Use of Intraoperative Dobutamine Stress Echocardiography on Outcomes of Septal Myectomy.

Septal myectomy is the standard treatment for obstructive hypertrophic cardiomyopathy. We studied the impact of intraoperative pre- and postprocedure dobutamine stress transesophageal echocardiography on surgical planning and outcomes of septal myectomy. We identified 55 patients undergoing septal myectomy over a 24-month period. All patients underwent resting and dobutamine stress (20-40 mcg/kg/min) echocardiography after induction of anesthesia pre- and postprocedure. Demographic, clinical, and imaging data were prospectively collected. Mean age was 59 (42-68). A total of 69% of patients were New York Heart Association Class III/IV. During outpatient evaluation, peak preoperative resting left ventricular outflow tract gradient was 91.6 mm Hg and 94% (50/53) had severe stress-induced mitral regurgitation (MR). After induction, peak resting gradient fell to 47.8 mm Hg and 43% (24/55) had improved gradients (<30 mm Hg). With stress, preprocedure left ventricular outflow gradient increased to 130 mm Hg and all occult gradients were unmasked. Postprocedure, peak resting and stress gradients were substantially reduced (10.2 ± 6.8 mm Hg and 23.6 ± 8.5 mm Hg, respectively). With stress, 84% (42/50) demonstrated reduction in severity of MR to none and/or mild with no patients having greater than moderate. Postprocedure stress echocardiography identified 3 patients with residual gradients, which led to return to bypass for additional procedures and resulted in resolution of elevated residual gradients. Postoperative 60-day stress echocardiography showed sustained resolution of gradients and MR. In this series, 43% of patients had occult left ventricular outflow gradients after induction of anesthesia. Intraoperative stress echocardiography during septal myectomy is useful to unmask occult gradients and confirm adequate myectomy. This imaging strategy is associated with reliable relief of obstruction and MR as demonstrated at 60-day follow-up.

Novel use of XSTAT 30 for mitigation of lethal non-compressible torso hemorrhage in swine.

BACKGROUND: Management of Non-Compressible Torso Hemorrhage (NCTH) consists primarily of aortic occlusion which has significant adverse outcomes, including ischemia-reperfusion injury, in prolonged field care paradigms. One promising avenue for treatment is through use of RevMedx XSTAT 30™ (an FDA approved sponge-based dressing utilized for extremity wounds). We hypothesized that XSTAT 30™ would effectively mitigate NCTH during a prolonged pre-hospital period with correctable metabolic and physiologic derangements. METHODS AND FINDINGS: Twenty-four male swine (53±2kg) were anesthetized, underwent line placement, and splenectomy. Animals then underwent laparoscopic transection of 70% of the left lobe of the liver with hemorrhage for a period of 10min. They were randomized into three groups: No intevention (CON), XSTAT 30™-Free Pellets (FP), and XSTAT 30™-Bagged Pellets (BP). Animals were observed for a pre-hospital period of 180min. At 180min, animals underwent damage control surgery (DCS), balanced blood product resuscitation and removal of pellets followed by an ICU period of 5 hours. Postoperative fluoroscopy was performed to identify remaining pellets or bags. Baseline physiologic and injury characteristics were similar. Survival rates were significantly higher in FP and BP (p<0.01) vs CON. DCS was significantly longer in FP in comparison to BP (p = 0.001). Two animals in the FP group had pellets discovered on fluoroscopy following DCS. There was no significant difference in blood product or pressor requirements between groups. End-ICU lactates trended to baseline in both FP and BP groups. CONCLUSIONS: While these results are promising, further study will be required to better understand the role for XSTAT in the management of NCTH.

Confidentiality concerns for surgical residents as educational research subjects: A pilot study.

BACKGROUND: Research within the field of surgical education has been expanding rapidly in order to guide future curricula. However, education studies often have minimal IRB oversight and evolving concerns exist regarding issues of informed consent of trainees. METHODS: We conducted an electronic, single center, anonymous survey of general surgery residents. The survey study was IRB approved and subjects were provided with information and opt-out sheets. RESULTS: The response rate was 43.5% (37/85). Approximately 76% of residents felt that education research was important and that they should participate. If a faculty member conducted the study, 18% of residents would feel coerced to participate and 21% would feel uncomfortable refusing to participate. The majority (81%) felt uncomfortable with peers viewing their identifiable records and a sizeable minority (24%) were uncomfortable with peers viewing de-identified records. CONCLUSION: Surgical residents believe that educational research is important, but researchers should be cognizant of unintended consequences on resident autonomy and confidentiality.

Surgical palliative care training in general surgery residency: An educational needs assessment.

INTRODUCTION: There is increasing recognition that Surgical Palliative Care is an essential component of the holistic care of surgical patients and involves more than end-of-life care in the intensive care unit. General surgery residents are clinically exposed to patients with palliative care needs during each year of training, but few have a dedicated surgical palliative care curriculum. We undertook this educational needs assessment as the first step towards a longitudinal curriculum. METHODS: We conducted an anonymous survey of 94 general surgery residents and 115 faculty at community and university hospitals to assess their experience and comfort with surgical palliative care delivery. Residents and faculty were asked multiple choice and open-ended questions. RESULTS: There was a 55% response rate from residents and 33% response rate from faculty. The majority (77%) of respondents were junior residents (PGY1-3) and university-based faculty (66%). Approximately half of residents felt comfortable leading conversations in goals of care (58%), comfort-focused care (52%) and delivering bad news (57%), while greater than 90% of faculty agreed that chief residents needed additional training. All residents agreed they needed additional training and 85% wanted a formal curriculum. Analysis of open-ended questions suggests a deficiency in the pre-operative setting as no residents had participated in these conversations in an outpatient setting. CONCLUSION: Residents and faculty believe trainees would benefit from further education in surgical palliative care with a dedicated curriculum. The outpatient, pre-operative counseling of patients was identified as a key learning need. These data support our ongoing work to develop a surgically pertinent palliative care curriculum.

Efficacy of the perfluorocarbon dodecafluoropentane as an adjunct to pre-hospital resuscitation.

BACKGROUND: Hemorrhage is the most common cause of preventable death in the pre-hospital phase in trauma, with a critical capability gap optimizing pre-hospital resuscitation in austere environments. One promising avenue is the concept of a multi-functional resuscitation fluid (MRF) that contains a blood product backbone with agents that promote clotting and enhance oxygen delivery. Oxygen therapeutics, such as hemoglobin based oxygen carriers(HBOCs) and perfluorocarbons(PFCs), may be a critical MRF component. Our purpose was to assess the efficacy of resuscitation with a PFC, dodecafluoropentane(DDFPe), compared to fresh whole blood(FWB). METHODS AND FINDINGS: Forty-five swine(78±5kg) underwent splenectomy and controlled hemorrhage via femoral arterial catheter until shock physiology(lactate = 7.0) was achieved prior to randomization into the following groups: 1) Control-no intervention, 2)Hextend-500mL, 3)FFP-500mL, 4)FFP+DDFPe-500mL, 5)FWB-500mL. Animals were observed for an additional 180 minutes following randomization. RESULTS: Baseline physiologic values did not statistically differ. At T = 60min, FWB had significantly decreased lactate(p = 0.001) and DDFPe was not statistically different from control. There was no statistical significance in tissue oxygenation(StO2) between groups at T = 60min. Survival was highest in the FWB and Hextend groups(30% at 180min). Kaplan-Meier analysis showed decreased survival of DDFPe+FFP in comparison to FWB(p<0.05) and was not significantly different from control or FFP. Four animals who received DDFPe died within 10 minutes of administration. This study was limited by a group receiving DDFPe alone, however this would not be feasible in this lethal swine model as DDFPe given its small volume. CONCLUSION: DDFPe administration with FFP does not improve survival or enhance tissue oxygenation. However, given similar survival rates of Hextend and FWB, there is evidence that an ideal MRF should contain an element of volume expansion to enhance oxygen delivery.