Assessment of seizure duration and utility of using SedLine® EEG tracing in veterans undergoing electroconvulsive therapy: a retrospective analysis.

BACKGROUND: Electroconvulsive therapy (ECT) endures as a definitive treatment for refractory depression and catatonia and is also considered an effective treatment for a number of other severe psychiatric disorders (Lisanby, N Engl J Med 357:1939-1945, 2007)(Weiner and Prudic, Biol Psychiatry 73:105-106, 2013). GA is an essential component of the ECT procedure for various reasons (Lee, Jenkins and Sparkle, Life 11, 2021). Monitoring anesthetic effects on the brain is desirable as anesthetic agents affect seizure duration and recovery (Rasulo, Hopkins, Lobo, et al,  Neurocrit Care 38:296-311, 2023) (Jones , Nittur , Fleming and Applegate,  BMC Anesthesiol 21:105, 2021) (Soehle , Kayser , Ellerkmann and Schlaepfer,  BJA 112:695-702, 2013). Perioperative anesthetic effects on consciousness can be assessed with brain function monitoring using raw electroencephalogram (EEG) traces and processed EEG indices. OBJECTIVE: We examined the usefulness and utility of the SedLine® anesthetic effect monitor during ECT procedures. We hypothesized that the seizure duration as measured by the EEG tracing of the ECT machine is equivalent to the duration assessed by the SedLine® EEG tracing. A secondary objective was to describe the SedLine® patient state indices (PSI) at different phases of treatment. METHODS: Following IRB approval, we analyzed the data of the electronic medical records of 45 ECT treatments of 23 patients in an urban VA medical center between July 01, 2021, and March 30, 2022. We compared the seizure duration in minutes and seconds as measured either by the ECT machine EEG tracing or the SedLine® EEG tracing. We then collected SedLine® processed EEG indices at four different stages during the treatment. Appropriate comparative and observational statistical analyses were applied. RESULTS: There was no significant difference in measured seizure duration between the two methods examined (p < 0.05). We observed a lag of the SedLine PSI value at the time before stimulus delivery and limited PSI utility during the course of ECT. CONCLUSION: The SedLine® EEG tracing can be an alternative to the machine EEG tracing for the determination of seizure duration. The SedLine® processed EEG indices are not consistently useful before and after ECT delivery. Anesthetic effect monitoring during ECT is feasible.

"The Big Three" of geriatrics: A review of perioperative cognitive impairment, frailty and malnutrition.

Cognitive impairment, frailty, and malnutrition are three of the most impactful pathologies facing an aging population, having dramatic effects on morbidity and mortality across nearly all facets of medical care and intervention. By 2050, the World Health Organization estimates that the population of individuals over the age of sixty worldwide will nearly double, and the public health toll of these demographic changes cannot be understated. With these changing demographics comes a need for a sharpened focus on the care and management of this vulnerable population. The average patient presenting for surgery is getting older, and this necessitates that clinicians understand the implications of these pathologies for both their immediate medical care needs and for appropriate procedural selection and prognostication of surgical outcomes. We believe it is incumbent on clinicians to consider the frailty, nutritional status, and cognitive function of each individual patient when offering a surgical intervention, as well as consider interventions that may delay the progression of these pathologies. Unfortunately, despite excellent evidence supporting things like routine pre-operative frailty screening and nutritional optimization, many interventions that would specifically benefit this population still have not been integrated into routine practice. In this review, we will synthesize the existing literature on these topics to provide a pragmatic approach and understanding for anesthesiologists and intensivists faced with this complex population.

Temperature Changes During Electrophysiology Ablation in Veterans and 1-Year Success Rates: A Retrospective Pilot Analysis.

OBJECTIVES: The authors hypothesized that body core temperature during cardiac arrhythmia procedures in the electrophysiology laboratory declines, and examined the association of changes with the patient or procedural factors. They hypothesized that a greater degree of change negatively affects 1-year ablation success. DESIGN: Retrospective observational study. SETTING: Veteran's Administration Boston Healthcare System. PARTICIPANTS: Consecutive records of veterans undergoing ablation procedures under general anesthesia. INTERVENTIONS: Retrospective data collection and analysis from the electronic medical record. MEASUREMENTS AND MAIN RESULTS: Patient and procedural characteristics were collected from the electronic medical record. Core temperature data included baseline (BT) (following entry to the care process on the day of the procedure), the start (ST) and end of the procedure temperatures (ET), and their differences. The 1-year ablation success was assessed as described elsewhere in the literature. The authors used the paired t-test, linear, and logistic regression for hypothesis testing. Among 107 veterans, core temperatures were significantly lower between BT and ST, BT and ET, and ST and ET (p < 0.001 for all). One-year ablation success was 74.8% (n = 80). In multivariate logistic regression adjusted for age, body mass index and BTs showed a greater degree of change from BT to ET, and the ST-to-ET temperature was significantly associated with lower odds of success (odds ratios of 0.57 and 0.42, respectively; p < 0.05 for both). CONCLUSIONS: Core temperature declines during ablation. Greater temperature decline during general anesthesia was associated with lower 1-year ablation success rates.

Intravenous lidocaine infusion in a case of severe COVID-19 infection.

A subset of patients with COVID-19 develops a severe inflammatory response that may lead to respiratory and multiorgan failure. Effective treatment strategies to mitigate or interrupt this self-destructive inflammatory process are limited. The local anesthetic lidocaine has anti-inflammatory properties in addition to its analgesic, antiarrhythmic, and sedating effects that may be beneficial in critically ill COVID-19 patients. We report the case of a patient with COVID-19 induced severe respiratory distress who was intubated and received supportive treatment including proning and neuromuscular blockade. He developed a strong inflammatory response that we treated with an intermittent lidocaine infusion resulting in subsequent resolution. This case occurred prior to emerging data from a large dexamethasone use trial that demonstrated a survival benefit from its use in hospitalized COVID-19 patients. At the time, lidocaine was the only anti-inflammatory medication our patient received.

Epiaortic Ultrasound for Assessment of Intraluminal Atheroma; Insights from the REGROUP Trial.

OBJECTIVES: To assess the use of epiaortic ultrasound in contemporary cardiac surgery, as well as its impact on surgical cannulation strategy and cerebrovascular events. DESIGN: Epiaortic ultrasound data was prospectively collected in the Randomized Endovein Graft Prospective (REGROUP) trial (VA Cooperative Studies Program #588, ClinicalTrials.gov, NCT01850082), which randomized 1,150 coronary artery bypass graft patients between 2014 and 2017 to endoscopic or open-vein graft harvest. SETTING: Sixteen cardiac surgery programs within the Veterans Affairs Healthcare System with expertise at performing endoscopic vein-graft harvesting. PARTICIPANTS: Veterans Affairs patients, greater than 18 years of age, undergoing elective or urgent coronary artery bypass grafting with cardiopulmonary bypass and cardioplegic arrest with at least one planned saphenous vein graft were eligible for enrollment. INTERVENTIONS: Epiaortic ultrasound was performed by the surgeon using a high frequency (>7 MHz) ultrasound transducer. Two-dimensional images of the ascending aorta in multiple planes were acquired before aortic cannulation and cross-clamping. MEASUREMENTS AND MAIN RESULTS: Epiaortic ultrasound was performed in 34.1% (269 of 790) of patients in REGROUP. Among these patients, simple intraluminal atheroma was observed in 21.9% (59 269), and complex intraluminal atheroma comprised 2.2% (6 of 269). The aortic cannulation or cross-clamp strategy was modified based on these findings in 7.1% of cases (19 of 269). There was no difference in stroke between patients who underwent epiaortic ultrasound and those who did not (1.9% v 1.2% p = 0.523). CONCLUSIONS: Despite current guidelines recommending routine use of epiaortic ultrasound (IIa/B) to reduce the risk of stroke in cardiac surgery, in this contemporary trial, use remains infrequent, with significant site-to-site variability.

Improving detection of intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) and their contribution to postoperative outcomes.

Our knowledge of the types of intraoperative patient safety events, their harm to patients, and relationship to postoperative complications is sparse. This study examined intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) voluntarily reported by providers using two programs at our hospital: surgical debriefing and incident reporting. Among the 3020 surgical procedures assessed, 142 iMEs and 103 iAEs were reported, yielding an overall rate of 8%. Of these events, 135 (55%) were obtained from incident reporting and 110 (45%) from surgical debriefing. The overall association between intraoperative events (iMEs and iAEs) and 30-day postoperative morbidity was significant (adjusted odds ratio = 1.08 with 95% confidence interval (CI) of (1.03, 1.13). This association was stronger when we included only the iAEs (1.47, 95% CI (1.35, 1.58)). Our findings suggest that hospitals should consider using both programs to obtain a more complete picture of intraoperative patient safety and to reduce postoperative morbidity.

Enhanced Recovery After Surgery in Laparoscopic Surgery.

BACKGROUND: As part of an effort to maximize value in the perioperative setting, a paradigm shift is underway in the way that patients are cared for preoperatively, on the day of surgery, and postoperatively-a setting collectively known as the perioperative care. Enhanced Recovery After Surgery (ERAS®) is an evidence-based, patient-centered team approach to delivering high-quality perioperative care to surgical patients. METHODS: This review focuses on anesthesiologists, with their unique purview of perioperative setting, who are important drivers of change in the delivery of valuable perioperative care. ERAS care pathways begin in the preoperative setting by both preparing the patient for the psychological stress of surgery and optimizing the patient's medical and physiologic status so the body is ready for the physical demands of surgery. RESULTS: Minimization of perioperative fasting is important to maintain volume status-decreasing reliance on intravenous fluid administration, and to reduce protein catabolism around the time of surgery. Intraoperative management in ERAS pathways relies on goal-directed fluid therapy and opioid-sparing multimodal analgesia. Postoperatively, early feeding and ambulation, as well as discontinuation of extraneous lines and catheters facilitate patients' functional recovery. CONCLUSION: The laparoscopic approach to surgery, when possible, compliments ERAS techniques by reducing abdominal wall trauma and the resultant milieu of inflammatory, neurohumoral, and pain responses. Anesthesiologists driving change in the perioperative setting, in collaboration with surgeons and other disciplines, can improve value in healthcare and provide optimal outcomes that matter most to patients and healthcare providers alike.

Detection and potential consequences of intraoperative adverse events: A pilot study in the veterans health administration.

Surgical quality improvement efforts have focused on tracking and reducing postoperative mortality and morbidity. However, the prevalence of intraoperative adverse events (IAEs) and their association with postoperative surgical outcomes has been poorly studied. In this study, we detected IAEs using both retrospective chart review and prospective provider reporting. We then examined the association of IAEs with postoperative outcomes. The overall IAE detection rate per case was 0.7 and 0.07 (P < 0.0001) based on chart review and provider reporting, respectively. Types of IAEs varied between detection methods. Provider-reported IAEs were more serious, i.e., had a stronger association with 30-day postoperative complications than chart-identified IAEs (risk-adjusted odds ratios were 1.52 vs 1.02, respectively, both p < 0.0001). Our findings suggest that IAEs can be detected using either retrospective chart review or prospective provider reporting. However, provider reporting appears more likely to detect serious (albeit infrequent) IAEs compared to chart review.

Effects of routine monitoring of delirium in a surgical/trauma intensive care unit.

BACKGROUND: Delirium is prevalent in surgical and trauma intensive care units (ICUs) and carries substantial morbidity. This study tested the hypothesis that daily administration of a diagnostic instrument for delirium in a surgical/trauma ICU decreases the time of institution of pharmacologic therapy and improves related outcomes. METHODS: Controlled trial of two concurrent groups. The Confusion-Assessment Method for ICU was administered daily to all eligible patients admitted to our surgical/trauma ICU for 48 hours or longer. The result was communicated to one of the two preexisting ICU services (intervention service) and not the other (control service). Primary outcome was the time between diagnosis of delirium and pharmacologic treatment. Secondary outcomes included duration of delirium, mechanical ventilation, and ICU stay. RESULTS: Delirium occurred in 98 (35%) of 283 consecutive patients. Time between diagnosis and therapy did not differ between intervention (35 [35] hours) and control (40 [41] hours) groups. There was a difference in the number of delirium days treated in the intervention (73%) versus control (64%) groups (p = 0.035). The intervention group had significantly lower odds to neglect treating delirium when delirium was present (odds ratio, 0.67; 95% confidence interval, 0.45-1.00; p = 0.05). In the subgroup of trauma patients, the odds ratio of negligence was 0.37 (95% confidence interval, 0.14-0.99; p = 0.048), indicating lower probability for trauma patients to be untreated. There was no difference in the average duration of delirium, mechanical ventilation, and ICU stay. CONCLUSION: In our surgical/trauma ICU, daily screening for delirium did not affect the timing of pharmacologic therapy. Although the intervention resulted in a higher number of delirious ICU patients being treated, particularly trauma patients, there was no effect on related outcomes. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Serum lipid profile on admission for ischemic stroke: failure to meet National Cholesterol Education Program Adult Treatment Panel (NCEP-ATPIII) guidelines.

OBJECTIVE: To determine the characteristics of patients with stroke/TIA whose admission low-density lipoprotein (LDL) levels were above goals defined by National Cholesterol Education Program Adult Treatment Panel (NCEP-ATPIII) guidelines. METHODS: From January 1, 2003, to June 30, 2005, there were 1,212 discharges (1,033 stroke, 179 TIA), of whom 1,040/1,212 (86%) had lipid measurement. The preadmission individual LDL goal was determined using 2001 NCEP-ATPIII guidelines. RESULTS: There were 284/1,040 (27%) whose measured LDL was greater than the individual preadmission LDL goal. Failure to be at goal was common even among those with previously diagnosed dyslipidemia (159/527, 30%) and those taking lipid-lowering agents (LLA) (71/370, 19%). LLA would have been indicated in 121/213 (57%) of those above LDL goal who were not already taking LLA, with optional consideration in 77/213 (36%). Lower LDL therapeutic targets were the strongest predictor, in a multivariable model, of failure to be at goal. Compared to LDL target <160 (reference), the OR for LDL target <130 was 6.4 (95% CI 3.4 to 12.0, p < 0.0001) and for LDL target <100 was 26.2 (95% CI 13.3 to 51.5, p < 0.0001). An increased likelihood of being at goal was associated with preadmission LLA (OR 4.2, 95% CI 2.9 to 6.2, p < 0.0001) and increasing calendar time (OR 1.09 per 3-month period, 95% CI 1.03 to 1.15, p = 0.004). CONCLUSIONS: Many patients hospitalized with ischemic stroke/TIA, including those with known dyslipidemia and those taking lipid lowering agents, have measured low-density lipoprotein (LDL) that is higher than recommended by national guidelines. Patients at the greatest risk of cardiovascular events are the least likely to be at guideline-recommended LDL levels.