Quelling the Storm: A Review of the Management of Electrical Storm.

Heightened sympathetic input to the myocardium potentiates cardiac electrical instability and may herald an electrical storm. An electrical storm is characterized by 3 or more episodes of ventricular tachycardia, ventricular fibrillation, or appropriate internal cardiac defibrillator shocks within 24 hours. Management of electrical storms is resource-intensive and inevitably requires careful coordination between multiple subspecialties. Anesthesiologists have an important role in acute, subacute, and long-term management. Identifying the phase of an electrical storm and understanding the characteristics of each morphology may help the anesthesiologist anticipate the management approach. In the acute phase, management of an electrical storm is aimed at providing advanced cardiac life support and identifying reversible causes. After initial stabilization, subacute management focuses on dampening the sympathetic surge with sedation, thoracic epidural, or stellate ganglion blockade. Definitive long-term management with surgical sympathectomy or catheter ablation also may be warranted. Our objective is to provide an overview of electrical storms and the anesthesiologist's role in management.

Evaluation of a survey for acute care programme directors on the utilisation of point-of-care ultrasound.

PURPOSE: Point-of-care ultrasound (POCUS) is ultrasound brought to the patient's bedside and performed in 'real time' by the healthcare provider. The utility of POCUS to facilitate management of the acutely ill patient has been demonstrated for multiple pathologies. However, the integration of ultrasonography and echocardiography training into residency curriculum varies across the acute care specialties. STUDY DESIGN: After an institutional review board approval, anaesthesiology, emergency medicine, family medicine, internal medicine, paediatrics and general surgery programme directors (PDs) were surveyed. The survey consisted of 11 questions evaluating the primary bedside assessment tool for common acute care situations, POCUS topics that the PDs were comfortable practising and topics that the PDs felt were useful for their specialty. Barriers to POCUS use, certification and documentation were also surveyed. RESULTS: Overall, 270 PD surveys were completed. The preferred primary assessment tool for common acute care situations varied with specialty; emergency medicine PDs consistently responded that POCUS was the diagnostic modality of choice (p<0.0001). The majority of the PDs reported lack of educational opportunities as the primary barrier to learning POCUS (64%). Most PDs indicated that POCUS examinations should be documented (95.7%), and 39% reported that departmental certification would be sufficient. CONCLUSIONS: This study is the first to evaluate differences in the preferred initial bedside assessment tool between the acute care specialties. Although POCUS is a superior tool for evaluating acute pathologies, disconnect between education and utilisation remains. This study highlights the need to incorporate POCUS into the acute care specialty curriculum.

Neuroendovascular Treatment of Acute Stroke During COVID-19: A Guide From the Frontlines.

Since the initial reports surfaced of a novel coronavirus causing illness and loss of life in Wuhan, China, COVID-19 has rapidly spread across the globe, infecting millions and leaving hundreds and thousands dead. As hospitals cope with the influx of patients with COVID-19, new challenges have arisen as health-care systems care for patients with COVID-19 while still providing essential emergency care for patients with acute strokes and acute myocardial infarction. Adding to this complex scenario are new reports that patients with COVID-19 are at increased risk of thromboembolic complications including strokes. In this article, we detail our experience caring for acute stroke patients and provide some insight into neurointerventional workflow modifications that have helped us adapt to the COVID-19 era.

Speckle-Tracking Strain Imaging Identifies Alterations in Left Atrial Mechanics With General Anesthesia and Positive-Pressure Ventilation.

OBJECTIVES: The primary aim of this study was to use speckle-tracking strain imaging to evaluate the effect of general anesthesia (GA) and positive-pressure ventilation (PPV) on left atrial (LA) mechanics. The authors hypothesized that GA and PPV would be associated with a decrease in LA strain. The secondary aims were to investigate the effects of GA and PPV on traditional Doppler-derived measures of LA function and Doppler echocardiographic grade of diastolic function. DESIGN: A prospective observational study. SETTING: A university hospital. PARTICIPANTS: Adult patients undergoing cardiac surgery. INTERVENTIONS: Transthoracic echocardiography was performed at baseline and under GA with PPV. MEASUREMENTS AND MAIN RESULTS: Changes in LA function associated with GA and PPV were assessed using LA speckle-tracking strain imaging. A reduction was observed in LA peak longitudinal strain (24% v 18%, p<0.001) and preatrial contraction strain (13% v 8%, p<0.001). No difference was seen in LA contraction strain or atrial ejection fraction. Indexed LA volume and Doppler diastolic indices also were reduced significantly, and 39% of patients had a change in measured diastolic grade under GA with PPV. CONCLUSIONS: Speckle-tracking strain imaging of the left atrium demonstrated that GA and PPV had a significant impact on LA mechanics by decreasing strain measures of LA preload, with a lesser effect on LA contractility.

Multidisciplinary Approach to Hemodynamic Management During High-Risk Ventricular Tachycardia Ablation.

Percutaneous ventricular assist devices have been used for high-risk ventricular tachycardia ablation when hemodynamic decompensation is expected. Utilizing a case example, we present our experience with development of a coordinated, team-based approach focused on periprocedural management of patients with high-risk ventricular tachycardia. (Level of Difficulty: Advanced.).

Automating Anesthesiology Resident Case Logs Reduces Reporting Variability.

Background: The Accreditation Council for Graduate Medical Education (ACGME) case log system for anesthesiology resident training relies on subjective categorization of surgical procedures and lacks clear guidelines for assigning credit roles. Therefore, resident reporting practices likely vary within and between institutions. Our primary aim was to develop a systematic process for generating automated case logs using data elements extracted from the electronic health care record. We hypothesized that automated case log reporting would improve accuracy and reduce reporting variability. Methods: We developed a systematic approach for automating anesthesiology resident case logs from the electronic health care record using a discrete classification system for assigning credit roles and Anesthesia Current Procedure Terminology codes to categorize cases. The median number of cases performed was compared between the automated case log and resident-reported ACGME case log. Results: Case log elements were identified in the electronic health care record and automatically extracted. A total of 42 individual case logs were generated from the extracted data and visualized in an external dashboard. Automated reporting captured a median of 1226.5 (interquartile range: 1097-1366) total anesthetic cases in contrast to 1134.5 (interquartile range: 899-1208) reported to ACGME by residents (P = .0014). Automation also decreased the case count interquartile range and the distribution approached normality, suggesting that automation reduces reporting variability. Conclusions: Automated case log reporting uniformly captures the resident training experience and reduces reporting variability. We hope this work provides a foundation for aggregating graduate medical education data from the electronic health care record and advances adoption of case log automation.

Real-time echocardiographic guidance for confirming septal placement of right ventricular leads: A pilot study.

INTRODUCTION: Accuracy of fluoroscopy in predicting septal placement of the right ventricular (RV) leads is poor. This pilot study evaluated the feasibility and impact of real-time transthoracic echocardiogram (TTE) during RV lead placement. METHOD: Consecutive patients undergoing transvenous RV lead placement and had a point of care ultrasound team available for TTE guidance were included in the study. TTE was performed to confirm or refute the septal position of RV lead initially positioned using fluoroscopy; leads were repositioned until a septal position was confirmed on TTE. The primary outcome measured was whether the use of TTE resulted in lead repositioning. RESULT: Among the 26 patients included in the study, real-time TTE during RV lead placement resulted in reposition of the lead to a septal position in 38.5% of patients. CONCLUSION: Use of real-time TTE guidance during fluoroscopic RV lead placement is feasible and can aid in confirming a septal position.

Appropriate Delivery of Antitachyarrhythmia Therapy Despite Magnet Placement Over Implanted Cardioverter-Defibrillator: A Case Report.

The fundamental perioperative concern for patients with implantable cardioverter-defibrillators (ICDs) is the potential for electromagnetic interference (EMI) from monopolar electrosurgery. The ICD may interpret electromagnetic signals as a tachyarrhythmia and deliver an inappropriate shock to the patient. Magnet placement is often used to avoid this problem since a magnet will often deactivate an ICD's tachyarrhythmia therapy. We report a case in which magnet placement over an ICD failed to suspend tachyarrhythmia therapy because of imprecise magnet positioning. This case demonstrates the possibility for error when relying on a magnet to suspend tachyarrhythmia therapies.

Left ventricular endocardial and epicardial strain changes with apical myocardial ischemia in an open-chest porcine model.

Early detection of acute myocardial ischemia is critical to prevent permanent myocardial damage. The impact of apical ischemia on global left ventricular (LV) function can be difficult to characterize using traditional volume-based echocardiography measures. Myocardial strain imaging is a sensitive, quantitative marker of myocardial deformation that can measure ventricular function. Recent advances allow layer-specific measurement of endo- and epicardial strain, enhancing the ability to evaluate myocardial ischemia. This study investigates the effects of apical ischemia on LV function using epi- and endocardial strain. We hypothesize that myocardial strain will identify changes in regional and global myocardial function associated with focal apical ischemia as compared to ejection fraction (EF), and that longitudinal strain will be a better indicator of myocardial dysfunction compared to circumferential or radial strain. In a porcine model (n = 9), acute ischemia was induced by left anterior descending coronary artery occlusion. Echocardiograms were performed at baseline, during 15-min ischemia, and after reperfusion. Global longitudinal strain decreased with acute focal ischemia of the left ventricular apical region (baseline: -16.4% vs. ischemia: -12.2%; P = 0.010), with no change observed in global circumferential and radial strain or EF Both endocardial and epicardial longitudinal strain decreased by 68% (P < 0.001) in the ischemic and peri-ischemic zone, while circumferential and radial strain only decreased in endocardium of the ischemic zone. Longitudinal strain was more sensitive to ischemia, being able to detect changes in global LV function and thus may confer clinical diagnostic advantage in the evaluation of acute LV apical ischemia.