The Women in Cardiothoracic Anesthesiology Special Interest Group: What Can the Lessons of One Anesthesiology Affinity Group Tell Us About How to Build Impactful Professional Communities?

The Women In Cardiothoracic Anesthesiology (WICTA), a special interest group of the Society of Cardiovascular Anesthesiologists, has been highly successful in mobilizing WICTA, a historically underrepresented and marginalized group in the subspecialty, and in supporting real and meaningful change in the professional community. The experience of WICTA as a professional affinity group in impacting a professional organization to diversify, evolve, and become more responsive to a wider professional audience has important lessons for other professional organizations. This article discusses the recent history of affinity organizations in anesthesiology, the benefits they offer professional organizations, and the strategies that have been used to effectively motivate change in professional communities. These strategies include engaging a strong advisory board, identifying the need of constituents, creating additional opportunities for networking and membership, addressing gaps in professional development, and aligning goals with those of the larger national organization. WICTA is just one example of the potential opportunities that affinity groups offer to professional societies and organizations for expanding their reach, enhancing their impact on physicians in their target audience, and achieving organizational missions.

Postcardiotomy Shock Syndrome: A Narrative Review of Perioperative Diagnosis and Management.

Postcardiotomy shock (PCS) is generally described as the inability to separate from cardiopulmonary bypass due to ineffective cardiac output after cardiotomy, which is caused by a primary cardiac disorder, resulting in inadequate tissue perfusion. Postcardiotomy shock occurs in 0.5% to 1.5% of contemporary cardiac surgery cases, and is accompanied by an in-hospital mortality of approximately 67%. In the last 2 decades, the incidence of PCS has increased, likely due to the increased age and baseline morbidity of patients requiring cardiac surgery. In this narrative review, the authors discuss the epidemiology and pathophysiology of PCS, the rationale and evidence behind the initiation, continuation, escalation, and discontinuation of mechanical support devices in PCS, and the anesthetic implications.

Pulmonary prehabilitation and smoking cessation.

PURPOSE OF REVIEW: This review aims to summarize the current literature on pulmonary prehabilitation programs, their effects on postoperative pulmonary complications, and the financial implications of implementing these programs. Additionally, this review has discussed the current trends in pulmonary prehabilitation programs, techniques for improving rates of perioperative smoking cessation, and the optimal timing of these interventions. RECENT FINDINGS: Prehabilitation is a series of personalized multimodal interventions tailored to individual needs, including lifestyle and behavioral measures. Pulmonary prehabilitation has shown to reduce postoperative pulmonary complications (PPCs). SUMMARY: The implications of clinical practice and research findings regarding PPCs are an increased burden of postoperative complications and financial cost to both patients and hospital systems. There is convincing evidence that pulmonary prehabilitation based on endurance training should be started 8-12 weeks prior to major surgery; however, similar rates of improved postoperative outcomes are observed with high-intensity interval training (HIIT) for 1-2 weeks. This shorter interval of prehabilitation may be more appropriate for patients awaiting thoracic surgery, especially for cancer resection. Additionally, costs associated with creating and maintaining a prehabilitation program are mitigated by shortened lengths of stay and reduced PPCs. Please see Video Abstract, http://links.lww.com/COAN/A90.

Predicting cardiac risk in noncardiac surgery: a narrative review.

Risk stratification endeavors to categorize patients into groups based on the level of risk for each group. Improved perioperative screening tests using more sensitive cardiac biomarkers have revealed that about 68% of perioperative myocardial infarctions (MI) are asymptomatic and may only be detected by routine postoperative screening with troponin measurements. This is important since myocardial injury not meeting criteria for myocardial infarction is associated with increased risk of 30-day mortality (Botto et al. in Anesthesiology 120:564-578, 2014). Traditional risk indices including the revised cardiac risk index (RCRI) and the myocardial infarction cardiac arrest (MICA) index were developed based on overt clinical signs of myocardial infarction and significantly underestimate adverse cardiac events. Recently, brain type natriuretic peptides (BNP) and its precursor n- terminal pro-brain type natriuretic peptide (nt-proBNP) have been shown to be powerful prognostic markers. Incorporating serum biomarkers into updated clinical risk indices is likely to improve their performance. Further studies are needed to determine appropriate clinical interventions to treat isolated elevations in cardiac troponin levels and further mitigate the increased risk of morbidity and mortality. The objective of this review is to summarize the current literature on the clinical diagnoses of perioperative myocardial injury in the setting of noncardiac surgery.

Racial and Ethnic Disparities in Perioperative Health Care Among Patients Undergoing Cardiac Surgery: JACC State-of-the-Art Review.

There has been little progress in reducing health care disparities since the 2003 landmark Institute of Medicine's report Unequal Treatment. Despite the higher burden of cardiovascular disease in underrepresented racial and ethnic groups, they have less access to cardiologists and cardiothoracic surgeons, and have higher rates of morbidity and mortality with cardiac surgical interventions. This review summarizes existing literature and highlights disparities in cardiovascular perioperative health care. We propose actionable solutions utilizing multidisciplinary perspectives from cardiology, cardiac surgery, cardiothoracic anesthesiology, critical care, medical ethics, and health disparity experts. Applying a health equity lens to multipronged interventions is necessary to eliminate the disparities in perioperative health care among patients undergoing cardiac surgery.

Mechanisms of Self-Inflicted Injuries at an Urban City Hospital.

BACKGROUND: Suicide is a major public health issue with root causes including psychological, economical, and societal factors. METHODS: Retrospective review identified self-inflicted traumatic injuries (SITIs) at Grady Health System between 2009 and 2017. Patients were categorized by penetrating or blunt mechanism of injury (MOI). Outcomes included hospital length of stay (HLOS) and ventilator duration, mortality, and location of death. RESULTS: 678 patients in total were identified. Penetrating MOI was most prevalent (n = 474). Patients with a blunt MOI were significantly younger (32 Y vs. 37 Y; P < .0001). Psychiatric illness was equally common between MOI at more than 50%. Penetrating traumas required longer ventilator times (1 D vs. 0 D; P < .0001) but shorter overall HLOS (4 D vs. 6 D; P = .0013). Mortality was twice as high in the penetrating group (29.8% vs. 11.8%; P < .0001). CONCLUSION: Self-inflicted traumatic injuries occurred most often among younger adults and those with history of psychiatric illness. Penetrating traumas result in worse outcomes. Self-inflicted traumatic injuries carry high morbidity and mortality. Improved prevention strategies targeting high-risk groups are needed.

Formation of an Anesthesiology Residency Mentoring Program Using a Mentee-Driven Approach.

Mentorship is crucial to career development and advancement in academic medicine with valuable benefits to residents realized during training and beyond. The primary aims of this program are to train faculty members to provide quality mentorship to every resident in our department and to reduce gender and racial disparities in access to mentorship. We piloted a new mentorship program that combines mentor self-nomination, mentor training with mentee-driven mentor selection. This report details the program design and early observations.

Utilization of the Transgastric View of the Left Atrial Appendange for Procedural Guidance during Left Atrial Appendage Clip Via Video-assisted Thoracoscopic Surgery.

Left atrial appendage (LAA) ligation is procedure which isolates the LAA and can decrease the risk of thrombus and arrhythmias in patients with atrial fibrillation, allowing patients to come off home anticoagulation medications. This procedure can be done through minimally invasive thoracoscopic surgery and requires guidance by transesophageal echocardiography. Visualization of the LAA and associated intrathoracic structures is vital for the success of the procedure. This echo rounds report describes an under-utilized method for LAA assessment to encourage cardiac anesthesiologists to consider employing it to increase their ability to completely evaluate the LAA.

Aorto-Left Atrial Fistula as Sequela of Endocarditis.

Aortoatrial fistula formation is a rare complication of bacterial endocarditis. Fistulous tracts may form between the aorta and either atrium. Clinical presentation varies from an insignificant murmur to refractory congestive heart failure. Most clinically relevant fistula manifests with acute and severe symptoms. Transesophageal echocardiography (TEE) is more sensitive than transthoracic echocardiography (TTE) in diagnosing intracardiac shunts, and invaluable in guiding intraoperative surgical repair. Definitive therapy involves closure of the fistula either through an open surgical approach or percutaneously with an occluder device.

A Case Report Describing the Use of Point of Care Ultrasound to Guide Successful Cardiopulmonary Resuscitation After Unanticipated Arrest in Ambulatory Surgery.

We present a case of a 41-year-old man who suffered cardiac arrest after induction of general anesthesia for an ambulatory ophthalmologic procedure. In this report, we highlight the use of focused transthoracic echocardiography by the anesthesia team to guide a prolonged resuscitation. Emergency room and critical care physicians have described the use of focused echocardiography to aid in diagnosing correctible causes of cardiac arrest, predicting outcomes, and in decision making regarding termination of resuscitation. We discuss benefits and barriers to anesthesiologists incorporating focused cardiac ultrasound into the perioperative arena.