Pecto-intercostal Fascial Plane Block: A Novel Technique for Analgesia in Patients with Sternal Dehiscence.

ABSTRACT: Sternal wound complications following sternotomy need a multidisciplinary approach in high-risk postoperative cardiac surgical patients. Poorly controlled pain during surgical management of such wounds increases cardiovascular stress and respiratory complications. Multimodal analgesia including intravenous opioids, non-opioid analgesics, and regional anesthesia techniques, like central neuraxial blocks and fascial plane blocks, have been described. Pecto-intercostal fascial plane block (PIFB), a novel technique, has been effectively used in patients undergoing cardiac surgery. Under ultrasound (US) guidance PIFB is performed with the aim of depositing local anesthetic between two superficial muscles, namely the pectoralis major muscle and the external intercostal muscle. The authors report a series of five cases where US-guided bilateral PIFB was used in patients undergoing sternal wound debridement. Patients had excellent analgesia intraoperatively as well as postoperatively for 24 hours with minimal requirement of supplemental analgesia. None of the patients experienced complications due to PIFB administration. The authors concluded that bilateral PIFB can be effectively used as an adjunct to multimodal analgesia with general anesthesia and as a sole anesthesia technique in selected cases of sternal wound debridement.

Changes in Right Ventricular Function After Off-Pump Coronary Artery Bypass Grafting.

OBJECTIVE: Right ventricular (RV) dysfunction is associated with poor outcomes after cardiac surgery. The aim of this study was to assess RV systolic and diastolic function in the perioperative period after off-pump coronary artery bypass grafting (OPCAB). DESIGN: Prospective observational study. SETTINGS: Tertiary care hospital. PARTICIPANTS: Thirty adult patients undergoing OPCAB. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Transthoracic echocardiography was performed twice: first preoperatively and second postoperatively, when patients were moved to wards. The following five parameters of RV systolic function were used: tricuspid annular plane systolic excursion (TAPSE), systolic tissue Doppler imaging of lateral tricuspid annulus (S'), fractional area change (FAC), RV myocardial performance index (RIMP), and isovolumic acceleration (IVA). Grading of RV diastolic function (RVDD) was done as per guidelines. Paired t test was used for comparing means and χ2 test was used for categorical and ordinal data. The parameters of RV longitudinal function (TAPSE and S') reduced significantly (preoperative 21.93 ± 2.80 mm and 13.24 ± 2.24 cm/s to postoperative 11.67 ± 1.91 mm and 10.31 ± 1.56 cm/s, respectively, p < 0.001), whereas parameters of RV global function (FAC, RIMP, and IVA) remained preserved (preoperative 46.75 ± 6.80%, 0.34 ± 0.06, and 4.66 ± 0.87 m/s2 to postoperative 46.21 ± 6.44%, 0.36 ± 0.06, and 4.37 ± 0.83 m/s2; p values of 0.76, 0.13, and 0.11, respectively). The median grade of RVDD worsened from normal in the preoperative period to pseudo-normal in the postoperative period (p < 0.001). The changes in both RV systolic and diastolic function were similar in patients with normal and reduced left ventricular systolic function. CONCLUSIONS: RV function can be assessed in perioperative settings with two-dimensional and tissue Doppler imaging. For systolic function assessment, exclusive measurement of longitudinal parameters might be inadequate; use of complementary global parameters like FAC, RIMP, and IVA is essential to complete the RV assessment after OPCAB. RVDD worsened significantly after OPCABG.

Does the endotracheal tube cuff pressure increases with transesophageal probe insertion?

Context: The cuff pressure (CP) of the endotracheal tube (ETT) exceeding 30 cm of H2O results in reduced perfusion of lateral mucosa of trachea leading to complications. As the posterior tracheal wall is in contact with the esophagus, there is a possibility that the insertion of transesophageal echo (TEE) probe may compress the tracheal wall and increase CP. Aims: This study was aimed to assess the impact of TEE probe insertion on CP in adults undergoing cardiac surgery. Settings and Design: Prospective observational study of 65 patients at tertiary care level hospital. Subjects and Methods: After balanced general anesthesia, patients were intubated with high volume low-pressure ET.TEE probe was then inserted with gentle jaw thrust. CP was measured by standard invasive pressure monitoring device at four points: T1 at baseline before TEE probe insertion; T2 maximum CP noted at TEE probe insertion; T3 at 5 min post TEE probe insertion; and T4 at post-TEE exam. Statistical Analysis Used: CP was compared between pairs of time points (T1 vs. T2; T1 vs. T3; and T1 vs. T4) using Mann-Whitney U test. Factors predicting CP >30 cm of H2O at T4 were assessed by backward stepwise regression. Results: CP (mean ± S.D.) at T1, T2, T3, and T4 was 22 ± 3, 38 ± 10, 30 ± 6, and 30 ± 7, respectively. CP increased significantly from T1 to T2 (P < 0.001), T1 to T3 (P < 0.001), and T1 to T4 (P < 0.001). There were 26 patients (40%) with CP >30 cm of H2O at end of TEE exam (T4). On multivariate analysis baseline, CP (T1) >20 cm of H2O was significantly associated with CP >30 cm of H2O at end of TEE exam with Odd's Ratio (OR) of 8.5 (1.76-41.06, P = 0.008). Conclusions: To conclude, the CP increases significantly with TEE probe insertion in 40% of patients exceeding a safe limit of 30 cm of H2O. The monitoring and optimization of CP is advisable.

Mitral Annular Plane Systolic Excursion: A Simple, Reliable Echocardiographic Parameter to Detect Left Ventricular Systolic Dysfunction in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting with Transesophageal Echocardiography.

OBJECTIVES: This study's objective was to test the hypothesis that transesophageal echocardiography (TEE)-based mitral annular plane systolic excursion (MAPSE) measurement is useful in perioperative settings to detect left ventricular (LV) systolic dysfunction in patients undergoing off-pump coronary artery bypass grafting (OPCAB). DESIGN: Retrospective observational study. SETTING: Tertiary-care level hospitals. PARTICIPANTS: The study comprised 116 patients undergoing OPCAB to obtain cutoffs of MAPSE to detect LV dysfunction. These cutoffs were validated in another 105 patients from 2 other institutions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In 116 patients who had undergone OPCAB during the study period with TEE monitoring, MAPSE was measured post hoc at the lateral and septal mitral (and average) annulus using the software tool M.mode.ify (http://www.ultrasoundoftheweek.com/M.mode.ify). Receiver operating curves were constructed to obtain cutoff values of MAPSE at the lateral and septal (and average) annulus of the mitral valve to predict LV systolic dysfunction, which was defined by an ejection fraction <52% for men and <54% for women as measured using the biplane method of disks. These cutoff values then were validated in another 105 patients. LV systolic dysfunction was present in 43% patients. Youden's index values of 9mm for lateral MPASE (area under the receiver operating curve [AUC] 0.93 [confidence interval {CI} 0.87-0.97]; p < 0.0001); 7mm for septal MAPSE (AUC 0.87 [CI 0.79-0.92]; p < 0.0001); and 9mm for average MAPSE (AUC 0.92 [CI 0.86-0.96]; p < 0.0001) were obtained. These cutoffs were statistically significant in the validation cohort (p < 0.0001) with an AUC of 0.84 (CI 0.75-0.90), sensitivity of 86.2%, specificity of 80.8%, positive predictive value of 84.8%, and negative predictive value of 82.6%. CONCLUSIONS: MAPSE is a simple, rapid, and reliable method to detect LV dysfunction using TEE in patients undergoing OPCAB. Its use as screening tool for LV dysfunction is recommended.

Predictors of nonstandard helmet use among San Francisco Bay-area motorcyclists.

OBJECTIVE: The use of helmets that do not comply with safety standards is common in California. The objective of this study was to describe the use of these nonstandard helmets among San Francisco Bay-area (SFBA) motorcyclists and to identify personal and motorcycle characteristics that are associated with the use of nonstandard helmets. METHODS: A survey of 860 SFBA motorcyclists was conducted. Log-binomial regression was used to estimate risk ratios to compare probabilities of nonstandard helmet use. RESULTS: Fifteen percent of motorcyclists reported wearing a nonstandard helmet sometimes or often. BMW riders had the lowest use of nonstandard helmet (5%) and Harley-Davidson riders had the highest use (51%). Among non-Harley-Davidsons, riders of cruiser-style motorcycles were 3.1 times as likely to wear a nonstandard helmet as riders of motorcycles of other styles. African American riders were more than twice as likely to use nonstandard helmets compared to riders with other self-reported race. DISCUSSION: Behavioral countermeasures are needed to improve motorcycle helmet choice in California. This study identified riders of Harley-Davidsons and riders of cruiser-style motorcycles of other brands as potential targets of interventions.

Geocoding police collision report data from California: a comprehensive approach.

BACKGROUND: Collision geocoding is the process of assigning geographic descriptors, usually latitude and longitude coordinates, to a traffic collision record. On California police reports, relative collision location is recorded using a highway postmile marker or a street intersection. The objective of this study was to create a geocoded database of all police-reported, fatal and severe injury collisions in the California Statewide Integrated Traffic Records System (SWITRS) for years 1997-2006 for use by public agencies. RESULTS: Geocoding was completed with a multi-step process. First, pre-processing was performed using a scripting language to clean and standardize street name information. A state highway network with postmile values was then created using a custom tool written in Visual Basic for Applications (VBA) in ArcGIS software. Custom VBA functionality was also used to incorporate the offset direction and distance. Intersection and address geocoding was performed using ArcGIS, StreetMap Pro 2003 digital street network, and Google Earth Pro. A total of 142,007 fatal and severe injury collisions were identified in SWITRS. The geocoding match rate was 99.8% for postmile-coded collisions and 86% for intersection-coded collisions. The overall match rate was 91%. CONCLUSIONS: The availability of geocoded collision data will be beneficial to clinicians, researchers, policymakers, and practitioners in the fields of traffic safety and public health. Potential uses of the data include studies of collision clustering on the highway system, examinations of the associations between collision occurrence and a variety of variables on environmental and social characteristics, including housing and personal demographics, alcohol outlets, schools, and parks. The ability to build maps may be useful in research planning and conduct and in the delivery of information to both technical and non-technical audiences.

Elucidating the Conformational Dependence of Calculated pKa Values.

The variability within calculated protein residue pKa values calculated using Poisson-Boltzmann continuum theory with respect to small conformational fluctuations is investigated. As a general rule, sites buried in the protein core have the largest pKa fluctuations but the least amount of conformational variability; conversely, sites on the protein surface generally have large conformational fluctuations but very small pKa fluctuations. These results occur because of the heterogeneous or uniform nature of the electrostatic microenvironments at the protein core or surface, respectively. Atypical surface sites with large pKa fluctuations occur at the interfaces between significant anionic and cationic potentials.