Postoperative pericardial effusion, pericardiotomy, and atrial fibrillation: An explanatory analysis of the PALACS trial.

BACKGROUND: In the Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery (PALACS) trial, posterior pericardiotomy was associated with a significant reduction in postoperative atrial fibrillation (POAF) after cardiac surgery. We aimed to investigate the mechanisms underlying this effect. METHODS: We included PALACS patients with available echocardiographic data (n = 387/420, 92%). We tested the hypotheses that the reduction in POAF with the intervention was associated with 1) a reduction in postoperative pericardial effusion and/or 2) an effect on left atrial size and function. Spline and multivariable logistic regression analyses were used. RESULTS: Most patients (n = 307, 79%) had postoperative pericardial effusions (anterior 68%, postero-lateral 51.9%). The incidence of postero-lateral effusion was significantly lower in patients undergoing pericardiotomy (37% vs 67%; P < .001). The median size of anterior effusion was comparable between patients with and without POAF (5.0 [IQR 3.0-7.0] vs 5.0 [IQR 3.0-7.5] mm; P = .42), but there was a nonsignificant trend towards larger postero-lateral effusion in the POAF group (5.0 [IQR 3.0-9.0] vs 4.0 [IQR 3.0-6.4] mm; P = .06). There was a non-linear association between postero-lateral effusion and POAF at a cut-off at 10 mm (OR 2.70; 95% CI 1.13, 6.47; P = .03) that was confirmed in multivariable analysis (OR 3.5, 95% CI 1.17, 10.58; P = 0.02). Left atrial dimension and function did not change significantly after posterior pericardiotomy. CONCLUSIONS: Reduction in postero-lateral pericardial effusion is a plausible mechanism for the effect of posterior pericardiotomy in reducing POAF. Measures to reduce postoperative pericardial effusion are a promising approach to prevent POAF.

Antiemetic Administration and Its Association with Race: A Retrospective Cohort Study.

BACKGROUND: Anesthesiologists' contribution to perioperative healthcare disparities remains unclear because patient and surgeon preferences can influence care choices. Postoperative nausea and vomiting is a patient- centered outcome measure and a main driver of unplanned admissions. Antiemetic administration is under the sole domain of anesthesiologists. In a U.S. sample, Medicaid insured versus commercially insured patients and those with lower versus higher median income had reduced antiemetic administration, but not all risk factors were controlled for. This study examined whether a patient's race is associated with perioperative antiemetic administration and hypothesized that Black versus White race is associated with reduced receipt of antiemetics. METHODS: An analysis was performed of 2004 to 2018 Multicenter Perioperative Outcomes Group data. The primary outcome of interest was administration of either ondansetron or dexamethasone; secondary outcomes were administration of each drug individually or both drugs together. The confounder-adjusted analysis included relevant patient demographics (Apfel postoperative nausea and vomiting risk factors: sex, smoking history, postoperative nausea and vomiting or motion sickness history, and postoperative opioid use; as well as age) and included institutions as random effects. RESULTS: The Multicenter Perioperative Outcomes Group data contained 5.1 million anesthetic cases from 39 institutions located in the United States and The Netherlands. Multivariable regression demonstrates that Black patients were less likely to receive antiemetic administration with either ondansetron or dexamethasone than White patients (290,208 of 496,456 [58.5%] vs. 2.24 million of 3.49 million [64.1%]; adjusted odds ratio, 0.82; 95% CI, 0.81 to 0.82; P < 0.001). Black as compared to White patients were less likely to receive any dexamethasone (140,642 of 496,456 [28.3%] vs. 1.29 million of 3.49 million [37.0%]; adjusted odds ratio, 0.78; 95% CI, 0.77 to 0.78; P < 0.001), any ondansetron (262,086 of 496,456 [52.8%] vs. 1.96 million of 3.49 million [56.1%]; adjusted odds ratio, 0.84; 95% CI, 0.84 to 0.85; P < 0.001), and dexamethasone and ondansetron together (112,520 of 496,456 [22.7%] vs. 1.0 million of 3.49 million [28.9%]; adjusted odds ratio, 0.78; 95% CI, 0.77 to 0.79; P < 0.001). CONCLUSIONS: In a perioperative registry data set, Black versus White patient race was associated with less antiemetic administration, after controlling for all accepted postoperative nausea and vomiting risk factors.

Baseline Intraoperative Left Ventricular Diastolic Function Is Associated with Postoperative Atrial Fibrillation after Cardiac Surgery.

BACKGROUND: Detailed understanding of the association between intraoperative left atrial and left ventricular diastolic function and postoperative atrial fibrillation is lacking. In this post hoc analysis of the Posterior Left Pericardiotomy for the Prevention of Atrial Fibrillation after Cardiac Surgery (PALACS) trial, we aimed to evaluate the association of intraoperative left atrial and left ventricular diastolic function as assessed by transesophageal echocardiography (TEE) with postoperative atrial fibrillation. METHODS: PALACS patients with available intraoperative TEE data (n = 402 of 420; 95.7%) were included in this cohort study. We tested the hypotheses that preoperative left atrial size and function, left ventricular diastolic function, and their intraoperative changes were associated with postoperative atrial fibrillation. Normal left ventricular diastolic function was graded as 0 and with lateral e' velocity 10 cm/s or greater. Diastolic dysfunction was defined as lateral e' less than 10 cm/s using E/e' cutoffs of grade 1, E/e' 8 or less; grade, 2 E/e' 9 to 12; and grade 3, E/e' 13 or greater, along with two criteria based on mitral inflow and pulmonary wave flow velocities. RESULTS: A total of 230 of 402 patients (57.2%) had intraoperative diastolic dysfunction. Posterior pericardiotomy intervention was not significantly different between the two groups. A total of 99 of 402 patients (24.6%) developed postoperative atrial fibrillation. Patients who developed postoperative atrial fibrillation more frequently had abnormal left ventricular diastolic function compared to patients who did not develop postoperative atrial fibrillation (75.0% [n = 161 of 303] vs. 57.5% [n = 69 of 99]; P = 0.004). Of the left atrial size and function parameters, only delta left atrial area, defined as presternotomy minus post-chest closure measurement, was significantly different in the no postoperative atrial fibrillation versus postoperative atrial fibrillation groups on univariate analysis (-2.1 cm2 [interquartile range, -5.1 to 1.0] vs. 0.1 [interquartile range, -4.0 to 4.8]; P = 0.028). At multivariable analysis, baseline abnormal left ventricular diastolic function (odds ratio, 2.02; 95% CI, 1.15 to 3.63; P = 0.016) and pericardiotomy intervention (odds ratio, 0.46; 95% CI, 0.27 to 0.78, P = 0.004) were the only covariates independently associated with postoperative atrial fibrillation. CONCLUSIONS: Baseline preoperative left ventricular diastolic dysfunction on TEE, not left atrial size or function, is independently associated with postoperative atrial fibrillation. Further studies are needed to test if interventions aimed at optimizing intraoperative left ventricular diastolic function during cardiac surgery may reduce the risk of postoperative atrial fibrillation.

Benzodiazepines and postoperative delirium: should we be as cautious as we are?

A recent systematic review and meta-analysis by Wang and colleagues in the British Journal of Anaesthesia calls into question the concept that perioperative benzodiazepine administration is associated with development of postoperative delirium in older individuals after anaesthesia and surgery. This editorial focuses on potential bias within the systematic review and addresses major concerns surrounding benzodiazepine use in the older perioperative population.

Connected consciousness after tracheal intubation in young adults: an international multicentre cohort study.

BACKGROUND: Connected consciousness, assessed by response to command, occurs in at least 5% of general anaesthetic procedures and perhaps more often in young people. Our primary objective was to establish the incidence of connected consciousness after tracheal intubation in young people aged 18-40 yr. The secondary objectives were to assess the nature of these responses, identify relevant risk factors, and determine their relationship to postoperative outcomes. METHODS: This was an international, multicentre prospective cohort study using the isolated forearm technique to assess connected consciousness shortly after tracheal intubation. RESULTS: Of 344 enrolled subjects, 338 completed the study (mean age, 30 [standard deviation, 6.3] yr; 232 [69%] female). Responses after intubation occurred in 37/338 subjects (11%). Females (13%, 31/232) responded more often than males (6%, 6/106). In logistic regression, the risk of responsiveness was increased with female sex (odds ratio [ORadjusted]=2.7; 95% confidence interval [CI], 1.1-7.6; P=0.022) and was decreased with continuous anaesthesia before laryngoscopy (ORadjusted=0.43; 95% CI, 0.20-0.96; P=0.041). Responses were more likely to occur after a command to respond (and not to nonsense, 13 subjects) than after a nonsense statement (and not to command, four subjects, P=0.049). CONCLUSIONS: Connected consciousness occured after intubation in 11% of young adults, with females at increased risk. Continuous exposure to anaesthesia between induction of anaesthesia and tracheal intubation should be considered to reduce the incidence of connected consciousness. Further research is required to understand sex-related differences in the risk of connected consciousness.

Resident Physicians as Clinical Educators in Anesthesiology: A Narrative Review.

The importance of resident physicians as clinical educators is widely acknowledged in many clinical specialties and by national accreditation organizations for medical education. Within anesthesiology training programs, there is growing attention to the role of trainees as clinical educators. This narrative review describes the theoretical and demonstrated benefits of clinical teaching by residents in anesthesiology and other medical fields, summarizes current efforts to support and promote residents as educators, and suggests ways in which anesthesiology training programs can further assess and develop the role of residents as clinical educators.

Patient care in rapid-expansion intensive care units during the COVID-19 pandemic crisis.

BACKGROUND: The coronavirus-2019 (COVID-19) pandemic highlighted the unfortunate reality that many hospitals have insufficient intensive care unit (ICU) capacity to meet massive, unanticipated increases in demand. To drastically increase ICU capacity, NewYork-Presbyterian/Weill Cornell Medical Center modified its existing operating rooms and post-anaesthesia care units during the initial expansion phase to accommodate the surge of critically ill patients. METHODS: This retrospective chart review examined patient care in non-standard Expansion ICUs as compared to standard ICUs. We compared clinical data between the two settings to determine whether the expeditious development and deployment of critical care resources during an evolving medical crisis could provide appropriate care. RESULTS: Sixty-six patients were admitted to Expansion ICUs from March 1st to April 30th, 2020 and 343 were admitted to standard ICUs. Most patients were male (70%), White (30%), 45-64 years old (35%), non-smokers (73%), had hypertension (58%), and were hospitalized for a median of 40 days. For patients that died, there was no difference in treatment management, but the Expansion cohort had a higher median ICU length of stay (q = 0.037) and ventilatory length (q = 0.015). The cohorts had similar rates of discharge to home, but the Expansion ICU cohort had higher rates of discharge to a rehabilitation facility and overall lower mortality. CONCLUSIONS: We found no significantly worse outcomes for the Expansion ICU cohort compared to the standard ICU cohort at our institution during the COVID-19 pandemic, which demonstrates the feasibility of providing safe and effective care for patients in an Expansion ICU.

Anesthesia and the neurobiology of fear and posttraumatic stress disorder.

PURPOSE OF REVIEW: Dysfunction of fear memory systems underlie a cluster of clinically important and highly prevalent psychological morbidities seen in perioperative and critical care patients, most archetypally posttraumatic stress disorder (PTSD). Several sedative-hypnotics and analgesics are known to modulate fear systems, and it is theoretically plausible that clinical decisions of the anesthesiologist could impact psychological outcomes. This review aims to provide a focused synthesis of relevant literature from multiple fields of research. RECENT FINDINGS: There is evidence in some contexts that unconscious fear memory systems are less sensitive to anesthetics than are conscious memory systems. Opiates may suppress the activation of fear systems and have benefit in the prevention of PTSD following trauma. There is inconsistent evidence that the use of propofol and benzodiazepines for sedation following trauma may potentiate the development of PTSD relative to other drugs. The benefits of ketamine seen in the treatment of major depression are not clearly replicated in PTSD-cluster psychopathologies, and its effects on fear processes are complex. SUMMARY: There are multiple theoretical mechanisms by which anesthetic drugs can modulate fear systems and clinically important fear-based psychopathologies. The current state of research provides some evidence to support further hypothesis investigation. However, the absence of effectiveness studies and the inconsistent signals from smaller studies provide insufficient evidence to currently offer firm clinical guidance.

Hospital Safety-Net Burden Is Associated With Increased Inpatient Mortality and Perioperative Complications After Colectomy.

BACKGROUND: Colectomies are common yet costly, with high surgical-site infection rates. Safety-net hospitals (SNHs) carry a large proportion of uninsured or Medicaid-insured patients, which has been associated with poorer surgical outcomes. Few studies have examined the effect of safety-net burden (SNB) status on colectomy outcomes. We aimed to quantify the independent effects of hospital SNB and surgical site infection (SSI) status on colectomy outcomes, as well as the interaction effect between SSIs and SNB. METHODS: We used the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland, and Kentucky. We included 459,568 colectomies (2009 to 2014) for analysis, excluding patients age <18 y and rectal cases. The primary and secondary outcomes were inpatient mortality and complications, respectively. RESULTS: Adjusting for patient, procedure, and hospital factors, colectomy patients were more likely to die in-hospital at high-burden SNHs (adjusted OR [aOR]: 1.38, 95% confidence interval [CI]: 1.25-1.51, P < 0.001), compared with low SNB hospitals and to experience perioperative complications (aOR: 1.12, 95% CI: 1.04-1.20, P < 0.01). Colectomy patients with SSIs also had greater odds of in-hospital mortality (aOR: 1.92, 95% CI: 1.83-2.02, P < 0.001) and complications (aOR: 3.65, 95% CI: 3.55-3.75, P < 0.001) compared with those without infections. Patients treated at SNHs who developed a SSI were even more likely to have an additional perioperative complication (aOR: 4.33, 95% CI: 3.98-4.71, P < 0.001). CONCLUSIONS: Our study demonstrated that colectomy patients at SNHs have poorer outcomes, and for patients with SSIs, this disparity was even more pronounced in the likelihood for a complication. SNB should be recognized as a significant hospital-level factor affecting colectomy outcomes, with SSIs as an important quality metric.

Anaesthetic depth and delirium after major surgery: a randomised clinical trial.

BACKGROUND: Postoperative delirium is a serious complication of surgery associated with prolonged hospitalisation, long-term cognitive decline, and mortality. This study aimed to determine whether targeting bispectral index (BIS) readings of 50 (light anaesthesia) was associated with a lower incidence of POD than targeting BIS readings of 35 (deep anaesthesia). METHODS: This multicentre randomised clinical trial of 655 at-risk patients undergoing major surgery from eight centres in three countries assessed delirium for 5 days postoperatively using the 3 min confusion assessment method (3D-CAM) or CAM-ICU, and cognitive screening using the Mini-Mental State Examination at baseline and discharge and the Abbreviated Mental Test score (AMTS) at 30 days and 1 yr. Patients were assigned to light or deep anaesthesia. The primary outcome was the presence of postoperative delirium on any of the first 5 postoperative days. Secondary outcomes included mortality at 1 yr, cognitive decline at discharge, cognitive impairment at 30 days and 1 yr, unplanned ICU admission, length of stay, and time in electroencephalographic burst suppression. RESULTS: The incidence of postoperative delirium in the BIS 50 group was 19% and in the BIS 35 group was 28% (odds ratio 0.58 [95% confidence interval: 0.38-0.88]; P=0.010). At 1 yr, those in the BIS 50 group demonstrated significantly better cognitive function than those in the BIS 35 group (9% with AMTS ≤6 vs 20%; P<0.001). CONCLUSIONS: Among patients undergoing major surgery, targeting light anaesthesia reduced the risk of postoperative delirium and cognitive impairment at 1 yr. CLINICAL TRIAL REGISTRATION: ACTRN12612000632897.

Differential Effects of Aortic Valve Replacement on Aortic Circumferential Strain in Aortic Stenosis and Aortic Insufficiency.

OBJECTIVES: Aortic valve replacement (AVR) potentially can modify pulse-wave propagation to the distal aorta. Echo-derived global circumferential strain (GCS) was used to test whether AVR for aortic stenosis (AS) or aortic insufficiency (AI) resulted in differential aortic biomechanics in the descending thoracic aorta. DESIGN: This was a prospective observational study of patients who underwent cardiac surgery between 2016 and 2019. SETTING: Weill Cornell Medicine, a single large academic medical center. PARTICIPANTS: The population comprised 48 patients undergoing AVR (62 ± 15 y/o, 79% male; 22 with AI and 26 with AS) and 11 patients undergoing coronary bypass surgery as controls. INTERVENTIONS: Elective cardiac surgery, transesophageal echocardiography (TEE), pulmonary artery catheter. MEASUREMENTS AND MAIN RESULTS: Pre- and postprocedural TEEs were collected. Descending aorta short-axis images were analyzed for GCS, time-to-peak strain, aortic end-diastolic, end-systolic area, and fractional area changes. Pulse pressure (PP) and stroke volume were quantified. Preprocedural GCS significantly differed between patients with AI and AS, with AI patients having greater GCS (median/interquartile range, 9.6 95.3,13.6) than patients with AS (4.3 [3.4-5.1]). After AVR, in AI patients, strain significantly decreased (5.5 [3.8,8.2], p = 0.001), along with PP (mean ± standard deviation) (66.4 ± 0.8 to 54.1 ± 13.7, p < 0.001), and PP corrected strain did not (GCS/PP = 14.8 [6.9-19.9] v 12.7[8.2-18.6], p = 0.34). In AS patients, GCS significantly increased after AVR to (5.45 [4.2-6.8], p = 0.003), as did PP-corrected strain (6.9 [5.8-9.2] v 9.7 [6.5-13.4], p = 0.016). Surgical AVR produced decrements in time-to-peak strain in AI and AS groups (both p < 0.001). CONCLUSIONS: After AVR for AI and AS, the direction of change in distal aortic strain from baseline depends on valve pathology. This finding may have important clinical implications in terms of indication for surgery and postoperative surveillance, especially in patients with aortopathies.

The effect of intravenous dexamethasone on postoperative nausea and vomiting after Cesarean delivery with intrathecal morphine: a randomized-controlled trial.

PURPOSE: Intrathecal morphine administered during spinal anesthesia for Cesarean delivery is associated with a high incidence of postoperative nausea and vomiting (PONV). Small studies performed to date provide conflicting evidence on the effectiveness of dexamethasone as prophylaxis in this setting, raising the possibility that efficacy may be linked to dose timing. This study hypothesized that intravenous dexamethasone given prior to intrathecal morphine during spinal anesthesia may reduce the incidence of PONV. METHODS: In this double-blind, placebo-controlled trial, 108 patients undergoing Cesarean delivery were randomized to receive 8 mg dexamethasone or placebo prior to spinal anesthesia that included 0.2 mg intrathecal morphine. Outcomes were assessed on postanesthesia care unit arrival, as well as at postoperative hours one, three, six, 24, and 48. The primary outcome was the total number of subjects experiencing PONV during the study period of 48 hr postpartum. Secondary outcomes included severity of pain via the numeric rating scale pain score, and the use of rescue antiemetics and analgesics. RESULTS: No significant difference in the number of patients experiencing PONV was found between the treatment (n = 44, 80.0%) and control groups (n = 45, 84.9%) (difference -4.9%; 95% confidence interval, -19.2 to 9.4; P = 0.50), nor for median numeric rating scale pain scores (P = 0.24), total consumption of rescue antiemetics (P = 0.40), or opioid analgesics (P = 0.26). CONCLUSIONS: This trial does not support the use of dexamethasone prior to intrathecal morphine for PONV prophylaxis in Cesarean delivery. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT01734161); registered 27 November, 2012.

RéSUMé: OBJECTIF: La morphine intrathécale administrée au cours de la rachianesthésie pour un accouchement par césarienne est associée à une forte incidence de nausées et vomissements postopératoires (PONV). Les petites études menées à ce jour ont fourni des données probantes contradictoires sur l'efficacité de la prophylaxie par dexaméthasone dans ce contexte, soulevant la possibilité que son efficacité soit liée au moment de l'administration. Les auteurs de cette étude ont fait l'hypothèse que la dexaméthasone intraveineuse administrée avant la morphine intrathécale au cours d'une rachianesthésie pouvait réduire l'incidence des PONV. MéTHODES: Dans cette étude en double insu, contrôlée contre placebo, 108 patientes subissant un accouchement par césarienne ont été randomisées pour recevoir 8 mg de dexaméthasone ou un placebo avant une rachianesthésie qui incluait 0,2 mg de morphine intrathécale. Les résultats ont été évalués à l'arrivée dans l'unité de soins post anesthésie ainsi qu'à 1, 3, 6, 24 et 48 heures postopératoires. Le critère d'évaluation principal était le nombre de patientes éprouvant des PONV au cours de la période d'étude de 48 heures post-partum. Les critères d'évaluation secondaires étaient, notamment, la sévérité de la douleur établie par le score de douleur sur une échelle d'évaluation numérique, et le recours aux antiémétiques et analgésiques de secours. RéSULTATS: Aucune différence significative n'a été constatée sur le nombre de patientes éprouvant des PONV entre le groupe recevant le traitement (n = 44; 80,0 %) et le groupe contrôle (n = 45; 84,9 %) (différence -4,9 %; intervalle de confiance à 95 % : -19,2 % à 9,4%; P = 0,50). Il n'y a pas eu non plus de différences dans les scores de douleur avec l'échelle d'évaluation numérique (P = 0,24) et la consommation totale de médicaments de secours, antiémétiques (P = 0,40) ou narcotiques (P = 0,26). CONCLUSIONS: Cette étude ne soutient pas l'utilisation de dexaméthasone avant l'administration de morphine intrathécale pour la prophylaxie des PONV dans l'accouchement par césarienne. ENREGISTREMENT DE L'ESSAI CLINIQUE: www.clinicaltrials.gov (NCT01734161); enregistré le 27 novembre 2012.

Two- or 3-Dimensional Echocardiography-Derived Cardiac Output Cannot Replace the Pulmonary Artery Catheter in Cardiac Surgery.

OBJECTIVES: Three-dimensional (3D) transesophageal echocardiography (TEE) has been shown to be more accurate than 2D TEE for the evaluation of the left ventricular outflow tract area. The aim of the present study was to compare the agreement of 3D echocardiography-derived cardiac output (CO) with thermodilution-derived CO (TDCO) before and after cardiopulmonary bypass (CPB). DESIGN: This was a prospective observational study of patients who underwent cardiac surgery between 2016 and 2018. SETTING: Weill Cornell Medicine, a single large academic medical center. PARTICIPANTS: The study comprised 78 patients undergoing elective cardiac surgery. INTERVENTIONS: CPB, TEE, pulmonary artery catheter, and elective cardiac surgery. MEASUREMENTS AND MAIN RESULTS: Two-dimensional CO, 3D CO-diameter, and 3D CO-area values pre-CPB were strongly correlated with one another both pre-CPB and post-CPB. The 3D CO-diameter and the 3D CO-area were mildly correlated, with TDCO measurements pre-CPB (r = 0.46 and 0.39, respectively) and post-CBP (r = 0.43 and 0.47, respectively). Pre-CPB 3D CO-diameter had the most agreement with TDCO in terms of bias (-0.13 L/min); however, the limits of agreement (LOA) were wide (-2.2- to- 2.45 L/min). Post-CPB, 3D CO-diameter had the most agreement with TDCO in terms of bias (0.41) but with wide LOA (-3.29 to 2.47). All pre-CPB echocardiography-derived CO (2D CO, 3D CO-diameter, 3D CO-area) had more agreement with TDCO than did post-CPB measurements. CONCLUSIONS: Three-dimensional CO measurements were only modestly correlated with pulmonary artery catheter-derived CO pre-bypass and post-bypass. Despite low bias, the wide LOA from 2D CO, 3D CO-diameter, and 3D-area compared with TDCO suggested that the 2 methods are not interchangeable.

Use of Pulmonary Artery Pulsatility Index in Cardiac Surgery.

OBJECTIVE: This study evaluated whether the pulmonary artery pulsatility index (PAPi) collected before and after cardiopulmonary bypass (CPB) is predictive and diagnostic of new onset right ventricular (RV) failure in the elective cardiac surgical population. DESIGN: This was a prospective observational study of patients who underwent cardiac surgery between 2017 and 2019. SETTING: Weill Cornell Medicine, a single large academic medical center. PARTICIPANTS: The study comprised 119 patients undergoing elective cardiac surgery. INTERVENTIONS: Cardiopulmonary bypass, transesophageal echocardiography, pulmonary artery catheter, and elective cardiac surgery. MEASUREMENTS AND MAIN RESULTS: Echocardiographic and hemodynamic data were collected at 2 time points: pre-CPB and post-chest closure/post-CPB. Patients with and without post-CPB RV dysfunction fractional area of change (<35%) were compared, and receiver operating characteristic curves were constructed. One hundred and nineteen patients undergoing elective surgery-coronary artery bypass grafting (23%), aortic valve replacement (21%), aortic surgery (19%), and combined surgery (37%)-were evaluated. Post-CPB RV dysfunction was associated with lower pre-CPB PAPi values (2.0 ± 1.0 v 2.5 ± 1.2; p = 0.001 and p = 0.03) and higher pre-CPB central venous pressure (8.3 ± 3.6 and 6.9 ± 2.7; p = 0.003 and p = 0.02, respectively). Pre-CPB PAPi (0.98 [95% confidence interval {CI} 0.96-0.99]), end systolic area (0.99 [95% CI 0.98-0.99]), and end diastolic area (1.01 [95% CI 1.001-1.02]) were independently associated with RV dysfunction in multivariable modeling, with a lower PAPi and end systolic area and higher end diastolic area demonstrating a greater risk of RV dysfunction post-CPB (post-CPB area under the curve for PAPi 0.80 [95% CI 0.71-0.88; sensitivity = 0.68, specificity = 0.93, optimal cutoff = 1.9]). CONCLUSIONS: PAPi measured pre-CPB is a potential predictor and marker of post-CPB RV dysfunction and may have diagnostic utility in cardiac surgery. Additional, large-scale studies are needed to confirm this finding.

Differential myocardial strain in the early postoperative period in patients receiving arterial vs venous bypass grafts: A hypothesis-generating study.

OBJECTIVE: Revascularization via coronary artery bypass grafting (CABG) remains a common therapy for coronary artery disease. CABG-based revascularization is most commonly performed via either single arterial graft (SAG) or multiple arterial grafting (MAG) strategies. Echo-derived global and regional longitudinal strain was used to test where SAG or MAG results in immediate differences in left ventricular (LV) function after CABG. MATERIALS AND METHODS: Pre- and postprocedural intraoperative transesophageal echos were prospectively collected. Two-dimensional LV images were analyzed for global and regional longitudinal strain (GLS), LV ejection fraction, end-diastolic volume, end-systolic volume, and stroke volume (SV). RESULTS: Twenty patients underwent open, on-pump CABG (63.9 ± 10 years old, 85% male; 10 with SAG and 10 with MAG. Preprocedural GLS significantly differed between patients with SAG and MAG, with patients with MAG having greater GLS (mean [standard deviation, SD], 20.41 [5.54]) than patients with SAG (16.28 [3.48]). After CABG, in patients with MAG, LV strain decreased both globally (-1.13 [3.15]) and regionally in the anterior-lateral (-1.22 [3.84]) and inferior-lateral regions (-1.32 [5.69]), along with LVEF. In patients with SAG, LV strain increased after CABG globally (1.34 [2.73]) and regionally in the anterior-lateral (1.20 [6.49]) and inferior-lateral regions (0.39 [7.26]), as did LVEF and SV. Postprocedure, more patients with MAG were given vasopressor (100% vs 60%) and inotrope infusions (70% vs 40%) than patients with SAG. CONCLUSIONS: After CABG, LV function quantified through GLS changes both globally and regionally increased after SAG and decreased after MAG. This finding may have important clinical implications in terms of optimizing intraoperative management for patients with CABG and have the potential to guide the improvement of clinical outcomes.

Immediate Impact of Prosthetic Graft Replacement of the Ascending Aorta on Circumferential Strain in the Descending Aorta.

OBJECTIVES: Prosthetic replacement of the ascending aorta (AA) can potentially modify energy propagation to the distal aorta and contribute to adverse aortic remodelling. This preliminary study employed intra-operative transoesophageal echocardiography (TOE) to assess the immediate impact of prosthetic graft replacement of the AA on circumferential strain in the descending aorta. METHODS: Intra-operative TOEs in patients undergoing AA graft replacement were analysed for circumferential strain, fractional area change (FAC), dimensions (end diastolic area [EDA], and end systolic area [ESA]) in the descending aorta immediately before and after graft replacement. Deformation was assessed via global peak circumferential aortic strain (CAS), together with pulse pressure corrected strain, time to peak strain (TTP), and aortic distensibility. RESULTS: Forty-five patients undergoing AA replacement with prosthetic graft (91% elective) were studied. Following grafting, descending thoracic aortic circumferential strain increased (6.3 ± 2.8% vs. 8.9 ± 3.4%, p = .001) paralleling distensibility (5.7 [3.7-8.6] 10-3 mmHg vs. 8.5 [6.4-12.4] 10-3 mmHg, p < .001). Despite slight increments in post graft left ventricular ejection fraction (LVEF) (52.3 ± 10.8% vs. 55.0 ± 11.9, p < .001), stroke volume was similar (p = .41), and magnitude of increased strain did not correlate with change in stroke volume (r = -.03, p = .86), LVEF (r = .18, p = .28), or pulse pressure (r = .28, p = .06). Descending aortic size (EDA 4 [2.7-4.6] cm2vs. 3.7 [2.5-5] cm2, p = .89; ESA 4.3 [3.2-5.3] cm2vs. 4.5 [3.3-5.8] cm2, p = .14) was similar pre- and post graft. In subgroup analysis, patients with cystic medial necrosis had a significantly higher post procedure CAS than patients with atherosclerotic aneurysms (9.7 ± 3.5% vs. 7.0 ± 2.3%, p = .03). CONCLUSIONS: Prosthetic graft replacement of the AA increases immediate aortic circumferential strain of the descending aorta, particularly in patients with cystic medial necrosis. Our findings suggest that grafts augment energy transfer to the distal aorta, a potential mechanism for progressive distal aortic dilation and/or dissection.

Characterization of the Rapid Drop in Pulse Oximetry Reading After Intraoperative Administration of Methylene Blue in Open Thoracoabdominal Aortic Repairs.

This study evaluates the changes of oxygen saturation (SpO2) after intravenous administration of methylene blue in 103 patients undergoing open repair of thoracoabdominal aortic aneurysms. We found that SpO2 decreased by a median (interquartile range [IQR]) of 49% (37%-81%) <1 minute after methylene blue administration and recovered completely after approximately 6 minutes-median (IQR) of 270 seconds (180-510). A shorter time to nadir SpO2 was associated with a higher nadir (Spearman r [95% confidence interval {CI}], -0.32 [-0.50 to -0.13]; P = .001). Body surface area (BSA) was positively correlated with nadir SpO2 (Spearman r [95% CI], 0.36 [0.15-0.51]; P < .001).

Impact of anesthesiologist's fellowship status on the risk of general anesthesia for unplanned cesarean delivery.

BACKGROUND: Neuraxial analgesia is preferred over general anesthesia for cesarean delivery (CD), particularly in the presence of a labor epidural catheter. We hypothesize that care by a non-obstetric anesthesiologist as compared to care by an obstetric anesthesiologist is associated with a higher risk for use of general anesthesia for CD for patients with a preexisting labor epidural catheter. METHODS: To determine whether fellowship status of the covering anesthesiologist was a risk factor for general anesthesia, we retrospectively investigated the rate of general anesthesia use in patients with epidural catheters placed for labor analgesia who subsequently required CD. To standardize the practice environment under which these cases occurred, we examined only cases which occurred during coverage by the call team on nights, weekends, and holidays. RESULTS: There were 1820 cases in which a patient had epidural labor analgesia followed by a CD. Nine hundred and twelve cases were covered by an obstetric anesthesiologist and 908 cases were covered by a non-obstetric anesthesiologist. General anesthesia was used in only 16 of these cases. General anesthesia was more likely to be performed by non-obstetric fellowship trained anesthesiologists (1.54% or 14/908 compared to 0.22% or 2/912; P = 0.002). CONCLUSIONS: This investigation suggests that the presence of an obstetric fellowship-trained anesthesiologist may be a predictor of decreased rate of general anesthesia use in patients with preexisting indwelling labor epidural catheters.

Carotid Revascularization Procedures and Perioperative Outcomes: A Multistate Analysis, 2007-2014.

OBJECTIVE: To compare in-hospital mortality, postoperative stroke, and combined stroke/mortality in carotid artery stenting (CAS) patients and carotid endarterectomy (CEA) patients. DESIGN: Retrospective observational study using data from the State Inpatient Database, Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality. SETTING: All coded CAS or CEA hospitalizations from 2007 to 2014 in California, Florida, New York, Kentucky, and Maryland. PARTICIPANTS: A total of 198,120 patients, 18 years of age or older, undergoing CAS or CEA. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcomes of the study were unadjusted rates and adjusted odds of in-hospital mortality, postoperative stroke, postoperative cardiovascular complications, and combined stroke/mortality, before and after correcting for confounders, following either CEA or CAS. In multivariate logistic regression analyses, in each successive individual year, CAS was associated with higher odds of in-hospital mortality (odds ratio [OR] ≥1.5 and p < 0.05), postoperative stroke (OR ≥1.4 and p < 0.05), and combined stroke/mortality (OR ≥1.5 and p < 0.05). Similar significant results were obtained when multivariate logistic regression was stratified by symptomatology. Carotid artery stenting was associated with higher odds of cardiovascular complications in 2012 (OR = 1.5, p < 0.05) and lower odds in 2009 (OR = 0.8, p < 0.05). CONCLUSION: This study associated carotid stenting, as compared to endarterectomy, with an increased risk of dying and/or stroke. These associations persisted after statistical adjustment for patient demographics, comorbidities, and symptomatology, as well as after post-stratification by patient symptomatology. Despite this study's large, representative sample and well-defined a priori statistical methods, further research into real-world revascularization outcomes with longer-term follow-up is needed to formulate treatment guidelines.

Intravenous and Inhaled Milrinone in Adult Cardiac Surgery Patients: A Pairwise and Network Meta-Analysis.

OBJECTIVE: To summarize the evidence on the hemodynamic, echocardiographic, and clinical effects of inhaled and intravenous milrinone (iMil and IvMil) in adult cardiac surgery patients. DESIGN: Systematic review, pairwise and network meta-analysis. SETTING: Multi-institutional. PARTICIPANTS: Adult cardiac surgery patients. INTERVENTIONS: Comparison between iMil and IvMil versus other agents or placebo. MEASUREMENTS AND MAIN RESULTS: The primary endpoints were mean pulmonary artery pressure (MPAP) and peripheral vascular resistance (PVR). Secondary endpoints included the following: (1) mean arterial pressure, heart rate, and cardiac index (CI); (2) echocardiographic data; and (3) clinical outcomes. Random model, leave-one-out-analysis, and meta-regression were used. Thirty studies (6 iMil and 24 IvMil) were included for a total of 1,438 patients (194 iMil and 521 IvMil). IvMil was associated with a lower MPAP, lower PVR, and higher CI compared to placebo (standardized mean difference [SMD] = -0.22 [95% CI = -0.48 to 0.05], SMD = -0.49 [95% CI = -0.71 to -0.27], and SMD = 0.94 [95% CI = 0.51 to 1.37]). No difference in any outcome was found between iMil and placebo. At network meta-analysis, significantly lower PVR and shorter hospital length of stay were found for IvMil compared to iMil (SMD = -0.82 [95% CI = -1.53 to -0.10] and SMD = -0.50 [95% CI = -0.95 to -0.05], respectively). CONCLUSION: These results support the clinical use of IvMil in cardiac surgery patients. No evidence at present supports the adoption of iMil.