Perioperative Management of Patients Receiving Sodium-Glucose Cotransporter 2 Inhibitors: Development of a Clinical Guideline at a Large Academic Medical Center.

The use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) is increasing rapidly for patients with diabetes, heart failure, and chronic kidney disease. These medications can cause euglycemic diabetic ketoacidosis in the perioperative period, and the Food and Drug Administration recently updated their recommendations that they be held for at least 3-to-4 days preoperatively. There is a paucity of guidelines for the perioperative management of patients taking SGLT2i who present for emergent surgery or elective surgery having not held the medications per Food and Drug Administration guidelines. At the University of Pennsylvania, a multidisciplinary team from the Departments of Anesthesiology, Endocrinology, and Pharmacy has developed comprehensive guidelines detailing preoperative, intraoperative, and postoperative management for patients using these medications. In this article, the authors present these guidelines and discuss challenges encountered while implementing them at a large academic medical center with satellite hospitals and surgery centers with varying resources and patient populations.

Development of an Anesthesiology Disaster Response Plan.

Events during the 2020 COVID-19 pandemic have demonstrated how disasters can disrupt the flow of health care delivery. Disaster events may become more common, and health care providers need proper training in how to manage patients affected by these events. Literature from anesthetic management from prior disasters, other specialties, and low-income and middle-income countries, offers guidance for how to respond to disasters. An effective disaster response requires a comprehensive plan that is rehearsed and well executed. Health care workers responding to a disaster may suffer physical and psychological consequences.

Reducing Opioid Use in Patients Undergoing Cardiac Surgery - Preoperative, Intraoperative, and Critical Care Strategies.

Patients undergoing cardiothoracic surgery are exposed to opioids in the operating room and intensive care unit and after hospital discharge. Opportunities exist to reduce perioperative opioid use at all stages of care and include alternative oral and intravenous medications, novel intraoperative regional anesthetic techniques, and postoperative opioid-sparing sedative and analgesic strategies. In this review, currently used and investigational strategies to reduce the opioid burden for cardiothoracic surgical patients are explored.

Perioperative Point-of-Care Ultrasound and Transesophageal Echocardiography in Resource- Limited Settings-A Focus on Nepal and Bangladesh.

The use of point-of-care ultrasound (POCUS) and transesophageal echocardiography (TEE) in the perioperative and critical care setting is increasing worldwide. This increase has been driven by increasing educational opportunities and technologic advances. Nepal and Bangladesh are resource-limited countries where concerted efforts have been made to increase training in POCUS or TEE in the perioperative and critical care settings. This paper's focus is to present the current state of use and international efforts to improve education and skills in perioperative POCUS and TEE in Nepal and Bangladesh. The authors also examine the challenges to improving and expanding ultrasound use in the perioperative environment in resource- limited environments in general, using the Nepalese and Bangladeshi experiences as case studies. The authors have held multiple short courses in POCUS or TEE in Nepal and Bangladesh over the past several years. The authors found a high level of interest in learning POCUS and TEE skills among participants. They encountered challenges with maintaining continuing education and quality assurance for participants after the courses. They also identified barriers to incorporating ultrasound into daily practice in local hospitals. An increasing prevalence of cardiovascular disease will increase the need for diagnostic strategies for patients worldwide, including the use of POCUS and TEE, to manage patients in the perioperative and critical care settings. The courses held in Nepal and Bangladesh may serve as models to expand educational opportunities in POCUS and perioperative TEE in resource-limited settings.

Venovenous Extracorporeal Membrane Oxygenation for Patients With Return of Spontaneous Circulation After Cardiac Arrest Owing to Acute Respiratory Distress Syndrome.

OBJECTIVE: The primary objective of this study was to determine the survival to hospital discharge of patients who were treated with venovenous (VV) extracorporeal membrane oxygenation (ECMO) for respiratory failure after cardiac arrest. DESIGN: Retrospective chart review. SETTING: University-affiliated tertiary care hospitals. PARTICIPANTS: The study comprised 21 patients. INTERVENTIONS: Implementation of VV ECMO in patients with return of spontaneous circulation after cardiac arrest owing to respiratory insufficiency. MEASUREMENTS AND MAIN RESULTS: The most common etiology of arrest was pneumonia-associated acute respiratory distress syndrome (8/21 [38%]). Overall, 12/21(57%) patients survived to hospital discharge. Two of 12 (17%) patients required hemodialysis upon discharge. CONCLUSION: VV ECMO may be an appropriate alternative to venoarterial ECMO in select patients with return of spontaneous circulation after cardiac arrest owing to profound respiratory failure.

Heparin-Induced Thrombocytopenia: A Review for Cardiac Anesthesiologists and Intensivists.

Patients undergoing cardiovascular surgery may be exposed to heparin before surgery, during cardiopulmonary bypass (CPB), or in the immediate postoperative period. For this reason, cardiovascular surgery patients are at increased risk for heparin-induced thrombocytopenia (HIT), occurring in 1 to 3% of patients. The diagnosis of HIT can be difficult, if based solely on the development of thrombocytopenia, because cardiac surgical patients have multiple reasons to be thrombocytopenic. Several clinical scoring systems have been developed to reduce unnecessary testing and better define the pretest probability of HIT, which we will review in detail with a diagnostic algorithm. In addition, we will cover the prevention and treatment HIT.