Superficial versus deep parasternal intercostal plane blocks: cadaveric evaluation of injectate spread.

BACKGROUND: Deep and superficial parasternal intercostal plane blocks provide anterior chest wall analgesia for both breast and cardiac surgery. Our primary objective of this cadaveric study was to describe the parasternal spread of deep and superficial parasternal intercostal plane blocks. Our secondary objectives were to describe needle proximity to the internal mammary artery when performing deep parasternal intercostal plane blocks, and compare lateral injectate spread and extension into the rectus sheath. METHODS: We performed ultrasound-guided deep and superficial parasternal intercostal plane blocks 2 cm from the sternum at the T3-4 interspace in four fresh frozen cadavers as described in clinical studies. RESULTS: Parasternal spread of injectate was greater with the deep parasternal intercostal plane injection than with the superficial parasternal intercostal plane injection. The internal mammary artery was ∼3 mm away from the needle trajectory in cadaver #1 and ∼5 mm from the internal mammary artery in cadaver #2. Lateral spread extended to the midclavicular line for all deep parasternal intercostal plane blocks and beyond the midclavicular line for all superficial parasternal intercostal plane blocks. Neither block extended to the rectus sheath. CONCLUSIONS: A greater number of parasternal interspaces were covered with the deep parasternal intercostal plane block than with the superficial parasternal intercostal plane block when one injection was performed at the T3-4 interspace. However, considering proximity to the internal mammary artery, and potential devastating consequences of an arterial injury, we propose that the deep parasternal intercostal plane block be classified as an advanced block and that future studies focus on optimising superficial parasternal intercostal plane parasternal spread.

Deep Parasternal Intercostal Plane Block for Postoperative Analgesia After Sternotomy for Cardiac Surgery-A Retrospective Cohort Study.

OBJECTIVE: To examine the analgesic efficacy of postoperative deep parasternal intercostal plane (DPIP) blocks for patients having cardiac surgery via median sternotomy. DESIGN: This single-center retrospective study compared patients receiving bilateral DPIP blocks with a matched cohort of patients not receiving DPIP blocks. SETTING: Large quaternary referral center. PARTICIPANTS: Adult patients admitted to the authors' institution from January 1, 2016, to August 14, 2020, for elective cardiac surgery via median sternotomy. INTERVENTIONS: Patients received ultrasound-guided bilateral DPIP blocks. MEASUREMENTS AND MAIN RESULTS: A total of 113 patients received a DPIP block; 3,461 patients did not. The estimated multiplicative change in cumulative opioid consumption through 24 hours was 0.42 (95% CI 0.32-0.56; p < 0.001), indicating that patients receiving DPIP blocks required 60% fewer opioids than patients who did not. Proportional odds ratios for the average pain score on postoperative day (POD) 0 was 0.46 (95% CI 0.32-0.65; p < 0.001), and POD 1 was 0.67 (95% CI 0.47-0.94; p = 0.021), indicating lower pain scores for patients receiving blocks. The exploratory analysis identified an inverse correlation between DPIP blocks and atrial fibrillation incidence (2% v 15%; inverse probability of treatment weighting odds ratio 0.088, 95% CI 0.02-0.41; p = 0.002). CONCLUSIONS: The use of DPIP blocks in patients undergoing cardiac surgery via median sternotomy was associated with less opioid use and improved pain scores in the early postoperative period compared with patients not receiving blocks. Prospective randomized controlled studies should further elucidate the efficacy and risks of DPIP blocks in cardiac surgery.

Pectoral Fascial Plane Versus Paravertebral Blocks for Minimally Invasive Mitral Valve Surgery Analgesia.

OBJECTIVES: This study examined the postoperative analgesic efficacy of single-injection pectoral fascial plane (PECS) II blocks compared to paravertebral blocks for elective robotic mitral valve surgery. DESIGN: A single-center retrospective study that reported patient and procedural characteristics, postoperative pain scores, and postoperative opioid use for patients undergoing robotic mitral valve surgery. SETTING: This investigation was performed at a large quaternary referral center. PARTICIPANTS: Adult patients (age ≥18) admitted to the authors' hospital from January 1, 2016, to August 14, 2020, for elective robotic mitral valve repair who received either a paravertebral or PECS II block for postoperative analgesia. INTERVENTIONS: Patients received an ultrasound-guided, unilateral paravertebral or PECS II nerve block. MEASUREMENTS AND MAIN RESULTS: One hundred twenty-three patients received a PECS II block, and 190 patients received a paravertebral block during the study period. The primary outcome measures were average postoperative pain scores and cumulative opioid use. Secondary outcomes included hospital and intensive care unit lengths of stay, need for reoperation, need for antiemetics, surgical wound infection, and atrial fibrillation incidence. Patients receiving the PECS II block required significantly fewer opioids in the immediate postoperative period than the paravertebral block group, and had comparable postoperative pain scores. No increase in adverse outcomes was noted for either group. CONCLUSIONS: The PECS II block is a safe and highly effective option for regional analgesia for robotic mitral valve surgery, with demonstrated efficacy comparable to the paravertebral block.

Standardized practice design with electronic support mechanisms for surgical process improvement: reducing mechanical ventilation time.

BACKGROUND: Hospital surgical care is complex and subject to unwarranted variation. OBJECTIVE: As part of a multiyear effort, we sought to reduce variability in intraoperative care and management of mechanical ventilation in cardiac surgery. We identified a patient population whose care could be standardized and implemented a protocol-based practice model reinforced by electronic mechanisms. METHODS: In a large cardiac surgery practice, we built a standardized practice model between 2009 and 2011. We compared mechanical ventilation time before (2008) and after (2012) implementation. To ensure groups were comparable, propensity analysis matched patients from the 2 operative years. RESULTS: In 2012, more than 50% of all cardiac surgical patients were managed with our standardized care model; of those, 769 were one-to-one matched with patients undergoing surgery in 2008. Patients had a mix of coronary artery bypass grafting, valve surgery, and combined procedures. Our practice model reduced median mechanical ventilation duration from 9.3 to 6.3 hours (2008 and 2012) (P < 0.001) and intensive care unit length of stay from 26.3 to 22.5 hours (P < 0.001). Reintubation and intensive care unit readmission were unchanged. Variability in ventilation time was also reduced. CONCLUSIONS: We demonstrate that in more than 50% of all cardiac surgical patients, a standardized practice model can be used to achieve better results. Clinical outcomes are improved and unwarranted variability is reduced. Success is driven by clear patient identification and well-defined protocols that are clearly communicated both by electronic tools and by empowerment of bedside providers to advance care when clinical criteria are met.

Some considerations of the tolerability of ketamine for ECT anesthesia: a case series and review of the literature.

Most anesthetic agents used for electroconvulsive therapy (ECT) have few intrinsic adverse effects. Ketamine, however, is well known to be associated with a variety of adverse effects including nausea, dizziness, and psychotomimetic phenomena. Over the past several decades, there have been numerous reports on the use of ketamine for ECT anesthesia, with varied assessments on how prominent these adverse effects are in the ECT situation. Ketamine has received a resurgence of interest as an ECT anesthetic of late owing to its established independent antidepressant effects and to theoretical reasons why it might lessen the cognitive adverse effects of ECT. In this case series, the author reviews the experience with 14 patients who had undergone ECT who were switched to ketamine as anesthetic from methohexital at the preference of the treating anesthesiologist. All 14 patients spontaneously reported a strong preference not to be given ketamine again due to bothersome adverse effects. The latter consisted of either vestibular-type symptoms (nausea/vomiting, dizziness, and vertigo) or psychotomimetic effects (dissociative phenomena). It is concluded that ketamine is not free of adverse effects when used as an ECT anesthetic. Electroconvulsive therapy clinicians should be vigilant about assessing for these effects when ketamine is used, and consideration should be given to using a benzodiazepine such as diazepam or midazolam at seizure termination when ketamine anesthesia is used to prevent bothersome adverse effects seen upon awakening.

Anesthetic-induced pain on injection in electroconvulsive therapy: review of the literature and suggestions for prevention.

Pain on injection (angialgia) is a common adverse effect of anesthetic medications, especially propofol and methohexital, which are both used for electroconvulsive therapy (ECT). In this review, the authors survey some general literature on angialgia incidence, mechanisms, and prevention efforts in non-ECT settings and follow this with a review of similar topics relevant to ECT. They review practical methods of angialgia prevention for ECT patients. The methods with the best research basis include the use of an antecubital vein for intravenous access as well as the local anesthetic lidocaine. Regarding the latter, concerns regarding shortening of seizure duration during ECT have been raised. If lidocaine is used for angialgia in ECT, low doses should be administered to avoid possible interference with ictal electroencephalogram expression. Other methods worth studying further for angialgia during ECT include use of the antiemetic agent metoclopramide and high-potency opiates.

Effect of drinker type on water disappearance of nursery pigs.

This study was conducted to evaluate the water disappearance of nursery pigs (from weaning to 6 wk post-weaning; 6.4 ±â€…1.07 to 22.0 ±â€…3.39 kg live body weight) using a randomized complete block design to compare two Drinker Type treatments: Nipple vs. Cup. A total of 336 pigs housed in 16 pens with 21 pigs per pen in 2 rooms (8 pens per room) were used. Pens had fully-slatted concrete floors; floor space was 0.32 m2/pig and there was one feeder and one drinker per pen. Pigs were fed corn-soybean-based diets formulated to meet or exceed nutrient requirements. Pigs and feeders were weighed at the start and end of the study. Water disappearance was measured using a water-flow meter fitted to the water pipeline supplying the drinker in each pen. For the overall study period, Drinker Type did not affect (P > 0.05) growth performance; however, average daily water disappearance was greater (P < 0.05) for Nipple than Cup drinkers (2.74 and 2.25 liters/d, respectively; SEM = 0.139). Water to feed disappearance ratio was greater (P < 0.05) for the Nipple than the Cup treatment (5.23 vs. 4.22 liters:kg, respectively; SEM = 0.263). These results suggest that water disappearance from nipple drinkers was greater than for cup drinkers. The lack of an effect of Drinker Type treatment on pig growth performance suggests that the treatment difference for water disappearance was most likely due to greater water wastage for the nipple drinkers rather than any effect on water intake per se.

Cardiac tamponade in a patient supported by veno-arterial extracorporeal membrane oxygenation.

Cardiac tamponade occurring in a patient supported on central veno-arterial extracorporeal membrane oxygenation is depicted in a transesophageal echocardiography image and associated rendering. Prompt recognition of tamponade, which can be assisted with echocardiography, and emergent evacuation is critical to restoring cardiovascular stability.

Influence of high cyclic ambient temperature and water drinker design on growth performance and water disappearance of growing-finishing pigs.

The objective of this study was to determine effects of room temperature and drinker design on growth and water disappearance of growing-finishing pigs (26.9 ±â€…3.67 to 130.9 ±â€…5.10 kg live body weight). A split-plot design was used with a 2 × 2 factorial arrangement of treatments: Room Temperature (RT) [Thermoneutral (TN) vs. High (HI); main plot], Drinker Design (DD; Nipple vs. Cup; sub-plot). A total of 316 pigs were used, housed in 32 pens in 4 rooms (8 pens/room; 7 pens of 10 pigs and 1 pen of 9 pigs). Two rooms were on each RT treatment. Room temperature for the TN treatment was constant throughout each day but decreased from 24°C at the start to 20°C and 18°C on d 14 and 45 of the study period, respectively. For the HI treatment, a single, cyclic RT protocol was used throughout the study (30°C from 08:00 to 19:00 h and 20°C from 20:00 to 07:00 h, with 1-h transition periods). Pens had fully-slatted concrete floors and 1 feeder and drinker (either nipple or cup); floor space was 0.67 m2/pig. Pigs had ad libitum access to standard corn-soybean diets, formulated to meet or exceed NRC (2012) nutrient requirements. Water disappearance was measured using a meter fitted to the water line supplying each drinker. There were no interactions (P > 0.05) between RT and DD treatments. Drinker Design did not affect (P > 0.05) growth performance; water disappearance was 7.3% greater (P ≤ 0.05) for Nipple than Cup drinkers. Compared to the TN treatment, the HI treatment had no effect (P > 0.05) on gain:feed ratio, but resulted in lower (P ≤ 0.05) average daily gain (6.5%) and average daily feed intake (5.5%) and greater (P ≤ 0.05) average daily water disappearance (16.8%). These results suggest that both drinker design and RT can affect water disappearance, and that the high, cyclic RT regime used reduced growth performance of growing-finishing pigs. Further research is needed to determine the contribution of water intake and wastage to treatment differences in water disappearance.

Paradoxical embolus caught in transit through a patent foramen ovale.

Diagnosing a paradoxical embolism is challenging, and it can be proven only if the thrombus is identified across the intracardiac defect. Very few cases have been diagnosed as an impending paradoxical embolism. Recently, the diagnosis and management of these entities have greatly improved with the advent of transesophageal echocardiography (compared with transthoracic echocardiography). Pulmonary hypertension may cause right-to-left shunting across a patent foramen ovale and predispose development of a paradoxical embolism. We report a patient with an impending paradoxical embolism that was caught in transit across the patent foramen ovale. The patient was treated successfully with emergent surgery.

New Q Waves and T-Wave Inversions Following Endovascular Surgery Lead to Diagnosis of Clinically Silent Myocardial Infarction Despite Negative Preoperative Cardiovascular Risk Evaluation: A Case Report.

In this case, a 79-year-old male presented with new anteroseptal Q waves and T-wave inversions across the precordial leads following an otherwise uneventful endovascular repair of his thoracoabdominal aortic aneurysm. The patient had no history of cardiac disease and had undergone a dobutamine stress echocardiogram within the preceding 6 months that showed no evidence of inducible ischemia. Nevertheless, routine postoperative electrocardiogram (EKG) revealed new Q waves and T-wave inversions and transthoracic echocardiogram that demonstrated akinesis of the left ventricle (LV) apex with chronic-appearing apical thrombus. We will further discuss preoperative evaluation of cardiovascular risk along with postoperative interpretation of EKG abnormalities.

Transport losses in market weight pigs: II. U.S. incidence and economic impact.

An industry survey representing approximately 310 million (M) market weight pigs was conducted with 20 U.S. slaughter facilities over the calendars years of 2012 to 2015 to determine the incidence, seasonal patterns, and estimated economic impact of dead and non-ambulatory pigs. Each plant entered daily totals in a secure online database for the following variables: 1) pigs slaughtered, 2) dead on arrival (DOA; dead on the truck), 3) euthanized on arrival (EOA; non-ambulatory pig with an injury that required euthanasia), 4) dead in pen (DIP; died after unloading), and 5) non-ambulatory (pig unable to move or keep up with the rest of the group from unloading to stunning). Total dead pigs were calculated as DOA + EOA + DIP, and total losses were calculated as non-ambulatory + total dead. The economic impact was estimated based on the 4-yr weighted averages from USDA annual reports for market swine slaughtered (108,470,550 pigs), live market weight (126.9 kg), and live market price ($1.44/kg). The 4-yr weighted averages for total dead, non-ambulatory, and total losses were 0.26%, 0.63%, and 0.88%, respectively. Total dead consisted of 0.15% DOA, 0.05% EOA, and 0.05% DIP. The months with the highest rates of total dead were July (0.29%), August (0.32%), and September (0.30%), while the lowest incidence rates occurred in February (0.22%), March (0.22%), and April (0.22%). The months with the highest rates of non-ambulatory pigs were observed during the months of October (0.70%), November (0.71%), and December (0.70%), whereas the lowest rates of non-ambulatory pigs were observed during the months of April (0.57%), May (0.53%), and June (0.54%). The following assumptions were used in the economic analysis: 1) dead pigs received no value and 2) non-ambulatory pigs were discounted 30%. Based on these assumptions, the annual cost to the industry for dead and non-ambulatory pigs was estimated to be $52 M ($0.48 per pig marketed) and $37 M ($0.35 per pig marketed), respectively. Therefore, total losses represent approximately $89 M in economic losses or $0.83 per pig marketed. This is the first industry-wide survey on the incidence of transport losses in market weight pigs at U.S. slaughter facilities, and this information is important for establishing an industry baseline and benchmark for transport losses that can be used for measuring industry improvements.

Undiagnosed Systemic Mastocytosis Presenting as Postoperative Distributive Shock: A Case Report.

Systemic mastocytosis (SM) is a rare clinical condition resulting from a clonal proliferation of abnormal mast cells. The clinical presentation may vary from mild cutaneous manifestations to aggressive systemic symptoms including intermittent episodes of anaphylaxis. We present a case of a 69-year-old male with abrupt and recurrent episodes of anaphylaxis with refractory distributive shock following cardiac surgery with cardiopulmonary bypass. Following a complex postoperative course, a bone marrow biopsy ultimately confirmed the diagnosis. Although rare, SM should be considered in the differential diagnosis of postoperative patients with unexplained and recurrent episodes of distributive shock.

Birth weight threshold for identifying piglets at risk for preweaning mortality.

Several studies have suggested there is a critical relationship between piglet birth weight and preweaning mortality. Thus, the objective of the current work was to identify a birth weight threshold value for preweaning mortality. Birth weight and survival data from two studies involving a combined total of 4,068 piglets from 394 litters on four commercial farms (three European, one U.S.) were compiled for a pooled, multistudy analysis. Overall preweaning mortality across the two studies was 12.2%. Key variables used in the analysis were piglet birth weight (measured within 24 h of birth) and corresponding survival outcome (dead or live) by weaning at 3-4 wk of age. A mixed effects logistic regression model was fit to estimate the relationship between preweaning mortality and birth weight. A random effect of study was included to account for overall differences in mortality between the two studies. A piecewise linear predictor was selected to best represent the drastic decrease in preweaning mortality found as birth weight increased in the range of 0.5-1.0 kg and the less extreme change in weight above 1.0 kg. The change point of the birth weight and preweaning mortality model was determined by comparing model fit based on maximizing the likelihood over the interval ranging from 0.5 to 2.3 kg birth weight. Results from the analysis showed a curvilinear relationship between birth weight and preweaning mortality where the birth weight change point value or threshold value was 1.11 kg. In the combined data set, 15.2% of pigs had birth weights ≤1.11 kg. This subpopulation of pigs had a 34.4% preweaning mortality rate and represented 43% of total preweaning mortalities. These findings imply interventions targeted at reducing the incidence of piglets with birth weights ≤1.11 kg have potential to improve piglet survivability. Additional research is needed to validate 1.11 kg as the birth weight threshold for increased risk of preweaning mortality.

Fiberoptic-Guided Use of an Airway Exchange Catheter During Exchange of a Kinked King LTS-D Laryngeal Tube for an Endotracheal Tube: A Case Report.

The use of supraglottic airway devices such as the King LTS-D laryngeal tube has increased in the prehospital setting because of their relative ease of successful insertion, even in the hands of inexperienced providers. However, these devices have their own associated complications. In patients with a known or suspected difficult airway, supraglottic airway device exchanges should occur under controlled conditions using an airway exchange catheter, preferably under direct visualization with a flexible fiberoptic bronchoscope. We report unanticipated difficulties with supraglottic airway exchange caused by a kinked King LTS-D laryngeal tube.

An epidemiological investigation to determine the prevalence and clinical manifestations of slow-moving finished cattle presented to slaughter facilities.

Cattle mobility is routinely measured at commercial slaughter facilities. However, the clinical signs and underlying causes of impaired mobility of cattle presented to slaughter facilities are poorly defined. As such, the objectives of this study were 1) to determine the prevalence of impaired mobility in finished cattle using a 4-point mobility scoring system and 2) to observe clinical signs in order to provide clinical diagnoses for this subset of affected cattle. Finished beef cattle (n = 65,600) were observed by a veterinarian during the morning shift from six commercial abattoirs dispersed across the United States; the veterinarian assigned mobility scores (MS) to all animals using a 1-4 scale from the North American Meat Institute's Mobility Scoring System, with 1 = normal mobility and 4 = extremely limited mobility. Prevalence of MS 1, 2, 3, and 4 was 97.02%, 2.69%, 0.27%, and 0.01%, respectively. Animals with an abnormal MS (MS > 1) were then assigned to one of five clinical observation categories: 1) lameness, 2) poor conformation, 3) laminitis, 4) Fatigued Cattle Syndrome (FCS), and 5) general stiffness. Of all cattle observed, 0.23% were categorized as lame, 0.20% as having poor conformation, 0.72% as displaying signs of laminitis, 0.14% as FCS, and 1.68% as showing general stiffness. The prevalence of lameness and general stiffness was greater in steers than heifers, whereas the prevalence of laminitis was the opposite (P < 0.05). FCS prevalence was higher in dairy cattle than in beef cattle (0.31% vs. 0.22%, respectively; P ≤ 0.05). These data indicate the prevalence of cattle displaying abnormal mobility at slaughter is low and causes of abnormal mobility are multifactorial.

A "Fundamentals" Train-the-Trainer Approach to Building Pediatric Critical Care Expertise in the Developing World.

Pediatric Fundamental Critical Care Support (PFCCS) is an educational tool for training non-intensivists, nurses, and critical care practitioners in diverse health-care settings to deal with the acute deterioration of pediatric patients. Our objective was to evaluate the PFCCS course as a tool for developing a uniform, reproducible, and sustainable model for educating local health-care workers in the optimal management of critically ill children in the Republic of Georgia. Over a period of 18 months and four visits to the country, we worked with Georgian pediatric critical care leadership to complete the following tasks: (1) survey health-care needs within the Republic of Georgia, (2) present representative PFCCS lectures and simulation scenarios to evaluate interest and obtain "buy-in" from key stakeholders throughout the Georgian educational infrastructure, and (3) identify PFCCS instructor candidates. Georgian PFCCS instructor training included the following steps: (1) US PFCCS consultant and content experts presented PFCCS course to Georgian instructor candidates. (2) Simulation learning principles were taught and basic equipment was acquired. (3) Instructor candidates presented PFCCS to Georgian learners, mentored by PFCCS course consultants. Objective evaluation and debriefing with instructor candidates concluded each visit. Between training visits Georgian instructors translated PFCCS slides to the Georgian language. Six candidates were identified and completed PFCCS instructor training. These Georgian instructors independently presented the PFCCS course to 15 Georgian medical students. Student test scores improved significantly from pretest results (n = 14) (pretest: 38.7 ± 7 vs. posttest 62.7 ± 6, p < 0.05). A Likert-type scale of 1 to 5 (1 = not useful or effective, 5 = extremely useful or effective) was used to evaluate each student's perception regarding (1) relevance of course content to clinical work students rated as median (IQR): (a) relevance of PFCCS content to clinical work, 5 (4-5); (b) effectiveness of lecture delivery, 4 (3-4); and (c) value of skill stations for clinical practice, 5 (4-5). Additionally, the mean (±SD) responses were 4.6 (±0.5), 3.7 (±0.6), and 4.5 (±0.6), respectively. Training local PFCCS instructors within an international environment is an effective method for establishing a uniform, reproducible, and sustainable approach to educating health-care providers in the fundamentals of pediatric critical care. Future collaborations will evaluate the clinical impact of PFCCS throughout the Georgian health-care system.

Aberrant right subclavian artery from an aneurysmal diverticulum of Kommerell in an 84-year-old man.

The investigators describe an unusual case of tracheal and esophageal compression by atherosclerotic dilatation of the diverticulum of Kommerell associated with a congenital aberrant right subclavian artery, illustrating how aging-related vascular degenerative disease can modify the clinical manifestations of congenital anomalies in an 84-year-old man. In conclusion, the potential interactions between congenital and acquired cardiovascular disease should be considered in the evaluation of cardiovascular symptoms in the elderly population.

Anesthetic considerations in robotic mitral valve surgery.

The robotic approach to cardiac surgery offers patients numerous potential advantages compared with a traditional sternotomy approach including shorter hospital length of stay, reduced pain, fewer blood transfusions, and a quicker return to normal daily activities. At the same time, robotic cardiac surgery requires that the anesthesiologist employs several subspecialty skillsets in order to provide optimal care for these patients. Multiple different regional anesthesia techniques may be used to improve analgesia, reduce opioid dosages, and facilitate rapid extubation at the conclusion of the case. Several peripheral cannulation strategies for cardiopulmonary bypass (CPB) exist and the anesthesia team may assist with percutaneous cannulation of the superior vena cava (SVC) or positioning of an endo-pulmonary vent. Similarly the anesthesiologist may be asked to percutaneously cannulate the coronary sinus for retrograde cardioplegia delivery. The need for one-lung ventilation (OLV) and heavy reliance on transesophageal echocardiography (TEE) occupy much of the anesthesiologist's attention during these cases. Variations in institutional practice exist. Reviews of current practice and future studies may help refine the anesthetic approach to robot-assisted cardiac surgery.