A complication of an axillary intra-aortic balloon pump.

Intra-aortic balloon pumps (IABPs) are used to mechanically temporize a failing heart by decreasing afterload while increasing coronary perfusion pressure of the heart while more definitive treatment is sought. We report a case of a 65-year-old male with nonischemic cardiomyopathy, atrial fibrillation, thyroiditis, and non-Hodgkin lymphoma who presented with worsening heart failure. He underwent a percutaneous placement of a left axillary IABP with seemingly no complications. Approximately 3 weeks post-placement, the patient was taken for a heart transplant when an intraoperative transesophageal echo showed that the IABP was in the aortic arch and ascending aorta, instead of its proper placement in the descending aorta. The patient's arterial line showed waveforms appropriate for an IABP patient, and the patient showed no signs indicative of improper placement. This erroneous placement carried the potential to affect the aortic valve function, injure the aortic intima and/or occlude the aortic arch vessels. .

High-Dose Insulin for Hyperkalemic Cardiac Arrest.

ABSTRACT: Hyperkalemic cardiac arrest diagnosis can be elusive and management difficult as the cardiac rhythm restoration is often not achieved until the potassium level decreases to a relatively normal level for the patient who suffers the arrest. Current treatment modalities can take hours to achieve this goal. We describe two patients who survived a witnessed hyperkalemic cardiac arrest after being managed with conventional advanced cardiac life support and unconventionally high doses of intravenous insulin.

The Utility of Pulse Fluoroscopy During Mediport Insertion to Diagnose Air Embolism.

An otherwise healthy man in his 40s recently diagnosed with esophageal adenocarcinoma sustained an air embolism during the insertion of a mediport under mild sedation that was noted while using pulse fluoroscopy to ensure good visibility of adequate placement of the catheter tip. Pulse fluoroscopy allowed the early detection of a potentially catastrophic situation caused by air in the right heart and main pulmonary artery, thus allowing prompt correction of the mistake that had allowed the air embolism to occur. Pulse fluoroscopy eliminates or greatly reduces the blurred vision of highly mobile objects and enhances the view of low contrast objects thus enhancing imaging quality.

Does cerebral oximetry always measure brain tissue oxygen saturation? An anatomical study utilizing computed tomography.

Background and Aims: to quantify the scalp-cortex distance and determine its variation among patients. We hypothesized that in a significant number of patients, this distance is greater than the maximum penetration depth of current cerebral oximeters. Material and Methods: A retrospective anatomic study using transverse head CT images selected randomly from 102 patients over the age of 18 years without brain swelling, intracranial mass effect, or brain hemorrhage. Scalp-cortex distances were determined at two separate locations along the craniocaudal axis; most cephalad to the frontal sinus (I0) and also 2 cm cephalad to that location (I2). Multiple measurements were obtained bilaterally at 1, 3, 5, 7, and 9 cm from midline. Results: The average scalp-cortex distance was 14.3 mm and 15 mm at I0 and I2 respectively. Distances varied more in I2 than in I0; from the measurements, 12.8% vs. 6.8% were over 20 mm, 4.4% vs. 2.2% over 25 mm, 1.1% vs. 0.6% over 35 mm and 0.6% vs. none over 40 mm at I2 and I0, respectively. 1.5% of the measurements at I2 were over 30 mm. Conclusion: Cerebral oximetry manufacturers all claim to measure cerebral tissue up to a depth of 20-25 mm; 20 mm with the EQUANOX and INVOS compared with 25 mm with the FORE-SIGHT. Scalp-cortex distance is within 25 mm in more than 95% of patients. However, even with the probe placed as per the manufacturer's recommendations, in a small but significant subset of patients, this distance is greater than the maximum penetration depth of current cerebral oximeters and hence may not reflect actual brain tissue oxygen saturation.

Paravertebral Nerve Block With Liposomal Bupivacaine for Pain Control Following Video-Assisted Thoracoscopic Surgery and Thoracotomy.

BACKGROUND: Some surgeons have adopted the use of video-assisted thoracoscopic surgery (VATS) or robotic surgery to perform resections for lung cancer. VATS is associated with less pain and a decrease in pulmonary complications compared with open thoracotomies. Long-acting liposomal bupivacaine (LB) intercostal nerve blocks are reported to provide superior pain relief compared with epidural catheters in the first 3 d after a thoracotomy. This study examined whether LB improves pain after VATS and if it provides effective analgesia after a thoracotomy. MATERIALS AND METHODS: A retrospective review was performed on 151 consecutive patients undergoing a VATS or thoracotomy who received paravertebral nerve blocks. VATS patients received paravertebral nerve blocks with LB (VATS-LB) or 0.25% bupivacaine with epinephrine (BE; VATS-BE). Thoracotomy patients received paravertebral nerve blocks via LB injections. Pain scores, narcotic utilization, complications, and hospital length of stay were examined. RESULTS: Fifty patients underwent a VATS-LB, 53 underwent a VATS-BE, and 32 underwent a thoracotomy. Thoracotomy and VATS-LB patients had pain scores lower than VATS-BE patients in the first 48 h after surgery (P < 0.004). Opioid use was not significantly different between the thoracotomy and VATS-LB patients throughout the first 2 wk postoperatively. CONCLUSIONS: LB paravertebral blocks significantly improve postoperative pain in comparison with 0.25% BE blocks in VATS patients. LB paravertebral blocks also provide effective analgesia in patients undergoing thoracotomies.

Effectiveness of P6 Stimulation for Reduction of Nausea and Vomiting During Caesarean Section Under Combined Spinal-Epidural Anaesthesia: A Randomised Controlled Trial.

OBJECTIVE: Obstetric patients who receive combined spinal-epidural (CSE) anaesthesia for elective caesarean section (CS) frequently experience intraoperative nausea and vomiting (N&V). Prophylactic therapy with antiemetic agents can have multiple adverse effects to the mother and baby. We designed a randomised clinical trial to evaluate the efficacy of electrical P6 stimulation for prophylactic N&V treatment for scheduled elective CS performed under CSE anaesthesia. METHODS: Following the Institutional Review Board approval and informed consent, a total of 180 patients were randomly allocated into three groups: (1) P6 stimulation (via a peripheral nerve stimulator), (2) intravenous (IV) antiemetics (metoclopramide and ondansetron), and (3) control (no IV antiemetic medications and no P6 stimulation), with 60 parturients in each group. RESULTS: Significantly fewer patients experienced intraoperative N&V in the P6 group (nausea 36.7% and vomiting 13.3%) and IV antiemetic group (nausea 23.3% and vomiting 16.7%) than those in the control group (nausea 73.3% and vomiting 45%; p<0.001). In addition, significantly fewer patients required rescue antiemetic medications in the P6 group (35%) and the IV antiemetic group (31.7%) than those in the control group (73.3%; p<0.001). There was no significant difference in the overall anaesthetic care satisfaction reported between the three study groups. CONCLUSION: Our data suggest that P6 stimulation is as simple and as effective as our routine prophylactic IV antiemetic treatment for prevention of N&V during CS performed under CSE anaesthesia that could be of great interest to patients and obstetric anaesthesiologists who prefer treatments with fewer potential side effects.

First-in-human evaluation of a hand-held automated venipuncture device for rapid venous blood draws.

Obtaining venous access for blood sampling or intravenous (IV) fluid delivery is an essential first step in patient care. However, success rates rely heavily on clinician experience and patient physiology. Difficulties in obtaining venous access result in missed sticks and injury to patients, and typically require alternative access pathways and additional personnel that lengthen procedure times, thereby creating unnecessary costs to healthcare facilities. Here, we present the first-in-human assessment of an automated robotic venipuncture device designed to safely perform blood draws on peripheral forearm veins. The device combines ultrasound imaging and miniaturized robotics to identify suitable vessels for cannulation and robotically guide an attached needle toward the lumen center. The device demonstrated results comparable to or exceeding that of clinical standards, with a success rate of 87% on all participants (n = 31), a 97% success rate on nondifficult venous access participants (n = 25), and an average procedure time of 93 ± 30 s (n = 31). In the future, this device can be extended to other areas of vascular access such as IV catheterization, central venous access, dialysis, and arterial line placement.

Ruptured Giant Coronary Artery Aneurysm With Coronary Artery to Pulmonary Artery Fistula Presenting as Cardiac Tamponade Diagnosed by Intraoperative Transesophageal Echocardiography: A Case Report.

A 63-year-old woman presented with cardiac tamponade because of a ruptured giant left anterior descending coronary artery aneurysm with a fistula to the main pulmonary artery. The diagnosis was made intraoperatively during an emergent subxiphoid pericardial window using transesophageal echocardiography and confirmed by intraoperative coronary angiography. Because of this prompt diagnosis, the patient was successfully managed with immediate surgical repair of the aneurysm and fistula.

Hospital initiatives in promoting smoking cessation: A 12-year follow-up.

In the present study, the availability of smoking cessation programs (SCP) was surveyed in the same randomly selected USA hospitals in 2000 and 2012. A total of 102 USA hospitals were randomly selected for this survey. Each hospital website was searched for the topic of smoking cessation. In the second phase of the survey, the main switchboard number of each hospital was anonymously telephoned and the 'stop smoking clinic' was requested. The phone survey results showed that the percentage of hospital switchboard calls that were connected to a SCP remained identical at 47% in 2000 and 2012. The results for the internet availability of SCP on hospital websites improved from 30% in 2000 to 47% in 2012. There were more hospitals that added additional SCP information (27%) compared with those that removed SCP information (15%) by 2012. Among the 57% of hospitals that showed no change in internet SCP information, 22% remained positive for such information while 35% remained negative. The phone survey of hospitals showed that 47% of USA hospitals were able to connect a caller to a SCP in the years 2000 and 2012. While there was no reduction over the 12 years, there was no increase in the percentage of hospital switchboards that connected to a SCP. Availability of SCP information on hospital web sites improved to a limited extent; increasing from 30% of sites in 2000 to 47% in 2012. Providing SCP on a hospital website is easy and free, for example adding a link to QuitNet or QuitLink. The present study adds to information gathered 12 years earlier, and is unusual in being able to provide follow-up data on the same set of hospitals studied previously.

Cerebral Oximetry Decrease After External Carotid Clamping with Normal Electroencephalography and No Change After Internal Carotid Clamping.

Monitoring of cerebral perfusion by near-infrared spectroscopy estimates regional cerebral oxygen saturation (rSO2). We present a case in which, before clamping the left carotid artery during an endarterectomy, the right and left rSO2 measurements were 72% and 74%, respectively. Within 15 seconds of clamping the external carotid artery, the left rSO2 decreased by 8%, yielding right and left rSO2 measurements of 70% and 66%, respectively. No electroencephalogram changes ensued. The internal carotid artery was clamped 1 minute later, whereas the external carotid remained clamped. No electroencephalogram changes were observed. The rSO2 measurements demonstrate that the value of this cerebral oximetry is not determined solely from internal carotid blood flow and can be significantly affected by the external carotid.

Lower incidence of hypo-magnesemia in surgical intensive care unit patients in 2011 versus 2001.

BACKGROUND: Hypo-magnesemia is described to occur in as many as 65% of intensive care unit (ICU) patients. Magnesium (Mg) is a cofactor in over 300 enzymatic reactions involving energy metabolism, protein, and nucleic acid synthesis. The membrane pump that creates the electrical gradient across the cell membrane is dependent on Mg, and it is important in the activity of electrically excitable tissues. Since Mg regulates the movement of calcium in smooth muscle cells, it is also important in peripheral vascular tone and blood pressure. Studies have linked hypo-magnesemia to multiple chronic diseases and to a higher mortality rate. METHODS: To explore trends within our own tertiary care surgical ICU, we sampled our patients' laboratory records in 2001 and in 2011. Hypo-magnesemia in our ICU is defined as an Mg less than 2.0 mg/dL. RESULTS: This retrospective review of all SICU patients from October to December revealed that there was a significant increase (P < 0.01) in the patients with their serum Mg level measured between 2001 (89%) and 2011 (95%). There was a significant decrease (P < 0.001) in patients with hypomagnesemia (< 2 mg/dL) between 2001 (47.5%) and 2011 (33.0%). On the other hand, there was a significant increase (P < 0.001) in patients with normal serum Mg level (> 2 mg/dL) between 2001 (52.5%) and 2011 (67.0%). CONCLUSIONS: There was not only more monitoring of Mg in 2011, but a lower incidence of hypo-Mg compared to 2001. Possible explanations include changing patterns of antibiotic and diuretic use, less amphotericin use, more frequent laboratory surveillance, and better trained ICU practitioners.

Increasing severity of aortic atherosclerosis in coronary artery bypass grafting patients evaluated by transesophageal echocardiography.

BACKGROUND: Atherosclerotic disease in coronary artery bypass grafting (CABG) patients is a potential contributor to complications in the perioperative periods. This study was undertaken to better define how the frequency of aortic atheromatous disease among patients coming for CABG has evolved over the last decade. METHODS: Data from elective patients coming for CABG who underwent transesophageal echocardiography (TEE) examinations following induction of anesthesia were obtained for the years 2002 and 2009. Aortas were graded according to the method of Kronzon, with the following interpretations: normal = grade I, intimal thickening = 2, atheroma of less than 5 mm = 3, atheroma of > 5 mm = 4, and any mobile atheroma = 5. The data of 124 patients who underwent comprehensive exam of the aorta by one cardiac anesthesiologist were gathered and assigned into two groups based on the year TEE was done. Student's t-test was used for statistical analysis. A P value < 0.05 was considered significant. The data were presented as mean ± SD. RESULTS: There was significant difference between group 2002 (2.05 ± 1.28) and group 2009 (2.59 ± 1.11) in atheroma grade (P = 0.013). CONCLUSIONS: Patients coming for CABG in group 2009 exhibited significantly higher grades of aortic atheroma on TEE, compared to group 2002. Understanding the risk of atheroma in the elderly CABG population may help in altering surgical approaches to lessen the risk of catastrophic stroke. Potential options needing further study include the off-pump approach and modification of cross-clamp site and technique as well as other modalities.

Noise levels in modern operating rooms during surgery.

OBJECTIVE: To determine if differences in noise levels exist in the cardiac operating room at various critical points. DESIGN: Prospective, nonrandomized study. SETTING: Cardiac operating rooms of a university hospital. PARTICIPANTS: Cardiac surgical patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The noise level was monitored in the operating room for 23 patients undergoing cardiac surgery requiring general anesthesia during room setup, induction, skin incision, 60 minutes after surgical incision, termination of extracorporeal circulation, emergence (drapes down), and transport. RESULTS: At each data point (induction, emergence, termination of extracorporeal circulation, emergence [drapes down], and transport), noise levels were louder than the baseline reference at room setup, surgical skin incision, and 60 minutes into the surgery. CONCLUSIONS: The aim of this study was to compare the level of noise in the operating room at times determined critical for anesthesiologists compared with other surgical periods. This study consistently showed that noise in the operating room is louder during the critical anesthesia components of the case. Several studies have found that the loudest sound levels recorded in an operating room are related to the use of particular surgical tools, which are not used typically during the induction and emergence from anesthesia. This suggests that the increased sound levels during these periods may be somewhat controllable by the health care providers in the room.

The Swan-Ganz catheter as a teaching tool for the anesthesiologist learning minimally invasive cardiac surgery.

OBJECTIVE: To perform minimally invasive cardiac surgery through the smallest possible wound and with the least number of incisions in the heart or aorta, the necessary cannulations to undergo cardiopulmonary bypass must be done through peripheral vessels. A difficult skill to learn for the cardiac anesthesiologist is how to safely and efficiently position the coronary sinus catheter (Endoplege; Edwards Lifesciences LLC, Irvine, CA USA) required for retrograde cardioplegia administration. METHODS: In patients in whom a Swan-Ganz catheter was inserted as part of the operative management strategy for non-minimally invasive heart surgery, we have been using it as a training tool to learn how to visualize and manipulate right-sided catheters under transesophageal echocardiography. We developed this teaching technique to help hone some of the necessary skills needed to place the Endoplege catheter for minimally invasive cardiac surgery. Manipulation was done with the goal of visualizing the catheter and guiding it into the coronary sinus. For a 4-month period, anesthesia records were retrospectively reviewed. RESULTS: Fifteen patients, for a total of 19 catheter manipulations, were found in whom we had documented the use of the Swan-Ganz catheter and details about the insertion as a training tool. The coronary sinus and the catheter were visualized 100% of the time. The Swan-Ganz catheter was successfully inserted into the coronary sinus in 17 of 19 catheter manipulations. CONCLUSIONS: The Swan-Ganz catheter can be used as a training tool to develop some of the necessary skills to place catheters into the coronary sinus with transesophageal echocardiography guidance.