Evaluation of the Simpson's Method to Determine Left Ventricular Ejection Fraction Using the Transgastric Two-Chamber View.

INTRODUCTION: Left ventricular chamber size and functional assessment by transesophageal echocardiography can be difficult if visualization is poor in the mid-esophageal views. However, the accuracy of using the Simpson's method in the transgastric 2-chamber (TG2C) as an alternative approach has not been assessed. METHODS: The Simpson's method was performed by 2 independent reviewers using midesophageal 2-chamber (ME2C) and TG2C views. Echocardiographic images were retrieved retrospectively for 49 adult cardiac surgical patients. RESULTS: Two-way random effects intraclass correlation coefficients demonstrated no significant interobserver variability. Linear mixed effects models showed no significant differences in ME2C and TG2C measurements with regard to EDV (P=.4407), ESV (P=.5113), or EF (P=.0610).Compared to the ME2C view, the TG2C view had better image quality of the LV walls (image quality score median [interquartile range]: 2.00 [.00] vs 1.00 [1.00]; P<.0001), but worse image quality of the mitral annulus (1.00 [1.00] vs 2.00 [.00]; P<.0001) and LV apex (.00 [1.00] vs 2.00 [1.00]; P<.0001). CONCLUSIONS: This study suggests the Simpson's method can be applied to the TG2C view as an alternative to the standard midesophageal method to estimate chamber volumes and EF.

Propofol Versus Remifentanil Sedation for Transcatheter Aortic Valve Replacement: A Single Academic Center Experience.

OBJECTIVE: Comparison of remifentanil versus propofol for sedation during transcatheter aortic valve replacement (TAVR) procedures to analyze the risk of sedation-related hypoxemia and hypotension. Secondary outcomes included the rate of conversion to general anesthesia, procedure length, rate of intensive care unit (ICU) admission, ICU and hospital lengths of stay, and 30-day mortality. DESIGN: Retrospective cohort study. SETTING: A single tertiary teaching hospital. PARTICIPANTS: Two hundred fifty-nine patients who had propofol or remifentanil sedation for TAVR between March 2017 and March 2020. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: There were 130 patients (50.2%) in the propofol cohort and 129 patients (49.8%) in the remifentanil cohort. The primary outcomes were oxygen saturation nadir values and vasopressor infusion use. Remifentanil was associated with a lower oxygen saturation nadir, as compared to propofol (91.3% v . 95.4%, p < 0.001). Risk factors associated with hypoxemia (defined as <92%) were body mass index (p = 0.0004), obstructive sleep apnea (p = 0.004), and remifentanil maintenance (p < 0.001). Vasopressor infusion use was significantly higher with propofol (64.9% v . 8.5%, p < 0.001). Propofol maintenance and angiotensin-converting enzyme inhibitor/angiotensin II receptor-blocker use were the only variables identified as risk factors for vasopressor use (p < 0.001 and p = 0.009). CONCLUSIONS: For patients undergoing TAVR with conscious sedation, remifentanil was associated with more hypoxemia while propofol was associated with a higher rate of vasopressor use.

Dollars for Diagnosis: A Single-Institutional Analysis of Billing for Intraoperative Transesophageal Echocardiography Examinations.

OBJECTIVES: The authors sought to identify correctable reasons for the failed completion of required billing elements necessary for the reimbursement of services for intraoperative transesophageal echocardiography (TEE). DESIGN: This was a retrospective study. SETTING: This study was completed at a single institution and large academic center. PARTICIPANTS: The patient population included all adult patients who underwent cardiac surgery at a single academic center over one year. INTERVENTIONS: This retrospective review of TEE documentation and billing data was performed for the all adults undergoing cardiac surgery over the course of one year. METHODS AND MAIN RESULTS: Documentation characteristics were compared between examinations that were reimbursed and those that were not. Out of 504 TEE examinations, 30% were not reimbursed. For these examinations, there was a lower compliance in the completion of minimum billing requirements, compared with those that were reimbursed; designation as "diagnostic" (29% v 93%, respectively, p < 0.0001), procedure note (70% v 99%, p < 0.0001), and procedure order (67% v 98%, p = 0.0002). The total estimated annual loss in revenue was $36,000. CONCLUSIONS: Understanding documentation requirements for TEE is an overlooked but important part of anesthesiology practice that may lead to substantial cost savings. Completion of a procedure note, procedure order, and documentation of an examination as "diagnostic" was associated with successful billing.

Thoracic Enhanced Recovery After Surgery: Single Academic Center Observations After Implementation.

BACKGROUND: Enhanced recovery after surgery (ERAS) is an evidence-based, multidisciplinary perioperative care model shown to reduce complications and hospital length of stay (LOS). While some thoracic ERAS studies were inconclusive, others demonstrated that ERAS improves patient outcomes after lung resections and provides more cost-effective care. We aimed to investigate the effects of preliminary implementation of an ERAS protocol, in comparison with conventional care, on lung resection outcomes at a single academic institution. METHODS: In this observational study, adult patients undergoing lung resections during the pre-ERAS (April 2014 to September 2015) and post-ERAS (January 2016 to May 2017) periods were identified. Relevant demographic, preoperative, anesthesia, and surgical variables were collected. Pre-ERAS and post-ERAS cohorts were compared in terms of hospital LOS, postoperative complications, and 30-day outcomes. RESULTS: We identified 264 patients, half in each cohort. Pre-ERAS and post-ERAS groups were similar with respect to age, race, and comorbidities. There were no significant differences in LOS, complications, 30-day readmission and mortality rates, or patient-reported outcomes. Of the patients with prolonged LOS, 31% had pulmonary complications, almost half of which were prolonged air leaks. ERAS adherence rate was approximately 60%. CONCLUSIONS: In the first year of implementation, median LOS, complications, and 30-day outcomes did not differ significantly between the pre-ERAS and post-ERAS groups. Prolonged air leaks commonly led to prolonged LOS; therefore, thoracic ERAS protocols could include interventions to reduce air leak and consideration for discharging patients with chest tubes placed to Heimlich valves. Buy-in and adherence to a new protocol are necessary for implementation to be effective.

Predictors of Admission After the Implementation of an Enhanced Recovery After Surgery Pathway for Minimally Invasive Gynecologic Surgery.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways in gynecologic surgery have been shown to decrease length of stay with no impact on readmission, but no study has assessed predictors of admission in this population. The purpose of this study was to identify predictors of admission after laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RAH) performed under an ERAS pathway. METHODS: This is a prospective observational study of women undergoing LH/RAH for benign indications within an ERAS pathway. Data collected included same-day discharge, reason for admission, incidences of urgent clinic and emergency room (ER) visits, readmissions, reoperations, and 9 postulated predictors of admission listed below. Patient demographics, markers of baseline health, and clinical outcomes were compared between groups (ERAS patients discharged on the day of surgery versus admitted) using Fisher exact and Student t tests. Multivariable logistic regression was used to assess the potential risk factors for being admitted, adjusting for age, race, body mass index, American Society of Anesthesiologists (ASA) physical status score, preoperative diagnosis indicative of hysterectomy, preoperative chronic pain, completion of a preprocedure pain-coping skills counseling session, procedure time, and compliance to the ERAS pathway. RESULTS: There were 165 patients undergoing LH/RAH within an ERAS pathway; 93 (56%) were discharged on the day of surgery and 72 were admitted. There were no significant differences in ER visits, readmissions, and reoperations between groups (ER visits: discharged 13% versus admitted 13%, P = .99; 90-day readmission: discharged 4% versus admitted 7%, P = .51; and 90-day reoperation: discharged 4% versus admitted 3%, P = .70). The most common reasons for admission were postoperative urinary retention (n = 21, 30%), inadequate pain control (n = 21, 30%), postoperative nausea and vomiting (n = 7, 10%), and planned admissions (n = 7, 10%). Increased ASA physical status, being African American, and increased length of procedure were significantly associated with an increased risk of admission (ASA physical status III versus ASA physical status I or II: odds ratio [OR], 3.12; 95% confidence interval [CI], 1.36-7.16; P = .007; African American: OR, 2.47; 95% CI, 1.02-5.96; P = .04; and length of procedure, assessed in 30-minute increments: OR, 1.23; 95% CI, 1.02-1.50; P = .04). CONCLUSIONS: We were able to define predictors of admission for patients having LH/RAH managed with an ERAS pathway. Increased ASA physical status, being African American, and increased length of procedure were significantly associated with admission after LH/RAH performed under an ERAS pathway. In addition, the incidences of urgent clinic and ER visits, readmissions, and reoperations within 90 days of surgery were similar for patients who were discharged on the day of surgery compared to those admitted.

Examination of the enhanced recovery guidelines in thoracic surgery.

PURPOSE OF REVIEW: Enhanced Recovery After Thoracic Surgery (ERATS) has gained momentum over the past few years, although the evidence base and expert recommendations lag behind other specialties. This review will present and examine key points from the first guidelines for enhanced recovery after lung surgery, released in 2018, jointly sponsored by the European Society of Thoracic Surgeons and the Enhanced Recovery After Surgery Society. RECENT FINDINGS: The recently released guidelines present core components of enhanced recovery as they pertain to lung resection surgery. Although evidence is still sparse in some areas, the guidelines summarize the available literature and incorporate levels of recommendation based upon the strength of available data as well as expert consensus. As of yet, the relative contribution of individual ERATS components to improvement in outcomes is unclear, but overall compliance does seem to be linked to positive results. Since the creation of the guidelines, additional literature related to ERATS has been released, and it will be incorporated and discussed into our review. SUMMARY: The creation of guidelines for enhanced recovery after lung resection will provide the thoracic anesthesiologist a framework upon which to build a comprehensive perioperative anesthetic plan.

Defining Value-Based Care in Cardiac and Vascular Anesthesiology: The Past, Present, and Future of Perioperative Cardiovascular Care.

Health care reimbursement models are transitioning from volume-based to value-based models. Value-based models focus on patient outcomes both during the hospital admission and postdischarge. These models place emphasis on cost, quality of care, and coordination of multidisciplinary services. Perioperative physicians are challenged to evaluate traditional practices to ensure coordinated, cost-effective, and evidence-based care. With the Centers for Medicare and Medicaid Services planned introduction of bundled payments for coronary artery bypass graft surgery, cardiovascular anesthesiologists are financially responsible for postdischarge outcomes. In order to meet these patient outcomes, multidisciplinary care pathways must be designed, implemented, and sustained, a process that is challenging at best. This review (1) provides a historical perspective of health care reimbursement; (2) defines value as it pertains to quality, service, and cost; (3) reviews the history of value-based care for cardiac surgery; (4) describes the drive toward optimization for vascular surgery patients; and (5) discusses how programs like Enhanced Recovery After Surgery assist with the delivery of value-based care.

Increased Intraoperative Vasopressor Use as Part of an Enhanced Recovery After Surgery Pathway for Pancreatectomy Does Not Increase Risk of Pancreatic Fistula.

Purpose: Enhanced recovery after surgery (ERAS) pathways are increasingly implemented. Goal directed fluid therapy (GDFT) is a core component of ERAS pathways that limit excessive volume administration and is associated with increased use of intraoperative vasopressors. Vasopressor effects on anastomotic healing and pancreatic fistula are inconclusive. We hypothesized that intraoperative vasopressor use in an ERAS GDFT algorithm would not increase risk of pancreatic fistulas. Methods: We reviewed all adult patients undergoing pancreatectomy at an academic institution from January 2013 to February 2016, before and after implementation of an ERAS pathway in July 2014. Retrospective chart review was performed. Log-binomial regression, weighted by stabilized inverse probability-of-treatment weights, estimated effect of ERAS and intraoperative vasopressors on fistula risk. Results: One hundred thirty two patients met inclusion criteria: 74 (56.1%) in the ERAS cohort. No significant differences in overall leak risk (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.38-2.09) were observed between the ERAS and pre-ERAS cohorts. Similarly, vasopressor infusions, independent of ERAS pathway, did not significantly increase the risk of anastomotic leaks (RR 1.19, 95% CI 0.52-2.72). Conclusions: Increased use of vasopressor infusions as part of an ERAS pathway for pancreatic surgery is not associated with an increase in the risk of clinically significant pancreatic fistulas.

Update on Perioperative Pulmonary Embolism Management: A Decision Support Tool to Aid in Diagnosis and Treatment.

Pulmonary embolism (PE) affects up to 1 in every 1000 people per year, one-third of whom do not survive. Moreover, perioperative presentation of PE is 5 times more likely than at other times and poses a unique set of challenges for both diagnosis and treatment. This article discusses several important aspects regarding the prevention, diagnosis, and management of perioperative PE, incorporating information from the most recent practice guidelines, emerging literature on medical therapy, and interventional therapies. It proposes a clinical decision support tool that organizes the salient aspects of perioperative PE management to serve as an aid in practice.

Intraoperative Hyperkalemia and Ventricular Arrhythmia During Parathyroidectomy: A Case Report.

We present a case of acute hyperkalemia and ventricular arrhythmia during parathyroidectomy in a patient with end-stage renal disease. This case highlights the under-recognized alterations in potassium homeostasis associated with parathyroidectomy and underscores the importance of preoperative optimization.

Application of a Multidisciplinary Enhanced Recovery After Surgery Pathway to Improve Patient Outcomes After Transcatheter Aortic Valve Implantation.

Enhanced recovery after surgery (ERAS) protocols have proven effective in a variety of surgical specialties. Published reports on these pathways within cardiac surgery and interventional cardiology are limited. Invasive aortic valve replacement procedures are increasingly being performed by hybrid groups of interventional cardiologists and surgeons through transcatheter aortic valve implantation (TAVI). The TAVI patient population is at a higher surgical risk compared with those undergoing surgical aortic valve replacement since they are older, frailer, and have significant co-morbidities which result in an increased risk of perioperative complications. ERAS protocols have the potential to help these patients undergoing TAVI procedures. In conclusion, we propose a TAVI ERAS protocol with a call-to-action for other centers to implement an ERAS protocol to improve hospital and cardiac outcomes.

Simulator training enhances resident performance in transesophageal echocardiography.

BACKGROUND: Standardized training via simulation as an educational adjunct may lead to a more rapid and complete skill achievement. The authors hypothesized that simulation training will also enhance performance in transesophageal echocardiography image acquisition among anesthesia residents. METHODS: A total of 42 clinical anesthesia residents were randomized to one of two groups: a control group, which received traditional didactic training, and a simulator group, whose training used a transesophageal echocardiography-mannequin simulator. Each participating resident was directed to obtain 10 commonly used standard views on an anesthetized patient under attending supervision. Each of the 10 selected echocardiographic views were evaluated on a grading scale of 0 to 10, according to predetermined criteria. The effect of the intervention was assessed by using a linear mixed model implemented in SAS 9.3 (SAS Institute Inc., Cary, NC). RESULTS: Residents in the simulation group obtained significantly higher-quality images with a mean total image quality score of 83 (95% CI, 74 to 92) versus the control group score of 67 (95% CI, 58 to 76); P = 0.016. On average, 71% (95% CI, 58 to 85) of images acquired by each resident in the simulator group were acceptable for clinical use compared with 48% (95% CI, 35 to 62) in the control; P = 0.021. Additionally, the mean difference in score between training groups was the greatest for the clinical anesthesia-1 residents (difference 24; P = 0.031; n = 7 per group) and for those with no previous transesophageal echocardiography experience (difference 26; P = 0.005; simulator n = 13; control n = 11). CONCLUSION: Simulation-based transesophageal echocardiography education enhances image acquisition skills in anesthesiology residents.

Transient heat hyperalgesia during resolution of ropivacaine sciatic nerve block in the rat.

BACKGROUND: Preliminary studies using perineural sciatic ropivacaine in rat demonstrated unexpected heat hyperalgesia after block resolution. To better characterize the time course relative to mechanical anesthesia-analgesia, we tested the hypothesis that ropivacaine 0.5% leads to transient heat hyperalgesia in rats independent of mechanical nociception. We also evaluated functional toxicity (eg, long-term hyperalgesia and/or tactile allodynia 2 weeks after injection). METHODS: Under surgical exposure, left sciatic nerve block was performed in 2 groups of adult male rats-ropivacaine (200 µL, 5 mg/mL; n = 14) versus vehicle (n = 11). The efficacy and duration of block were assessed with serial heat, mechanical (Randall-Selitto testing), and tactile (von Frey-like monofilaments) tests; motor-proprioceptive (rotating rod) and sedation tests were used at 1 and 7 hrs after injection. The presence of nerve injury was assessed by repeating the heat, tactile, and motor tests 12 to 14 days after injection. RESULTS: Ropivacaine-induced anesthesia was fully manifest at 1 hr after injection. At 3 hrs after injection, heat hypersensitivity was present in the setting of resolved mechanical analgesia. All behavioral measures returned to baseline by 2 weeks after injection. There was no evidence of (i) behavioral sedation, (ii) persistent changes in heat or mechanical sensitivity, or (iii) persistent changes in proprioceptive-motor function at 12 to 14 days after injection. CONCLUSIONS: Ropivacaine 0.5% induces transient heat hyperalgesia in the setting of resolved mechanical analgesia, further suggestive of modality and/or nociceptive fiber specificity. Whether this finding partially translates to "rebound pain" after patients' nerve blocks wear off requires further study.