Update on guidelines and recommendations for enhanced recovery after thoracic surgery.

PURPOSE OF REVIEW: Enhanced recovery after thoracic surgery (ERATS) has continued its growth in popularity over the past few years, and evidence for its utility is catching up to other specialties. This review will present and examine some of that accumulated evidence since guidelines sponsored by the Enhanced Recovery after Surgery (ERAS) Society and the European Society of Thoracic Surgeons (ESTS) were first published in 2019. RECENT FINDINGS: The ERAS/ESTS guidelines published in 2019 have not been updated, but new studies have been done and new data has been published regarding some of the individual components of the guidelines as they relate to thoracic and lung resection surgery. While there is still not a consensus on many of these issues, the volume of available evidence is becoming more robust, some of which will be incorporated into this review. SUMMARY: The continued accumulation of data and evidence for the benefits of enhanced recovery techniques in thoracic and lung resection surgery will provide the thoracic anesthesiologist with guidance on how to best care for these patients before, during, and after surgery. The data from these studies will also help to elucidate which components of ERAS protocols are the most beneficial, and which components perhaps do not provide as much benefit as previously thought.

Family Anesthesia Experience: Improving Social Support of Residents Through Education of Their Family and Friends.

Introduction: The prevalence of burnout among anesthesiology residents is 41%-51%. Burnout is associated with medical errors, physician turnover, and substance use disorder. Social support and wellness may reduce burnout, but a barrier is support persons' lack of understanding of an anesthesiologist's work demands. We developed the Family Anesthesia Experience (FAX) to help support persons best support their resident. Methods: FAX consisted of a 4-hour event with hands-on experience, didactics portion, and panel discussion. Participants learned about a typical day in the life of an anesthesiology resident, wellness, burnout, substance use disorder, and available support resources, and had hands-on experience with procedures. The panel discussion offered logistical information about anesthesiology residency and allowed support persons to ask panel members questions. A postevent survey collected feedback on the event. Results: Fifty-one participants (first-year anesthesiology residents and their support persons) attended the event. Eight of 11 residents (73%) and 32 of 40 support persons (80%) completed the survey. All enjoyed the event, would recommend it to other anesthesiology resident support persons, and felt the event would improve communication and support. Most learned a moderate (35%) to large amount (50%) from the event. Qualitative feedback suggested most support persons found the event helpful in improving their understanding of anesthesiology residents' work demands. Discussion: The FAX was well liked by participants. Although we did not assess specific knowledge gained and long-term effects of the 2022 event, evaluations of previous years' events suggest that the event improved participants' understanding of anesthesiology residents' work and stressors.

Harlequin Syndrome Following Regional Liposomal Bupivacaine Use in a Partial Sternectomy.

Harlequin syndrome is a condition in which disruption of the autonomic nervous system results in ipsilateral anhidrosis and pallor of the face. We report the first documented case of Harlequin syndrome following the use of liposomal bupivacaine, in which a patient developed symptoms five hours after a bilateral erector spinae plane (ESP) block with liposomal bupivacaine before partial sternectomy. It is additionally unique as the first report of delayed onset of symptoms. The proposed mechanism is the diffusion of the anesthetic into the paravertebral space with cephalad migration to the T2-T3 level, where facial vasomotor fibers exit the spinal cord.

Evaluation of the Simpson's Method to Determine Left Ventricular Ejection Fraction Using the Transgastric Two-Chamber View.

INTRODUCTION: Left ventricular chamber size and functional assessment by transesophageal echocardiography can be difficult if visualization is poor in the mid-esophageal views. However, the accuracy of using the Simpson's method in the transgastric 2-chamber (TG2C) as an alternative approach has not been assessed. METHODS: The Simpson's method was performed by 2 independent reviewers using midesophageal 2-chamber (ME2C) and TG2C views. Echocardiographic images were retrieved retrospectively for 49 adult cardiac surgical patients. RESULTS: Two-way random effects intraclass correlation coefficients demonstrated no significant interobserver variability. Linear mixed effects models showed no significant differences in ME2C and TG2C measurements with regard to EDV (P=.4407), ESV (P=.5113), or EF (P=.0610).Compared to the ME2C view, the TG2C view had better image quality of the LV walls (image quality score median [interquartile range]: 2.00 [.00] vs 1.00 [1.00]; P<.0001), but worse image quality of the mitral annulus (1.00 [1.00] vs 2.00 [.00]; P<.0001) and LV apex (.00 [1.00] vs 2.00 [1.00]; P<.0001). CONCLUSIONS: This study suggests the Simpson's method can be applied to the TG2C view as an alternative to the standard midesophageal method to estimate chamber volumes and EF.

Propofol Versus Remifentanil Sedation for Transcatheter Aortic Valve Replacement: A Single Academic Center Experience.

OBJECTIVE: Comparison of remifentanil versus propofol for sedation during transcatheter aortic valve replacement (TAVR) procedures to analyze the risk of sedation-related hypoxemia and hypotension. Secondary outcomes included the rate of conversion to general anesthesia, procedure length, rate of intensive care unit (ICU) admission, ICU and hospital lengths of stay, and 30-day mortality. DESIGN: Retrospective cohort study. SETTING: A single tertiary teaching hospital. PARTICIPANTS: Two hundred fifty-nine patients who had propofol or remifentanil sedation for TAVR between March 2017 and March 2020. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: There were 130 patients (50.2%) in the propofol cohort and 129 patients (49.8%) in the remifentanil cohort. The primary outcomes were oxygen saturation nadir values and vasopressor infusion use. Remifentanil was associated with a lower oxygen saturation nadir, as compared to propofol (91.3% v . 95.4%, p < 0.001). Risk factors associated with hypoxemia (defined as <92%) were body mass index (p = 0.0004), obstructive sleep apnea (p = 0.004), and remifentanil maintenance (p < 0.001). Vasopressor infusion use was significantly higher with propofol (64.9% v . 8.5%, p < 0.001). Propofol maintenance and angiotensin-converting enzyme inhibitor/angiotensin II receptor-blocker use were the only variables identified as risk factors for vasopressor use (p < 0.001 and p = 0.009). CONCLUSIONS: For patients undergoing TAVR with conscious sedation, remifentanil was associated with more hypoxemia while propofol was associated with a higher rate of vasopressor use.

Thoracic Enhanced Recovery After Surgery: Single Academic Center Observations After Implementation.

BACKGROUND: Enhanced recovery after surgery (ERAS) is an evidence-based, multidisciplinary perioperative care model shown to reduce complications and hospital length of stay (LOS). While some thoracic ERAS studies were inconclusive, others demonstrated that ERAS improves patient outcomes after lung resections and provides more cost-effective care. We aimed to investigate the effects of preliminary implementation of an ERAS protocol, in comparison with conventional care, on lung resection outcomes at a single academic institution. METHODS: In this observational study, adult patients undergoing lung resections during the pre-ERAS (April 2014 to September 2015) and post-ERAS (January 2016 to May 2017) periods were identified. Relevant demographic, preoperative, anesthesia, and surgical variables were collected. Pre-ERAS and post-ERAS cohorts were compared in terms of hospital LOS, postoperative complications, and 30-day outcomes. RESULTS: We identified 264 patients, half in each cohort. Pre-ERAS and post-ERAS groups were similar with respect to age, race, and comorbidities. There were no significant differences in LOS, complications, 30-day readmission and mortality rates, or patient-reported outcomes. Of the patients with prolonged LOS, 31% had pulmonary complications, almost half of which were prolonged air leaks. ERAS adherence rate was approximately 60%. CONCLUSIONS: In the first year of implementation, median LOS, complications, and 30-day outcomes did not differ significantly between the pre-ERAS and post-ERAS groups. Prolonged air leaks commonly led to prolonged LOS; therefore, thoracic ERAS protocols could include interventions to reduce air leak and consideration for discharging patients with chest tubes placed to Heimlich valves. Buy-in and adherence to a new protocol are necessary for implementation to be effective.

Examination of the enhanced recovery guidelines in thoracic surgery.

PURPOSE OF REVIEW: Enhanced Recovery After Thoracic Surgery (ERATS) has gained momentum over the past few years, although the evidence base and expert recommendations lag behind other specialties. This review will present and examine key points from the first guidelines for enhanced recovery after lung surgery, released in 2018, jointly sponsored by the European Society of Thoracic Surgeons and the Enhanced Recovery After Surgery Society. RECENT FINDINGS: The recently released guidelines present core components of enhanced recovery as they pertain to lung resection surgery. Although evidence is still sparse in some areas, the guidelines summarize the available literature and incorporate levels of recommendation based upon the strength of available data as well as expert consensus. As of yet, the relative contribution of individual ERATS components to improvement in outcomes is unclear, but overall compliance does seem to be linked to positive results. Since the creation of the guidelines, additional literature related to ERATS has been released, and it will be incorporated and discussed into our review. SUMMARY: The creation of guidelines for enhanced recovery after lung resection will provide the thoracic anesthesiologist a framework upon which to build a comprehensive perioperative anesthetic plan.

General Anesthesia for Transcatheter Aortic Valve Replacement: Total Intravenous Anesthesia is Associated with Less Delirium as Compared to Volatile Agent Technique.

OBJECTIVE: Investigate the effect of volatile anesthesia versus total intravenous anesthesia on the incidence of postoperative delirium and length of stay in patients undergoing transcatheter aortic valve replacement under general anesthesia. DESIGN: Retrospective study. SETTING: Single institution, academic medical center. PARTICIPANTS: Adult patients who underwent transcatheter aortic valve replacement under general anesthesia between November 2014 and February 2017. INTERVENTIONS: This study was not an interventional study. MEASUREMENTS AND MAIN RESULTS: Electronic medical records were reviewed for intraoperative maintenance anesthetic technique, hospital and intensive care unit length of stay, 30-day mortality, and documentation of delirium. Delirium was defined as either 1) positive Confusion Assessment Method for the Intensive Care Unit score or 2) documentation of delirium or confusion by the care team within 2 days of surgery. Overall, 116 patients were included and 84 (72%) received a total intravenous anesthesia technique. Twenty-three patients (20%) had postoperative delirium. The odds of delirium were lower in patients undergoing transcatheter aortic valve replacement with total intravenous anesthesia, compared with volatile anesthesia, even after adjusting for procedure approach (odds ratio 0.22, 95% confidence interval 0.06, 0.79, p = 0.02). No significant difference in hospital or intensive care unit length of stay was seen after adjusting for procedural characteristics. CONCLUSIONS: While postoperative delirium is a complex and multifactorial problem, the type of general anesthetic maintenance may contribute to the incidence of postoperative delirium in patients undergoing transcatheter aortic valve replacement, and total intravenous anesthesia may be an attractive alternative to volatile-based general anesthesia maintenance.

BioGlue-Associated Loss of Aortic Valve Leaflet Motility Sonographically Masked by Both Newly Replaced Mechanical Aortic and Mitral Valves.

BioGlue is a surgical adhesive widely used to help reinforce complex cardiac and vascular repairs. Since its introduction, several case reports have emerged revealing complications that all providers should be mindful of whenever the product is used. This report considers a unique situation where BioGlue was used after double cardiac valve repair that resulted in adhesion of the new mechanical aortic valve leaflets and was difficult to visualize with transesophageal echocardiography.

Assessment of Paravalvular Leak After Transcatheter Aortic Valve Replacement: Transesophageal Echocardiography Compared With Transthoracic Echocardiography.

OBJECTIVES: Determine whether moderate or greater paravalvular leak (PVL) after transcatheter aortic valve replacement quantified using intraoperative transesophageal echocardiography (TEE) is associated with mortality and investigate the correlation between PVL grading using intraoperative TEE and postoperative transthoracic echocardiography (TTE). DESIGN: Retrospective, observational study. SETTING: Single academic institution. PARTICIPANTS: The study comprised adult patients undergoing elective transcatheter aortic valve replacement between April 2011 and February 2014. INTERVENTIONS: Patients were grouped by amount of PVL on intraoperative TEE into "significant" (moderate or greater) and "nonsignificant" (no, trivial, or mild) PVL groups. Demographics and patient characteristics were compared. Continuous variables were assessed with t-tests or Wilcoxon rank sum tests and categorical variables with the chi-square or Fisher exact test. A Cox proportional hazards model adjusted for EuroSCORE was used to test the independent association of PVL with late mortality, and covariate-adjusted survival curves were constructed. A Fleiss-Cohen-weighted kappa value was used to assess agreement between PVL grading using intraoperative TEE and postoperative TTE. MEASUREMENTS AND MAIN RESULTS: One hundred ninety-six patients were grouped into the "significant" (n = 22) or "nonsignificant" (n = 174) PVL group. Twenty patients (10%) died during the follow-up period. Significant PVL on either TTE (p = 0.62, hazard ratio 1.68, 95% confidence interval [CI] 0.22-12.85) or TEE (p = 0.49, hazard ratio 0.49; 95% CI 0.06-3.68) was not associated with a survival difference. Modest agreement was found between PVL on intraoperative TEE and postoperative TTE (kappa = 0.47, CI 0.37-0.57, p < 0.0001). CONCLUSIONS: Larger studies are needed to evaluate the association of PVL graded on intraoperative TEE with survival. There is modest agreement between the degree of PVL found on TEE and TTE.

Application of a Multidisciplinary Enhanced Recovery After Surgery Pathway to Improve Patient Outcomes After Transcatheter Aortic Valve Implantation.

Enhanced recovery after surgery (ERAS) protocols have proven effective in a variety of surgical specialties. Published reports on these pathways within cardiac surgery and interventional cardiology are limited. Invasive aortic valve replacement procedures are increasingly being performed by hybrid groups of interventional cardiologists and surgeons through transcatheter aortic valve implantation (TAVI). The TAVI patient population is at a higher surgical risk compared with those undergoing surgical aortic valve replacement since they are older, frailer, and have significant co-morbidities which result in an increased risk of perioperative complications. ERAS protocols have the potential to help these patients undergoing TAVI procedures. In conclusion, we propose a TAVI ERAS protocol with a call-to-action for other centers to implement an ERAS protocol to improve hospital and cardiac outcomes.