Propofol vs etomidate for induction prior to invasive mechanical ventilation in patients with acute myocardial infarction.

BACKGROUND: Patients with acute myocardial infarction (AMI) requiring invasive mechanical ventilation (IMV) have a high mortality. However, little is known regarding the impact of induction agents, used prior to IMV, on clinical outcomes in this population. We assessed for the association between induction agent and mortality in patients with AMI requiring IMV. METHODS: We compared clinical outcomes between those receiving propofol compared to etomidate for induction among adults with AMI between October 2015 and December 2019 using the Vizient® Clinical Data Base, a multicenter, US national database. We used inverse probability treatment weighting (IPTW) to assess for the association between induction agent and in-hospital mortality. RESULTS: We identified 5,147 patients, 1,386 (26.9%) of received propofol and 3,761 (73.1%) received etomidate for IMV induction. The mean (SD) age was 66.1 (12.4) years, 33.0% were women, and 51.6% and 39.8% presented with STEMI and cardiogenic shock, respectively. Patients in the propofol group were more likely to require preintubation vasoactive medication and mechanical circulatory support (both, P < .05). Utilization of propofol was associated with lower mortality compared to etomidate (32.3% vs 36.1%, P = .01). After propensity weighting, propofol use remained associated with lower mortality (weighted mean difference -4.7%; 95% confidence interval: -7.6% to -1.8%, P = .002). Total cost, ventilator days, and length of stay were higher in the propofol group (all, P < .001). CONCLUSIONS: Induction with propofol, compared with etomidate, was associated with lower mortality for patients with AMI requiring IMV. Randomized trials are needed to determine the optimal induction agent for this critically ill patient population.

The Year in Graduate Medical Education: Selected Highlights from 2023.

This special article is the third in an annual series of the Journal of Cardiothoracic and Vascular Anesthesia that highlights significant literature from the world of graduate medical education published over the past year. Major themes addressed in this review include the potential uses and pitfalls of artificial intelligence in graduate medical education, trainee well-being and the rise of unionized house staff, the effect of gender and race/ethnicity on residency application and attrition rates, and the adoption of novel technologies in medical simulation and education. The authors thank the editorial board for again allowing us to draw attention to some of the more interesting work published in the field of graduate medical education during 2023. We hope that the readers find these highlights thought-provoking and informative as we all strive to successfully educate the next generation of anesthesiologists.

The Year in Graduate Medical Education: Selected Highlights From 2021.

This special article is the first in a planned annual series for the Journal of Cardiothoracic and Vascular Anesthesia that will highlight significant literature from the world of graduate medical education (GME) that was published over the past year. The major themes selected for this inaugural review are the educational value of simulation and training workshops, the expanding role of social media and other information technologies in GME and recruitment, the state of residency and fellowship training before the COVID-19 pandemic, and the inevitable effects COVID-19 has had on graduate medical education. The authors would like to thank the editorial board for allowing us to shine a light on a small subset of the writing and research produced in this field, so that educators may understand how best to educate and train the next generation of anesthesiologists.

Mechanical circulatory support devices in geriatric patients: more than just age.

PURPOSE OF REVIEW: The use of mechanical circulatory support (MCS) devices, such as left ventricular assist device and extracorporeal membrane oxygenation in the elderly have been rapidly increasing in various clinical settings over the past two decades. This review briefly summarizes recent literature on the role and outcomes of such mechanical circulatory support devices use in the elderly. RECENT FINDINGS: Elderly patients are receiving increasing number of LVADs with improved survival and quality-of-life outcomes, despite multiple comorbidities. ECMO is a viable option in elderly patients but they have a higher risk of mortality after both VA ECMO and VV ECMO support. However, comorbidities, clinical presentation and timing of ECMO initiation seems to have a greater impact on prognosis than for younger patients. SUMMARY: MCS device use continue to rise in the elderly population. Meticulously selected elderly patients could be successfully supported with MCS devices with favorable outcomes and acceptable mortality and complication rate.

Ethics Consultation in Anesthesia Practice.

Because modern surgical and medical care have advanced, patients increasingly present for procedural and surgical intervention with life-limiting diagnoses and/or advanced care goals such as "do not resuscitate." Anesthesiologists now care for these patients across the complete perioperative setting and frequently find themselves at the crossroads of these mounting pressures. As the boundaries and capabilities of anesthetic care and critical care anesthesiology expand so too do the specialty's needs for support in ethical decision-making. Herein, we review the role of the ethics consultation in anesthesia practice and special ethic issues encountered by the anesthesiologist.

A proposed rescue transesophageal echocardiographic protocol for anesthetized dogs.

OBJECTIVE: To describe the acquisition and pitfalls of a 3-view transesophageal echocardiography (TEE) protocol in anesthetized, dorsally recumbent dogs. ANIMALS: 8 beagles, 1 to 2 years old, 7.4 to 11.2 kg. METHODS: Dogs were anesthetized, mechanically ventilated, and placed in dorsal recumbency. A TEE probe was advanced, and 3 views were performed: midesophageal 4-chamber and long axis (ME 4C and ME LAX) and caudal esophageal short axis (CE SAX) at the level of the papillary muscles. Probe insertion depth, flexion, omniplane angle, and image acquisition time were recorded. Two observers assessed 24 video clips each and identified anatomical structures. RESULTS: The ME 4C and ME LAX were obtained at 35 (30 to 40) cm insertion depth, omniplane at 0° and 103° (90 to 116), respectively. Views were obtained in ≤30 seconds once the TEE was in the cervical esophagus. Left-sided structures were identified in all cases, whereas right-sided structures were not always simultaneously obtained in the ME 4C, requiring further probe manipulation. All structures were identified on ME LAX. CE SAX was obtained at 40 (35 to 45) cm, omniplane at 0°, and in 15 (10 to 90) seconds. A true SAX view (circular left ventricle at the level of papillary muscles) could not be obtained in all dogs. CLINICAL RELEVANCE: A 3-view TEE protocol using core views as those described in humans may be applicable to dogs under general anesthesia and in dorsal recumbency. The CE SAX view at the level of the papillary muscles appears more difficult to obtain with consistency than midesophageal views.

Mechanical Cardiac Circulatory Support: an Overview of the Challenges for the Anesthetist.

Purpose of Review: Owing to increased utilization of Mechanical Circulatory Support (MCS) devices, patients with these devices frequently present for surgeries requiring anesthetic support. The current article provides basics of perioperative management of these devices. Recent Findings: Use of extracorporeal membrane oxygenation (ECMO) and left ventricular assist devices (LVADs) are on the rise with recently updated management guidelines. Veno-venous ECMO utilization has been widely utilized as a salvage therapy during the COVID-19 pandemic. Summary: Intra-Aortic Balloon Pumps continue to be one of the most frequently used devices after acute myocardial infarction. ECMO is utilized for pulmonary or cardiopulmonary support as salvage therapy. LVADs are used in patients with end-stage heart failure as a destination therapy or bridge to transplant. Each of these devices present with their own set of management challenges. Anesthetic management of patients with MCS devices requires a thorough understanding of underlying operating and hemodynamic principles.

Impact of Obesity on Heart Transplantation Outcomes.

Background Patients with obesity and advanced heart failure face unique challenges on the path to heart transplantation. There are limited data on waitlist and transplantation outcomes in this population. We aimed to evaluate the impact of obesity on heart transplantation outcomes, and to investigate the effects of the new organ procurement and transplantation network allocation system in this population. Methods and Results This cohort study of adult patients listed for heart transplant used the United Network for Organ Sharing database from January 2006 to June 2020. Patients were stratified by body mass index (BMI) (18.5-24.9, 25-29.9, 30-34.9, 35-39.9, and 40-55 kg/m2). Recipient characteristics and donor characteristics were analyzed. Outcomes analyzed included transplantation, waitlist death, and posttransplant death. BMI 18.5 to 24.9 kg/m2 was used as the reference compared with progressive BMI categories. There were 46 645 patients listed for transplantation. Patients in higher BMI categories were less likely to be transplanted. The lowest likelihood of transplantation was in the highest BMI category, 40 to 55 kg/m2 (hazard ratio [HR], 0.19 [0.05-0.76]; P=0.02). Patients within the 2 highest BMI categories had higher risk of posttransplantation death (HR, 1.29; P<0.001 and HR, 1.65; P<0.001, respectively). Left ventricular assist devices among patients in obese BMI categories decreased after the allocation system change (P<0.001, all). After the change, patients with obesity were more likely to undergo transplantation (BMI 30-35 kg/m2: HR, 1.31 [1.18-1.46], P<0.001; BMI 35-55 kg/m2: HR, 1.29 [1.06-1.58]; P=0.01). Conclusions There was an inverse relationship between BMI and likelihood of heart transplantation. Higher BMI was associated with increased risk of posttransplant mortality. Patients with obesity were more likely to undergo transplantation under the revised allocation system.