Total Intravenous Anesthesia Is Preferred Over Volatile Agents in Cardiac Surgery.

The choice of maintenance anesthetic during cardiopulmonary bypass has been a subject of ongoing debate. Systematic reviews on the topic have so far failed to demonstrate a difference between volatile agents and total intravenous anesthesia (TIVA) in terms of mortality, myocardial injury, and neurological outcomes. Studies using animal models and noncardiac surgical populations suggest numerous mechanisms whereby TIVA has been associated with more favorable outcomes. However, even if the different anesthetic methods are assumed to equivalent in terms of patient outcomes in the context of cardiac surgery, additional factors, namely variables of occupational exposure and environmental impact, strongly support the preferred use of TIVA.

The Promise of Artificial Intelligence-Assisted Point-of-Care Ultrasonography in Perioperative Care.

The role of point-of-care ultrasonography in the perioperative setting has expanded rapidly over recent years. Revolutionizing this technology further is integrating artificial intelligence to assist clinicians in optimizing images, identifying anomalies, performing automated measurements and calculations, and facilitating diagnoses. Artificial intelligence can increase point-of-care ultrasonography efficiency and accuracy, making it an even more valuable point-of-care tool. Given this topic's importance and ever-changing landscape, this review discusses the latest trends to serve as an introduction and update in this area.

2023 Update on Vascular Anesthesia.

The authors thank the editors for this opportunity to review the recent literature on vascular surgery and anesthesia and provide this clinical update. The last in a series of updates on this topic was published in 2019.1 This review explores evolving discussions and current trends related to vascular surgery and anesthesia that have been published since then. The focus is on the major points discussed in the recent literature in the following areas: carotid artery surgery, infrarenal aortic surgery, peripheral vascular surgery, and the preoperative evaluation of vascular surgical patients.

Comparison of Landmark-Guided Versus Fluoroscopy-Guided Cerebrospinal Fluid Drain-Related Complications After Aortic Repairs.

OBJECTIVE: Cerebrospinal fluid drains (CSFDs) are efficacious in preventing spinal cord injury after thoracic or thoracoabdominal aortic repair with extensive coverage. Increasingly, fluoroscopy is used to guide placement instead of the traditional landmark-based approach, but it is unknown which approach is associated with fewer complications. DESIGN: A retrospective cohort study. SETTING: In the operating room. PARTICIPANTS: Patients having undergone thoracic or thoracoabdominal aortic repair with a CSFD over a 7-year period at a single center. INTERVENTIONS: No intervention. MEASUREMENTS AND MAIN RESULTS: Groups were reviewed and statistically compared with respect to baseline characteristics, ease of CSFD placement, and major and minor complications directly related to placement. A total of 150 CSFDs were placed with landmark guidance as opposed to 95 with fluoroscopy guidance. Compared to the landmark group, patients with fluoroscopy-guided CSFDs were older (p < 0.008), had lower American Society of Anesthesiologists physical status scores (p = 0.008), required fewer CSFD placement attempts (p = 0.011), had the CSFD in place for longer duration (p < 0.001), and had a similar incidence of CSFD-related complications (p > 0.999). Composites of both major (4.5% of cases) and minor CSFD-related complications (6.1% of cases), the primary outcomes of the study, occurred with similar incidences between the 2 groups (p > 0.999 for both comparisons) after adjusting potential confounders. CONCLUSIONS: In patients undergoing thoracic or thoracoabdominal aortic repairs, there were no significant differences in the risk of major and minor CSFD-related complications between fluoroscopic guidance and the landmark approach. Although the authors' institution is a high-volume center for this type of procedure, the study was limited by a small sample size. Hence, regardless of the technique used for the placement of CSFD, the risks related to the placement should be balanced carefully against the potential benefits resulting from spinal cord injury prevention. Fluoroscopy-aided insertion of CSFD requires fewer attempts and, hence, may be better tolerated by patients.

Right Heart Failure Management: Focus on Mechanical Support Options.

Millions of American adults suffer from right heart failure (RHF), a condition associated with high rates of hospitalization, organ failure, and death. There is a multitude of etiologies and mechanisms that lead to RHF, often in a feedforward spiral of decline. The management of advanced cases of RHF can be particularly difficult. For patients who are refractory to the medical optimization of volume status, hemodynamic and pharmacologic support, and rhythm control, mechanical therapies may be warranted. Currently available mechanical assist devices for RHF include venoarterial extracorporeal oxygenation and right ventricular assist devices, both surgical and percutaneous. Each advanced therapy has its own potential advantages and limitations, and often is appropriate in different clinical contexts. In this review, the authors describe the pathophysiology and medical therapies for RHF and then focus on the different types of advanced therapies that currently exist to help inform medical decision-making for this complicated patient cohort.

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.

Hypothermia and Prolonged Time From Procedure End to Extubation After Endovascular Thoracic Aortic Surgery.

OBJECTIVE: Perioperative hypothermia (core temperature <36°C) occurs in 50%-to-80% of patients recovering from thoracic aortic surgery, though its effects have not been described fully in this context. The authors, therefore, sought to characterize the incidence of perioperative hypothermia and its association with time from procedure end to extubation in endovascular aortic surgical patients. DESIGN: A retrospective cohort study. SETTING: At a single academic tertiary center. PARTICIPANTS: Patients recovering from thoracic aortic surgery with lumbar drains. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: A total of 196 patients were included in this study, 55 of whom were hypothermic with temperatures <35.0°C at the end of surgery. Though the unadjusted time to extubation was not statistically different in the hypothermic group (median 8 minutes, IQR 5-13.5 minutes) compared to the normothermic group (median 7 minutes, IQR 4-12 minutes; p = 0.062), multivariate predictors of increased time from procedure end to extubation included hypothermia (p = 0.011), age (p = 0.009), diabetes (p = 0.015), history of carotid disease (p = 0.040), and crystalloid volume (p = 0.019). CONCLUSIONS: Hypothermia in patients recovering from endovascular aortic surgery was associated with prolonged time from procedure end to extubation. Because of the retrospective observational nature of the authors' analysis, it was not possible to determine the extent to which prolonged mechanical ventilation was influenced by low temperature.

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.

Anesthesia for Combined Heart and Liver Transplantation.

A heart or liver transplantation procedure performed in isolation itself presents multiple challenges for the perioperative team. Accordingly, combining both transplants yields a vastly more complicated surgery, with many unique multisystem and multidisciplinary considerations. Although combined heart and liver transplantations are being performed with increasing frequency, nationwide experience is relatively limited at most institutions. The aim of this review is to discuss the perioperative challenges presented to the anesthesiology teams and provide evidence-based guidance for the management of these daunting procedures.

Anesthesia for Resection and Reconstruction of the Trachea and Carina.

Airway surgery poses a host of unique challenges to both the surgical and anesthesiology teams. Accordingly, there are a variety of surgical, anesthetic, and airway management options to be strategically considered. Management can be challenging during multidisciplinary preoperative planning, during the surgical procedure itself, and during recovery. In this review, emphasis is placed on anesthesia challenges for patients undergoing major tracheal or carinal surgery with specific considerations related to perioperative management.

Elevated Pulse Pressure, Intraoperative Hemodynamic Perturbations, and Acute Kidney Injury After Coronary Artery Bypass Grafting Surgery.

OBJECTIVE: To explore whether baseline pulse pressure (PP) confers an increased risk for acute kidney injury (AKI) independent of intraoperative hypotension or hypertension in patients who undergo coronary artery bypass grafting (CABG) surgery. DESIGN: Retrospective study. SETTING: Single academic center. PARTICIPANTS: 5,808 patients who underwent CABG surgery. MEASUREMENTS AND MAIN RESULTS: Baseline arterial blood pressure was defined as the mean of the first 5 measurements recorded by the automated record keeping system before anesthesia was induced. Weighted duration of intraoperative hypotension and hypertension were defined as the area (min × mmHg) below a mean arterial pressure of 55 mmHg and above a mean arterial pressure of 100 mmHg. Multivariable logistic and proportional odds regression analyses were performed to determine whether baseline PP and weighted duration of intraoperative hypotension and hypertension were independently associated with postoperative AKI. Of the 5,808 patients, PP was <40 mmHg in 90 (1.6%), 40-to-80 mmHg in 2,463 (42.4 %), and >80 mmHg in 3,255 (56%) patients. The incidence of AKI was 57.7%, which included 7.4% (249 patients) and 2.8% (93 patients) who experienced stages 2 and 3 AKI, respectively. In the risk-adjusted analyses, baseline PP was associated with higher odds for postoperative AKI (odds ratio for every 20 mmHg increase in PP, 1.15; 95% confidence interval 1.10-1.21; p < 0.0001) and a higher severity of postoperative AKI (proportional odds ratio, 1.13; 95% confidence interval 1.03-1.24; p = 0.0098). There was no evidence that weighted duration of intraoperative hypotension or hypertension was associated with postoperative AKI or that either interacted with the association of baseline PP with AKI. CONCLUSIONS: Baseline PP was significantly associated with postoperative AKI after CABG surgery, independent of weighted duration of intraoperative hypotension or hypertension.

General Anesthesia for Transcatheter Aortic Valve Replacement: Total Intravenous Anesthesia is Associated with Less Delirium as Compared to Volatile Agent Technique.

OBJECTIVE: Investigate the effect of volatile anesthesia versus total intravenous anesthesia on the incidence of postoperative delirium and length of stay in patients undergoing transcatheter aortic valve replacement under general anesthesia. DESIGN: Retrospective study. SETTING: Single institution, academic medical center. PARTICIPANTS: Adult patients who underwent transcatheter aortic valve replacement under general anesthesia between November 2014 and February 2017. INTERVENTIONS: This study was not an interventional study. MEASUREMENTS AND MAIN RESULTS: Electronic medical records were reviewed for intraoperative maintenance anesthetic technique, hospital and intensive care unit length of stay, 30-day mortality, and documentation of delirium. Delirium was defined as either 1) positive Confusion Assessment Method for the Intensive Care Unit score or 2) documentation of delirium or confusion by the care team within 2 days of surgery. Overall, 116 patients were included and 84 (72%) received a total intravenous anesthesia technique. Twenty-three patients (20%) had postoperative delirium. The odds of delirium were lower in patients undergoing transcatheter aortic valve replacement with total intravenous anesthesia, compared with volatile anesthesia, even after adjusting for procedure approach (odds ratio 0.22, 95% confidence interval 0.06, 0.79, p = 0.02). No significant difference in hospital or intensive care unit length of stay was seen after adjusting for procedural characteristics. CONCLUSIONS: While postoperative delirium is a complex and multifactorial problem, the type of general anesthetic maintenance may contribute to the incidence of postoperative delirium in patients undergoing transcatheter aortic valve replacement, and total intravenous anesthesia may be an attractive alternative to volatile-based general anesthesia maintenance.

Platelet Counts and Postoperative Stroke After Coronary Artery Bypass Grafting Surgery.

BACKGROUND: Declining platelet counts may reveal platelet activation and aggregation in a postoperative prothrombotic state. Therefore, we hypothesized that nadir platelet counts after on-pump coronary artery bypass grafting (CABG) surgery are associated with stroke. METHODS: We evaluated 6130 adult CABG surgery patients. Postoperative platelet counts were evaluated as continuous and categorical (mild versus moderate to severe) predictors of stroke. Extended Cox proportional hazard regression analysis with a time-varying covariate for daily minimum postoperative platelet count assessed the association of day-to-day variations in postoperative platelet count with time to stroke. Competing risks proportional hazard regression models examined associations between day-to-day variations in postoperative platelet counts with timing of stroke (early: 0-1 days; delayed: ≥2 days). RESULTS: Median (interquartile range) postoperative nadir platelet counts were 123.0 (98.0-155.0) × 10/L. The incidences of postoperative stroke were 1.09%, 1.50%, and 3.02% for platelet counts >150 × 10/L, 100 to 150 × 10/L, and <100 × 10/L, respectively. The risk for stroke increased by 12% on a given postoperative day for every 30 × 10/L decrease in platelet counts (adjusted hazard ratio [HR], 1.12; 95% confidence interval [CI], 1.01-1.24; P= .0255). On a given day, patients with moderate to severe thrombocytopenia were almost twice as likely to develop stroke (adjusted HR, 1.89; 95% CI, 1.13-3.16; P= .0155) as patients with nadir platelet counts >150 × 10/L. Importantly, such thrombocytopenia, defined as a time-varying covariate, was significantly associated with delayed (≥2 days after surgery; adjusted HR, 2.83; 95% CI, 1.48-5.41; P= .0017) but not early postoperative stroke. CONCLUSIONS: Our findings suggest an independent association between moderate to severe postoperative thrombocytopenia and postoperative stroke, and timing of stroke after CABG surgery.