The Year in Cardiothoracic Critical Care: Selected Highlights from 2019.

In 2019, cardiothoracic and vascular critical care remained an important focus and subspecialty. This article continues the annual series to review relevant contributions in postoperative critical care that may affect the cardiac anesthesiologist. Herein, the pertinent literature published in 2019 is explored and organized by organ system.

Major themes for 2013 in cardiothoracic and vascular anaesthesia and intensive care.

There has been significant progress throughout 2013 in cardiothoracic and vascular anaesthesia and intensive care. There has been a revolution in the medical and interventional management of atrial fibrillation. The medical advances include robust clinical risk scoring systems, novel oral anticoagulants, and growing clinical experience with a new antiarrhythmic agent. The interventional advances include left atrial appendage occlusion for stroke reduction, generalization of ablation techniques in cardiac surgery, thoracoscopic ablation techniques, and the emergence of the hybrid ablation procedure. Recent European guidelines have defined the organization and practice of two subspecialties, namely general thoracic surgery and grown-up congenital heart disease. The pivotal role of an effective multidisciplinary milieu is a central theme in both these clinical arenas. The anaesthesia team features prominently in each of these recent guidelines aimed at harmonizing delivery of perioperative care for these patient cohorts across Europe. Web-Enabled Democracy-Based Consensus is a system that allows physicians worldwide to agree or disagree with statements and expert consensus meetings and has the potential to increase the understanding of global practice and to help clinicians better define research priorities. This "Democratic based medicine", firstly used to assess the interventions that might reduce perioperative mortality has been applied in 2013 to the setting of critically ill patient with acute kidney injury. These advances in 2013 will likely further improve perioperative outcomes for our patients.

Practice variations in the conduct of hypothermic circulatory arrest for adult aortic arch repair: focus on an emerging European paradigm.

INTRODUCTION: Hypothermic circulatory arrest for adult aortic arch repair is still high-risk. Despite decades of clinical experience, significant practice variations exist around the world. These practice variations in hypothermic circulatory arrest may offer multiple opportunities to improve practice. The hypothesis of this study was that the current conduct of adult hypothermic circulatory arrest in Europe has significant variations that might suggest opportunities for risk reduction. METHODS: An adult hypothermic circulatory arrest questionnaire was developed and then administered at thoracic aortic sessions at international conferences during 2010 in Beijing and Milan. The data was collected, abstracted and analyzed. RESULTS: The majority of the 105 respondents were anesthesiologists based in Europe and China. The typical adult aortic arch repair in Europe was with hypothermic circulatory arrest at moderate hypothermia utilizing bilateral antegrade cerebral perfusion, typically monitored with radial arterial pressure and cerebral oximetry. Brain temperature was frequently measured at distal locations. The preferred neuroprotective agents were steroids, propofol and thiopental. CONCLUSIONS: The opportunities for outcome improvement in this emerging European paradigm of tepid adult aortic arch repair include nasal/tympanic temperature measurement and adoption of unilateral antegrade cerebral perfusion monitored with radial artery pressure and cerebral oximetry. The publication of an evidence-based consensus would enhance these practice-improvement opportunities.

Intensive care monitoring after total joint replacement.

Patient safety is a critical issue in elective total joint replacement surgery. Identifying risk factors that might predict complications and intensive care unit (ICU) admission proves instrumental in reducing morbidity and mortality. The institution's experience with risk stratification and pre-operative ICU triage has resulted in a reduction in unplanned ICU admissions and post-operative complications after total hip replacement. The application of the prediction tools to total knee replacement has proven less robust so far. This work also reviews areas for future research in patient safety and cost containment.