Erector Spinae Plane Block Decreases Narcotic Requirements in Patients Undergoing Subcutaneous Implantable Cardioverter-defibrillator Placement Under Sedation.

Providing adequate analgesia perioperatively during subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation can be a challenge. The objective of our study was to assess the efficacy and safety of the erector spinae plane (ESP) block technique in providing analgesia and minimizing the risk of opioid use in high-risk patient populations. We enrolled consecutive patients >18 years of age undergoing S-ICD implantation from February 2020 to February 2022 at our center prospectively. Patients were randomly assigned to receive the ESP block or traditional wound infiltration. A total of 24 patients were enrolled, including 13 patients randomized to ESP block and 11 patients as controls who received only wound infiltration. The primary outcome assessed was the overall use of perioperative analgesic medications in the ESP block group versus the surgical wound infiltration group. A significant reduction in intraoperative fentanyl use was observed [median ([interquartile range]) in the ESP block group (0 [0-50] µg) compared to the wound infiltration block group (75 [50-100] µg) (P = .001). The overall postoperative day (POD) 0 fentanyl use was also significantly decreased (75 [50-100] µg) in the ESP block group compared to the surgical wound infiltration group (100 [87.5-150] µg) (P = .049). There was also a trend of decreased POD 0 oxycodone-acetaminophen use. Finally, the number of days to discharge was less in the ESP block group. These results indicate that ESP block is an innovative, safe, and effective technique that decreases intraoperative and postoperative opioid consumption and may be a useful adjunct pain-management technique in these high-risk patients. Larger studies are needed to further validate its use.

Perioperative Implementation of Low-Dose Pregabalin in an Enhanced Recovery After Cardiac Surgery Protocol: A Pre-Post Observational Study.

OBJECTIVES: Determine the effect of low-dose pregabalin in the perioperative enhanced recovery after cardiac surgery protocol. DESIGN: Pre-post observational study. SETTING: Tertiary care hospital. PARTICIPANTS: Patients undergoing off-pump coronary artery bypass graft procedures. INTERVENTIONS: Pregabalin 75 mg BID for 48 hours postoperatively versus no pregabalin in a perioperative setting. MEASUREMENTS AND MAIN RESULTS: Perioperative opioid use, pain scores, length of stay, time to extubation, and mortality were all measured. Descriptive data were presented as mean (SD), median (IQR), or N (%). Ordinal and continuous data used the t-test or Kruskal-Wallis test. Categorical data were compared between groups using the chi-square test or Fisher's exact test, as appropriate. Low-dose pregabalin administration (75 mg twice daily for 48 hours after surgery) was associated with a clinically significant reduction in opioid consumption on postoperative day 0 by 30.6%, with a median requirement of 318 (233, 397) morphine milligram equivalents (MME) in the pregabalin group compared with 458 (375, 526) MME in the control group (p < 0.001). There was no significant difference in pain scores between the groups with the exception at 0-to-12 hours, during which the pregabalin group had greater pain scores (median 3.32 [1.65, 4.36] v 2.0 [0, 3.25], p = 0.013) (Table 3). Moreover, there was no significant difference in pain scores on postoperative day 1 (p = 0.492), day 2 (p = 0.442), day 3 (p = 0.237), and day 4 (p = 0.649). The difference in average Richmond Agitation Sedation Score scores was also not statistically significant between groups at 12 hours (p = 0.954) and at 24 hours (p = 0.301). The pregabalin group had no increased incidence of adverse events or any significant differences in intensive care unit length of stay, time to extubation, or mortality. CONCLUSIONS: In this evaluation of perioperative pregabalin administration for patients requiring cardiac surgery, pregabalin reduced postoperative opioid use, with significant reductions on postoperative day 0, and without any significant increase in adverse reactions. However, no differences in intensive care unit length of stay, time to extubation, or mortality were noted. The implementation of low-dose perioperative pregabalin within an Enhanced Recovery After Cardiac Surgery protocol may be effective at reducing postoperative opioid use in the immediate postoperative period, and may be safe with regard to adverse events. Ideal dosing strategies have not been determined; thus, further randomized control trials with an emphasis on limiting confounding factors need to be conducted.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2023.

This special article is the 16th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. The major themes selected for 2023 are outlined in this introduction, and each highlight is reviewed in detail in the main article. The literature highlights in the specialty for 2023 begin with an update on perioperative rehabilitation in cardiothoracic surgery, with a focus on novel methods to best assess patients in the preoperative and postoperative periods, and the impact of rehabilitation on outcomes. The second major theme is focused on cardiac surgery, with the authors discussing new insights into inhaled pulmonary vasodilators, coronary revascularization surgery, and discussion of causes of coronary graft failure after surgery. The third theme is focused on cardiothoracic transplantation, with discussions focusing on bridge-to-transplantation strategies. The fourth theme is focused on mechanical circulatory support, with discussions focusing on both temporary and durable support. The fifth and final theme is an update on medical cardiology, with a focus on outcomes of invasive approaches to heart disease. The themes selected for this article are only a few of the diverse advances in the specialty during 2023. These highlights will inform the reader of key updates on various topics, leading to improved perioperative outcomes for patients with cardiothoracic and vascular disease.

Hypothermic Circulatory Arrest in Adult Aortic Arch Surgery: A Review of Hypothermic Circulatory Arrest and its Anesthetic Implications.

Diseases affecting the aortic arch often require surgical intervention. Hypothermic circulatory arrest (HCA) enables a safe approach during open aortic arch surgeries. Additionally, HCA provides neuroprotection by reducing cerebral metabolism and oxygen requirements. However, HCA comes with significant risks (eg, neurologic dysfunction, stroke, and coagulopathy), and the cardiac anesthesiologist must completely understand the surgical techniques, possible complications, and management strategies.

The use of transesophageal echocardiography to predict surgical complexity scoring system for degenerative mitral valve repair.

BACKGROUND: For severe mitral valve (MV) degenerative disease, repair is recommended. Prediction of repair complexity and referral to high volume centers can increase rates of successful repair. This study sought to demonstrate that TEE is a feasible imaging modality to predict the complexity of surgical MV repair. METHODS: Two hundred TEE examinations of patients who underwent MV repair (2009-2011) were retrospectively reviewed and scored by two cardiac anesthesiologists. TEE scores were compared to surgical complexity scores, which were previously assigned based on published methods. Kappa values were reported for the agreement of TEE and surgical scores. McNemar's tests were used to test the homogeneity of the marginal probabilities of different scoring categories. RESULTS: TEE scores were slightly lower (2[1,3]) than surgical scores (3[1,4]). The agreement was 66% between the scoring methods, with a moderate kappa (.46). Using surgical scores as the gold standard, 70%, 71%, and 46% of simple, intermediate and complex surgical scores, respectively, were correctly scored by TEE. P1, P2, P3, and A2 prolapse were easiest to identify with TEE and had the highest agreement with surgical scoring (P1 agreement 79% with kappa .55, P2 96% [kappa .8], P3 77% [kappa .51], A2 88% [kappa .6]). The lowest agreement between the two scores occurred with A1 prolapse (kappa .05) and posteromedial commissure prolapse (kappa .14). In the presence of significant disagreement, TEE scores were more likely to be of higher complexity than surgical. McNemar's test was significant for prolapse of P1 (p = .005), A1 (p = .025), A2 (p = .041), and the posteromedial commissure (p < .0001). CONCLUSION: TEE-based scoring is feasible for prediction of the complexity of MV surgical repair, thus allowing for preoperative stratification.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2022.

This special article is the 15th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief Dr. Kaplan and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialties of cardiothoracic and vascular anesthesiology. The major themes selected for 2022 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights, in the specialties for 2022, begin with an update on COVID-19 therapies, with a focus on the temporal updates in a wide range of therapies, progressing from medical to the use of extracorporeal membrane oxygenation and, ultimately, with lung transplantation in this high-risk group. The second major theme is focused on medical cardiology, with the authors discussing new insights into the life cycle of coronary disease, heart failure treatments, and outcomes related to novel statin therapy. The third theme is focused on mechanical circulatory support, with discussions focusing on both right-sided and left-sided temporary support outcomes and the optimal timing of deployment. The fourth and final theme is an update on cardiac surgery, with a discussion of the diverse aspects of concomitant valvular surgery and the optimal approach to procedural treatment for coronary artery disease. The themes selected for this 15th special article are only a few of the diverse advances in the specialties during 2022. These highlights will inform the reader of key updates on a variety of topics, leading to the improvement of perioperative outcomes for patients with cardiothoracic and vascular disease.

Trends in Cardiac Anesthesiologist Compensation, Work Patterns, and Training From 2010 to 2020: A Longitudinal Analysis of the Society of Cardiovascular Anesthesiologists Salary Survey.

Increasing cardiac procedural volume, a shortage of practicing cardiac anesthesiologists, and growth in specialist physician compensation would be expected to increase cardiac anesthesiologist compensation and work load. Additionally, more cardiac anesthesiologists are graduating from accredited fellowships and completing echocardiography certification. The Society of Cardiovascular Anesthesiologists (SCA) biannual salary survey longitudinally measures these data; we analyzed these data from 2010 to 2020 and hypothesized survey respondent inflation-adjusted total compensation, work load, and training would increase. For the primary outcome, we adjusted the median reported annual gross taxable income for inflation using the Consumer Price Index and then used linear regression to assess changes in inflation-adjusted median compensation. For the secondary outcomes, we analyzed the number of cardiac anesthetics managed annually and the most common care delivery staffing ratios. For the tertiary outcomes, we assessed changes in the proportion of respondents reporting transesophageal echocardiography (TEE) certification and completion of a 12-month cardiac anesthesia fellowship. We performed sensitivity analyses adjusting for yearly proportions of academic and private practice respondents. Annual survey response rates ranged from 8% to 17%. From 2010 to 2020, respondents reported a continuously compounded inflation-adjusted compensation decrease of 1.1% (95% confidence interval [CI], -1.6% to -0.6%; P = .003), equivalent to a total inflation-adjusted salary reduction of 10%. In sensitivity analysis, private practice respondents reported a continuously compounded compensation loss of -0.8% (95% CI, -1.4% to -0.2%; P = .022), while academic respondents reported no significant change (continuously compounded change, 0.4%; 95% CI, -0.4% to 1.1%; P = .23). The percentage of respondents managing more than 150 cardiac anesthetics per year increased from 26% in 2010 to 43% in 2020 (adjusted odds ratio [aOR], 1.03 per year; 95% CI, 1.03-1.04; P < .001). The proportion of respondents reporting high-ratio care models increased from 31% to 41% (aOR, 1.01 per year; 95% CI, 1.01-1.02; P < .001). Reported TEE certification increased from 69% to 90% (aOR, 1.10 per year; 95% CI, 1.10-1.11; P < .001); reported fellowship training increased from 63% to 82% (aOR, 1.15 per year; 95% CI, 1.14-1.16; P < .001). After adjusting for the proportion of academic or private practice survey respondents, SCA salary survey respondents reported decreasing inflation-adjusted compensation, rising volumes of cardiac anesthetics, and increasing levels of formal training in the 2010 to 2020 period. Future surveys measuring burnout and job satisfaction are needed to assess the association of increasing work and lower compensation with attrition in cardiac anesthesiologists.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2021.

This special article is the fourteenth in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the Editor-in-Chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series; namely, the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. The major themes selected for 2021 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in the specialty for 2021 begin with an update on structural heart disease, with a focus on updates in arrhythmia and aortic valve disorders. The second major theme is an update on coronary artery disease, with discussion of both medical and procedural management. The third major theme is focused on the perioperative management of patients with COVID-19, with the authors highlighting literature discussing the impact of the disease on the right ventricle and thromboembolic events. The fourth and final theme is an update in heart failure, with discussion of diverse aspects of this area. The themes selected for this fourteenth special article are only a few of the diverse advances in the specialty during 2021. These highlights will inform the reader of key updates on a variety of topics, leading to improvement of perioperative outcomes for patients with cardiothoracic and vascular disease.

Regional Analgesia for Cardiac Surgery. Part 2: Peripheral Regional Analgesia for Cardiac Surgery.

The introduction of regional analgesia in the past decades have revolutionized postoperative pain management for various types of surgery, particularly orthopedic surgery. Nowadays, they are being constantly introduced into other types of surgeries including cardiac surgeries. Neuraxial and paravertebral plexus blocks for cardiac surgery are considered as deep blocks and have the risk of hematoma formation in the setting of anticoagulation associated with cardiac surgeries. Moreover, hemodynamic compromise resulting from sympathectomy in patients with limited cardiac reserve further limits the use of neuraxial techniques. A multitude of fascial plane blocks involving chest wall have been developed, which have been shown the potential to be included in the regional analgesia armamentarium for cardiac surgery. In myofascial plane blocks, the local anesthetic spreads passively and targets the intermediate and terminal branches of intercostal nerves. They are useful as important adjuncts for providing analgesia and are likely to be included in "Enhanced Recovery after Cardiac Surgery (ERACS)" protocols. There are several small studies and case reports that have shown efficacy of the regional blocks in reducing opioid requirements and improving patient satisfaction. This review article discusses the anatomy of various fascial plane blocks, mechanism of their efficacy, and available evidence on outcomes after cardiac surgery.

Comparative Analysis of Intravenous Pumps Relocation for Critically Ill Isolated COVID-19 Patients From Bedside to Outside the Patient Room.

OBJECTIVES: To quantify the impact of IV pump relocation for COVID-19 patients from the bedside to outside the patient room on nurse exposure to COVID-19 and conservation of PPE. DESIGN: Original Article. SETTING: Intensive care units at a single-center teaching hospital. PATIENTS: Critically ill COVID-19 patients under contact and special droplet precautions. INTERVENTIONS: Relocation of intravenous pumps for COVID-19 patients from bedside to outside the patient room using extension tubing. MEASUREMENTS AND MAIN RESULTS: The primary objective of the study was to measure the impact of this strategy on COVID-19 exposure, utilizing the number of nurse entries into the patient room as a surrogate endpoint, and extrapolation of this data to determine the reduction or PPE usage. Secondary endpoints included incidence of extravasation, hyperglycemia, hypotension, and diagnosis of CLABSI/bacteremia. A statistically significant reduction in the primary endpoint of the study was observed as room entries prior to pump relocation averaged 15.36 (± 4.10) as opposed to an average of 7.92 (± 2.19) following pump relocation (p < 0.0001). In both pre- and post-pump relocation groups, there was no incidence of extravasation or CLABSI. No significant differences were noted in number of patients experiencing hyperglycemia, hypotensive episodes, or bacteremia. CONCLUSIONS: There was a significant decrease in COVID-19 exposure based on the number of nurse entries following the relocation of intravenous pumps from inside to outside of the patient room. These results may be cautiously extrapolated to suggest a decrease in personal protective equipment utilization. Future prospective, randomized controlled trials investigating the impact of this strategy are required.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2020.

THIS SPECIAL article is the 13th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr Kaplan, and the editorial board for the opportunity to continue this series; namely, the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology.1 The major themes selected for 2020 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in the specialty for 2020 begin with an update on valvular disease, with a focus on updates in management of aortic and mitral valve disorders. The second major theme is an update on coronary artery disease, with discussion of both medical and surgical management. The third major theme is focused on the perioperative management of patients with coronavirus disease 2019 (COVID-19), with the authors highlighting literature discussing medical, surgical, and anesthetic considerations for their cardiac care. The fourth major theme is an update in heart failure, with discussion of medical, psychosocial, and procedural aspects of this complicated disease process. The fifth and final theme focuses on the latest analyses regarding survival in heart transplantation. The themes selected for this 13th special article are only a few of the diverse advances in the specialty during 2020. These highlights will inform the reader of key updates on a variety of topics, leading to improvement of perioperative outcomes for patients with cardiothoracic and vascular disease.

Relocating IV Pumps for Critically Ill Isolated Coronavirus Disease 2019 Patients From Bedside to Outside the Patient Room.

Discuss advantages and disadvantages of relocating IV pumps for coronavirus disease 2019 patients from bedside to outside the patient room and characterize reproducible details of an external infusion pump model. DESIGN: Brief report. SETTING: ICUs at a single-center teaching hospital. PATIENTS: Critically ill coronavirus disease 2019 patients under contact and special droplet precautions. INTERVENTIONS: Relocation of IV pumps for coronavirus disease 2019 patients from bedside to outside the patient room using extension tubing. MEASUREMENTS AND MAIN RESULTS: Infusion pumps secured to a rolling IV pole are moved immediately outside the patient room with extension tubing, reaching the patient through a closed door. It is anticipated that this practice may reduce unnecessary coronavirus disease 2019 exposure for healthcare professionals, reduce the consumption of personal protective equipment, and promote patient safety by limiting delays of donning personal protective equipment to initiate or adjust medications. CONCLUSIONS: Risks of situating IV pumps outside the patient room must be carefully weighed against the benefits. Relocation of IV pumps outside the patient room may be considered given shortages of personal protective equipment and high risk of healthcare professional exposure. Institutional review-approved studies investigating the measured impact on decreased exposure, personal protective equipment usage, and patient safety are required.

Robotic Cardiac Surgery Part I: Anesthetic Considerations in Totally Endoscopic Robotic Cardiac Surgery (TERCS).

The application and evolution of total endoscopic robotic cardiac surgery (TERCS) has become greater as institutions and surgeons become more comfortable with robotic technology. Over the years many improvements have been made to facilitate technically challenging cardiac procedures using robotics and increase overall survival and quality of life for these patients. However, a dedicated multidisciplinary approach led by a core group of clinicians is necessary for good patient experience and outcomes. In addition, good communication and performance improvement measures with attention to detailed perioperative management are essential to a successful robotic cardiac program.

Second crossclamp to perfect degenerative mitral valve repair: Decision-making algorithm, safety, and outcomes.

OBJECTIVES: Residual mitral regurgitation reduces the efficacy of mitral repair and is associated with worse outcomes. We adopted a policy using a second bypass run for patients with residual mitral regurgitation (>+1) and described our decision-making algorithm and outcomes. METHODS: From January 1, 2011, to December 31, 2016, 40 patients with degenerative disease underwent a second bypass run to address residual mitral regurgitation. The echocardiographic criteria for a second bypass run was the presence of moderate or greater mitral regurgitation or mild mitral regurgitation with unfavorable mechanism. RESULTS: A second bypass run was used in 40 patients. The mean age was 57.3 ± 13.5 years (21-79 years), and 14 patients (35%) were asymptomatic. Residual mitral regurgitation was mild in 25 patients, moderate in 9 patients, and moderate/severe in 6 patients. The cause of postbypass mitral regurgitation was technical or residual pathology in 35 patients and systolic anterior motion in 5 patients. Re-repair techniques were cleft closure in 22 patients, primary suture repair in 13 patients, and expanded polytetrafluoroethylene chordoplasty in 9 patients. After re-repair, 34 patients (85%) had no mitral regurgitation, 4 patients (10%) had trace mitral regurgitation, and 2 patients (5%) had mild mitral regurgitation. Median total cardiopulmonary bypass time was 208.5 minutes, first crossclamp time was 106 minutes, and second crossclamp time was 34 ± 12 minutes. Median intensive care stay was 2 days, and hospital stay was 8 days. On discharge, there was no mitral regurgitation in 13 patients (33%), trace in 23 patients (58%), and mild mitral regurgitation in 4 patients (10%). Freedom from moderate or greater mitral regurgitation at 5 years was 100%. CONCLUSIONS: Residual mitral regurgitation can be effectively treated using a second bypass run with good long-term outcome and minimal incremental risk.

Robotic Cardiac Surgery Part II: Anesthetic Considerations for Robotic Coronary Artery Bypass Grafting.

Coronary artery bypass grafting represents one of the most commonly performed cardiac surgeries worldwide. Recently, interest has increased in providing patients with a less invasive approach to cardiac surgery, such as thoracotomy and endoscopic techniques using robotic technology as an alternative to traditional sternotomy. As the population gets older, the need for additional methods to provide care for sick patients will continue to expand. These advancements will further allow physicians to provide cardiac surgical procedures with less pain and faster recovery for patients.