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BACKGROUND: Although high-opioid anesthesia was long the standard for cardiac surgery, some anesthesiologists now favor multimodal analgesia and low-opioid anesthetic techniques. The typical cardiac surgery opioid dose is unclear, and the degree to which patients, anesthesiologists, and institutions influence this opioid dose is unknown. METHODS: We reviewed data from nonemergency adult cardiac surgeries requiring cardiopulmonary bypass performed at 30 academic and community hospitals within the Multicenter Perioperative Outcomes Group registry from 2014 through 2021. Intraoperative opioid administration was measured in fentanyl equivalents. We used hierarchical linear modeling to attribute opioid dose variation to the institution where each surgery took place, the primary attending anesthesiologist, and the specifics of the surgical patient and case. RESULTS: Across 30 hospitals, 794 anesthesiologists, and 59,463 cardiac cases, patients received a mean of 1139 (95% confidence interval [CI], 1132-1146) fentanyl mcg equivalents of opioid, and doses varied widely (standard deviation [SD], 872 µg). The most frequently used opioids were fentanyl (86% of cases), sufentanil (16% of cases), hydromorphone (12% of cases), and morphine (3% of cases). 0.6% of cases were opioid-free. 60% of dose variation was explainable by institution and anesthesiologist. The median difference in opioid dose between 2 randomly selected anesthesiologists across all institutions was 600 µg of fentanyl (interquartile range [IQR], 283-1023 µg). An anesthesiologist's intraoperative opioid dose was strongly correlated with their frequency of using a sufentanil infusion (r = 0.81), but largely uncorrelated with their use of nonopioid analgesic techniques (|r| < 0.3). CONCLUSIONS: High-dose opioids predominate in cardiac surgery, with substantial dose variation from case to case. Much of this variation is attributable to practice variability rather than patient or surgical differences. This suggests an opportunity to optimize opioid use in cardiac surgery.
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This special article is a continuation of an annual series for the Journal of Cardiothoracic and Vascular Anesthesia, highlighting the latest developments in the field of electrophysiology, particularly concerning cardiac anesthesiologists. The selected topics in the specialty for 2023 include consensus statements on left atrial appendage closure, outcomes in patients with atrial fibrillation and heart failure after ablation, further developments in the field of pulse field ablation, alternate defibrillation strategies for refractory ventricular fibrillation, updates on conduction system pacing, new devices such as the Aurora EV system and AVEIR leadless pacemaker system, artificial intelligence and its use in electrocardiogram-based diagnosis and latest evidence regarding the impact of anesthetic techniques on patient outcomes undergoing electrophysiology procedures.
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Fibrilación Atrial , Humanos , Fibrilación Atrial/terapia , Fibrilación Atrial/cirugía , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/diagnóstico , Electrofisiología/métodos , Electrofisiología/tendenciasRESUMEN
This special article is the fifth in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors would like to thank the Editor-in-Chief, Dr Kaplan, the Associate Editor-in-Chief, Dr Augoustides, and the editorial board for the opportunity to author this series, which summarizes the key research papers in the electrophysiology (EP) field relevant to cardiothoracic and vascular anesthesiologists. These articles are shaping perioperative EP procedures and practices, such as pulsed-field ablation, cryoablation for first-line treatment for atrial fibrillation, advancements in conduction system pacing, safety issues related to smartphones and cardiac implantable electronic devices, and alterations in EP workflow as the world emerges from the COVID-19 pandemic. Special emphasis is placed on the implications of these advancements for the anesthetic care of patients undergoing EP procedures.
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Anestesiología , Fibrilación Atrial , COVID-19 , Humanos , Pandemias , Fibrilación Atrial/cirugía , ElectrofisiologíaRESUMEN
It is timely and necessary to consider what Postgraduate Medical Training Programme outcomes are, how they are defined and revised over time, and how they can be used to align health professional performance with the healthcare needs of society. This article which addresses those issues, with specific reference to training in anaesthesiology, was prepared using a modified nominal group (or expert panel) approach.
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Anestesiología , Internado y Residencia , Humanos , Anestesiología/educación , Curriculum , ConsensoRESUMEN
We present a 62-year-old patient with COVID-19 pneumonia on Veno-venous (VV) Extracorporeal Membrane Oxygenation (ECMO) with unique perturbations to pre and post oxygenator pressures due to fibrin deposition in despite being on a Heparin/Bivalirudin infusion and activated Partial Thromboplastin Time (aPTT) within therapeutic range of 60-80 seconds. On Day 8 of ECMO support, it was noticed that flows steadily decreased despite unchanged RPMs. Unlike typical blood flow to circuit pressure relationships, the circuit pressures did not correlate with the observed decreased flow. The Delta Pressure (ΔP) was not elevated. The patient's vitals were stable. On inspection post change-out, clots were noted in the oxygenator outlets. Oxygenator clots are usually associated with increased ΔP. In this scenario, clots in the oxygenator blocked 1 of the 4 outlets in the oxygenator causing the flow, pressures, and ΔP to drop consecutively. Due to reduced flow, the ΔP was not elevated despite extensive clots. The fibrin clot location in the CardioHelp ECMO circuit may lead to unexpected pressure and flow alterations. Sole reliance on ΔP as a marker for oxygenator clots may be misleading. Careful monitoring and timely diagnosis of coagulation status may lead to changes in anticoagulation goals and meaningfully impact patient outcomes.
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COVID-19 , Oxigenación por Membrana Extracorpórea , Trombosis , Humanos , Persona de Mediana Edad , COVID-19/complicaciones , Oxigenadores/efectos adversos , Trombosis/etiología , Oxigenación por Membrana Extracorpórea/efectos adversos , FibrinaRESUMEN
Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.
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Anestesiólogos , Oxigenación por Membrana Extracorpórea/métodos , Cuidados Intraoperatorios/métodos , Consenso , Paro Cardíaco/terapia , Humanos , Selección de PacienteRESUMEN
In the second part of the Society of Cardiovascular Anesthesiologists Extracorporeal Membrane Oxygenation (ECMO) working group expert consensus statement, venoarterial (VA) and venovenous (VV) ECMO management and troubleshooting in the operating room are discussed. Expert consensus statements are provided about intraoperative monitoring, anesthetic drug dosing, and management of intraoperative problems in VA and VV ECMO patients.
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Anestesiólogos , Oxigenación por Membrana Extracorpórea/métodos , Cuidados Intraoperatorios/métodos , Anestésicos/administración & dosificación , Consenso , HumanosRESUMEN
Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.
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Oxigenación por Membrana Extracorpórea , Adulto , Anestesiólogos , Consenso , HumanosRESUMEN
BACKGROUND: Five percent of adult patients undergoing noncardiac inpatient surgery experience a major pulmonary complication. The authors hypothesized that the choice of neuromuscular blockade reversal (neostigmine vs. sugammadex) may be associated with a lower incidence of major pulmonary complications. METHODS: Twelve U.S. Multicenter Perioperative Outcomes Group hospitals were included in a multicenter observational matched-cohort study of surgical cases between January 2014 and August 2018. Adult patients undergoing elective inpatient noncardiac surgical procedures with general anesthesia and endotracheal intubation receiving a nondepolarizing neuromuscular blockade agent and reversal were included. Exact matching criteria included institution, sex, age, comorbidities, obesity, surgical procedure type, and neuromuscular blockade agent (rocuronium vs. vecuronium). Other preoperative and intraoperative factors were compared and adjusted in the case of residual imbalance. The composite primary outcome was major postoperative pulmonary complications, defined as pneumonia, respiratory failure, or other pulmonary complications (including pneumonitis; pulmonary congestion; iatrogenic pulmonary embolism, infarction, or pneumothorax). Secondary outcomes focused on the components of pneumonia and respiratory failure. RESULTS: Of 30,026 patients receiving sugammadex, 22,856 were matched to 22,856 patients receiving neostigmine. Out of 45,712 patients studied, 1,892 (4.1%) were diagnosed with the composite primary outcome (3.5% sugammadex vs. 4.8% neostigmine). A total of 796 (1.7%) patients had pneumonia (1.3% vs. 2.2%), and 582 (1.3%) respiratory failure (0.8% vs. 1.7%). In multivariable analysis, sugammadex administration was associated with a 30% reduced risk of pulmonary complications (adjusted odds ratio, 0.70; 95% CI, 0.63 to 0.77), 47% reduced risk of pneumonia (adjusted odds ratio, 0.53; 95% CI, 0.44 to 0.62), and 55% reduced risk of respiratory failure (adjusted odds ratio, 0.45; 95% CI, 0.37 to 0.56), compared to neostigmine. CONCLUSIONS: Among a generalizable cohort of adult patients undergoing inpatient surgery at U.S. hospitals, the use of sugammadex was associated with a clinically and statistically significant lower incidence of major pulmonary complications.
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Neostigmina/efectos adversos , Bloqueo Neuromuscular , Fármacos Neuromusculares no Despolarizantes/antagonistas & inhibidores , Complicaciones Posoperatorias/inducido químicamente , Trastornos Respiratorios/inducido químicamente , Sugammadex/efectos adversos , Inhibidores de la Colinesterasa/efectos adversos , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Despite well-defined criteria for use of antibiotics in patients presenting with mild to moderate Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD), their overuse is widespread. We hypothesized that following implementation of a molecular multiplex respiratory viral panel (RVP), AECOPD patients with viral infections would be more easily identified, limiting antibiotic use in this population. The primary objective of our study was to investigate if availability of the RVP decreased antibiotic prescription at discharge among patients with AECOPD. METHODS: This is a single center, retrospective, before (pre-RVP) - after (post-RVP) study of patients admitted to a tertiary medical center from January 2013 to March 2016. The primary outcome was antibiotic prescription at discharge. Groups were compared using univariable and multivariable logistic-regression. RESULTS: A total of 232 patient-episodes were identified, 133 following RVP introduction. Mean age was 68.1 (pre-RVP) and 68.3 (post-RVP) years respectively (p = 0.88). Patients in pre-RVP group were similar to the post-RVP group with respect to gender (p = 0.54), proportion of patients with BMI < 21(p = 0.23), positive smoking status (p = 0.19) and diagnoses of obstructive sleep apnea (OSA, p = 0.16). We found a significant reduction in antibiotic prescription rate at discharge in patients admitted with AECOPD after introduction of the respiratory viral assay (pre-RVP 77.8% vs. post-RVP 63.2%, p = 0.01). In adjusted analyses, patients in the pre-RVP group [OR 2.11 (CI: 1.13-3.96), p = 0.019] with positive gram stain in sputum [OR 4.02 (CI: 1.61-10.06), p = 0.003] had the highest odds of antibiotic prescription at discharge. CONCLUSIONS: In patients presenting with mild to moderate Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD), utilization of a comprehensive respiratory viral panel can significantly decrease the rate of antibiotic prescription at discharge.
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Antibacterianos/administración & dosificación , Prescripciones de Medicamentos/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Infecciones del Sistema Respiratorio/tratamiento farmacológico , Anciano , Estudios Controlados Antes y Después , Progresión de la Enfermedad , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Enfermedad Pulmonar Obstructiva Crónica/diagnóstico , Enfermedad Pulmonar Obstructiva Crónica/virología , Infecciones del Sistema Respiratorio/diagnóstico , Infecciones del Sistema Respiratorio/virología , Estudios Retrospectivos , Esputo/microbiologíaRESUMEN
PURPOSE OF REVIEW: Sodium-glucose cotransporter 2 (SGLT-2) inhibitors are a relatively new class of drugs used in the management of diabetes mellitus. This review will highlight key pharmacologic characteristics of this class of drugs; discuss their potential role in management of patients with cardiac disease; and raise several perioperative concerns for anesthesiologists caring for patients on SGLT-2 inhibitors. RECENT FINDINGS: Recent trials have shown a strong mortality benefit in diabetic patients on SGLT 2 inhibitors especially in patients with a high cardiovascular burden. In addition, there is a reduction in HbA1c levels, blood pressure, weight and readmissions secondary to heart failure in this patient population. However, these drugs have been also associated with an increased incidence of adverse events, such as euglycemic ketoacidosis, urinary tract infections, acute kidney injury and limb amputations. SUMMARY: SGLT 2 inhibitors are being increasingly prescribed secondary to their significant salutatory effect in patients with type II diabetes mellitus. Although there are no perioperative consensus guidelines for management of patients on SGLT2 inhibitors, they should be discontinued at least 24-48âh prior to major surgeries. Their overall management in the perioperative period should be carried out on a case-to-case basis using a multidisciplinary approach.
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Diabetes Mellitus Tipo 2/tratamiento farmacológico , Atención Perioperativa/normas , Inhibidores del Cotransportador de Sodio-Glucosa 2/efectos adversos , Lesión Renal Aguda/inducido químicamente , Lesión Renal Aguda/epidemiología , Lesión Renal Aguda/prevención & control , Diabetes Mellitus Tipo 2/sangre , Cetoacidosis Diabética/inducido químicamente , Cetoacidosis Diabética/epidemiología , Cetoacidosis Diabética/prevención & control , Humanos , Incidencia , Seguridad del Paciente , Guías de Práctica Clínica como Asunto , Periodo Preoperatorio , Factores de Tiempo , Resultado del Tratamiento , Infecciones Urinarias/inducido químicamente , Infecciones Urinarias/epidemiología , Infecciones Urinarias/prevención & control , Privación de Tratamiento/normasRESUMEN
OBJECTIVES: Although real-time ultrasound guidance during central venous catheter insertion has become a standard of care, postinsertion chest radiograph remains the gold standard to confirm central venous catheter tip position and rule out associated lung complications like pneumothorax. We hypothesize that a combination of transthoracic echocardiography and lung ultrasound is noninferior to chest radiograph when used to accurately assess central venous catheter positioning and screen for pneumothorax. SETTING: All operating rooms and surgical and trauma ICUs at the institution. DESIGN: Single-center, prospective noninferiority study. PATIENTS: Patients receiving ultrasound-guided subclavian or internal jugular central venous catheters. INTERVENTIONS: During ultrasound-guided central venous catheter placement, correct positioning of central venous catheter was accomplished by real-time visualization of the guide wire and positive right atrial swirl sign using the subcostal four-chamber view. After insertion, pneumothorax was ruled out by the presence of lung sliding and seashore sign on M-mode. MEASUREMENTS AND MAIN RESULTS: Data analysis was done for 137 patients. Chest radiograph ruled out pneumothorax in 137 of 137 patients (100%). Lung ultrasound was performed in 123 of 137 patients and successfully screened for pneumothorax in 123 of 123 (100%). Chest radiograph approximated accurate catheter tip position in 136 of 137 patients (99.3%). Adequate subcostal four-chamber views could not be obtained in 13 patients. Accurate positioning of central venous catheter with ultrasound was then confirmed in 121 of 124 patients (97.6%) as described previously. CONCLUSIONS: Transthoracic echocardiography and lung ultrasound are noninferior to chest x-ray for screening of pneumothorax and accurate central venous catheter positioning. Thus, the point of care use of ultrasound can reduce central venous catheter insertion to use time, exposure to radiation, and improve patient safety.
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Cateterismo Venoso Central/métodos , Neumotórax/diagnóstico , Ultrasonografía Intervencional/métodos , Anciano , Ecocardiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neumotórax/diagnóstico por imagen , Sistemas de Atención de Punto , Estudios Prospectivos , Radiografía TorácicaRESUMEN
BACKGROUND: Preoperative hemoglobin A1c (HbA1c) and postoperative glycemic variability predict major adverse events (MAEs) after coronary artery bypass grafting in a protocolized glycemic control setting. However, the influence of preoperative HbA1c and postoperative glycemic variability in isolated cardiac valvular surgery is unknown. In this study, we sought to establish (a) whether preoperative HbA1c could identify patients at increased risk of MAEs and (b) whether postoperative glycemic variability was associated with MAEs after isolated cardiac valvular surgery. METHODS: Patients >18 years of age undergoing isolated valve surgery from January 2008 to December 2013 were enrolled in this prospective, single-center, observational cohort study with IRB approval. Patient demographics, intraoperative data, and postoperative MAEs were extracted from the institutional Society of Thoracic Surgery (STS) database. The primary outcome, MAEs, was a composite of in-hospital death, myocardial infarction, reoperations, sternal infection, cardiac tamponade, pneumonia, stroke, or renal failure. Glycemic variability in the postoperative period was assessed by the coefficient of variation. Patents were stratified by HbA1c levels (<6.5% or ≥6.5%) and assessed using multivariable logistic regression. RESULTS: Of the enrolled 763 patients, 109 (14.3%) had a preoperative HbA1c level ≥6.5%. Patients with HbA1c ≥6.5% were older (70 [63-79] vs 66 [56-75], P < .001) and had a higher incidence of dyslipidemia (83.5% vs 57.0%, P < .001) and congestive heart failure (39.5% vs 27.8%, P = .01). The calculated STS risk score for morbidity and mortality was also statistically higher in this group (0.18 [0.13-0.27] vs 0.13 [0.09-0.21], P < .001). The occurrence of MAEs was similar between the 2 groups (13.8% in HbA1c ≥6.5% vs 11.0% in HbA1c <6.5%, P = .40). Multivariate logistic regression analysis revealed that neither preoperative HbA1c ≥ 6.5% (odds ratio [OR] 1.48, 95% confidence interval [CI]: 0.78-2.82; P = .23) nor postoperative glycemic variability (CV per quartile; OR 1.05, 95% CI: 0.85-1.30; P = .67) was found to be associated with MAEs. An HbA1c ≥ 6.5% was associated with the increased glycemic variability in the postoperative period (0.173 [0.129-0.217] vs 0.141 [0.106-0.178], P < .0001). CONCLUSIONS: This study did not show an association between preoperative HbA1c and postoperative glycemic variability with MAEs after isolated cardiac valvular surgery. Specifically, lack of association between postoperative glycemic variability and MAEs is noteworthy and is in contrast to our previous finding in CABG patients. Future studies should focus a targeted glycemic variability reduction in CABG patients and evaluate the reduction in MAEs, without risk of employing a one-size fits all approach when approaching other cardiac procedures.
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Glucemia/metabolismo , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Hemoglobina Glucada/metabolismo , Válvulas Cardíacas/cirugía , Complicaciones Posoperatorias/etiología , Anciano , Biomarcadores/sangre , Boston , Procedimientos Quirúrgicos Cardíacos/mortalidad , Distribución de Chi-Cuadrado , Bases de Datos Factuales , Femenino , Mortalidad Hospitalaria , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Complicaciones Posoperatorias/sangre , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/mortalidad , Periodo Preoperatorio , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Oxigenación por Membrana Extracorpórea , Adulto , Anestesiólogos , Consenso , Humanos , Cuidados IntraoperatoriosRESUMEN
BACKGROUND: Vasoplegic syndrome (VS) is a common occurrence during heart transplantation (HT). It currently lacks a uniform definition between transplant centers, and its pathophysiology and treatment remain enigmatic. This systematic review summarizes the available published clinical data regarding VS during HT. METHODS: We searched databases for all published reports on VS during HT. Data collected included the incidence of VS in the HT population, patient and intraoperative characteristics, and postoperative outcomes. RESULTS: Twenty-two publications were included in this review. The prevalence of VS during HT was 28.72% (95% confidence interval: 27.37%, 30.10%). Factors associated with VS included male sex, higher body mass index, hypothyroidism, pre-HT left ventricular assist device or venoarterial extracorporeal membrane oxygenation (VA-ECMO), pre-HT calcium channel blocker or amiodarone usage, longer cardiopulmonary bypass time, and higher blood product transfusion requirement. Patients who developed VS were more likely to require postoperative VA-ECMO support, renal replacement therapy, reoperation for bleeding, longer mechanical ventilation, and a greater 30-day and 1-year mortality. CONCLUSIONS: The results of our systematic review are an initial step for providing clinicians with data that can help identify high-risk patients and avenues for potential risk mitigation. Establishing guidelines that officially define VS will aid in the precise diagnosis of these patients during HT and guide treatment. Future studies of treatment strategies for refractory VS are needed in this high-risk patient population.