Randomized trial of routine versus on-demand intraoperative extracorporeal membrane oxygenation in lung transplantation: A feasibility study.

In most centers, extracorporeal membrane oxygenation (ECMO) is the preferred means to provide cardiopulmonary support during lung transplantation. However, there is controversy about whether intraoperative venoarterial (VA) ECMO should be used routinely or selectively. A randomized controlled trial is the best way to address this controversy. In this publication, we describe a feasibility study to assess the practicality of a protocol comparing routine versus selective VA-ECMO during lung transplantation. This prospective, single-center, randomized controlled trial screened all patients undergoing lung transplantation. Exclusion criteria include retransplantation, multiorgan transplantation, and cases where ECMO is mandatory. We determined that the trial would be feasible if we could recruit 19 participants over 6 months with less than 10% protocol violations. Based on the completed feasibility study, we conclude that the protocol is feasible and safe, giving us the impetus to pursue a multicenter trial with little risk of failure due to low recruitment.

Hypoxemia During One-Lung Ventilation: Does It Really Matter?

PURPOSE OF REVIEW: Hypoxemia during one-lung ventilation, while decreasing in frequency, persists as an intraoperative challenge for anesthesiologists. Discerning when desaturation and resultant hypoxemia correlates to tissue hypoxia is challenging in the perioperative setting and requires a thorough understanding of the physiology of oxygen delivery and tissue utilization. RECENT FINDINGS: Oxygen delivery is not directly correlated with peripheral oxygen saturation in patients undergoing one-lung ventilation, emphasizing the importance of hemoglobin concentration and cardiac output in avoiding tissue hypoxia. While healthy humans can tolerate acute hypoxemia without long-term consequences, there is a paucity of evidence from patients undergoing thoracic surgery. Increasingly recognized is the potential harm of hyperoxic states, particularly in the setting of complex patients with comorbid diseases. SUMMARY: Anesthesiologists are left to determine an acceptable oxygen saturation nadir that is individualized to the patient and procedure based on an understanding of oxygen supply, demand, and the consequences of interventions.

Current trends in anesthesia for esophagectomy.

PURPOSE OF REVIEW: Despite marked improvements in perioperative outcomes, esophagectomy continues to be a high-risk operation associated with significant morbidity and mortality. Progress has been achieved through evidence-based changes in preoperative optimization, intraoperative ventilation strategies, fluid therapy, and analgesia, as well as expedited postoperative recovery pathways. This review will summarize the recent literature on the anesthetic management of patients undergoing esophageal resection. RECENT FINDINGS: The current focus in publications on the perioperative management of esophagectomy patients can be summarized under the umbrella term of enhanced recovery pathways, focusing on ventilation, fluid therapy, analgesia and minimally invasive surgical approaches. Lung protective ventilation reduces pulmonary complications in cases requiring one-lung ventilation. Excess fluid administration contributes to morbidity while restrictive approaches have not resulted in an increased risk of acute kidney injury. Goal-directed fluid therapy remains intuitive yet unproven. Thoracic epidural analgesia reduces the systemic inflammatory response, pulmonary complications, and enhances postoperative pain control, yet if causing perioperative hypotension may be associated with anastomotic leaks. Enhanced recovery pathways have facilitated low morbidity and mortality rates in a high-risk population but are heterogeneous and limited by a weak evidence base. Minimally invasive surgical approaches are increasingly popular and appear to have at least equivalent outcomes to open procedures. SUMMARY: The morbidity and mortality after esophagectomy remains high despite significant improvements over the last decades. Enhanced recovery pathways appear promising in achieving further marginal gains but at present are lacking large scale, prospective, multicenter evidence.

Intraoperative Transesophageal Echocardiography for the Evaluation and Management of Diastolic Dysfunction in Patients Undergoing Cardiac Surgery: A Survey of Current Practice.

OBJECTIVES: To characterize existing practice patterns for intraoperative evaluation and grading of diastolic dysfunction in patients undergoing cardiac surgery. DESIGN: A 14-question, multiple-choice survey of current practice for patients with diastolic dysfunction and the use of intraoperative transesophageal echocardiography (TEE) to evaluate, grade, and monitor changes in diastolic function. SETTING: Online survey. PARTICIPANTS: Members of the Society of Cardiovascular Anesthesiologists. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 515 respondents, there was a near-even spread between those based in an academic setting (53%) and those based in private practice (43%). Most respondents (81%) had completed training with certification in TEE. Most respondents (86%) currently modified their intraoperative management, at least some of the time, if they believed a patient was experiencing diastolic dysfunction, with 72% varying the nature of any modification according to the identified grade of diastolic dysfunction. Although 62% of respondents usually evaluated diastolic dysfunction in the pre-bypass period, only 59% of those evaluating diastolic dysfunction typically graded the dysfunction, with a variety of algorithms used for this purpose. The majority of respondents (62%) typically did not re-evaluate diastolic function using TEE in the post-bypass period. In 2 sample patients with Doppler data provided, there was marked variation in grading of diastolic dysfunction by respondents; this variation remained marked even within subgroups of respondents who typically used the same grading algorithm. CONCLUSIONS: Marked variation currently exists in how intraoperative TEE is used to evaluate, grade, and monitor diastolic function during cardiac surgery. This suggests clinically important knowledge gaps that should be addressed.

An urgent access neurovascular clinic: audit of timeliness.

This study aimed to evaluate timeliness of an outpatient urgent access neurovascular clinic in a district general hospital setting through an audit of delay from event to completion of evaluation following transient ischaemic attack (TIA) or minor stroke. Participants included those referred for evaluation of suspected TIA or minor stroke. The median delay from event to completion was 16 days, with 45% seen within two weeks of symptom onset, and 15% within one week of symptom onset. A weekly TIA clinic is not capable of achieving the National Clinical Guidelines for Stroke recommendation for evaluation within one week of symptoms. This audit supports the National Stroke Strategy recommendation for immediate evaluation of patients presenting with a recent TIA or minor stroke.