Assessing Skill Acquisition in Anesthesiology Interns Practicing Central Venous Catheter Placement Through Advancements in Motion Analysis.

OBJECTIVES: The study authors hypothesized that a combination of previously used (path length, translational motions, and time) and novel (rotational sum) motion metrics could be used to analyze learning curves of anesthesiology interns (postgraduate year 1) practicing central venous catheter placement in the simulation setting. They also explored the feasibility of using segmented motion recordings to inform deliberate practice. DESIGN: A prospective cohort study. SETTING: A single academic medical center. PARTICIPANTS: Anesthesiology interns (postgraduate year 1). INTERVENTIONS: Anesthesiology interns underwent a 2-day training course in which they performed 9 central venous catheter placements, while attached to motion sensors on the dorsum of their dominant hand and ultrasound probe. MEASUREMENTS AND MAIN RESULTS: Motion metrics were analyzed using generalized estimating equations for both the overall procedure and predefined segments. Five attending anesthesiologists performed 3 trials each for comparison. Overall, there was a negative trend in path length, translational motions, rotational sum, and time (p < 0.001), with the exception of translational motions of the ultrasound probe. Interns reached within 1 standard deviation of the attending anesthesiologists by trials 7-to-8 for most metrics. Segmentation identified specific components of the procedure that were either significantly improved upon or required deliberate practice. The novel metric of rotational sum exhibited a moderate-to-strong positive correlation with other metrics (p < 0.001). CONCLUSIONS: A comprehensive series of motion metrics was able to describe the learning curves of novices training to perform central venous catheter placement in the simulation setting. Furthermore, it was determined that segmentation may provide additional insight into skill acquisition and inform deliberate practice.

Comprehensive Ultrasound Course for Special Operations Combat and Tactical Medics.

BACKGROUND: Advances in ultrasound technology with enhanced portability and high-quality imaging has led to a surge in its use on the battlefield by nonphysician providers. However, there is a consistent need for comprehensive and standardized ultrasound training to improve ultrasound knowledge, manual skills, and workflow understanding of nonphysician providers. MATERIALS AND METHODS: Our team designed a multimodal ultrasound course to improve ultrasound knowledge, manual skills, and workflow understanding of nine Special Operations combat medics and Special Operations tactical medics. The course was based on a flipped classroom model with a total time of 43 hours, consisting of an online component followed by live lectures and hands-on workshops. The effectiveness of the course was determined using a knowledge exam, expert ratings of manual skills using a global rating scale, and an objective structured clinical skills examination (OSCE). RESULTS: The average knowledge exam score of the medics increased from pre-course (56% ± 6.8%) to post-course (80% ± 5.0%, p < .001). Based on expert ratings, their manual skills improved from baseline to day 4 of the course for image finding (p = .007), image optimization (p = .008), image acquisition speed (p = .008), final image quality (p = .008), and global assessment (p = .008). Their average score at every OSCE station was > 91%. CONCLUSION: A comprehensive multimodal training program can be used to improve military medics' ultrasound knowledge, manual skills, and workflow understanding for various applications of ultrasound. Further research is required to develop a reliable, sustainable course.

Transcatheter mitral valve-in-valve-in-valve replacement with transseptal puncture in the presence of an atrial septal occluder device.

Quite often the iatrogenic atrial septal defect created after percutaneous transcatheter mitral valve replacement procedures is closed with an atrial septal occluder device thus precluding further transseptal interventions if required. In this case report, we describe a patient who previously underwent a valve-in-valve transcatheter mitral valve replacement and iatrogenic atrial septal defect closure with an Amplatzer device, who developed severe prosthetic mitral valve stenosis. This patient required a second percutaneous valve-in-valve in-valve procedure with a transseptal puncture in the presence of an atrial septal occluder device.

Regional Anaesthesia for Lower Extremity Amputation is Associated with Reduced Post-operative Complications Compared with General Anaesthesia.

OBJECTIVE: Primary and secondary lower extremity amputation, performed for patients with lower extremity arterial disease, is associated with increased post-operative morbidity. The aim of the study was to assess the impact of regional anaesthesia vs. general anaesthesia on post-operative pulmonary complications. METHODS: A retrospective analysis of 45 492 patients undergoing lower extremity amputation between 2005 and 2018 was conducted using data from the American College of Surgeons National Safety Quality Improvement Program database. Multivariable logistic regression was carried out to assess differences in primary outcome of post-operative pulmonary complications (pneumonia or respiratory failure requiring re-intubation) within 48 hours and 30 days after surgery between patients receiving regional (RA) or general anaesthesia (GA). Secondary outcomes included post-operative blood transfusion, septic shock, re-operation, and post-operative death within 30 days. RESULTS: Of 45 492 patients, 40 026 (88.0%) received GA and 5 466 (12.0%) RA. Patients who received GA had higher odds of developing pulmonary complications at 48 hours (2.1% vs. 1.4%; adjusted odds ratio [aOR] 1.39, 95% confidence interval [CI] 1.09 - 1.78; p = .007) and within 30 days (6.3% vs. 5.9%; aOR 1.15, 95% CI 1.09 - 1.78; p = .039). The odds of blood transfusions (aOR 1.11, 95% CI 1.02 - 1.21; p = .017), septic shock (aOR 1.29, 95% CI 1.03 - 1.60; p = .025) and re-operation (OR 1.26, 95% CI 1.03 - 1.53; p = .023) were also higher for patients who received GA vs. patients who received RA. No difference in mortality rate was observed between patients who received GA and those who received RA (5.7% vs. 7.1%; odds ratio 0.95, 95% CI 0.84 - 1.07). CONCLUSION: A statistically significant reduction in pulmonary complications was observed in patients who received RA for lower extremity amputation compared with GA.

Simplified Algorithm for Evaluation of Perioperative Hypoxia and Hypotension (SALVATION): A Practical Echo-guided Approach Proposal.

Despite the valuable use of modern applications of perioperative ultrasound across multiple disciplines, there have been limitations to its implementation, restricting its impact on patient-based clinical outcomes. Point-of-care ultrasound evaluation of hypoxia and hypotension is an important tool to assess the underlying undifferentiated etiologies in a timely manner. However, there is a lack of consensus on the formal role of ultrasound during evaluation of perioperative hypoxia or hypotension. The previous ultrasound algorithms have adopted a complex technique that possibly ignore the pathophysiologic mechanisms underlying the conditions presenting in a similar fashion. The authors here propose a simple, sequential and focused multiorgan approach, applicable for the evaluation of perioperative hypotension and hypoxia in emergency scenarios. The authors believe this approach will enhance the care provided in the postanesthesia care unit, operating room, and intensive care unit.

Enhanced Post-Operative Recovery with Continuous Peripheral Nerve Block After Lower Extremity Amputation.

BACKGROUND: Despite progress in perioperative care standards, there has not been a significant risk reduction in morbidity and mortality rates of lower extremity amputations, an intermediate risk surgery performed on high risk patients. The single-shot peripheral nerve block has shown equivocal impact on postoperative course following lower extremity amputation. Hence, we assessed the potential of preemptive use of continuous catheter-based peripheral nerve block in lower extremity amputations for reduction in pulmonary complications, acute post-operative pain scores, and opioid use in post-operative period. METHODS: A retrospective review of a quality improvement project initiated in 2018 was conducted to compare outcomes amongst general anesthesia in combination with a catheter-based peripheral nerve block (catheter group) and general anesthesia alone in patients receiving lower extremity amputation. The rate of postoperative pulmonary complications was identified as a primary endpoint. The secondary outcomes assessed were acute post-operative pain scores and opioid consumption up to 48 hours. Our analysis was adjusted for potential confounding variables inclusive of demographics, medical comorbidities, type of surgical procedure and smoking status. RESULTS: Ninety-six patients were included in the study (61 in the general anesthesia group, 35 in the catheter group). After adjusting for baseline demographics, comorbidities, surgical technique and smoking status, the odds of postoperative pulmonary complications were significantly lower with catheter-based peripheral nerve block in comparison to general anesthesia alone, OR 0.11 [95% CI, 0.01- 0.88] (P = 0.048). The decrease in acute pain scores was also observed in the catheter group when compared to general anesthesia alone, OR 0.72 [95% CI, 0.56 - 0.93] (P = 0.012). Similarly, the opioid consumption was also lower in the catheter group in comparison to general anesthesia alone, OR 0.97 [95% CI, 0.95 - 0.99] (P = 0.025). CONCLUSION: Preemptive use of continuous peripheral nerve block in patients undergoing lower extremity amputation reduces the incidence of pulmonary complications, acute postoperative pain scores and narcotic use in post-operative period.

Heterotopic caval valve implantation for the management of severe tricuspid regurgitation: a case series.

BACKGROUND: Severe tricuspid regurgitation (TR) is a complex condition that can be difficult to treat medically, and often surgical intervention is prohibited due to the high morbidity and mortality associated with this intervention. In patients who have failed maximal medical therapy and have progressive symptoms related to their severe TR, heterotopic caval valve implantation (CAVI) offers potential for symptom relief for these patients. CASE SUMMARY: We present two cases of patients with severe TR with symptoms of heart failure that were refractory to medical therapy. Due to extensive comorbidities in these patient's surgical intervention was deemed unsuitable and the decision was made to proceed with heterotopic CAVI in order to try and control their symptoms. Both patients successfully underwent the procedure and had an Edwards SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA, USA) implanted in the inferior vena cava/right atrium junction. In both patients, there was improvement in the postoperative haemodynamics as measured by invasive and non-invasive methods. Successful discharge was achieved in both patients with improvement in their symptoms. DISCUSSION: Selective use of heterotopic CAVI to treat symptomatic severe TR that is refractory to medical therapy may be a viable option to improve symptoms in those patients that are unsuitable for surgical intervention.

A Case Report on Papillary Muscle Rupture Following Mitral Valve Replacement in the Setting of Previously Undiagnosed Amyloidosis.

This case describes a patient who underwent mitral valve replacement (MVR) surgery with preservation of the subvalvular apparatus who suffered anterolateral papillary muscle rupture (PMR) postseparation from cardiopulmonary bypass. This patient had no history of coronary artery disease (CAD); subsequent pathology of the papillary muscle showed evidence of amyloid deposition. Although most PMRs are caused by ischemia from CAD, cardiac amyloidosis must be considered in the absence of CAD and worked up appropriately as cardiac involvement of amyloidosis, especially the amyloid light-chain (AL) subtype, is prognostic of increased mortality that can be mitigated with therapy.

Workflow of Ultrasound-Guided Arterial Access.

Arterial line cannulations frequently are performed in various clinical settings to facilitate hemodynamic monitoring and metabolic assessments. Palpation-guided technique generally is performed due to the superficial nature of the peripheral arteries; however, this approach may be challenging in patients with obesity, edema, and hypotension. Difficult line placements are a significant contributor of reduced operating room efficiency due to time delays seen in procedural workflow. Real-time ultrasound guidance is shown to improve success rates of arterial cannulation and reduction in multiple attempts, leading to time efficiency and less likelihood of arterial spasms or hematoma formation. In this report, the authors demonstrate the workflow of ultrasound-guided arterial line cannulation, outline the features of their institutional multi-modal training project for quality improvement, and evaluate the possible effect of the initiative on surgical delays seen with difficult line placements.

Protocolized Based Management of Cerebrospinal Fluid Drains in Thoracic Endovascular Aortic Aneurysm Repair Procedures.

BACKGROUND: Spinal cord ischemia (SCI) resulting in paraplegia is a devastating complication associated with thoracic endovascular aortic aneurysm repair (TEVAR) whose incidence has significantly declined over time. In this review, we present our experience with a multidisciplinary clinical protocol for cerebrospinal fluid (CSF) drain management in patients undergoing TEVAR. Furthermore, we aimed to characterize complications of CSF drain placement in a large, single center experience of patients who underwent TEVAR. METHODS: This retrospective review is of patients undergoing TEVAR with and without CSF drain placement between January 2014 and December 2019 at a single institution. Patient demographics, hospital course, and drain-related complications were analyzed to assess the incidence of CSF drain-related complications. RESULTS: A total of 235 patients were included in this study, of which 85 received CSF drains. Eighty patients (94.1%) were placed by anesthesiologists, while 5 (5.9%) were placed under fluoroscopic guidance by interventional neurosurgery. The most common level of placement was L3-L4 in 38 (44.7%) cases followed by L4-L5 in 36 (42.4%) cases. The mean duration of CSF drain was 1.9 ± 1.4 days. Complications due to CSF drainage occurred in 5 (5.9%) patients and included partial retainment of catheter, subdural edema, epidural hematoma, headache, and bleeding near the drain site. The overall 30-day mortality rate was 5.5% and did not differ between those who received a CSF drain and those who did not (P = 0.856). The overall incidence of SCI resulting in paraplegia was 1.7% in the studied patients. CONCLUSIONS: A protocol-based CSF drainage program for spinal cord protection involves a multifaceted approach in identification and selection of patients meeting criteria for prophylactic drain placement, direct closed loop communication, and perioperative management by an experienced team. Despite the inherent advantages of CSF drain placement, it is not without complications, thus risk and benefit need to be weighed in context of the procedure and the patient with close communication and team approach.

Cardiopulmonary Bypass Suppresses Forkhead Box O3 and Downstream Autophagy in the Diabetic Human Heart.

BACKGROUND: Autophagy is an integral component of cellular homeostasis and metabolism. The exact mechanism of impaired autophagy in diabetes mellitus is unknown. Forkhead Box O3 (FOXO3α) is a key regulator of oxidative stress-related responses. We hypothesize FOXO3α is a direct upstream regulator of the autophagy pathway, and its upregulation is compromised in diabetic patients during stress of cardiopulmonary bypass (CPB). METHODS: The study enrolled 32 diabetic and 33 nondiabetic patients undergoing a cardiac surgical procedure on CPB. Right atrial tissue and serum samples were collected before and after CPB per protocol. A set of key components were quantitatively assessed and compared by microarray, immunoblotting, and immunohistochemistry studies. Data were analyzed using paired or unpaired student test. A P of <.05 or less was considered significant. RESULTS: Serum microarray showed FOXO3α was upregulated in the diabetic vs nondiabetic group after CPB (P = .033), autophagy-related 4B gene and Beclin 1 gene were greatly upregulated in the nondiabetic group (P = .028 and P = .002, respectively). On immunoblotting, there was upregulation of FOXO3α in the nondiabetic patients after CPB (P = .003). There were increased levels of Beclin-1, Bcl-2, and light chain 3B after CPB in the nondiabetic group only (P = .016, P = .005, P = .002, respectively). Sirtuin 1, Unc-51-like autophagy activating kinase 1 (ULK1), peroxisome proliferator-activated receptor gamma coactivator 1α (PGC1α), and mammalian target of rapamycin (mTOR) were not significantly changed in the nondiabetic group after CPB. CONCLUSIONS: Compared with nondiabetic patients, there was no significant upregulation of FOXO3α in diabetic patients, which could possibly explain the lack of upregulation of the autophagy process after CPB. FOXO3α could potentially serve as a therapeutic target to improve cellular homeostasis.

Handheld Point-of-Care Ultrasound Probes: The New Generation of POCUS.

Recent advances in ultrasound technology have made ultrasound equipment more versatile, portable, and accessible than ever. Modern handheld, ultra-portable ultrasound devices have been developed by multiple companies and are contributing to make bedside ultrasound evaluation a practice available to all physicians. The significance of making point-of-care ultrasound (POCUS) a common practice that all physicians eventually can use in the evaluation of their patients is changing the way medicine is practiced, allowing physicians to quickly obtain valuable information to complement the traditional physical examination. Despite the proven benefits of using bedside ultrasound imaging as a part of the patient evaluation and for procedure guidance, adoption of this technology still is not widespread among anesthesiology clinicians nor is there uniform teaching of ultrasound skills to anesthesia residents and faculty. Among obstacles that have been identified as precluding achievement of the goal of widespread utilization of POCUS among anesthesia professionals and trainees, are the availability of equipment for all physicians when it is needed and lack of instructor supervision for trainees who desire to use ultrasound but do not always have an instructor knowledgeable in POCUS with them when an ultrasound examination is warranted. Herein, the characteristics, advantages, and limitations of available ultra-portable, handheld ultrasound devices are analyzed, with a focus on the Butterfly iQ (Butterfly Network, Inc, Guilford, CT) pocket probe, which is available at the authors' institution, and how some of its features, such as the capacity to emulate multiple transducers and its cloud-sharing and teleguidance technology, may contribute to increase the availability and use of POCUS by anesthesia clinicians.

Impact of Left Atrial Appendage Exclusion on Short-Term Outcomes in Isolated Coronary Artery Bypass Graft Surgery.

BACKGROUND: The objective of this study was to evaluate the impact of left atrial appendage (LAA) exclusion on short-term outcomes in patients with atrial fibrillation undergoing isolated coronary artery bypass graft surgery. METHODS: We queried the 2010 to 2014 National Readmissions Database for patients who underwent coronary artery bypass graft repair with and without LAA ligation by using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification: 36.1xx). Only patients with a history of atrial fibrillation were included in our analysis. The primary outcome of our study was 30-day readmissions following discharge. Secondary outcomes were in-hospital mortality and stroke. To assess the postoperative outcomes, we used multivariate logistic regression models to adjust for clinical and demographic covariates. RESULTS: In total, we analyzed 253 287 patients undergoing coronary artery bypass graft surgery, 7.0% of whom received LAA closure. LAA exclusion was associated with a greater risk of postoperative respiratory failure (8.2% versus 6.2%, P<0.0001) and acute kidney injury (21.8% versus 18.5%, P<0.0001), but it did not significantly change the rate of blood transfusions or occurrence of cardiac tamponade. LAA exclusion was associated with a nonsignificant reduction in stroke (7.9% versus 8.6%, P=0.12), no difference in in-hospital mortality (2.2% versus 2.2% P=0.99), and a greater risk of 30-day readmission (16.0% versus 9.6%, P<0.0001). After covariate adjustment, LAA ligation remained a significant predictor of 30-day readmission (odds ratio, 1.640 [95% CI, 1.603-1.677], P<0.0001). CONCLUSIONS: LAA exclusion during isolated coronary artery bypass graft surgery in patients with atrial fibrillation is associated with a higher rate of 30-day readmission. Postoperative measures to mitigate the loss of the hormonal and hemodynamic effects of the LAA may increase the therapeutic benefit of this procedure.

Artificial Intelligence for Dynamic Echocardiographic Tricuspid Valve Analysis: A New Tool in Echocardiography.

There has been a resurgence of interest in the structure and function of the tricuspid valve (TV) with the established prognostic impact of functional tricuspid regurgitation. Current 3-dimensional transesophageal echocardiography prototype software is limited to exploration of the mitral and aortic valves exclusively. Thus, newer analytical software is required for dynamic geometric analysis of the TV morphology for remodeling. This article presents a preliminary experience with novel artificial intelligence-based semiautomated software for TV analysis. The software offers high correlation to surgical inspection by its ability to analyze morphology and dynamics of the valve throughout the cardiac cycle. In addition, it allows higher reproducibility of data analysis and reduces interobserver variability with minimal need for manual intervention. Integration of interactivity through preprocedural placement of specific devices of different sizes and shapes in the mitral and aortic positions facilitates prognostic evaluation of surgical and interventional procedures.

Neuropeptide Y3-36 incorporated into PVAX nanoparticle improves angiogenesis in a murine model of myocardial ischemia.

Neuropeptide-Y (NPY) leads to angiogenesis and remodeling of the ischemic myocardium. The objective of this study is to assess the therapeutic potential of NPY in a model of acute myocardial ischemia using a nanoparticles delivery system targeted to tissue with oxidative stress. NPY3-36 was loaded onto copolyoxalate containing vanillyl alcohol (PVAX) using a double emulsification strategy. Adult C57BL/J6 mice (n = 49) were randomly divided into PVAX-NPY3-36 (n = 22), Vehicle (Saline) (n = 16), and Sham (n = 11) groups. The ischemia to left anterior descending artery was induced in PVAX-NPY3-36 or vehicle groups. The tissue was collected at the end of two weeks after assessing the functional and echocardiographic data. There was a significant decrease in infarction size and mortality in PVAX-NPY3-36 group compared to the Vehicle group (P = 0.01 and P = 0.05). On echocardiography, there was significant improvement in contractility and diastolic parameters (P = 0.01). On pressure-volume loop there was significant increase in stroke volume (P = 0.01), cardiac output (P = 0.01) and ventricular stroke work (P = 0.01) in the PVAX-NPY3-36 group. On Western blot analysis, there was a significant increase in pro-angiogenic factors Ang-1, TGF-ß, PDGF- ß and its receptors and VEGF in the ischemic tissue treated with PVAX-NPY3-36 as compared to Vehicle ischemic tissue (P = 0.01, P = 0.0003, and P < 0.05 respectively). It may be possible to have targeted delivery of labile neurotransmitters NPY3-36 to the ischemic myocardium using nanoparticle PVAX and achieving angiogenesis and significant functional improvement.

Use of Erector Spinae Plane Block in Thoracic Surgery Leads to Rapid Recovery From Anesthesia.

BACKGROUND: Ultrasound guidance has resulted in a continuous evolution in techniques for pain control for video-assisted thoracoscopic surgery (VATS). The objective of this study was to compare erector spinae plane block with intercostal block as multimodal analgesia to elucidate quality of postoperative pain control and preservation of pulmonary function after VATS. METHODS: A consecutive cohort of patients undergoing elective VATS was enrolled in the study and divided into erector spinae plane block and intercostal block groups. Spirometry and visual analog scale pain score exams were performed to measure forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), FEV1/FVC ratio, and forced expiratory flow in intervals of 25% to 75%. Chronic pain was assessed by reviewing surgical follow-up notes. RESULTS: Seventy-eight patients were included. Comparing the erector spinae plane block group with the intercostal block group found significant improvement in visual analog scale pain score (3.2 vs 6.4, P < .001), postanesthesia care unit length of stay (127.3 vs 189.5 minutes, P = .045), preservation in lung volume parameters at 2 hours (FVC: 40.5% vs 51.4%, P < .001; FEV1: 40.9% vs 53.8%, P < .001; and forced expiratory flow in intervals of 25%-75%: 39.7% vs 53.7%, P = .019) and at 24 hours (FVC: 37.8% vs 50.5%, P < .001; FEV1: 34.3% vs 51.9%, P < .001; forced expiratory flow in intervals of 25%-75%: 27.1% vs 56.3%, P < .001), respectively. CONCLUSIONS: Erector spinae plane block improves acute and chronic pain control and preserves lung function. Thus, it has the potential for enhanced recovery from VATS as part of a multimodal analgesia regimen.