techniques can assist in clarifying the underlying mechanism. Based on this experience and existing literature, we outline a pragmatic stepwise approach that may assist clinicians when managing similar situations.
Trigeminal trophic syndrome (TTS) is an unusual presentation of painless facial ulceration with associated facial anaesthesia and paraesthesia. The syndrome stems from injury to branches of the trigeminal nerve. TTS can also be triggered by conditions such as ischaemic strokes and herpes zoster virus. The altered superficial sensation to the skin causes irritation along the distribution of the trigeminal nerve, usually described as burning and tingling. This sensation leads to repetitive scratching and rubbing over the affected area. Self-manipulation injuries then progress into an erosive ulcer, typically around the cheek, face and lateral nasal ala. We present the cases of two patients with erosive lateral nasal ulcers and a history of ipsilateral vestibular schwannoma repair. In both cases, symptoms resolved following diagnosis and treatment for TTS. We also provide a literature review of the condition, including a summary of the most recently published case reports.
Advances in anaesthesia and minimally invasive surgical techniques have expanded therapeutic options for patients with complex cardiac disease. While conventional open-heart surgery carries significant risks for this population, hybrid strategies offer a viable alternative. We report the first case of concurrent hypertrophic obstructive cardiomyopathy (HOCM) and coronary artery disease (CAD) treated with a one-stage hybrid strategy: combining the Liwen procedure (echocardiography-guided percutaneous intramyocardial septal radiofrequency ablation) with minimally invasive direct coronary artery bypass (MIDCAB) via a single access. This approach effectively addressed both left ventricular outflow tract obstruction and myocardial ischaemia, while reducing trauma and accelerating recovery. This case demonstrates that the concomitant Liwen procedure and MIDCAB through a single minimally invasive access is a feasible and promising strategy for patients with coexisting HOCM and CAD, offering reduced trauma and faster recovery compared to traditional approaches.
Plasma exchange (PLEX) improves survival in acute liver failure (ALF); however, there is no study specifically analyzing its utility in hepatitis A virus-related ALF (HAV-ALF). A few reports suggest that ALF patients who are not on inotropes tolerate PLEX better. We aimed at comparing the efficacy of PLEX and of standard medical treatment (SMT) to treat HAV-ALF. We retrospectively compared consecutive HAV-ALF patients treated with PLEX (2018-2024) vs. SMT (2011-2024) at 13 centers across India. We compared in-hospital native liver survival in both groups. In the subset of patients not on inotropes, we compared survival and assessed predictors of poor outcome in PLEX and SMT groups. Eighty-four HAV-ALF patients in PLEX group (61 males; age = 23.5 [21-33] years, median [IQR]; King's College Criteria [KCC] fulfilled = 22 patients, 26.2%) and 150 HAV-ALF in SMT group (101 males; 24 [19-32.3] years; KCC fulfilled = 16, 10.7%) were studied. Overall survival was comparable in PLEX (70.2%) and SMT groups (65.3%) (p-value = 0.47). In a sub-group of hemodynamically stable patients not on inotropes, univariate analysis showed better survival in PLEX group (52/54, 96.3%) as compared to SMT group (81/104, 77.9%; OR = 0.135, 95% CI = 0.03-0.6; p-value = 0.002). However, this benefit was not noted in propensity score matched/regression analyses. While PLEX did not influence in-hospital outcome across all HAV-ALF patients, it may confer survival benefit in a sub-group who remained hemodynamically stable not requiring inotropes. Studies with larger patient numbers are needed to explore this hypothesis.
Left cardiac sympathetic denervation (LCSD) via video-assisted thoracoscopy (VATS) is an effective therapy for drug-refractory malignant arrhythmias in congenital long QT syndromes and requires meticulous perioperative planning in children with automatic implantable cardioverter-defibrillators (AICDs). We describe what is likely the first paediatric VATS-LCSD performed in Pakistan. A boy in early childhood with Jervell and Lange-Nielsen syndrome, severe QT prolongation and recurrent ventricular arrhythmias despite beta-blockade and mexiletine had received multiple AICD shocks. Intraoperative management focused on preventing electrocautery-induced AICD activation by applying a magnet to suspend antitachycardia therapies, using external defibrillation pads and ensuring continuous electrophysiology support. Anaesthesia incorporated sevoflurane, dexmedetomidine, cisatracurium and lidocaine, with one-lung ventilation achieved by intentional endobronchial tracheal tube placement. Thoracoscopic excision of the left sympathetic chain (T5-T1), including the lower stellate, was completed uneventfully. The child was extubated in the operating room and discharged the next day without complications.