New-onset intra-operative hyperthermia in a large surgical patient population: A retrospective observational study.

BACKGROUND: Intra-operative hypothermia has been extensively investigated. However, the incidence of intra-operative hyperthermia has not been investigated in detail. OBJECTIVE: The main objective of this study was to assess the incidence and risk factors of new-onset intra-operative hyperthermia in a large surgical patient population. DESIGN: Retrospective database review. SETTING: Tertiary-care teaching hospital. PATIENTS: Patients undergoing surgery with general anaesthesia between 1 January 2002 and 31 December 2017 were included. MAIN OUTCOME MEASURES: The primary outcome measurement was new-onset intra-operative hyperthermia (>37.5 °C). A logistic regression model was fitted to identify risk factors for intra-operative hyperthermia. RESULTS: A total of 103 648 patients were included in the final analyses. The incidence of new-onset hyperthermia in the overall patient cohort was 6.45%, reaching 20 to 30% after prolonged (>8 h) surgery, and was up to 26.5% in paediatric patients. The use of forced air active patient warming, larger amounts of fluid administration, longer surgery, younger age and smaller body size were all independently associated with intra-operative hyperthermia. The adoption of the Surgical Care Improvement Project (SCIP) temperature measures was associated with an increased incidence of intra-operative hyperthermia. CONCLUSION: Mild intra-operative hyperthermia is not uncommon particularly in longer procedures and small children.

Intraoperative Cardiac Arrest During Adult Liver Transplantation: Incidence and Risk Factor Analysis From 7 Academic Centers in the United States.

BACKGROUND: Intraoperative cardiac arrest (ICA) has a reported frequency of 1 in 10,000 anesthetics but has a much higher estimated incidence in orthotopic liver transplantation (OLT). Single-center studies of ICA in OLT are limited by small sample size that prohibits multivariable regression analysis of risks. METHODS: Utilizing data from 7 academic medical centers, we performed a retrospective, observational study of 5296 adult liver transplant recipients (18-80 years old) between 2000 and 2017 to identify the rate of ICA, associated risk factors, and outcomes. RESULTS: ICA occurred in 196 cases (3.7% 95% confidence interval [CI], 3.2-4.2) and mortality occurred in 62 patients (1.2%). The intraoperative mortality rate was 31.6% in patients who experienced ICA. In a multivariable generalized linear mixed model, ICA was associated with body mass index (BMI) <20 (odds ratio [OR]: 2.04, 95% CI, 1.05-3.98; P = .0386), BMI ≥40 (2.16 [1.12-4.19]; P = .022), Model for End-Stage Liver Disease (MELD) score: (MELD 30-39: 1.75 [1.09-2.79], P = .02; MELD ≥40: 2.73 [1.53-4.85], P = .001), postreperfusion syndrome (PRS) (3.83 [2.75-5.34], P < .001), living donors (2.13 [1.16-3.89], P = .014), and reoperation (1.87 [1.13-3.11], P = .015). Overall 30-day and 1-year mortality were 4.18% and 11.0%, respectively. After ICA, 30-day and 1-year mortality were 43.9% and 52%, respectively, compared to 2.6% and 9.3% without ICA. CONCLUSIONS: We established a 3.7% incidence of ICA and a 1.2% incidence of intraoperative mortality in liver transplantation and confirmed previously identified risk factors for ICA including BMI, MELD score, PRS, and reoperation and identified new risk factors including living donor and length of surgery in this multicenter retrospective cohort. ICA, while rare, is associated with high intraoperative mortality, and future research must focus on therapy to reduce the incidence of ICA.

Unusual Complication of the Nuss Procedure: Fistulization of the Internal Thoracic Artery to the Pulmonary Artery.

Although minimally invasive repair of pectus excavatum has been shown to have a low complication rate in large series, several case reports have documented life-threatening complications, including bleeding and cardiac perforation. We present a rare case of an arteriovenous malformation from the internal thoracic artery to the pulmonary artery caused by occlusion of the internal thoracic artery by the Nuss bar followed by an unidentified angiogenic process. The patient became symptomatic and required transcatheter coil embolization.

Reducing Fluoroscopic Radiation Exposure During Endomyocardial Biopsy in Pediatric Transplant Recipients.

Endomyocardial biopsy (EMB) with fluoroscopy is used for rejection surveillance in pediatric heart transplantation. Lowering frame rate may reduce radiation, but decreases temporal resolution and image quality. We undertook a quality initiative reducing frame rate from 10 frames per second (FPS) to 5 FPS. To assess whether lowering frame rate can reduce radiation exposure without compromising safety, data on EMBs from 9/2009 to 4/2013 without angiography or intervention were reviewed. Effective dose was calculated from dose area product (DAP) and fluoroscopy time. Complications were reviewed. Independent t test compared pre- and post-data and a general linear model were used to control for confounders. Paired t test of most proximate data was used for pts with EMB before and after our change. Eighty-six patients had 543 EMB. After adjusting for weight, attending, and presence of a fellow, the lower FPS group had a 60.3% reduction in DAP (p < 0.0001) and 53.8% drop in effective dose (p < 0.0001). Fluoroscopy time did not differ. Twenty-eight pts had EMBs both before and after the FPS change. Pair-wise analysis of this group demonstrated a 33% reduction in DAP (p < 0.05) and 37% drop in effective dose (p < 0.01), without difference in fluoroscopy time. No patient had an increase in TR > 1 grade by ECHO. There were no deaths or perforations. Lowering the frame rate reduces radiation exposure by >50% without compromising safety. Efforts to further minimize radiation exposure of this vulnerable population should be considered.

Novel Technique to Evaluate Pulmonary Vascular Resistance in a Patient With Aortopulmonary Window.

We report a case of a 15-month-old female presenting with a large aortopulmonary window during a medical mission. The optimal surgical correction for this patient would be based on an estimation of her pulmonary vascular reactivity. This report details the use of antegrade/retrograde flow ratios using Doppler measurements in the proximal descending aorta at baseline and while receiving 100% oxygen. A large increase in the proportion of retrograde flow under the 100% oxygen condition suggested a reactive pulmonary vascular bed. She underwent a complete repair with patch closure of the aortopulmonary window. A postoperative echocardiographic assessment showed near normal right ventricular pressures.

Arteriovenous Fistula: A Rare Complication After Nuss Procedure for Pectus Excavatum.

We report a case of a 13-year-old female patient who underwent the Nuss procedure for surgical correction of pectus excavatum. As a result of the procedure, the patient developed an arteriovenous fistula between the left internal mammary artery and the pulmonary venous system.

Standardizing radiation dose reporting in the pediatric cardiac catheterization laboratory-a multicenter study by the CCISC (Congenital Cardiovascular Interventional Study Consortium).

OBJECTIVES: We examine normalized air Kerma area product (PKA ) by body weight (PKA /BW) as a reference value of radiation dose and benchmark PKA /BW in pediatric laboratories using a multicenter registry database. BACKGROUND: Reduction of radiation dose is an important quality improvement task in pediatric cardiac catheterization laboratories. Physicians need to agree on a standard method of reporting radiation dose that would allow comparisons to be made between operators and institutions. METHODS: This was a multicenter observational study of radiation dose in pediatric laboratories. Patient demographic, procedural and radiation data including fluoroscopic time and PKA (µGy m(2) ) were analyzed. PKA /BW was obtained by indexing PKA to body weight. RESULTS: A total of 8,267 pediatric catheterization procedures (age <18 years) were included from 16 institutions. The procedures consisted of diagnostic (n = 2,827), transplant right ventricular (RV) biopsy (n = 1,172), and interventional catheterizations (n = 4268). PKA correlated with body weight better than with age and best correlated with weight-fluoroscopic time product. PKA /BW showed consistent values across pediatric ages. Interventional catheterizations had the highest PKA /BW (50th, 75th, and 90th percentiles: 72, 151, and 281 µGy m(2) /kg), followed by diagnostic (59, 105, and 175 µGy m(2) /kg) and transplant RV biopsy (27, 79, and 114 µGy m(2) /kg). CONCLUSION: PKA /BW appeared to be the most reliable standard to report radiation dose across all procedure types and patient age. We recommend PKA /BW to be used as the standard unit in documenting radiation usage in pediatric laboratories and can be used to evaluate strategies to lower radiation dosage in pediatric patients undergoing cardiac catheterizations. © 2014 Wiley Periodicals, Inc.

The FLUSH study--flush the line and ultrasound the heart: ultrasonographic confirmation of central femoral venous line placement.

STUDY OBJECTIVE: Inadvertent arterial placement of a femoral venous catheter may result in serious morbidity, including limb necrosis. The Flush the Line and Ultrasound the Heart (FLUSH) test is visualization of the heart by a subxiphoid ultrasonic view while the central catheter is flushed with agitated saline solution. We wish to determine whether the FLUSH test can verify proper femoral venous line placement. METHODS: We prospectively studied a convenience sample of children undergoing cardiac catheterization, for whom both femoral venous and arterial access were part of their standard care. The cardiologist flushed manually agitated saline solution through each catheter in randomized sequence while the blinded physician sonographer recorded the presence or absence of right atrial opacification. We calculated the sensitivity and specificity of the FLUSH test relative to our reference standard, the cardiologist's fluoroscopic visualization of catheter wire placement. RESULTS: Of the 51 subjects enrolled, the FLUSH test was 100% sensitive (95% confidence interval 95% to 100%) and 90.3% specific (95% confidence interval 81% to 96%) in confirming femoral catheter placement. In no case was an arterial flush misidentified as a femoral flush. The interrater reliability of the test was strong: κ 0.82 for all images and 0.9 for those of good quality. CONCLUSION: The FLUSH test is simple and reliable, and appears to accurately confirm femoral venous line placement.

Association of preanesthesia hypertension with adverse outcomes.

OBJECTIVE: To investigate the incidence of preanesthesia hypertension, case cancellation for hypertension, and association with postoperative outcomes. DESIGN: Retrospective descriptive, univariate, and multivariate analyses of electronic anesthesia and hospital records. SETTING: A large urban academic medical center. PARTICIPANTS: Adult elective surgical patients with preinduction blood pressure (BP) >140/90 mmHg during calendar years 2002 to 2008. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Preinduction hypertension was present in 21,126 of 209,985 (10%) patients, and the incidence of adverse outcomes (elevated troponin or in-hospital death) was 1.3% overall and 2.8% for the subset of patients with baseline systolic BP >200 mmHg. Independent predictors of adverse outcome included increased baseline systolic BP, intraoperative diastolic BP <85 mmHg, increased intraoperative heart rate, blood transfusion, and anesthetic technique, controlling for standard risk factors. A total of 69 hypertensive patients (0.3%) had surgery cancelled before the induction of anesthesia; 29 of these cancellations occurred among the 1,330 patients with baseline SBP >200 mmHg (2.2%). Among 42 "cancelled" patients who returned for surgery hours to years later, the average preinduction BP was 192/102 mmHg, and adverse cardiovascular outcomes occurred in 4.8%. CONCLUSIONS: The increasing severity of preinduction hypertension was an independent risk factor for postoperative myocardial injury/infarction or in-hospital death. Only a small percentage of cases with patients presenting with severe hypertension were cancelled, and the delay of surgery did not result in interval normalization of blood pressure.

Intraoperative carbon dioxide management and outcomes.

BACKGROUND AND OBJECTIVE: Intraoperative hyperventilation to induce hypocapnia has historically been common practice and has physiological effects that may be detrimental. In contrast, hypercapnia has effects that may be beneficial. As these effects may influence postoperative recovery, we investigated the association between variations in intraoperative carbon dioxide and length of hospital stay in patients who had elective colon resections and hysterectomies. METHODS: Data were extracted from electronic records for elective colon resections and hysterectomies done from 2002 to 2008. Patients were divided into four groups based on surgical procedure and use of laparoscopic technique. Parameters extracted for analysis included mean end-tidal carbon dioxide (EtCO2) during the surgical procedure as well as others previously purported to affect postoperative outcomes. In-hospital length of stay (LOS) was determined from administrative records and was used as the independent outcome variable. For each group, Poisson regression analysis was performed to find factors that were independently associated with the outcome. RESULTS: A total of 3421 case records in our database met inclusion criteria. Median EtCO2 was 31 mmHg. Median LOS was 7 and 5 days for open and laparoscopic colon resections, and 3 and 2 days for open and laparoscopic hysterectomies, respectively. Regression analysis revealed a statistically significant independent association between higher EtCO2 and reduced LOS for colon resection and open hysterectomy. CONCLUSION: There is a significant association between higher intraoperative EtCO2 and shorter LOS after colon resection and open hysterectomy. The common practice of inducing hypocapnia may be deleterious, and maintaining normocapnia or permitting hypercapnia may improve clinical outcomes.

Intraoperative management of robotic-assisted versus open radical prostatectomy.

BACKGROUND AND OBJECTIVES: Minimally invasive surgery has been shown to decrease postoperative morbidity and length of stay for several laparoscopic procedures. We sought to retrospectively compare intraoperative surgical and anesthetic parameters, post-anesthetic care unit (PACU) length of stay, and hospital length of stay of patients who underwent robotic-assisted laparoscopic radical prostatectomy (RAP) versus open radical retropubic prostatectomy (ORP). METHODS: A retrospective investigation was performed using a urologic surgery database and an anesthesia electronic medical record. We queried information regarding 106 ORP patients from 2002 through 2007 and 575 RAP patients from 2007 through 2008. RESULTS: Patients in the RAP group compared with ORP patients had reductions in surgical time, anesthesia time, estimated blood loss, crystalloid administration, and PACU and hospital length of stays. Compared with ORP procedures, intraoperative respiratory rates, peak inspiratory pressures, and arterial pressures in RAP procedures were higher; tidal volumes and heart rates were decreased; but end-tidal carbon dioxide concentrations were not different. In the RAP group, intraoperative complications included severe bradycardia, corneal abrasions, and 2 patients required reintubation. Surgically, no rectal perforations were noted, and no operative mortalities occurred. CONCLUSIONS: Our data demonstrate the safety and efficacy of RAP due to a combination of surgical and anesthetic factors.

Anesthetic experience with endovascular aortic aneurysm repair.

BACKGROUND: We endeavored to characterize the anesthesia experience with endovascular aneurysm repair (EVAR) at a large academic medical center in the United States. METHODS: A retrospective review of electronic medical records was conducted for all patients undergoing elective EVAR from 2002 to 2007 in a large academic medical center. RESULTS: A total of 522 cases met inclusion criteria, with 4% of cases using general anesthesia (GA), 92% regional anesthesia (RA), and 4% local anesthesia (LA). There was no statistically significant difference between the groups for duration of surgery or in-hospital mortality. In-hospital length of stay was longer for GA than LA or RA. Four cases were converted to open repair. Two mortalities occurred during the perioperative period (0.4% of cases). CONCLUSIONS: The vast majority of EVAR were successfully performed under RA, involved mild blood loss, involved infrequent need for conversion to GA, and resulted in brief in-hospital length of stay and low mortality rate.

A comparison of transmittance and reflectance pulse oximetry during vascular surgery.

BACKGROUND: New reflectance pulse oximetry probes placed on the forehead may be an improvement over transmittance probes placed on a finger, toe, or earlobe in patients with compromised perfusion. We compared the reliability and accuracy of the 2 types of probes in patients undergoing vascular surgery. METHODS: Patients with peripheral vascular disease undergoing vascular surgery under general anesthesia were monitored with both a transmittance earlobe probe and a reflectance forehead probe. Spo(2) was recorded continuously from both probes, and arterial blood gas samples were analyzed when clinically indicated. The average values from both probes over each minute were compared using Bland-Altman analysis. RESULTS: Twenty patients were included yielding a total of 3993 1-min averaged data pairs. Neither probe failed to report a value for more than 1 min. A Bland-Altman plot showed the limits of agreement between the probes of -4.0% to +2.6%. Twenty-eight arterial blood samples were analyzed for 14 patients and Sao(2) closely matched both Spo(2) probe values at the time of sampling. Compared with Sao(2), analysis demonstrated limits of agreement of -4.7% to 6.1% for ear and -3.3% to 3.4% for forehead sites. CONCLUSIONS: The new reflectance forehead Spo(2) probe tested has acceptable agreement with the older transmittance probe placed on the earlobe for pulse oximetry within typical ranges of Spo(2) in patients undergoing vascular surgery.

Coarctation of the aorta: midterm outcomes of resection with extended end-to-end anastomosis.

BACKGROUND: We began using the technique of resection with extended end-to-end anastomosis for infants and children with coarctation of the aorta in 1991. The purpose of this review is to evaluate the midterm outcomes of this technique, specifically determining the incidence of and risk factors for transcatheter or surgical reintervention. METHODS: A retrospective analysis of the cardiac surgery database was performed to identify all patients who had a diagnosis of coarctation of the aorta with or without ventricular septal defect and had resection with extended end-to-end anastomosis from 1991 to 2007. Perioperative course and follow-up with physical examination, echocardiogram, and cardiology evaluation were obtained. RESULTS: From 1991 through 2007, 201 patients had repair of coarctation of the aorta with resection with extended end-to-end anastomosis. The median age was 23 days, and the median weight was 4.0 kg. Surgical approach was by left thoracotomy in 157 patients (78%) with a mean cross-clamp time of 18 +/- 4 minutes. Median sternotomy approach was used in 44 patients (22%) to repair a hypoplastic transverse aortic arch (n = 16) or because of associated ventricular septal defect (n = 28) with a mean circulatory arrest time of 14 +/- 9 minutes. Early mortality occurred in 4 patients (2.0%). Three patients (1.5%) required early arch revision: 2 intraoperatively and 1 on postoperative day 1. Follow-up data were available for 182 patients (91%) with a mean follow-up of 5.0 +/- 4.3 years (908 patient-years). Reinterventions (n = 8; 4.0%) included three balloon angioplasties and five reoperations; 75% of the reinterventions occurred in the first postoperative year. Hypoplastic transverse aortic arch was not a risk factor for reintervention (p = 0.36), but was a risk factor for mortality (p = 0.039). Aberrant right subclavian artery was the only risk factor for recoarctation (p = 0.007). CONCLUSIONS: Repair of coarctation of the aorta with resection with extended end-to-end anastomosis has a low early mortality, effectively addresses transverse arch hypoplasia, and at midterm follow-up has a low rate of reintervention for recurrent coarctation.

Porcine skin-derived stem cells can serve as donor cells for nuclear transfer.

Although transgenic animal production through somatic cell nuclear transfer (SCNT) has been successful, the process is still inefficient. One major limitation is the use of somatic donor cells that have a finite life span. Identification and isolation of a cell type capable of rapid proliferation while possessing immortal or prolonged life span in culture and is capable of being genetically modified would be very valuable for utilization in the production of genetically modified pigs. Here we report the birth of live piglets after cloning by using porcine skin-derived stem cells (SSC) as a donor cell type. In the present study, cell cycle analysis indicates that the porcine SSC proliferate rapidly in vitro. The porcine SSC are capable of producing live offspring and can be genetically modified with positive selection. Utilization of porcine SSC may prove to be an excellent cell type for genetic modification followed by nuclear transfer for the production of transgenic pigs.

Disruption of the CFTR gene produces a model of cystic fibrosis in newborn pigs.

Almost two decades after CFTR was identified as the gene responsible for cystic fibrosis (CF), we still lack answers to many questions about the pathogenesis of the disease, and it remains incurable. Mice with a disrupted CFTR gene have greatly facilitated CF studies, but the mutant mice do not develop the characteristic manifestations of human CF, including abnormalities of the pancreas, lung, intestine, liver, and other organs. Because pigs share many anatomical and physiological features with humans, we generated pigs with a targeted disruption of both CFTR alleles. Newborn pigs lacking CFTR exhibited defective chloride transport and developed meconium ileus, exocrine pancreatic destruction, and focal biliary cirrhosis, replicating abnormalities seen in newborn humans with CF. The pig model may provide opportunities to address persistent questions about CF pathogenesis and accelerate discovery of strategies for prevention and treatment.

Development and implementation of a pediatric cardiac anesthesia/intensive care database.

Systematic collection and electronic storage of data can assist in improving quality and efficiency of patient care and can provide a data set to interrogate for subsequent performance improvement and clinical research purposes. In this article, an electronic perioperative pediatric cardiac surgery database to be used by a multidisciplinary care team was designed, developed, and implemented. Technical goals for the design included low cost, rapid development and implementation, adequate security, and potential for internal and external distribution. Implementation of the described database has proved to be invaluable for quality assurance and statistical analysis of data relevant to patient care. From the overall positive experience, it was concluded that the electronic data management does not always need major cost investment.

Production of CFTR-null and CFTR-DeltaF508 heterozygous pigs by adeno-associated virus-mediated gene targeting and somatic cell nuclear transfer.

Progress toward understanding the pathogenesis of cystic fibrosis (CF) and developing effective therapies has been hampered by lack of a relevant animal model. CF mice fail to develop the lung and pancreatic disease that cause most of the morbidity and mortality in patients with CF. Pigs may be better animals than mice in which to model human genetic diseases because their anatomy, biochemistry, physiology, size, and genetics are more similar to those of humans. However, to date, gene-targeted mammalian models of human genetic disease have not been reported for any species other than mice. Here we describe the first steps toward the generation of a pig model of CF. We used recombinant adeno-associated virus (rAAV) vectors to deliver genetic constructs targeting the CF transmembrane conductance receptor (CFTR) gene to pig fetal fibroblasts. We generated cells with the CFTR gene either disrupted or containing the most common CF-associated mutation (DeltaF508). These cells were used as nuclear donors for somatic cell nuclear transfer to porcine oocytes. We thereby generated heterozygote male piglets with each mutation. These pigs should be of value in producing new models of CF. In addition, because gene-modified mice often fail to replicate human diseases, this approach could be used to generate models of other human genetic diseases in species other than mice.