Blood or Fat? Differentiating Hemopericardium versus Epicardial Fat Using Focused Cardiac Ultrasound.

Basic point-of-care ultrasound of the heart-also known as Focused Cardiac Ultrasound (FoCUS)-has emerged as a powerful bedside tool to narrow the differential diagnosis of causes of hypotension. The list of causes of hypotension that a FoCUS provider is expected to be able to recognize includes a compressive pericardial effusion due to hemopericardium (blood in the pericardial sac). But hemopericardium can be difficult to distinguish from a more common condition that is not immediately life-threatening: epicardial fat. This paper reviews illustrative images of both epicardial fat and hemopericardium to provide practice guidance to the FoCUS user on how to differentiate these two phenomena.

Prevention of contamination after endotracheal intubation using a dedicated sleeve.

Background: Contamination of work surfaces by used laryngoscopes after endotracheal intubation is a serious infection control concern but no strategies are available to address it. We assessed if contamination of the surfaces after endotracheal intubation would be reduced when providers used a dedicated, self-erected, disposable plastic sleeve (BladePouch) to store the used laryngoscope as compared to using single gloves or double gloves and sheathing the laryngoscope with the outer gloves. Methods: Twenty participants were recruited including attending physicians, trainees and allied health care professionals. They performed endotracheal intubation on a mannequin with oral cavity coated with a dye and stored the used laryngoscope blade using single gloves, double gloves or BladePouch. Each participant used both direct and video laryngoscopes. Following intubation, dye contamination of gloves, gown and work surface was evaluated. Results: There was no difference in the contamination of gloves or gowns between the single gloves, double gloves or BladePouch groups. However, work surface contamination was significantly reduced when using BladePouch compared to single or double gloves (13% vs. 100% vs. 80% respectively, P<0.001). The odds of work surface contamination were significantly lower with BladePouch vs. single or double gloves, even when adjusted for intubation device, role and experience of participants with an adjusted odds ratio of 0.0054 (95% confidence interval: 0.0009-0.0314), P<0.001. Conclusions: In conjunction with standard precautions, the use of a dedicated plastic sleeve to store contaminated laryngoscope blade after endotracheal intubation may reduce the work surface contamination, independent of intubation device, role and experience of providers.

The Quality Improvement Fellow: Educating on Making the Difference.

The critical care medicine (CCM) fellowship is an opportunity for advanced anesthesiology trainees to refine their quality improvement (QI) skills. However, the short training period and inconsistent curricula make this challenging. The QI fellow (QIF) is described as an education program to provide consistent QI training during the CCM fellowship. The QIF is a mentored position to help manage data review, QI conferences, and improvement efforts within the CCM Division. The curriculum is focused on a QI education framework and mentored experiential learning. The QIF program is an opportunity for education and mentorship in the role of a CCM operational leader.

Predictive capabilities of the European registry for patients with mechanical circulatory support right-sided heart failure risk score after left ventricular assist device implantation.

OBJECTIVES: The prediction of right heart failure (RHF) after left ventricular assist device (LVAD) implantation remains a challenge. Recently, risk scores were derived from analysis of the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) data, the EUROMACS-RHF, and the modified postoperative EUROMACS-RHF. The authors assessed the performance characteristics of these 2 risk score formulations in a continuous-flow LVAD cohort at their institution. DESIGN: A retrospective, observational study. SETTING: At a tertiary-care academic medical center. PARTICIPANTS: Adult patients who underwent durable LVAD implantation between 2015 and 2018. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Early post-LVAD RHF was defined as follows: (1) need for right ventricular assist device, or (2) inotropic or inhaled pulmonary vasodilator support for ≥14 postoperative days. The authors used logistic regression and examined receiver operating characteristic (ROC) curves to evaluate the ability of the 2 risk scores to distinguish between outcome groups. A total of 207 patients met the inclusion criteria. Of the patients, 16% developed RHF (33/207). The EUROMACS-RHF score was not predictive of RHF in the authors' cohort (odds ratio [OR] 1.25; 95% CI [0.99-1.60]; p = 0.06), but the postoperative EUROMACS-RHF CPB score was significantly associated (OR 1.38; 95% CI [1.03-1.89]; p = 0.03). The scores had similar ROC curves, with weak discriminatory performance: 0.601 (95% CI [0.509-0.692]) and 0.599 (95% CI [0.505-0.693]) for EUROMACS-RHF and postoperative EUROMACS-RHF, respectively. CONCLUSIONS: In the authors' single-center retrospective analysis, the EUROMACS-RHF risk score did not predict early RHF. An optimized risk score for the prediction of RHF after LVAD implantation remains an urgent unmet need.

Anesthetic Management in Adults with Congenital Heart Disease.

PURPOSE OF REVIEW: Adults with congenital heart disease (ACHD) are a complex and growing population that presents numerous challenges for anesthetic management. This review summarizes special considerations for anesthetic management in ACHD. RECENT FINDINGS: The adult patient with congenital heart disease may require anesthetic care for multiple surgeries and interventions throughout their lifetime. The cardiac and extracardiac manifestations of ACHD have important perioperative implications that affect anesthetic management. Recent American Heart Association/American College of Cardiology and European Society of Cardiology guidelines endorse a multidisciplinary, team-based approach to care. The cardiac anesthesiologist, endorsed as part of this multidisciplinary team, must have a thorough understanding of congenital heart disease pathophysiology and common extra-cardiac manifestations of ACHD. Safe anesthetic management in adult congenital heart disease should incorporate a multi-disciplinary approach to patient care. Anesthesiologists and centers with special expertise in ACHD care should be utilized or consulted whenever possible.

Blood product transfusion and lung transplant outcomes: A systematic review.

The perioperative transfusion of blood products has long been linked to development of acute lung injury and associated with mortality across both medical and surgical patient populations.1,2 The need for blood product transfusion during and after lung transplantation is common and, in many instances, unavoidable. However, this practice may potentially be modifiable.3 In this systematic review, we explore and summarize what is known regarding the impact of blood product transfusion on outcomes following lung transplantation, highlighting the most recent work in this area. Overall, the majority of the literature consists of single center retrospective analyses or the work of multicenter working groups referencing the same database. In the end, there are a number of remaining questions regarding blood product transfusion and their downstream effects on graft function and survival.

The Year in Perioperative Echocardiography: Selected Highlights from 2020.

This article is the fifth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank Editor-in-Chief Dr. Kaplan and the editorial board for the opportunity to continue this series. In most cases, these will be research articles that are targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles will target the use of perioperative echocardiography in general.

Pneumonia: Hiding in Plain (Film) Sight.

Herein, a case describing how point-of-care lung ultrasound was used to identify the source of progressive multiorgan failure when a chest x-ray and other routine tests failed to provide a conclusive answer is presented. The discussion after the case focuses on the following: (1) the relative strengths and weaknesses of chest x-ray versus lung ultrasound in screening for lung disease and (2) suggestions of how lung ultrasound practice can be standardized within the field of anesthesiology.

Durability and Efficacy of Tricuspid Valve Repair in Patients Undergoing Left Ventricular Assist Device Implantation.

OBJECTIVES: This study sought to determine the durability of tricuspid valve repair (TVr) performed concurrently with left ventricular assist device (LVAD) implantation and its association with the development of late right heart failure (RHF). BACKGROUND: Surgical management of tricuspid regurgitation (TR) at the time of LVAD implantation is performed in an attempt to reduce the occurrence of postoperative RHF. Limited data exist regarding the durability of TVr in patients with LVAD as well as its impact on development of late RHF. METHODS: A retrospective review was conducted of consecutive adult patients who underwent durable LVAD implantation and concurrent TVr at the authors' institution between 2009 and 2017. Late RHF was defined as readmission for HF requiring inotropic or diuretic therapy. TVr failure was defined as moderate or severe TR at any follow-up echocardiographic examination after LVAD implantation. RESULTS: A total of 156 patients underwent LVAD and concurrent TVr during the study. Of the total, 59 patients (37.8%) had a failed TVr. The mean duration of echocardiographic follow-up was 23 ± 22 months. Of the 146 patients who were discharged after the index hospitalization, 53 patients (36.3%) developed late RHF. Multivariate Cox proportional hazard analysis demonstrated that TVr failure was an independent predictor of late RHF development (hazard ratio: 2.62; 95% confidence interval: 1.38 to 4.96; p = 0.003). CONCLUSIONS: Failure of TVr in this cohort occurred at a significant rate. Failure of TVr is an independent risk factor for development of late RHF. Future studies should investigate strategies to reduce recurrence of significant TR.

Patient-Reported Chronic Pain Outcomes After Lung Transplantation.

Chronic pain after lung transplantation is a significant concern, in particular given the heterogeneity of the patient population and the challenges of achieving adequate pain control amid concerns related to complex immunosuppressant regimens and the possibility of respiratory depression. We undertook a patient-reported outcomes (PRO) survey administered via our electronic health care portal to examine the postoperative incisional pain prevalence in a cohort of lung transplant recipients at a single, high-volume center where bilateral thoracosternotomy is the preferred surgical approach. The Patient Reported Outcomes Measurement Information System (PROMIS) Global Health and Pain Intensity short forms were sent to a total of 173 lung transplant recipients who were more than 2 months postsurgery at the time of the study. A total of 64 patients responded to both PROMIS surveys (response rate 38%). In the cohort of survey respondents, we observed a chronic pain incidence of 58% after lung transplantation (median pain score 1/10) and an overall good quality of life score (median score 4/5); however, only 9.4% reported moderate-severe pain (pain score ≥5/10). Survey nonrespondents had higher rates of pretransplant opioid and psychiatric medication use compared with respondents. In this study, we demonstrated the feasibility of using an electronic PRO survey for assessing postoperative pain outcomes after lung transplantation. However, measuring pain outcomes using this type of tool highlights issues of response rate and potential selection bias. Larger studies are needed to adequately assess the risk and predictors of chronic pain after lung transplantation and its impact on quality of life.

Three-factor prothrombin complex concentrates for refractory bleeding after cardiovascular surgery within an algorithmic approach to haemostasis.

BACKGROUND/OBJECTIVES: Prothrombin complex concentrates (PCC) are increasingly administered off-label in the United States to treat bleeding in cardiovascular surgical patients and carry the potential risk for acquired thromboembolic side-effects after surgery. Therefore, we hypothesized that the use of low-dose 3-factor (3F) PCC (20-30 IU/kg), as part of a transfusion algorithm, reduces bleeding without increasing postoperative thrombotic/thromboembolic complications. MATERIALS/METHODS: After IRB approval, we retrospectively analysed 114 consecutive, complex cardiovascular surgical patients (age > 18 years), between February 2014 and June 2015, that received low-dose 3F-PCC (Profilnine® ), of which seven patients met established exclusion criteria. PCC was dosed according to an institutional perioperative algorithm. Allogeneic transfusions were recorded before and after PCC administration (n = 107). The incidence of postoperative thromboembolic events was determined within 30 days of surgery, and Factor II levels were measured in a subset of patients (n = 20) as a quality control measure to avoid excessive PCC dosing. RESULTS: Total allogeneic blood product transfusion reached a mean of 12·4 ± 9·9 units before PCC and 5·0 ± 6·3 units after PCC administration (P < 0·001). The mean PCC dose was 15·8 ± 7·1 IU/kg. Four patients (3·8%) each experienced an ischaemic stroke on postoperative day 1, 2, 4 and 27. Seven patients (6·5%) had acquired venous thromboembolic disease within 10 days of surgery. Median factor II level after transfusion algorithm adherence and PCC administration was 87%. CONCLUSIONS: 3F-PCC use for refractory bleeding after cardiovascular surgery resulted in reduced transfusion of allogeneic blood and blood products. Adherence to this algorithmic approach was associated with an acceptable incidence of postoperative thrombotic/thromboembolic complications.

Methemoglobinemia with the use of benzocaine spray for awake fiberoptic intubation.

We report a case in which the use of benzocaine spray to facilitate awake fiber optic intubation (FOI) in a patient with a difficult airway caused methemoglobinemia intraoperatively. Local benzocaine was sprayed to numb the patient's airway for a total time of one second, fifteen minutes later SpO2 decreased to 85% on the pulse oximeter. Arterial blood gas (ABG) showed a MetHb of 24.6% of total Hemoglobin. The patient was successfully treated with methylene blue intravenously and recovered uneventfully. Small amounts of local benzocaine sprayed to numb the airway can cause significant methemoglobinemia that requires immediate recognition and appropriate management.

Antibiotic eluting chitosan glycerophosphate implant in the setting of acute bacterial sinusitis: a rabbit model.

BACKGROUND: Topical therapy offers the potential for treatment of sinonasal disease with minimal systemic side effects. Chitosan glycerophosphate (CGP) is a mucoadhesive polymer that can be used as an antibiotic eluting sinonasal implant in the treatment of sinusitis. The purpose of this study was to assess the potential for CGP as an antibiotic impregnated implant in a rabbit model of acute bacterial sinusitis. METHODS: The Institutional Animal Care and Use Committee approved study of acute bacterial sinusitis in 12 New Zealand white rabbits using either Pseudomonas aeruginosa (n = 6) or Staphylococcus aureus (n = 6). CGP impregnated with 50 mg of either gentamicin or vancomycin was bilaterally implanted in two rabbits in each arm, respectively. The sinuses were irrigated with saline for 4 days and the lavage was collected for colony-forming unit (CFU) determination. Within each group, the CFU log reduction in the lavage was compared with that of rabbits receiving saline alone (n = 2) or a daily 80-microgram/mL gentamicin or vancomycin irrigation (n = 2) and analyzed using a Student's t-test. RESULTS: Within the S. aureus group, the CFU log reduction using CGP + vancomycin (-2.57 +/- 0.21) was greater than vancomycin irrigation (-1.66 +/- 0.5; p = NS) and significantly greater than saline alone (2.46 +/- 0.97; p = 0.018). Within the P. aeruginosa group, the CFU log reduction using the CGP + gentamicin (-4.62 +/- 0.74) was greater than gentamicin irrigation (-4.09 +/- 0.70) and saline alone (-1.90 +/- 0.90); however, the results were not significant. In all rabbits receiving the CGP + antibiotic implant, no viable bacteria were present in the lavage by day 4. CONCLUSION: Placement of a single antibiotic impregnated CGP implant in the setting of an acute Gram-positive or Gram-negative bacterial sinusitis resulted in a greater log reduction of CFU than daily antibiotic irrigation and led to complete sterilization of the lavage within 4 days.

Quality of life and self-image in patients undergoing tracheostomy.

OBJECTIVES: The objective of this study is to understand trends in the Quality of Life and Self Image in patients undergoing an elective tracheostomy for non-malignant laryngeotracheal pathologies. We will also discuss the relationship between quality of life and patient demographics. STUDY DESIGN: A prospective, IRB approved cohort study was conducted in a tertiary referral center. The SF-12, was used to assess the mental and physical health of patients. The 12 questions on this tool were scored to generate a Physical Composite Score(PCS) and a Mental Composite Score (MCS). A higher score indicates better health. METHODS: The retrospective arm of the study included patients who presented to the senior author and had a trachesotomy for greater than 6 months. For the prospective arm of the study patients were recruited when they were to undergo an elective tracheostomy. Patients were recruited over a 12 month period. In the prospective arm the questionnaire was administered one to seven days pre-operatively and one to three weeks postoperatively. Variables analyzed included age, gender, marital status, education, occupation and other co-morbidities. RESULTS: In the prospective group, Mean PCS scores were higher in the post-trach period (38.2 ± 6.9) compared to the pre-trach period (35.4 ± 11.5). However, there is a decline in the MCS score in the post-trach period (49 ± 8.5) compared to the pre-trach period (55.4 ± 7.3). In the retrospective group, Mean PCS scores in this group was 28.5 ± 12.3 while the mean MCS score was 40.5 ± 18.3. CONCLUSION: Planned tracheostomy is a beneficial intervention for patients with benign airway pathologies, since they experience an improvement in their physical health and the ability to perform activities of daily living. There is a decline in mental health postoperatively, which we attribute to worsening self esteem. Patients who did not undergo planned tracheostomy as seen in the retrospective group, experienced a decline in their physical and mental functioning. This can be attributed to the lack of understanding of the benefit of the procedure and poor preoperative counseling. We recommend perioperative psychological assessment to improve mental health in patients undergoing elective trachesotomies.

Laryngeal mask airway in laryngoscopies: a safer alternative for the difficult airway.

PURPOSE OF THE STUDY: This study was undertaken to highlight the method, usefulness and postoperative morbidity of using a laryngeal mask airway (LMA) to ventilate patients with difficult airways undergoing laryngeal procedures. PROCEDURES: Retrospective chart review where we identified patients deemed to have a difficult airway who underwent laryngeal and upper tracheal procedures, and were electively ventilated using an LMA. The pertinent clinical history, indications for the procedure and postoperative course were discussed. RESULTS: Airway procedures were performed on 6 patients. Airway visualization was excellent, and there were no intraoperative or postoperative complications in any patient. CONCLUSIONS: Insertion of an LMA and maintenance of airway and ventilation were performed with ease in all patients. The airway lesions were easy to visualize, there was minimal vocal cord trauma, and it served as a wide conduit for therapeutic bronchoscopes and laryngoscopes. Therefore, we recommend preoperative identification of difficult airways and consideration of elective LMA use with a flexible endoscope during laryngeal and upper tracheal procedures.