A Novel Use of a Not So "EZ-Blocker" For Lung Isolation During a Direct Transaortic Transcatheter Aortic Valve Replacement.

Alternate access transcatheter aortic valve replacement presents unique challenges for anesthesiologists, including the possible need for lung isolation while working with space constraints around the patient's airway. Troubleshooting lung isolation in these cases can be challenging, requiring quick thinking and adaptability while maintaining patient safety. We present a case of direct transaortic transcatheter aortic valve replacement with an endobronchial blocker ("EZ-blocker") used for lung isolation that required a novel use of the "EZ-blocker" to achieve adequate lung isolation.

Hemodynamic Monitoring In The Cardiac Surgical Patient: Comparison of Three Arterial Catheters.

OBJECTIVE: Systemic systolic (SAP) and mean (MAP) arterial pressure monitoring is the cornerstone in hemodynamic management of the cardiac surgical patient, and the radial artery is the most common site of catheter placement. The present study compared 3 different arterial line procedures. It is hypothesized that a 20-G 12.7- cm catheter inserted into the radial artery will be equal to a 20-G 12.7- cm angiocath placed in the brachial artery, and superior to a 20-G 5.00 cm angiocath placed in the radial artery. DESIGN: A prospective randomized control study was performed. SETTING: Single academic university hospital. PARTICIPANTS: Adult patients ≥18 years old undergoing nonemergent cardiac surgery using cardiopulmonary bypass (CPB). INTERVENTIONS: After approval by the Rhode Island Hospital institutional review board, a randomized prospective control study to evaluate 3 different peripheral intraarterial catheter systems was performed: (1) Radial Short (RS): 20-G 5- cm catheter; (2) Radial Long (RL): 20-G 12- cm catheter; and (3) Brachial Long (BL): 20-G 12- cm catheter. MEASUREMENTS AND RESULTS: Gradients between central aortic and peripheral catheters (CA-P) were compared and analyzed before CPB and 2 and 10 minutes after separation from CPB. The placement of femoral arterial lines and administration of vasoactive medications were recorded. After exclusions, 67 BL, 61 RL, and 66 RS patients were compared. Before CPB, CA-P SAP and MAP gradients were not significant among the 3 groups. Two minutes after CPB, the CA-P SAP gradient was significant for the RS group (p = 0.005) and insignificant for BL (p = 0.47) and RL (p = 0.39). Two-group analysis revealed that CA-P SAP gradients are similar between BL and RL (p = 0.84), both of which were superior to RS (p = 0.02 and p = 0.04, respectively). At 10 minutes after CPB, the CA-P SAP gradient for RS remained significant (p = 0.004) and similar to the gradient at 2 minutes. The CA-P SAP gradients increased from 2 to 10 minutes for BL (p = 0.13) and RL (p = 0.06). Two minutes after CPB, the CA-P MAP gradients were significant for the BL (p = 0.003), RL (p < 0.0001), and RS (p < 0.0001) groups. Two-group analysis revealed that the CA-P MAP gradients were lower for the BL group compared with the RL (p = 0.054) and RS (p< 0.05) groups. Ten minutes after CPB, the CA-P MAP gradients in the RL and RS groups remained significant (p < 0.0001) and both greater than the BL group (p = 0.002). A femoral arterial line was placed more frequently in the RS group (8/66 = 12.1%) than in the RL group (3/61 = 4.9%) and the BL group (2/67 = 3.0%). Vasopressin was administered significantly more frequently in the RS group. CONCLUSION: Regarding CA-P SAP gradients, the RL group performed equally to the BL group, both being superior to RS. Regarding CA-P MAP gradients, BL was superior to RL and RS. Clinically, femoral line placement and vasopressin administration were fewer for the BL and RL groups when compared with the RS group. This study demonstrated the benefits of a long (12.7 cm) 20- G angiocath placed in the radial artery.

Caught by POCUS: Post-TAVR Pericardial Effusion.

Point-of-care ultrasound (POCUS) is becoming increasingly popular in the field of anesthesiology and is being incorporated into anesthesia resident education. Ultrasound provides a portable, quick, and inexpensive diagnostic tool to help guide clinicians in their decision making and management of medically complex patients. One important utilization of POCUS is helping to guide management of undifferentiated hypotension. We present a case of a patient who underwent a Transcatheter Aortic Valve Replacement (TAVR) procedure who then suffered from hypotension in the post-anesthesia care unit (PACU). POCUS was used to help identify the cause of the patient's hypotension and led to the diagnosis of a pericardial effusion.

Impact of a Preclinical Medical Student Anesthesiology Elective on the Attitudes and Perceptions of Medical Students Regarding Anesthesiology.

Purpose: First- and second-year medical students typically have limited exposure to the field of anesthesiology, yet recent match data shows growing interest in the specialty. Early, structured exposure to anesthesiology in the form of a preclinical elective may allow medical students to make more informed decisions on their specialty of choice. Methods: The anesthesiology preclinical elective, BIOL 6704: "Anesthesia: Much More than Putting you to Sleep", is a one-credit course taught at The Warren Alpert Medical School of Brown University. A survey consisting of fifteen questions assessing changes in attitudes, perceptions, and interest in anesthesiology was distributed to first- and second-year medical students before and after course participation. The results were analyzed using the Wilcoxon's signed-rank test for paired samples. Results: The biggest impact of the preclinical elective was observed in the students' subjective understanding of key aspects of the practice of anesthesiology. Statistically significant improvement was seen in the understanding of airway management, anesthetic pharmacology, basics of ultrasound, vascular access, anesthesiology subspecialties, and an understanding of anesthesiology residency. Overall, results were limited by our small sample size. Conclusion: Our elective allows medical students to explore anesthesiology early in their medical school career. After taking this course, students noted more familiarity with various topics in anesthesiology. Peer institutions lacking a similar course may consider using our experience to increase interest about the specialty of anesthesiology for future students.

Effect of concurrent mitral valve surgery for secondary mitral regurgitation upon mortality after aortic valve replacement or coronary artery bypass surgery.

Objectives: It is uncertain whether concurrent mitral valve repair or replacement for moderate or greater secondary mitral regurgitation at the time of coronary artery bypass graft or aortic valve replacement surgery improves long-term survival. Methods: Patients undergoing coronary artery bypass graft and/or aortic valve replacement surgery with moderate or greater secondary mitral regurgitation were reviewed. The effect of concurrent mitral valve repair or replacement upon long-term mortality was assessed while accounting for patient and operative characteristics and mitral regurgitation severity. Results: Of 1,515 patients, 938 underwent coronary artery bypass graft or aortic valve replacement surgery alone and 577 underwent concurrent mitral valve repair or replacement. Concurrent mitral valve repair or replacement did not alter the risk of postoperative mortality for patients with moderate mitral regurgitation (hazard ratio = 0.93; 0.75-1.17) or more-than-moderate mitral regurgitation (hazard ratio = 1.09; 0.74-1.60) in multivariable regression. Patients with more-than-moderate mitral regurgitation undergoing coronary artery bypass graft-only surgery had a survival advantage from concurrent mitral valve repair or replacement in the first two postoperative years (P = 0.028) that did not persist beyond that time. Patients who underwent concurrent mitral valve repair or replacement had a higher rate of later mitral valve operation or reoperation over the five subsequent years (1.9% vs. 0.2%; P = 0.0014) than those who did not. Conclusions: These observations suggest that mitral valve repair or replacement for more-than-moderate mitral regurgitation at the time of coronary artery bypass grafting may be reasonable in a suitably selected coronary artery bypass graft population but not for aortic valve replacement, with or without coronary artery bypass grafting. Our findings are supportive of 2021 European guidelines that severe secondary mitral regurgitation "should" or be "reasonabl[y]" intervened upon at the time of coronary artery bypass grafting but do not support 2020 American guidelines for performing mitral valve repair or replacement concurrent with aortic valve replacement, with or without coronary artery bypass grafting.

The Impact of a New Anesthesiology Residency Program on the Number of Medical Students Matching Into Anesthesiology at a Single Institution: A Retrospective Longitudinal Study.

Introduction There are projected workforce shortages within anesthesiology exacerbated by an increase in demand for anesthesia services and an aging anesthesia workforce. Given this mismatch, it is critical for the specialty to recruit the next generation of anesthesiologists and understand the factors affecting medical students' decision to apply to anesthesiology. This study aims to evaluate the impact of establishing a new anesthesiology residency program at a single institution on the number of medical students that match into anesthesiology in the subsequent years. Methods A single-center, retrospective longitudinal study examined the number of medical students matching into anesthesiology at a single institution between 2013 and 2023, five years before and after the establishment of an accredited anesthesiology residency program. The data were compared to aggregated data on all US medical student applicants through the National Resident Matching Program. Results The pre-anesthesiology residency match rate (2013-2018) of medical students from Alpert Medical School (AMS) was 2.47% while the post-anesthesiology residency match rate (2019-2023) was 4.30%. This represents a 74% increase in the average proportion of medical students matching into anesthesiology after the start of the residency program compared to a 20% increase nationally over the same time period. The rate of change of AMS matched applicants after the implementation of the AMS anesthesia residency program increased compared to the national applicant pool (p= 0.002). Conclusion The establishment of a new accredited anesthesiology residency program increased the proportion of medical students matching into anesthesiology at the affiliated medical school in the subsequent five years. Exposure to an academic anesthesiology program improves medical student interest and ultimately matches rates in anesthesiology, a vital tool to address the projected shortages in the anesthesiology workforce.

A Pilot Study to Assess the Clinical Onset of IV Heparin in Interventional Cardiology and Cardiac Surgery.

OBJECTIVES: To determine the onset of heparin anticoagulation, using 2 different measures of activated clotting times (ACT), thromboelastography (TEG; R-time), and anti-Xa levels, after administering low- (100 U/kg) and high- (300 U/kg) dose intravenous (IV) heparin to patients undergoing transcatheter aortic valve replacement (TAVR) and cardiac surgery, respectively. DESIGN: Prospective study. SETTING: Single academic institution. PARTICIPANTS: Patients with normal baseline coagulation presenting for TAVR or cardiac valve surgery. INTERVENTIONS: Coagulation studies were performed at baseline, 30 seconds, 90 seconds, and 180 seconds after IV heparin administration. The tests included iSTAT (iACT) and Hemochron ACT (hACT), TEG R-Time, and anti-Xa levels. At the authors' institution, anti-Xa is the preferred measure of heparin anticoagulation when time permits. ACT, a rapid point- of-care test, is used to assess intraprocedural anticoagulation. MEASUREMENTS AND MAIN RESULTS: After both low- and high-dose heparin, there are peak increases in ACT and anti-Xa at 30 seconds, followed by a decline at 90 seconds and plateau at 180 seconds. The TEG R-time remained elevated (>80 minutes) throughout. For TAVR cases, all anti-Xa was >1.5 IU/mL, and was associated with an iACT >180 seconds and an hACT >200 seconds. For cardiac valve surgery cases, all anti-Xa was >2.4 and associated with an iACT >420 seconds and and hACT >340 seconds. Compared with hACT, iACTs were significantly lower at all time points after low-dose heparin, but not after high-dose heparin. CONCLUSIONS: In this pilot study, heparin anticoagulation was detected as early as 30 seconds after IV administration, based on ACT, anti-Xa levels, and TEG R-time.

Two Endotracheal Tubes in One Trachea with a Traumatic Injury.

BACKGROUND: Traumatic airway injuries often require improvising solutions to altered anatomy under strict time constraints. We describe here the use of two endotracheal tubes simultaneously in the trachea to facilitate securing an airway which has been severely compromised by a self-inflicted wound to the trachea. Case Presentation: A 71-year-old male presented with a self-inflicted incision to his neck, cutting deep into the trachea itself. An endotracheal tube was emergently placed through the self-inflicted hole in the trachea in the ED. The patient was bleeding profusely, severely somnolent, and desaturating upon arrival to the operating room. Preservation of the tenuous airway was a priority while seeking to establish a more secure one. A video laryngoscope was used to gain a wide view of the posterior oropharynx and assist with oral intubation using a fiberoptic scope loaded with a second endotracheal tube. The initial tube's cuff was deflated as the second tube was advanced over the fiberoptic scope, thereby securing the airway while a completion tracheostomy was performed. CONCLUSIONS: Direct penetrating airway trauma may necessitate early, albeit less secure, intubations though the neck wounds prior to operating room arrival. The conundrum is weighing the risk of losing a temporary airway while attempting to establish a more secure airway. Here, we demonstrate the versatility of common anesthesia tools such as a video laryngoscope and a fiberoptic bronchoscope and the welcome discovery of the trachea's ability to accommodate two endotracheal tubes simultaneously so as to ensure a patent airway at all points throughout resuscitation.

Joint preoperative transthoracic and intraoperative transoesophageal echocardiographic assessment of functional mitral regurgitation severity provides better association with long-term mortality.

OBJECTIVES: Functional mitral regurgitation (MR) is observed with ischaemic heart disease or aortic valve disease. Assessing the value of mitral valve repair or replacement (MVR/P) is complicated by frequent discordance between preoperative transthoracic echocardiographic (pTTE) and intraoperative transoesophageal echocardiographic (iTOE) assessment of MR severity. We examined the association of pTTE and iTOE with postoperative mortality in patients with or without MR, at the time of coronary artery bypass grafting (CABG) and/or aortic valve replacement without MVR/P. METHODS: Medical records of 6629 patients undergoing CABG and/or aortic valve replacement surgery with or without functional MR and who did not undergo MVR/P were reviewed. MR severity assessed by pTTE and iTOE were examined for association with postoperative mortality using proportional hazards regression while accounting for patient and operative characteristics. RESULTS: In 72% of 709 patients with clinically significant (moderate or greater) functional MR detected by pTTE, iTOE performed after induction of anaesthesia demonstrated a reduction in MR severity, while 2% of patients had increased severity of MR by iTOE. iTOE assessment of MR was better associated with long-term postoperative mortality than pTTE in patients with moderate MR [hazard ratio (HR) 1.31 (1.11-1.55) vs 1.02 (0.89-1.17), P-value for comparison of HR 0.025] but was not different for more than moderate MR [1.43 (0.96-2.14) vs 1.27 (0.80-2.02)]. CONCLUSIONS: In patients undergoing CABG and/or aortic valve replacement without MVR/P, these findings support intraoperative reassessment of MR severity by iTOE as an adjunct to pTTE in the prediction of mortality. Alone, these findings do not yet provide evidence for an operative strategy.

Break the Spasm with Succinylcholine, but Risk Intraoperative Awareness with Undiagnosed Pseudocholinesterase Deficiency.

Succinylcholine is a commonly used medication in all aspects of anesthetic care, and there are a number of known side effects and complications associated with its use. However, when succinylcholine is used emergently, anesthesia providers must remain vigilant to undiagnosed conditions that pose additional risks to patients. We report the use of succinylcholine to treat acute, refractory laryngospasm after extubation leading to prolonged neuromuscular paralysis. There are unique challenges presented by this case including the risk of anesthesia awareness with recall due to the cognitive biases that prevent the clinical diagnosis of pseudocholinesterase deficiency.

Survival advantage and PaO2 threshold in severe traumatic brain injury.

BACKGROUND: Hypoxemia can adversely affect outcome after traumatic brain injury (TBI). However, the effect of high PaO2 on TBI outcomes is controversial. The primary aim of this study was to identify the optimal PaO2 range early after severe TBI. METHODS: In this single-center retrospective study conducted at a level-1 trauma center, patients with severe TBI (head Abbreviated Injury Scale score >3, admission Glasgow Coma Scale score ≤8) were included. The crude and adjusted (including chest injuries and acute respiratory distress syndrome) effects of 50 mm Hg incremental PaO2 thresholds during the first 72 hours on discharge survival were examined. RESULTS: Data from 193 patients (44±18 y; 77% male; admission Glasgow Coma Scale score 4±2) were reviewed. Overall survival was 57%. PaO2 thresholds in increments of 50 mm Hg between 250 and 486 mm Hg (68%) were associated with discharge survival in patients with severe TBI compared with PaO2 60 mm Hg