Anesthetic implications of perioperative Takotsubo syndrome: a retrospective cohort study.

PURPOSE: Takotsubo syndrome is a reversible cardiomyopathy triggered by emotional or physical stressors. Although surgeries could be physical triggers, this has been scantily investigated. We aimed to describe the baseline characteristics, surgical/anesthesia-related triggering events, clinical presentation, and in-hospital outcomes of a cohort of patients diagnosed with perioperative Takotsubo syndrome. METHODS: In this retrospective study, we included all consecutive adult patients who were admitted to Hospital Italiano de Buenos Aires between 1 June 2008 and 30 November 2017 and diagnosed with Takotsubo syndrome according to the revised criteria of the European Society of Cardiology during hospitalization. RESULTS: We diagnosed 21 patients with perioperative Takotsubo syndrome out of 305,906 patients undergoing procedures with anesthesia care. The median (interquartile range [IQR]) patient age was 75 (55-82) yr, and 16 (76%) were women. The median (IQR) left ventricular ejection fraction was 35 (35-42)% at diagnosis and 55 (46-55)% at discharge. Fifteen patients (71%) required inotropic/vasopressor support; however, this is a controversial treatment considering the physiopathology of the syndrome. Severe complications such as unexplained syncope/cardiac arrest, cardiogenic shock, and ventricular thrombus formation occurred in seven (33%) patients, and two (10%) patients died. These results were compared with 31 patients who experienced non-perioperative Takotsubo syndrome during the same period of time. CONCLUSION: Perioperative Takotsubo syndrome is a reversible cardiomyopathy. Nevertheless, it seems to be associated with severe complications, the need for aggressive treatment, and non-negligible mortality.

RéSUMé: OBJECTIF: Le syndrome de Takotsubo est une cardiomyopathie réversible déclenchée par des facteurs de stress émotionnels ou physiques. Bien que les chirurgies puissent constituer des déclencheurs physiques, cela n'a été que peu étudié. Nous avons cherché à décrire les caractéristiques de base, les événements déclencheurs chirurgicaux / anesthésiques, la présentation clinique et les devenirs hospitaliers d'une cohorte de patients ayant reçu un diagnostic de syndrome périopératoire de Takotsubo. MéTHODE: Dans cette étude rétrospective, nous avons inclus tous les patients adultes consécutifs qui ont été admis à l'Hôpital Italiano de Buenos Aires entre le 1er juin 2008 et le 30 novembre 2017 et qui ont reçu un diagnostic de syndrome de Takotsubo selon les critères révisés de la Société européenne de cardiologie pendant leur hospitalisation. RéSULTATS: Nous avons diagnostiqué 21 patients atteints d'un syndrome de Takotsubo périopératoire sur 305 906 patients subissant des interventions nécessitant des soins d'anesthésie. L'âge médian des patients (écart interquartile [ÉIQ]) était de 75 ans (55-82 ans) et 16 (76 %) étaient des femmes. La médiane de la fraction d'éjection ventriculaire gauche (ÉIQ) était de 35 (35 à 42) % au moment du diagnostic et de 55 (46 à 55 ) % au congé. Quinze patients (71 %) ont eu besoin d'un soutien inotrope/vasopresseur; cependant, il s'agit d'un traitement controversé compte tenu de la physiopathologie du syndrome. Des complications graves telles qu'une syncope / un arrêt cardiaque inexpliqué, un choc cardiogénique et la formation de thrombus ventriculaire, sont survenues chez sept patients (33 %), et deux (10 %) patients sont décédés. Ces résultats ont été comparés à 31 patients ayant présenté un syndrome de Takotsubo non périopératoire au cours de la même période. CONCLUSION: Le syndrome de Takotsubo périopératoire est une cardiomyopathie réversible. Néanmoins, il semble être associé à des complications graves, à la nécessité d'un traitement agressif et à une mortalité non négligeable.

Simulation-based training for early procedural skills acquisition in new anesthesia trainees: a prospective observational study.

BACKGROUND: In a setting in which learning of basic procedural skills commences upon graduation from medical school, and as a first step towards integration of simulation-based learning into the anesthesiology training program, a preparatory course for new anesthesia trainees was designed. Three educational strategies were sequentially combined (e-learning, simulation-based hands on workshops, and on-site observational learning), and performance was assessed in a stepwise approach on five procedural skills considered essential for early anesthetic management (peripheral intravenous cannulation, sterile hand wash and gowning, anesthesia workstation preparation, face-mask ventilation, and orotracheal intubation). The primary aim of this study was to determine if this preparatory training course at the onset of anesthesiology residency is useful to achieve a competent trainee performance in the clinical setting. METHODS: This prospective study was carried out at a university-affiliated hospital in Buenos Aires, Argentina, from 2017 to 2019. The 24 participants, comprising three cohorts of 8 residents each, underwent a preparatory course at the onset of residency. Diverse, consecutive educational strategies, and assessments (three stages: 1, 2, 3) took place using task-specific tools (checklists) and global rating scales for five procedural skills. The primary outcome was achievement of competent scores (85%) in final assessments, and the secondary outcomes were performance improvement between assessment stages and compliance with predefined safety items. RESULTS: Twenty trainees (83.3%) were found to be globally competent (both assessment tools for all procedures) during final assessments (stage 3). Statistically significant improvement was found for all procedural skills between baseline and after workshop assessment scores (stages 1-2), except for orotracheal intubation in checklists, and for all procedural skills between stages 2 and 3 except for sterile hand wash and gowning in checklists. CONCLUSIONS: In our single-center experience, the gap for competent trainee performance in essential early anesthetic management skills can be effectively covered by conducting an intensive, preparatory course using the combination of three educational strategies (e-learning, simulation-based hands on workshops, and observational learning) at the onset of residency. This course has allowed learning to be generated in a secure environment for both patients and trainees.

Deep sedation using propofol target-controlled infusion for gastrointestinal endoscopic procedures: a retrospective cohort study.

BACKGROUND: Propofol sedation is effective for gastrointestinal endoscopic procedures, but its narrow therapeutic window highlights the importance of identifying an optimal administration technique regarding effectiveness and safety. This study aimed to determine the incidence of significant adverse events in adult patients scheduled for gastrointestinal endoscopy under anaesthetist-performed sedation using propofol target-controlled infusion and determine the existence of associations between these events and potentially related variables. METHODS: This single-centre, retrospective cohort study took place in a tertiary referral university hospital. Medical records of 823 patients (age > 18 years, American Society of Anesthesiologists physical status classification scores I-III) who had undergone elective gastrointestinal endoscopy under propofol target-controlled infusion sedation during September 2018 were reviewed. Outcomes included hypoxia, hypotension, and bradycardia events, requirement of vasoactive drugs, unplanned tracheal intubation or supraglottic device insertion, and need for advanced cardiac life support. RESULTS: The most frequently encountered adverse event was oxygen desaturation < 95% with an incidence of 22.35%. Vasoactive drug administration, hypotension, and oxygen desaturation < 90% followed, with incidences of 19.2, 12.64, and 9.92%, respectively. Only 0.5% of patients required advanced airway management. Multivariate analysis revealed an association between hypotension events, colonoscopic procedures, and propofol doses (odds ratio: 3.08, 95% confidence interval: 1.43 to 6.61; P = 0.004 and odds ratio: 1.14, 95% confidence interval: 1.00 to 1.29; P = 0.046). A strong dose-effect relationship was found between hypoxia and obesity; patients with body mass index ≥40 were nine times (odds ratio: 10.22, 95% confidence interval: 2.83 to 36.99) more likely to experience oxygen desaturation < 90% events. CONCLUSIONS: Propofol sedation using target-controlled infusion appears to be a safe and effective anaesthetic technique for gastrointestinal endoscopic procedures with acceptable rates of adverse events and could be more widely adopted in clinical practice.

Usefulness of intra-operative neuromuscular blockade monitoring and reversal agents for postoperative residual neuromuscular blockade: a retrospective observational study.

BACKGROUND: Complete avoidance of residual neuromuscular blockade (RNMB) during the postoperative period has not yet been achieved in current anesthesia practice. Evidently, compliance with NMB monitoring is persistently low, and the risk of RNMB during the perioperative period remains underestimated. To our knowledge, no publications have reported the incidence of RNMB in a university hospital where access to quantitative NMB monitoring and sugammadex is unlimited and where NMB management is not protocolised. The primary aim of this study was to estimate the incidence of RNMB in patients managed with or without sugammadex or neostigmine as antagonists and quantitative NMB monitoring in the operating room. The secondary aim was to explore the associations between RNMB and potentially related variables. METHODS: This retrospective observational cohort study was conducted at a tertiary referral university hospital in Buenos Aires, Argentina. Records created between June 2015 and December 2015 were reviewed. In total, 240 consecutive patients who had undergone elective surgical procedures requiring NMB were included. All patients were monitored via acceleromyography at the adductor pollicis muscle within 5 min of arrival in the postanaesthesia care unit (PACU). Scheduled recovery in the intensive care unit was the only exclusion criterion. RESULTS: RNMB was present in 1.6% patients who received intra-operative quantitative NMB monitoring and 32% patients whose NMB was not monitored (P <  0.01). Multivariable analysis revealed that the use of intra-operative quantitative NMB monitoring and sugammadex were associated with a lower incidence of RNMB, with calculated odds ratios of 0.04 (95% confidence interval [CI]: 0.005 to 0.401) and 0.18 (95% CI: 0.046 to 0.727), respectively. CONCLUSIONS: The results of the present study suggest that intra-operative quantitative NMB monitoring and use of sugammadex are associated with a decreased incidence of RNMB in the PACU, reinforcing the contention that the optimal strategy for RNMB avoidance is the use of quantitative NMB monitoring and eventual use of reversal agents, if needed, prior to emergence from anaesthesia.