Postoperative Nausea and Vomiting and Pain After Robotic-Assisted Mitral Valve Repair.

OBJECTIVE: To determine the rate and clinical factors associated with postoperative nausea and vomiting (PONV) and severe pain after robotic-assisted mitral valve repair. DESIGN: Retrospective chart review. SETTING: Major quaternary academic medical center. PARTICIPANTS: Adult patients undergoing robotic-assisted mitral valve repair from May 5, 2018 through September 13, 2019. INTERVENTIONS: Participant electronic medical records were abstracted for clinical characteristics, PONV within the first 72 postoperative hours, episodes of severe pain (defined as pain score ≥7 using an 11-point numerical pain rating scale), and opioid use within the first 24 postoperative hours. Multivariate analyses were performed. MEASUREMENTS AND MAIN RESULTS: Of 124 participants, PONV was noted in 83 (67%; 95% confidence interval [CI] 58%-75%) patients and severe pain in 96 (77%, 95% CI 69%-84%) patients. The median (interquartile range) time to PONV was 6.1 (3.7-14.7) hours. After adjusting for age, sex, and duration of surgery, pre-incisional use of methadone was associated with reduced risk for severe pain (odds ratio 0.40 [95% CI 0.16-0.99]; p = 0.048) and a lower 24-postoperative hour opioid requirement (estimate -29.0 mg intravenous morphine equivalents [95% CI -46.7 to -11.3]; p = 0.006). However, methadone was not associated with a reduction of the cumulative opioid dose (intraoperative and 24-hour postoperative opioid dose; p = 0.248). Both severe pain and PONV were associated with longer hospital stay. CONCLUSION: PONV and severe pain are common after robotic-assisted mitral valve repair. Peri-incisional methadone is associated with a modest decrease in the severe pain rate but without a reduction in opioid dose or hospital stay.

Whole-lung Lavage and Pulmonary Alveolar Proteinosis: Review of Clinical and Patient-centered Outcomes.

OBJECTIVE: The objective of this retrospective review was to evaluate the perioperative and procedural management of patients with pulmonary alveolar proteinosis (PAP) who presented for whole-lung lavage (WLL). DESIGN: The records of all adult patients with PAP who underwent WLL between January 1, 1988 and August 20, 2017 were reviewed and pertinent demographic, preoperative, anesthetic, procedural, and postoperative data were recorded. SETTING: Large academic tertiary referral center. PARTICIPANTS: Forty patients with PAP underwent 79 WLL procedures. INTERVENTIONS: Patients with PAP undergoing WLL. MEASUREMENTS: Successful WLL, defined by visual clearing of lavage fluid, was completed in 91% of cases. Whole-lung lavage was terminated prematurely in 9% of cases (refractory hypoxia most common), while 8% of cases were found to have 30-day complications. There were no cases of intraoperative death, hemodynamic collapse, pneumothorax or hydrothorax, or need for emergent reintubation. Postoperative clinical follow-up at the authors' institution within 6 months of WLL showed 68% of patients reported improvement in symptoms and/or functional status. CONCLUSION: The authors here present a retrospective study describing the perioperative and procedural management of PAP patients undergoing WLL to help familiarize providers with the management of this population (Fig 1). The findings of this study outline a successful and consistent approach to WLL using a multidisciplinary team experienced in this procedure. Even in experienced hands, procedural complications and 30-day postoperative complications emphasize the risk in this complex patient population.

Three-Dimensional Echocardiographic Assessment of Mitral Annular Physiology in Patients With Degenerative Mitral Valve Regurgitation Undergoing Surgical Repair: Comparison between Early- and Late-Stage Severe Mitral Regurgitation.

BACKGROUND: Ventricular-annular decoupling is thought to exist in all degenerative myxomatous mitral valve (MV) diseases. However, the annular physiology of degenerative MV disease may differ when severe mitral regurgitation (MR) presents at different stages. The aim of this study was to assess differences in mitral annular physiology and surgical effects between early- and late-stage severe MR. METHODS: Three-dimensional (3D) transesophageal echocardiography was performed before and after MV surgery in 74 patients with degenerative MV disease, including 57 with early-stage severe MR (without left ventricular remodeling) and 17 with late-stage MR (with left ventricular remodeling). A control group comprised 46 patients without MV disease. Novel 3D MV software was used to evaluate mitral annular dynamics. The degree of annular saddle shape was calculated as the ratio of annular height (AH) to lateromedial diameter (LM). Ventricular-annular decoupling was defined as insufficient systolic AH/LM compared with the control group. RESULTS: Prebypass 3D measurements demonstrated that systolic AH/LM in the early-stage group (0.19 ± 0.04) was similar to that in the control group (0.21 ± 0.05; P = .101), while systolic AH/LM in the late-stage group (0.17 ± 0.04) was lower than that in the control group (P = .011). Postbypass comparison showed saddle shape accentuation in the early-stage group (0.20 ± 0.04), similar to that in the control group (P = .3127); the mitral annulus remained flat in the late-stage group (0.17 ± 0.03; P = .004). CONCLUSIONS: Ventricular-annular decoupling, present in the late-stage group, was absent in the early-stage group. MV repair surgery did not disrupt mitral annular saddle shape in the early-stage group; however, it failed to correct annular dysfunction in the late-stage group. Sequential 3D transesophageal echocardiographic analysis provides comprehensive mitral annular evaluation beyond conventional two-dimensional parameters for determining stages of severe MR.

Whole-lung lavage in a patient with pulmonary alveolar proteinosis.

Pulmonary alveolar proteinosis (PAP) is a rare syndrome in which phospholipoproteinaceous matter accumulates in the alveoli leading to compromised gas exchange. Whole-lung lavage is considered the gold standard for severe autoimmune PAP and offers favorable long-term outcomes. In this case report, we describe the perioperative management and procedural specifics of a patient undergoing WLL for PAP in which an anesthesiologist serves as the proceduralist and a separate anesthesiologist provides anesthesia care for the patient.

Impact of New-Onset Left Ventricular Dysfunction on Outcomes in Mechanically Ventilated Patients With Severe Sepsis and Septic Shock.

BACKGROUND:: Left ventricular systolic dysfunction (LVSD) and LV diastolic dysfunction (LVDD) are commonly seen in severe sepsis and septic shock; however, their role in patients with concurrent invasive mechanical ventilation (IMV) is less well defined. METHODS:: This was a prospective observational study on all patients admitted to all the intensive care units (ICUs) at Mayo Clinic, Rochester from August 2007 to January 2009. All adult patients with severe sepsis and septic shock and concurrent IMV without prior heart failure underwent transthoracic echocardiography within 24 hours. Patients with active pregnancy, prior congenital or valvular heart disease, and prosthetic cardiac valves were excluded. Left ventricular systolic dysfunction was defined as LV ejection fraction (LVEF) <50% and LVDD as E/e' >15. Primary outcome was hospital mortality, and secondary outcomes included IMV duration, ICU length of stay (LOS), and total LOS. Two-tailed P value of <.05 was considered statistically significant. RESULTS:: In a total of 106 patients, 58 (54.7%) met our inclusion criteria, with 17 (29.3%), 11 (19.0%), and 5 (8.6%) having LVSD, LVDD, and both, respectively. The cohorts with and without LVSD and LVDD did not differ significantly in their baseline characteristics and laboratory and ventilatory parameters. Compared to those without LVSD, patients with LVSD had higher LV end-systolic diameters but were not different in their left atrial diameters or E/e' ratio. Patients with LVDD had a higher E velocity and E/e' ratio compared to those without LVDD. Hospital mortality was not different in patients with and without LVSD (8 [47%] vs 21 [51%], P = 1.00) and LVDD (8 [73%] vs 21 [45%], P = .18). Secondary outcomes were not different between the 2 groups. CONCLUSION:: Left ventricular systolic or diastolic dysfunction did not influence in-hospital outcomes in patients with severe sepsis and septic shock and concurrent IMV.

Urgent Ultrasound-Guided Bilateral Stellate Ganglion Blocks in a Patient With Medically Refractory Ventricular Arrhythmias.

OBJECTIVES: To describe the successful treatment of medically refractory ventricular arrhythmias in the ICU with ultrasound-guided bilateral stellate ganglion blocks. DATA SOURCES: The data were gathered from the medical record. STUDY SELECTION: This case was selected as it describes the use of ultrasound in the successful termination of a recurrent, malignant arrhythmia, rather than fluoroscopy, to perform bilateral stellate ganglion blocks at the patient's bedside in the ICU. DATA EXTRACTION: The data were extracted from the medical record. DATA SYNTHESIS: The data were synthesized from the patient's medical record. CONCLUSIONS: Performance of stellate ganglion blocks at the bedside in the ICU is feasible for patients who are suffering from refractory ventricular arrhythmias. This potentially life-saving block can be performed using ultrasound guidance, sparing the patient transport to a fluoroscopy suite.

Outcome prediction in sepsis: speckle tracking echocardiography based assessment of myocardial function.

INTRODUCTION: Speckle tracking echocardiography (STE) is a relatively novel and sensitive method for assessing ventricular function and may unmask myocardial dysfunction not appreciated with conventional echocardiography. The association of ventricular dysfunction and prognosis in sepsis is unclear. We sought to evaluate frequency and prognostic value of biventricular function, assessed by STE in patients with severe sepsis or septic shock. METHODS: Over an eighteen-month period, sixty patients were prospectively imaged by transthoracic echocardiography within 24 hours of meeting severe sepsis criteria. Myocardial function assessment included conventional measures and STE. Association with mortality was assessed over 12 months. RESULTS: Mortality was 33% at 30 days (n = 20) and 48% at 6 months (n = 29). 32% of patients had right ventricle (RV) dysfunction based on conventional assessment compared to 72% assessed with STE. 33% of patients had left ventricle (LV) dysfunction based on ejection fraction compared to 69% assessed with STE. RV free wall longitudinal strain was moderately associated with six-month mortality (OR 1.1, 95% confidence interval, CI, 1.02-1.26, p = 0.02, area under the curve, AUC, 0.68). No other conventional echocardiography or STE method was associated with survival. After adjustment (for example, for mechanical ventilation) severe RV free wall longitudinal strain impairment remained associated with six-month mortality. CONCLUSION: STE may unmask systolic dysfunction not seen with conventional echocardiography. RV dysfunction unmasked by STE, especially when severe, was associated with high mortality in patients with severe sepsis or septic shock. LV dysfunction was not associated with survival outcomes.

Left Main Coronary Artery Compression following Melody Pulmonary Valve Implantation: Use of Impella Support as Rescue Therapy and Perioperative Challenges with ECMO.

The purpose of this case is to describe the complex perioperative management of a 30-year-old woman with congenital heart disease and multiple resternotomies presenting with pulmonary homograft dysfunction and evaluation for percutaneous pulmonary valve replacement. Transvenous, transcatheter Melody valve placement caused left main coronary artery occlusion and cardiogenic shock. An Impella ventricular assist device (VAD) provided rescue therapy during operating room transport for valve removal and pulmonary homograft replacement. ECMO support was required following surgery. Several days later during an attempted ECMO wean, her hemodynamics deteriorated abruptly. Transesophageal and epicardial echocardiography identified pulmonary graft obstruction, requiring homograft revision due to large thrombosis. This case illustrates a role for Impella VAD as bridge to definitive procedure after left coronary occlusion and describes management of complex perioperative ECMO support challenges.

Clinical spectrum, frequency, and significance of myocardial dysfunction in severe sepsis and septic shock.

OBJECTIVE: To determine the frequency and spectrum of myocardial dysfunction in patients with severe sepsis and septic shock using transthoracic echocardiography and to evaluate the impact of the myocardial dysfunction types on mortality. PATIENTS AND METHODS: A prospective study of 106 patients with severe sepsis or septic shock was conducted from August 1, 2007, to January 31, 2009. All patients underwent transthoracic echocardiography within 24 hours of admission to the intensive care unit. Myocardial dysfunction was classified as left ventricular (LV) diastolic, LV systolic, and right ventricular (RV) dysfunction. Frequency of myocardial dysfunction was calculated, and demographic, hemodynamic, and physiologic variables and mortality were compared between the myocardial dysfunction types and patients without cardiac dysfunction. RESULTS: The frequency of myocardial dysfunction in patients with severe sepsis or septic shock was 64% (n=68). Left ventricular diastolic dysfunction was present in 39 patients (37%), LV systolic dysfunction in 29 (27%), and RV dysfunction in 33 (31%). There was significant overlap. The 30-day and 1-year mortality rates were 36% and 57%, respectively. There was no difference in mortality between patients with normal myocardial function and those with left, right, or any ventricular dysfunction. CONCLUSION: Myocardial dysfunction is frequent in patients with severe sepsis or septic shock and has a wide spectrum including LV diastolic, LV systolic, and RV dysfunction types. Although evaluation for the presence and type of myocardial dysfunction is important for tailoring specific therapy, its presence in patients with severe sepsis and septic shock was not associated with increased 30-day or 1-year mortality.

Attributable mortality of nosocomial candidemia, revisited.

We reexamined the attributable mortality of nosocomial candidemia 15 years after a retrospective cohort study performed at our hospital demonstrated an attributable mortality of 38%. For all episodes of nosocomial candidemia between 1 July 1997 and 30 June 2001, we matched control patients with case patients by age, sex, date of hospital admission, underlying disease(s), length of time at risk, and surgical procedure(s). We analyzed 108 matched pairs. There were no statistically significant differences in age, sex, underlying disease(s), time at risk, surgical procedure, or vital signs at admission between cases and controls. The crude mortality among case patients was 61% (66 of 108 patients), compared with 12% (13 of 108) among control patients, for an attributable mortality of 49% (95% CI, 38%-60%). Nosocomial candidemia is still associated with an extremely high crude and attributable mortality--much higher than that expected from underlying disease alone.