Hypoxemia After Endobronchial Valve Deployment for Persistent Air Leak.

Endobronchial valves (EBVs) are a novel, minimally invasive bronchoscopic management technique for persistent air leaks that fail conservative therapy. Currently, 2 EBVs are available in the United States: the Spiration Valve System (Olympus, Redmond, WA) and the Zephyr Valve (Pulmonx, Redwood, CA). These valves are Food and Drug Administration-approved to reduce hyperinflation in emphysematous patients via bronchoscopic lung-volume reduction. However, more recently, the Spiration Valve has been granted a compassionate use exemption through the Food and Drug Administration for persistent postsurgical air leaks. Despite their popularity, these devices are not free from side effects. As an anesthesiologist, it is vital to be aware of the pathophysiology of this patient population so that safe and effective anesthetics may be provided during valve placement. Here, the use of EBVs is discussed in a patient who presented with a persistent air leak after a transthoracic needle aspiration that failed treatment due to persistent hypoxemia, warranting EBV removal.

Intraoperative Hypotension-Physiologic Basis and Future Directions.

Intraoperative hypotension (IOH) is a major concern to the anesthesiologist. Its appropriate identification and management require an understanding of the physiology of blood pressure regulation, prudent blood pressure monitoring, and treatment. Even short durations of low mean arterial pressure have been associated with adverse postoperative clinical outcomes. The challenge is for the clinician to respond proactively, address the specific etiology of IOH, and keep in mind any changes to the patient's physiology. Predictive technology, such as the Hypotension Prediction Index, offers the clinician new insight into IOH. It has been shown to predict hypotension up to 15 minutes before occurrence. It also calculates stroke volume variation, dynamic arterial elastance, and left ventricular contractility, which can inform the anesthesiologist of the etiology of IOH to direct management. This new technology has the potential to reduce duration or even prevent IOH. In the authors' opinion, it is an example of how human-machine interaction will contribute to future advances in medicine. Additional studies should evaluate the effects of its use on postoperative outcomes.

Transfusion-Related Acute Lung Injury During Liver Transplantation: A Scoping Review.

Liver transplantation is associated with significant blood loss, often requiring massive blood product transfusion. Transfusion-related acute lung injury (TRALI) is a devastating cause of transfusion-related deaths. While reports have investigated the general incidence of TRALI, the incidence of TRALI specifically following transfusion during liver transplant remains unclear. This scoping review summarizes existing literature regarding TRALI during the liver transplantation perioperative period. Databases were searched for all articles and abstracts reporting on TRALI after liver transplantation. Data collected included number of patients studied, patient characteristics, incidences of TRALI, TRALI characteristics, and patient outcomes. The primary outcome investigated was the incidence of TRALI in the setting of liver transplantation. Thirteen full-text citations were included in this review. The incidence of TRALI post-liver transplant was 0.68% (65 of 9,554). Based on reported transfusion data, patients diagnosed with TRALI received an average of 10.92 ± 10.81 units of packed red blood cells (pRBC), 20.05 ± 15.72 units of fresh frozen plasma, and 5.75 ± 10.00 units of platelets. Common interventions following TRALI diagnosis included mechanical ventilation with positive end-expiratory pressure, inhaled high-flow oxygen, inhaled pulmonary vasodilator, and pharmacologic treatment using pressors or inotropes, corticosteroids, or diuretics. Based on reported mortality data, 26.67% of patients (12 of 45) diagnosed with TRALI died during the postoperative period. This scoping review underscores the importance of better understanding the incidence and presentation of TRALI after liver transplant surgery. The clinical implications of these results warrant the development of identification and management strategies for liver transplant patients at increased risk for developing TRALI.

Primary Stroke and Failure-to-Rescue Following Thoracic Endovascular Aortic Aneurysm Repair.

OBJECTIVE: To characterize the impact, on failure to rescue, of cerebrovascular accident as a first postoperative complication after thoracic endovascular aortic aneurysm repair (TEVAR). DESIGN: A retrospective cohort study using of National Surgical Quality Improvement Program Participants User File. SETTING: United States hospitals taking part in the National Surgical Quality Improvement Program. PARTICIPANTS: Patients >18 years, who underwent TEVAR for nonruptured thoracic aortic aneurysm between 2005 and 2018, and developed one or more major postoperative complications within 30 days after surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Out of 3,937 patients who underwent TEVAR for nonruptured thoracic aneurysm, 1,256 (31.9%) developed major postoperative complications (stroke incidence: 11.4% [143/1256]). In adults <65 years old, the occurrence of stroke as the primary complication, relative to the occurrence of other complications, was associated with ten times greater risk of failure to rescue (29.4% v 4.6%; odds ratio [OR]: 10.10; 95% confidence interval [CI] 2.45-41.56; p < 0.001). The effect size was relatively lower when stroke occurred but was not the primary complication (20.0% v 4.6%; OR: 7.55; 95% CI 1.37-41.71; p = 0.020). In patients ≥65 years, the occurrence of stroke as the primary complication did not carry the similar prognostic value. CONCLUSION: Younger patients who developed stroke were up to ten times more likely to die, relative to patients who developed other major complications. Survival was substantially reduced when stroke was the primary complication. The authors' findings imply that to maximize the survival of patients undergoing TEVAR, efforts may be needed to predict and prevent stroke occurrence as a primary postoperative morbidity event.

Implantation of subcutaneous defibrillator is feasible and safe with monitored anesthesia care.

BACKGROUND: The perioperative anesthesia care during subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation is still evolving. OBJECTIVE: To assess the feasibility and safety of S-ICD implantation with monitored anesthesia care (MAC) versus general anesthesia (GA) in a tertiary care center. METHODS: This is a single-center retrospective study of patients undergoing S-ICD implantation between October 2012 and May 2019. Patients were categorized into MAC and GA group based on the mode of anesthesia. Procedural success without escalation to GA was the primary endpoint of the study, whereas intraprocedural hemodynamics, need of pharmacological support for hypotension and bradycardia, length of the procedure, stay in the post-anesthesia care unit, and postoperative pain were assessed as secondary endpoints. RESULTS: The study comprises 287 patients with MAC in 111 and GA in 176 patients. Compared to MAC, patients in GA group were younger and had a higher body mass index. All patients had successful S-ICD implantation. Only one patient (0.9%) in the MAC group was converted to GA. Despite a similar baseline heart rate (HR) and mean arterial blood pressure (MAP) in both groups, patients with GA had significantly lower HR and MAP during the procedure and more frequently required pharmacological hemodynamic support. Length of the procedure, stay in the postanesthesia care unit, and postoperative pain was similar in both groups. CONCLUSION: This retrospective experience suggests that implantation of S-ICD is feasible and safe with MAC. Use of GA is associated with more frequent administration of hemodynamic drugs during S-ICD implantation.

Timing of Postoperative Stroke and Risk of Mortality After Noncardiac Surgery: A Cohort Study.

Background: Postoperative stroke is a devastating complication of surgery, given its association with severe long-term disability and mortality. Previous investigators have confirmed the association of stroke with postoperative mortality. However, limited data exist regarding the relationship between the timing of stroke and survival. Addressing this knowledge gap will help clinicians develop tailored perioperative strategies to reduce the incidence, severity, and mortality associated with perioperative stroke. Therefore, our objective was to determine whether the timing of postoperative stroke influenced mortality risk. Methods: We performed a retrospective cohort study of patients > 18 years who underwent noncardiac surgery and developed postoperative stroke during the first 30 days of surgery (National Surgical Quality Improvement Program Pediatrics 2010 - 2021). Our primary outcome was 30-day mortality following the occurrence of postoperative stroke. We subdivided patients into two mutually exclusive groups: early and delayed stroke. Early stroke was defined as the occurrence within 7 days following surgery, consistent with a previous study. Results: We identified 16,750 patients who underwent noncardiac surgery and developed stroke within 30 days of surgery. Of these, 11,173 (66.7%) had an early postoperative stroke (≤ 7 days). Perioperative physiological status, operative characteristics, and preoperative comorbidities were generally comparable between patients with early and delayed postoperative stroke. Despite the comparability in these clinical characteristics, the mortality risk was 24.9% for early and 19.4% for delayed stroke. After adjusting for perioperative physiological status, operative characteristics, and preoperative comorbidities, early stroke was associated with an increased mortality risk (adjusted odds ratio: 1.39, confidence interval: 1.29 - 1.52, P-value < 0.001). In patients with an early postoperative stroke, the most common preceding complications were bleeding requiring transfusion (24.3%), followed by pneumonia (13.2%) and renal insufficiency (11.3%). Conclusions: Postoperative stroke tends to occur within 7 days following noncardiac surgery. Such timing of postoperative stroke carries a higher mortality risk, suggesting that targeted efforts to prevent stroke should focus on the first week following surgery to reduce the incidence and mortality associated with this complication. Our findings contribute to the growing understanding of stroke after noncardiac surgery and may help clinicians develop tailored perioperative neuroprotective strategies to prevent or improve treatment and outcomes of postoperative stroke.