Pulmonary Artery Catheter Placement Aided by Transesophageal Echocardiography versus Pressure Waveform Transduction.

OBJECTIVE: To compare pulmonary artery catheter (PAC) placement by transesophageal echocardiography combined with pressure waveform transduction versus the traditional technique of pressure waveform transduction alone. DESIGN: A prospective, randomized trial. SETTING: Single university hospital. PARTICIPANTS: Forty-eight patients with chronic thromboembolic pulmonary hypertension (CTEPH) scheduled for pulmonary thromboendarterectomy. INTERVENTIONS: PACs were placed in 48 patients with CTEPH scheduled for pulmonary thromboendarterectomy by either a combined approach (eg, transesophageal echocardiography [TEE] and pressure waveform transduction) or by pressure waveform transduction alone. MEASUREMENTS AND MAIN RESULTS: Successful placement of the PAC via a combined technique or pressure waveform transduction alone was timed, number of attempts recorded, and final location noted. The final location of the pressure waveform-guided catheters was the proximal right pulmonary artery in 6 of 24 cases (25%), whereas the combined method resulted in successful placement in the proximal right pulmonary artery in 24 of 24 cases (100%). The pressure waveform technique resulted in a mean time to placement and mean number of attempts of 74 seconds and 1.70 attempts, respectively. The combined approach resulted in a mean time to placement and mean number of attempts of 89 seconds and 1.79 attempts, respectively. The combined method resulted in placement in the proximal right pulmonary artery significantly more often than the pressure-only method but did not reduce significantly the number of attempts or time required to place the catheter successfully. Additionally, among those cases that required more than 1 attempt or manipulation, there was no difference in the time to successful placement or the number of attempts required for successful placement. CONCLUSION: TEE guidance during PAC insertion was hypothesized to result in a higher success rate, precise placement, and shorter times to placement. One hundred percent of the PACs inserted with TEE guidance were positioned successfully in the proximal right pulmonary artery, which is the institutional preference. Although the combined technique resulted in greater precision, the clinical significance of this is unknown. The time to placement benefit was not confirmed by this study.

Hemodynamic Consequence of Hand Ventilation Versus Machine Ventilation During Transport After Cardiac Surgery.

OBJECTIVES: The hemodynamic consequences of ventilation of intubated patients during transport either by hand or using a transport ventilator have not been reported in patients after cardiac surgery. The authors hypothesized that bag-mask ventilation would alter end-tidal CO2 during transport and hemodynamic parameters in patients post-cardiac surgery. DESIGN: A prospective, randomized trial. SETTING: A university-affiliated tertiary care hospital. PARTICIPANTS: Cardiac surgery patients. INTERVENTIONS: Thirty-six patients were randomized to hand ventilation or machine ventilation. Hemodynamic variables including blood pressure, heart rate, peripheral saturation of oxygen, and end-tidal carbon dioxide (ETCO2) were measured in these patients prior to transport, every 2 minutes during transport and upon arrival in the intensive care unit (ICU). Pulmonary artery pressure (PA) pressures were measured at origin and at destination. MEASUREMENTS AND MAIN RESULTS: Outcomes were changes from baseline in end-tidal CO2, hemodynamic changes from baseline and pulmonary artery pressure changes from origin to destination. The average transport time between the 2 groups was not different: 5 minutes for patients ventilated by hand and 5.47 minutes for patients ventilated with a transport ventilator (p = 0.369 by 2-sided t-test). The difference in all measured changes in ETCO2 between hand-ventilated and machine-ventilated patients during transport was 2.74 mmHg (p = 0.013). The difference between operating room and ICU ETCO2 from each cohort was 1.31 mmHg (p = 0.067). The difference in PAmean measured at origin and destination was 0.783 mmHg (p = 0.622). All other hemodynamic variables were not different during transport. CONCLUSIONS: Hand ventilation during transport was associated with greater change from baseline of ETCO2 compared to machine ventilation during transport after cardiac surgery, but this did not translate into any difference in hemodynamic changes upon arrival in ICU. A hemodynamic benefit of machine transport ventilation to cardiac patients was not demonstrated.

Preoperative risk factors for massive transfusion, prolonged ventilation requirements, and mortality in patients undergoing liver transplantation.

BACKGROUND: Despite improvements in techniques and management of liver transplant patients, numerous perioperative complications that contribute to perioperative mortality remain. Models to predict intraoperative massive blood transfusion, prolonged mechanical ventilation, or in-hospital mortality in liver transplant recipients have not been identified. In this study we aim to identify preoperative factors associated with the above mentioned complications. METHODS: A retrospective observational analysis was conducted on data collected from 124 orthotopic liver transplants performed at a single institution between 2014 and 2017. A multivariable logistic regression using backwards elimination was performed for three defined outcomes (massive transfusion ≥ 10 units packed red blood cells (PRBC), prolonged mechanical ventilation > 24 h, and in-hospital mortality) to identify associations with preoperative characteristics. RESULTS: Statistically significant (P < 0.05) associations with massive transfusion ≥ 10 units PRBC were hepatocellular carcinoma and preoperative transfusion of PRBC. Significant associations with prolonged mechanical ventilation > 24 h were hepatitis C, alcoholic hepatitis, elevated preoperative ALT, and hepatorenal syndrome. Male gender was protective for requiring prolonged mechanical ventilation. End-stage renal disease and hepatitis B were significantly associated with increased in-hospital mortality. CONCLUSIONS: This study identified risk factors associated with common perioperative complications of liver transplantation. These factors may assist practitioners in risk stratification and may form the basis for further investigations of potential interventions to mitigate these risks.

Effects of routine monitoring of delirium in a surgical/trauma intensive care unit.

BACKGROUND: Delirium is prevalent in surgical and trauma intensive care units (ICUs) and carries substantial morbidity. This study tested the hypothesis that daily administration of a diagnostic instrument for delirium in a surgical/trauma ICU decreases the time of institution of pharmacologic therapy and improves related outcomes. METHODS: Controlled trial of two concurrent groups. The Confusion-Assessment Method for ICU was administered daily to all eligible patients admitted to our surgical/trauma ICU for 48 hours or longer. The result was communicated to one of the two preexisting ICU services (intervention service) and not the other (control service). Primary outcome was the time between diagnosis of delirium and pharmacologic treatment. Secondary outcomes included duration of delirium, mechanical ventilation, and ICU stay. RESULTS: Delirium occurred in 98 (35%) of 283 consecutive patients. Time between diagnosis and therapy did not differ between intervention (35 [35] hours) and control (40 [41] hours) groups. There was a difference in the number of delirium days treated in the intervention (73%) versus control (64%) groups (p = 0.035). The intervention group had significantly lower odds to neglect treating delirium when delirium was present (odds ratio, 0.67; 95% confidence interval, 0.45-1.00; p = 0.05). In the subgroup of trauma patients, the odds ratio of negligence was 0.37 (95% confidence interval, 0.14-0.99; p = 0.048), indicating lower probability for trauma patients to be untreated. There was no difference in the average duration of delirium, mechanical ventilation, and ICU stay. CONCLUSION: In our surgical/trauma ICU, daily screening for delirium did not affect the timing of pharmacologic therapy. Although the intervention resulted in a higher number of delirious ICU patients being treated, particularly trauma patients, there was no effect on related outcomes. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Uneventful epidural labor analgesia and vaginal delivery in a parturient with Arnold-Chiari malformation type I and sickle cell disease.

Arnold-Chiari malformation is a disorder of the hindbrain which can lead to altered craniospinal pressures and abnormal flow of cerebrospinal fluid. The possibility of increased intracranial pressure imparts significant risk during labor and delivery, and has led to concern over the use of neuraxial anesthesia. Sickle cell disease is a disorder of abnormal hemoglobin that is prone to sickling under stressful conditions. The physiologic and metabolic changes associated with pregnancy and labor can precipitate sickling, which increases risks for both the mother and the fetus. Vaso-occlusive pain crisis in a parturient with sickle cell disease has been shown to improve with the initiation of neuraxial anesthesia. We present the first reported case of a parturient with both Arnold-Chiari malformation type I and sickle cell disease who presented to labor and delivery with acute pain crisis and who subsequently received epidural labor analgesia and underwent successful vaginal delivery. We include a discussion of the risks associated with pregnancy, labor, neuraxial anesthesia, and delivery in a patient with Arnold-Chiari malformation type I and sickle cell disease.