Anesthetic considerations for thoracoscopic sympathetic ganglionectomy to treat ventricular tachycardia storm: a single-center experience.

OBJECTIVE: The aim of this study was to determine the pertinent anesthetic considerations for patients undergoing surgical sympathectomy for electrical storm (incessant ventricular tachycardia (VT) refractory to traditional therapies). DESIGN: This is a retrospective review of a prospective database. SETTING: This single-center study took place in a university hospital setting. PARTICIPANTS: Twenty-six patients were enrolled. INTERVENTIONS: Fifteen patients underwent left-sided sympathectomy, whereas 11 patients underwent bilateral sympathectomy. MEASUREMENTS AND MAIN RESULTS: Anesthetic management of these patients was quite complex, requiring invasive monitoring, transesophageal echocardiography, one-lung ventilation, programming of cardiac rhythm management devices, and titration of vasoactive medications. Paired t test of hemodynamic data before, during, and after surgery showed no significant difference between preoperative and postoperative blood pressure values, regardless of whether the patient underwent unilateral or bilateral sympathectomy. Eight patients remained free of VT, three patients responded well to titration of oral medications, and one patient required 2 radiofrequency ablations after sympathectomy to control his VT. Three patients continued to have VT episodes, although reduced in frequency compared with before the procedure. Four patients were lost to followup. Overall, five patients within the cohort died within 30 days of the procedure. No patients developed any anesthetic complications or Horner's syndrome. The overall perioperative mortality (within the first 7 days of the procedure) was 2 of 26, or 7.7%. CONCLUSIONS: The anesthetic management of patients undergoing surgical sympathectomy for electrical storm can be quite complex, because these patients often present in a moribund and emergent state and cannot be optimized using current ACC/AHA guidelines. Expertise in invasive monitoring, transesophageal echocardiography, one-lung ventilation, cardiac rhythm device management, and pressor management is crucial for optimal anesthetic care.

Transthoracic echocardiography simulation is an efficient method to train anesthesiologists in basic transthoracic echocardiography skills.

BACKGROUND: The clinical utility of focused transthoracic echocardiography (TTE) is increasingly recognized in perioperative medicine. However its use is limited among anesthesiologists because of a lack of training. The most efficient training methods have not been determined. We hypothesized that simulation-based TTE training would be more effective than traditional lecture-based methods for teaching basic TTE skills to the anesthesiology residents. METHODS: In this prospective randomized study, 61 anesthesiology residents (in anesthesia clinical training years 1 to 3) were randomized to either control (n = 30) or simulation groups (n = 31) for TTE training. A standardized pretest was administered before TTE training sessions of 45 minutes each. The first training session used a lecture-based video didactic in the control group or a TTE simulator in the simulation group. Comprehension in both groups was then assessed using a written posttest and by performing a TTE examination on a volunteer subject. TTE examinations were graded on the ability to acquire the correct image, image quality, anatomy identification, and time required to attain proper imaging by 2 blinded experts. A second training session incorporating "hands-on" training with a volunteer subject was conducted in a subset of 21 residents (n = 11 control, n = 10 simulation). The simulation group included additional simulator training. After the second session, another posttest on a volunteer subject was administered. RESULTS: Pretest scores revealed similar preintervention knowledge among residents (56.0% ± 11.9% vs 59.3% ± 11.0%, P = 0.25; control versus simulator group, respectively). The simulation group scored higher on all criteria after the first training session: written posttest (57.9% ± 8.8% vs 68.2% ± 10.1%; P < 0.001), volunteer subject posttest image quality scores (0 to 25 scale) (6.4 ± 3.5 vs 12.4 ± 4.2; P = 0.003), anatomy identification scores (0 to 25 scale) (8.3 ± 6.6 vs 17.8 ± 6.6; P = 0.003), and percentage correct views (50 ± 19 vs 78 ± 21; P < 0.001). After the second session, all scores were again improved in the simulation group: volunteer subject posttest image quality scores (9.6 ± 3.3 vs 15.6 ± 2.8; P = 0.002), anatomy identification scores: (17.6 ± 3.8 vs 22.8 2.4; P = 0.003), and percentage correct views (80 ± 16 vs 96 ± 8; P = 0.007). DISCUSSION: This prospective randomized study demonstrated that anesthesiology residents trained with simulation acquired better skills in TTE image acquisition and anatomy identification on volunteer subjects. The educational benefit of simulation persisted even with introduction of hands-on instruction with volunteer subjects in both groups. The impact of these short-term educational approaches on longer-term retention and actual clinical application warrants further investigation.