Management of Anticoagulation and Antifibrinolytics in Catastrophic Antiphospholipid Syndrome.

Antiphospholipid syndrome (APS) is an autoimmune disorder that presents with hypercoagulability and results in a lab artifact of prolonged PTT. The most severe form is catastrophic antiphospholipid antibody syndrome (CAPS), which manifests as rapidly progressing thromboses in multiple organ systems leading to multi-organ ischemia. The mainstay management CAPS is anticoagulation and systemic corticosteroids. Antifibrinolytic agents have previously been thought to be relatively contraindicated in CAPS due to the pro-thrombotic nature of the disease; the complex coagulation profile of CAPS can make it difficult to assess the risks and benefits of antifibrinolytic therapy. Also, should a patient with CAPS require cardiopulmonary bypass (CPB) for surgery, it poses a unique challenge in providing appropriate anticoagulation in the setting of prolonged ACT. We present a case of a 32-year-old postpartum female with CAPS requiring heart transplant who safely received intraoperative antifibrinolytic therapy and was successfully anticoagulated during CPB after perioperative plasmapheresis.

Frequency and Analysis of Unplanned Extubation in Coronavirus Disease 2019 Patients.

OBJECTIVES: To determine if patients with coronavirus disease 2019 had a greater number of unplanned extubations resulting in reintubations than in patients without coronavirus disease 2019. DESIGN: Retrospective cohort study comparing the frequency of unplanned extubations resulting in reintubations in a group of coronavirus disease 2019 patients to a historical (noncoronavirus disease 2019) control group. SETTING: This study was conducted at Henry Ford Hospital, an academic medical center in Detroit, MI. The historical noncoronavirus disease 2019 patients were treated in the 68 bed medical ICU. The coronavirus disease 2019 patients were treated in the coronavirus disease ICU, which included the 68 medical ICU beds, 18 neuro-ICU beds, 32 surgical ICU beds, and 40 cardiovascular ICU beds, as the medical ICU was expanded to these units at the peak of the pandemic in Detroit, MI. PATIENTS: The coronavirus disease 2019 cohort included patients diagnosed with coronavirus disease 2019 who were intubated for respiratory failure from March 12, 2020, to April 13, 2020. The historic control (noncoronavirus disease 2019) group consisted of patients who were admitted to the medical ICU in the year spanning from November 1, 2018 to October 31, 2019, with a need for mechanical ventilation that was not related to surgery or a neurologic reason. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: To identify how many patients in each cohort had unplanned extubations, an electronic medical records query for patients with two intubations within 30 days was performed, in addition to a review of our institutional quality and safety database of reported self-extubations. Medical charts were manually reviewed by board-certified anesthesiologists to confirm each event was an unplanned extubation followed by a reintubation within 24 hours. There was a significantly greater incidence of unplanned extubations resulting in reintubation events in the coronavirus disease 2019 cohort than in the noncoronavirus disease 2019 cohort (coronavirus disease 2019 cohort: 167 total admissions with 22 events-13.2%; noncoronavirus disease 2019 cohort: 326 total admissions with 14 events-4.3%; p < 0.001). When the rate of unplanned extubations was expressed per 100 intubated days, there was not a significant difference between the groups (0.88 and 0.57, respectively; p = 0.269). CONCLUSIONS: Coronavirus disease 2019 patients have a higher incidence of unplanned extubation that requires reintubation than noncoronavirus disease 2019 patients. Further study is necessary to evaluate the variables that contribute to this higher incidence and clinical strategies that can reduce it.

Comparison of Patient Outcomes of Transfemoral Transcatheter Aortic Valve Replacement Using Pre-Sedation Radial Versus Post-Sedation Femoral Arterial Sites for Blood Pressure Monitoring.

OBJECTIVE: To compare outcomes among patients with and without preprocedural radial arterial catheters who underwent transfemoral transcatheter aortic valve replacement (TF-TAVR) under deep intravenous (IV) sedation and to assess predictive variables for preprocedural placement. DESIGN: Single-center, retrospective, cohort analysis. SETTING: Department of Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Hospital, which is a tertiary care, university-affiliated hospital. PARTICIPANTS: The study comprised 157 patients. The primary focus was the 106 patients who underwent TF-TAVR when routine placement of preprocedure radial arterial catheters was abandoned. They were analyzed for hospital length of stay, 30-day mortality, and predictive factors of preprocedure placement. The remaining patients served as historical controls when routine radial artery catheter placement was practiced. INTERVENTIONS: Patient, procedure, and provider factors were analyzed. The transitional period consisted of 169 consecutive days from April 13 to September 28, 2017. A reference group of historical patients served as a control. MEASUREMENTS AND MAIN RESULTS: Seventy-five of 106 patients did not have a preprocedural radial arterial catheter. The primary outcome measures of length of stay and 30-day mortality within the transitional group were not different. Secondary outcome measures included identification of predictive variables for preprocedure placement and outcome comparisons between the transitional and historical groups. Anesthesia provider (p = 0.015) and ejection fraction (p = 0.039) were significant factors. There were no differences in outcome measures. CONCLUSION: There was no difference in primary outcomes in patients with or without radial arterial catheters for TF-TAVR. The findings of this study suggest anesthesia provider and ejection fraction were significant factors for preprocedural placement.

Expansion of postoperative pneumothorax and pneumomediastinum: determining when it is safe to fly.

INTRODUCTION: The possibility of expansion of pneumothorax (PTX) and/or pneumomediastinum (PMED) during commercial flights makes air travel after thoracic surgery particularly worrisome. Guidelines from the Aerospace Medical Association (AsMA) suggest delaying air travel 2 to 3 wk following uncomplicated thoracic surgery and 1 wk following radiographic resolution of PTX; they also state that PTX is an "absolute contraindication" to air travel. However, both AsMA guidelines and thoracic surgeons' recommendations for postoperative air travel require further examination. METHODS: We reviewed the literature looking for evidence supporting official guidelines and conducted a survey of U.S. thoracic surgeons about their recommendations for air travel by patients with postoperative PTX and/or PMED. RESULTS: We found no experimental evidence supporting the AsMA guidelines. Of the 68 thoracic surgeons who returned our questionnaire, 44% recommended that patients wait variable periods of time of up to 42 d (13.8 +/- 11.6 d) following complete resolution of PTX prior to air travel, while 46% of them allowed their patients to fly with some degree of PTX. Following mediastinoscopy, 76.9% of the surgeons allowed their patients to fly without delay, even with PMED. The only adverse in-flight event reported was a case of thoracic pain during ascent. DISCUSSION: A wide variability exists among thoracic surgeons regarding their recommendations for air travel by patients with postoperative PTX and/or PMED. Both AsMA guidelines and surgeons' recommendations should rely more on scientific evidence. Studies of PTX and PMED expansion during simulated flight are needed to develop better guidelines.