Comparison between ultrasound and chest X-ray to confirm central venous catheter tip position.

Background: Mechanical central venous catheter (CVC) placement complications are mostly malposition or iatrogenic pneumothorax. Verification of catheter position by chest X-ray (CXR) is usually performed postoperatively. Objectives: This prospective observational study assessed the diagnostic accuracy of peri-operative ultrasound and a 'bubble test' to detect malposition and pneumothorax. Method: Sixty-one patients undergoing peri-operative CVC placement were included. An ultrasound protocol was used to directly visualise the CVC, perform the 'bubble test' and assess for the presence of pneumothorax. The time from agitated saline injection to visualisation of microbubbles in the right atrium was evaluated to determine the correct position of the CVC. The time required to perform the ultrasound assessment was compared to that of conducting the CXR. Results: Chest X-ray identified 12 (19.7%) malpositions while ultrasound identified 8 (13.1%). Ultrasound showed a sensitivity of 0.85 (95% confidence interval [CI]: 0.72 to 0.93) and a specificity of 0.5 (95% CI: 0.16 to 0.84). The positive and negative predictive values were 0.92 (95% CI: 0.80 to 0.98) and 0.33 (95% CI: 0.10 to 0.65), respectively. No pneumothorax was identified on ultrasound and CXR. The median time for ultrasound assessment was significantly shorter at 4 min (interquartile range [IQR]: 3-6 min), compared to performing a CXR that required a median time of 29 min (IQR: 18-56 min) (p < 0.0001). Conclusion: This study showed that ultrasound produced a high sensitivity and moderate specificity in detecting CVC malposition. Contribution: Ultrasound can improve efficiency when used as a rapid bedside screening test to detect CVC malposition.

Evaluating the Usability of a 3D-Printed Video Laryngoscope for Tracheal Intubation of a Manikin.

Background: Compared to direct laryngoscopy, videolaryngoscopy (VL) can provide improved laryngeal and glottic view, higher intubation success rates in patients with a known or predicted difficult airway and reduced incidence of laryngeal/airway trauma. However, the cost and availability of these devices handicap its use in resource-restricted facilities. The objective was to design and manufacture a novel VL using additive manufacturing (AM) and evaluate its usability on an intubation manikin by comparing it to one of the most common video laryngoscopes used in clinical practice, the CMAC®, by measuring the time to first pass of the endotracheal tube as the main outcome. Methods: A randomised cross-over study was performed with 36 anaesthetists attempting tracheal intubation of a manikin. The novel 3D-printed hyperangulated VL blade was compared to a CMAC® VL (D-blade). Participants had no prior experience or training with the novel device. The participants included consultants, registrars/trainees and medical officers in the Department of Anaesthesiology at the University of the Free State (UFS) in South Africa. Results: The CMAC® had a statistically shorter time to first pass (median 13.8 seconds) compared to the 3D-printed model (median 19.0 seconds) (95% confidence interval [CI] 1.0-6.2; P=0.0013). No failed attempts occurred with either device. Conclusion: Intubation times were faster with the CMAC® than with the novel device. However, with a comparable intubation success rate, 3D printing technology potentially can improve access to video laryngoscopy. Further design improvements, validation of materials and manufacturing processes are required before 3D-printed laryngoscope blades can be used in human subjects.

Determining the Minimum Dataset for Surgical Patients in Africa: A Delphi Study.

BACKGROUND: It is often difficult for clinicians in African low- and middle-income countries middle-income countries to access useful aggregated data to identify areas for quality improvement. The aim of this Delphi study was to develop a standardised perioperative dataset for use in a registry. METHODS: A Delphi method was followed to achieve consensus on the data points to include in a minimum perioperative dataset. The study consisted of two electronic surveys, followed by an online discussion and a final electronic survey (four Rounds). RESULTS: Forty-one members of the African Perioperative Research Group participated in the process. Forty data points were deemed important and feasible to include in a minimum dataset for electronic capturing during the perioperative workflow by clinicians. A smaller dataset consisting of eight variables to define risk-adjusted perioperative mortality rate was also described. CONCLUSIONS: The minimum perioperative dataset can be used in a collaborative effort to establish a resource accessible to African clinicians in improving quality of care.

Impact of simulator-based training on acquisition of transthoracic echocardiography skills in medical students.

Introduction: Due to the expanding role of ultrasound as a diagnostic tool in modern medicine, medical schools rapidly include ultrasound training in their curriculum. The objective of this study was to compare simulator-based training along with classical teaching, using human models, to impart focused transthoracic echocardiography examination. Subject and Methods: A total of 22 medical students, with no former transthoracic echocardiography training, undertook a 90-min e-learning module, dealing with focused echocardiography and important echocardiographic pathologies. Subsequently, they had to complete a multiple-choice-questioner, followed by a 120-min practical training session either on the Heartworks™, (Cardiff, UK) and the CAE Vimedix®, (Québec, Canada) simulator (n = 10) or on a live human model (n = 12). Finally, both groups had to complete a post-test consisting of ten video-based multiple-choice-questions and a time-based, focused echocardiography examination on another human model. Two blinded expert observers scored each acquired loop which recorded 2 s of each standard view. Statistical analysis was performed with SPPS 24 (SPSS™ 24, IBM, USA) using the Mann-Whitney-Test to compare both groups. Results: Analysis of measurable outcome skills showed no significant difference between transthoracic echocardiography training on human models and high-fidelity simulators for undergraduate medical students. Conclusions: Both teaching methods are effective and lead to the intended level of knowledge and skills.

Retrospective study of complete atrioventricular canal defects: Anesthetic and perioperative challenges.

OBJECTIVE: The objective of this study was to highlight anesthetic and perioperative management and the outcomes of infants with complete atrioventricular (AV) canal defects. DESIGN: This retrospective descriptive study included children who underwent staged and primary biventricular repair for complete AV canal defects from 1999 to 2013. SETTING: A single-center study at a university affiliated heart center. PARTICIPANTS: One hundred and fifty-seven patients with a mean age at surgery of 125 ± 56.9 days were included in the study. About 63.6% of them were diagnosed as Down syndrome. Mean body weight at surgery was 5.6 ± 6.3 kg. METHODS: Primary and staged biventricular repair of complete AV canal defects. MEASUREMENTS AND MAIN RESULTS: A predefined protocol including timing of surgery, management of induction and maintenance of anesthesia, cardiopulmonary bypass, and perioperative intensive care treatment was used throughout the study. Demographic data as well as intraoperative and perioperative Intensive Care Unit (ICU) data, such as length of stay in ICU, total duration of ventilation including reintubations, and total length of stay in hospital and in hospital mortality, were collected from the clinical information system. Pulmonary hypertension was noted in 60% of patients from which 30% needed nitric oxide therapy. Nearly 2.5% of patients needed permanent pacemaker implantation. Thorax was closed secondarily in 7% of patients. In 3.8% of patients, reoperations due to residual defects were undertaken. Duration of hospital stay was 14.5 ± 4.7 days. The in-hospital mortality was 0%. CONCLUSION: Protocolized perioperative management leads to excellent outcome in AV canal defect repair surgery.

Role of 3D Echocardiography in Cardiac Surgery: Strengths and Limitations.

PURPOSE OF REVIEW: This review aims to highlight the general and specific strengths and limitations of intraoperative 3D echocardiography. This article explains the value of real-time three-dimensional transesophageal echocardiography (RT 3D TEE) during cardiac surgery and cardiac interventions. RECENT FINDINGS: Recently published recommendations and guidelines include the use of RT 3D TEE. RT 3 D TEE provides additional value particularly for guidance during cardiac interventions (i.e., transcatheter mitral valve repair, left atrial appendix and atrial septal defect closures), assessment of the mitral valve in surgical repair, measurement of left ventricular outflow tract area for transcatheter valvular replacements, and estimating right and left ventricular volumes and function. The exact localization of paravalvular leakage is another strength of RT 3D TEE. The major limitation is the reduced temporal resolution compared to 2D TEE. SUMMARY: Three-dimensional echocardiography is a powerful tool that improves communication and accurate measurements of cardiac structures.

Fluid Management in Cardiac Surgery: Results of a Survey in European Cardiac Anesthesia Departments.

OBJECTIVE: To evaluate the current practice of perioperative fluid management in cardiac surgery patients. DESIGN: Multiple choice survey with 26 questions about existing practice of perioperative fluid management in cardiac surgery patients. SETTING: Online survey. PARTICIPANTS: Representatives of anesthesia departments in European cardiac surgical centers. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The study comprised 106 respondents from 18 European countries who mainly worked in teaching hospitals (66%). In 73% of institutions, patients were admitted to a cardiac surgery intensive care unit (ICU) postoperatively. Perfusionists were responsible for the cardiopulmonary bypass priming solution, whereas anesthesiologists were responsible for intraoperative and postoperative fluid management. For cardiopulmonary bypass priming, balanced crystalloids were used in 51.5% of the centers, whereas in 36%, a combination of crystalloid with either synthetic colloid or albumin was administered. Intraoperatively, balanced crystalloids were used by 74% of centers, followed by a combination of crystalloids with synthetic colloids (15%) and other combinations (11%). No colloids were used by 32% of respondents. When colloids were used, gelatin was preferred, compared with hydroxyethyl starches and albumin (60% v 24% v 16%, respectively). Seventy-three percent of respondents, also involved in ICU treatment, did not change their fluid strategy in the ICU compared with their intraoperative strategy. Thirty-two percent of those who changed their strategy either added (32%) or decreased (29%) synthetic colloids or added (32%) or decreased (7%) natural colloids. CONCLUSIONS: Perioperative fluid management in cardiac surgery patients may have changed in the last few years in European centers. Balanced crystalloids now seem to be the preferred solutions, followed by synthetic colloids (mainly gelatins) and albumin.

Feasibility of measurements of valve dimensions in en-face-3D transesophageal echocardiography.

Newest 3D software allows measurements directly in the en-face-3D TEE mode. Aim of the study was to ascertain whether measurements performed in the en-face-3D TEE mode are comparable with conventional measurement methods based on 2D TEE and 3D using the multiple plane reconstruction mode with the Qlab® software. En-face-3D TEE is used more frequently in daily clinical routine during cardiac operations. So far measurements could only be done based on 2D images or with the use of multi planar reconstruction mode with additional software. Measurement directly in the 3D image (en-face-3D TEE) would make measurements faster and easier to use in clinical practice. After approval by the local ethic committee and written informed consent from the patients additionally to a comprehensive perioperative 2D TEE examination a real time (RT) 3D zoom- dataset was recorded. Routine measurements of the length of anterior and posterior mitral valve leaflets as well as mitral valve and aortic valve areas were performed in en-face-3D TEE, multiplanar reconstruction mode using Qlab®-software (Philips, Netherlands) and 2D TEE standard views. Twenty nine patients with a mean age of 67 years undergoing elective cardiac surgery/interventions were enrolled in this study. Direct measurements in en-face-3D TEE mode lead to non significant underestimation of all parameters as compared to Qlab® and 2D TEE measurements. Measurements in en-face-3D TEE are feasible but lead to non significant underestimation compared to measurements performed with Qlab® or in 2D TEE views.

Agreement of tricuspid annular systolic excursion measurement between transthoracic and transesophageal echocardiography in the perioperative setting.

OBJECTIVE: The aim of our study was to evaluate the level of agreement between tricuspid annular plane systolic excursion (TAPSE) measured by transthoracic echocardiography (TTE) and TAPSE measured using transesophageal echocardiography (TEE) in anesthetized patients. MATERIALS AND METHODS: Thirty patients scheduled for elective cardiac surgery were prospectively studied. Shortly after induction of anesthesia before the operation, TAPSE was measured by TTE using M-mode in apical 4chamber view (4CH) and by TEE in six different views: using 2D echocardiography in midesophageal (ME) 4CH view, using M-mode in deep transgastric right ventricle (dTG RV) view at 0° and dTG RV longaxis view (LAX) as well as using anatomical M-mode (AM-mode) in ME 4CH, dTG RV at 0° and dTG RV LAX views. RESULTS: Bland-Altman analysis showed a good agreement for TAPSE measured using M-mode in TTE and using AM-mode in TEE in the ME 4CH and dTG RV at 0° views (-2.5 ± 18 and -2.2 ± 14% respectively). The agreement between TAPSE measured in TTE and TEE using 2D in ME 4CH, using M-mode in dT GRV 0° and using M-mode and AM-mode in dTG RV LAX view showed a significant systematic underestimation of the measurements (-8.8 ± 21, -8.8 ± 24, -17.8 ± 28 and -6.4 ± 20%). CONCLUSION: Our study showed that the right ventricular function can be accurately and precisely estimated using TAPSE measurement by TEE in the midesophageal four chamber and deep transgastric right ventricle view at 0° using anatomical M-mode.

Impact of the post-anesthetic care unit opening hours on fast-track success in cardiac surgery.

BACKGROUND: Fast-track (FT) treatment in cardiac anesthesia is a state-of-the-art technique. The aim of our study was to compare FT treatment in a post-anesthetic care unit (PACU) with limited opening hours with a PACU opened for unlimited hours. Primary endpoints were extubation time (ET), length of stay (LOS) in PACU and LOS in intermediate care unit (IMC). Secondary endpoints were FT success/failure, hospital LOS, re-intubation and in hospital mortality. METHODS: At our institution, FT is usually managed in a PACU with limited opening hours from 10 a.m. to 10 p.m., Monday to Friday (PACU12). Due to reconstruction work in 2011, this PACU was open 24 hours a day, Monday to Saturday (PACU24). We retrospectively compared patients admitted to PACU24 during 2011 (January to December) and patients admitted to PACU12 during 2013 (January to December). RESULTS: A total of 2174 patients were primarily included in the study, 319 of them had to be excluded. Primary endpoints in PACU12 compared to PACU24 were significantly shorter: median ET (2.0 [95% confidence interval: 1.4-2.8] vs. 3.3 [95% CI: 2.2-5.0] hours), median LOS in PACU (4.8 [95% CI: 4.0-5.9] vs. 21.2 [95% CI: 18.3-23.5] hours) and median LOS in IMC (24 [95% CI: 18-64] vs. 38 [95% CI: 22-77] hours). FT success was significantly higher in PACU12 compared to PACU24 (75.3% vs. 39.6%). The in-hospital mortality and re-intubation rate were not significantly different. CONCLUSIONS: FT treatment in a PACU with limited opening hours leads to more effective treatment for patients regarding extubation time and LOS in IMC than in a PACU with limited opening hours, without compromising safety.