Intraoperative hypotension and perioperative acute ischemic stroke in patients having major elective non-cardiovascular non-neurological surgery.

PURPOSE: The association between intraoperative hypotension and perioperative acute ischemic stroke is not well described. We hypothesized that intraoperative hypotension would be associated with perioperative acute ischemic stroke. METHODS: Four-year retrospective cohort study of elective non-cardiovascular, non-neurological surgical patients. Characteristics of patients who had perioperative acute ischemic stroke were compared against those of patients who did not have acute ischemic stroke. Multivariable logistic regression was used to determine whether hypotension was independently associated with increased odds of perioperative acute ischemic stroke. RESULTS: Thirty-four of 9816 patients (0.3%) who met study inclusion criteria had perioperative acute ischemic stroke. Stroke patients were older and had more comorbidities including hypertension, coronary artery disease, diabetes mellitus, active tobacco use, chronic obstructive pulmonary disease, cerebral vascular disease, atrial fibrillation, and peripheral vascular disease (all P < 0.05). MAP < 65 mmHg was not associated with increased odds of acute ischemic stroke when modeled as a continuous or categorical variable. MAP < 60 mmHg for more than 20 min was independently associated with increased odds of acute ischemic stroke, OR = 2.67 [95% CI = 1.21 to 5.88, P = 0.02]. CONCLUSION: Our analysis suggests that when MAP is less than 60 mmHg for more than 20 min, there is increased odds of acute ischemic stroke. Further studies are needed to determine what MAP should be targeted during surgery to optimize cerebral perfusion and limit ischemic stroke risk.

Isolated platelet concentrate transfusion during surgery: a single-center observational cohort study.

BACKGROUND: Surgical patients receive platelet concentrates (PCs) for a variety of indications. However, there is limited evidence for efficacy or dosing of PCs. STUDY DESIGN AND METHODS: We performed a retrospective cohort study of surgical patients receiving isolated PC transfusion at a single academic tertiary medical center during 1 year. The primary outcome was reoperation for a bleeding complication. Bleeding complication rates were compared in patients transfused for different indications, and multivariable logistic regression was performed to determine variables associated with bleeding complications. RESULTS: Approximately 1% of surgical patients (n = 205), including 7% of cardiac surgery patients, received an isolated PC transfusion. Cardiac surgery patients accounted for 47% of isolated PC transfusions, followed by neurosurgery (19%) and gastrointestinal surgery (13%). Most patients (81%) received a single apheresis unit of PC. Common indications were antiplatelet drugs (50%), thrombocytopenia (19%), congenital platelet disorders (2%), and both thrombocytopenia and antiplatelet drugs (12%). Bleeding complications occurred in 23% of patients, with the lowest bleeding complication rate observed in patients transfused for antiplatelet drugs (13%) and the highest rate in patients transfused for thrombocytopenia with or without antiplatelet drugs (40% and 38%, respectively). Bleeding complications were more common in noncardiac surgery but had no association with transfusion indication. CONCLUSION: Despite transfusion for conventionally accepted indications, patients who received an isolated PC transfusion experienced a high rate of bleeding complications, particularly noncardiac surgery patients. Further studies are needed to establish optimal dosing, timing, and indications for perioperative PC transfusion.

Use of partial venovenous cardiopulmonary bypass in percutaneous hepatic perfusion for patients with diffuse, isolated liver metastases: a case series.

OBJECTIVES: Diffuse isolated liver metastases are the dominant mode of tumor progression in a number of cancers and present a major treatment challenge for oncologists. An experimental treatment, percutaneous hepatic perfusion (PHP), utilizes partial venovenous cardiopulmonary bypass to allow administration of high-dose chemotherapy directly and solely to the liver with filtration of chemotherapeutic agents from the blood prior to its return to the systemic circulation, thereby minimizing toxic systemic effects. The following case series describes the management of 5 patients with metastatic melanoma undergoing serial PHPs. DESIGN: A single-center experience from a national multi-center random-assignment trial comparing PHP to best alternative care (BAC) in patients with diffuse melanoma liver metastases. SETTING: A tertiary care hospital. PARTICIPANTS: Five patients with metastatic melanoma to the liver. INTERVENTION: Five patients underwent a total of fifteen PHPs using a venovenous bypass circuit with hemofiltration, receiving hepatic intra-arterial melphalan, 3 mg/kg of ideal body weight, for 30 minutes with a total of 60 minutes of hemofiltration. MEASUREMENTS AND MAIN RESULTS: Five patients tolerated the procedure well with transient hemodynamic and metabolic changes. CONCLUSIONS: In patients with diffuse isolated liver metastases, PHP is a safe and well-tolerated procedure that can be performed more than once and is associated with marked anti-tumor activity in some patients.

Impact of Pandemic Response on Training Experience of Anesthesiology Residents in an Academic Medical Center: A Retrospective Cohort Study.

Background The impact of the coronavirus disease 2019 (COVID-19) pandemic substantially altered operations at hospitals that support graduate medical education. We examined the impact of the pandemic on an anesthesiology training program with respect to overall case volume, subspecialty exposure, procedural skill experience, and approaches to airway management. Methods Data for this single center, retrospective cohort study came from an Institutional Review Board approved repository for clinical data. Date ranges were divided into the following phases in 2020: Pre-Pandemic (PP), Early Pandemic (EP), Recovery 1 (R1), and Recovery 2 (R2). All periods were compared to the same period from 2019 for case volume, anesthesia provider type, trainee exposure to Accreditation Council for Graduate Medical Education (ACGME) index case categories, airway technique, and patient variables. Results 15,087 cases were identified, with 5,598 (37.6%) in the PP phase, 1,570 (10.5%) in the EP phase, 1,451 (9.7%) in the R1 phase, and 6,269 (42.1%) in the R2 phase. There was a significant reduction in case volume during the EP phase compared to the corresponding period in 2019 (-55.3%; P < .001) that improved but did not return to baseline by the R2 phase (-17.6%; P < .001). ACGME required minimum cases were reduced during the EP phase compared to 2019 data for pediatric cases (age < 12 y, -72.1%; P < .001 and age < 3 y, -53.5%; P < .006) and cardiopulmonary bypass cases (52.3%, P < .003). Surgical subspecialty case volumes were significantly reduced in the EP phase except for transplant surgery. By the R2 phase, all subspecialty volumes had recovered except for plastic surgery (14.9 vs. 10.5 cases/week; P < .006) and surgical endoscopy (59.2 vs. 40 cases/week; P < .001). Use of video laryngoscopy (VL) and rapid sequence induction and intubation (RSII) also increased from the PP to the EP phase (24.6 vs. 79.6%; P < .001 and 10.3 vs. 52.3%; P < .001, respectively) and remained elevated into the R2 phase (35.2%; P < 0.001 and 23.1%; P < .001, respectively). Conclusions The COVID-19 pandemic produced significant changes in surgical case exposure for a relatively short period. The impact was short-lived, with sufficient remaining time to meet the annual ACGME program minimum case requirements and procedural experiences. The longer-term impact may be a shift towards the increased use of VL and RSII, which became more prevalent during the early phase of the pandemic.

Patients with disease of brain, cerebral vasculature, and spine.

Several structural abnormalities involving the brain and surrounding structures have perioperative implications. This article reviews the preoperative assessment and preparation of patients with intracranial masses, vascular lesions, cerebrospinal fluid abnormalities, traumatic injuries, and dementia. Until definitive treatment of the underlying condition occurs, prevention of secondary injury to the patient's brain is the goal of medical management and final functional outcome.

Advanced visualization platform for surgical operating room coordination: distributed video board system.

One of the major challenges for day-of-surgery operating room coordination is accurate and timely situation awareness. Distributed and secure real-time status information is key to addressing these challenges. This article reports on the design and implementation of a passive status monitoring system in a 19-room surgical suite of a major academic medical center. Key design requirements considered included integrated real-time operating room status display, access control, security, and network impact. The system used live operating room video images and patient vital signs obtained through monitors to automatically update events and operating room status. Images were presented on a "need-to-know" basis, and access was controlled by identification badge authorization. The system delivered reliable real-time operating room images and status with acceptable network impact. Operating room status was visualized at 4 separate locations and was used continuously by clinicians and operating room service providers to coordinate operating room activities.