Enhanced recovery after cardiac surgery: A literature review.

Enhanced recovery after cardiac surgery (ERACS) represents a constellation of evidence-based peri-operative methods aimed to reduce the physiological and psychological stress patients experience after cardiac surgery, with the primary objective of providing an expedited recovery to pre-operative functional status. The method involves pre-operative, intra-operative, and post-operative interventions as well as direct patient engagement to be successful. Numerous publications in regard to the benefits of enhanced recovery have been presented, including decreased post-operative complications, shortened length of stay, decreased overall healthcare costs, and higher patient satisfaction. Implementing an ERACS program undeniably requires a culture change, a methodical shift in the approach of these patients that ultimately allows the team to achieve the aforementioned goals; therefore, team-building, planning, and anticipation of obstacles should be expected.

Analyzing the impact of preoperative interrogation of cardiac implantable electronic devices.

Background: Cardiac implantable electronic devices (CIED) are becoming more common for the management of underlying of cardiac dysrhythmias, and more patients with these devices are presenting for cardiac and noncardiac procedures. Methods: We performed a retrospective, cohort, single-center study at a tertiary teaching medical center, gathering 151 patients with CIED undergoing elective and emergent surgeries for the time period between November 2013 and December 2016. We aimed to determine whether patients with CIED had the device interrogated before surgery as recommended by the Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) consensus, whether this lack of compliance led to delay in the holding area before surgery and determine the presence of intra- or postoperative cardiac events in these patients. Results: A total of 76% of patients had interrogation of the device before surgery. Emergent cases were not interrogated as much as elective cases preoperatively (43% vs. 18%, respectively; P < 0.05). In total, 6% of cases had a CIED-related average holding area delay time of 54 minutes. Patients without preoperative device interrogation had more perioperative cardiac events than those who had the device checked (25% vs. 8%, respectively; odds ratio [OR] 0.26; 95% CI, 0.09-0.7, P < 0.013). Conclusions: Our findings suggest that preoperative interrogation of the device plays a significant role to minimize the incidence of perioperative cardiac adverse events. Institutional providers show a lack of compliance with HRS/ASA recommendations for preoperative CIED management. Further research is required to determine if improved compliance to recommendations will lead to enhanced outcomes.

Supra-systemic pulmonary hypertension after complicated percutaneous mitral balloon valvuloplasty: a case report and review of literature.

BACKGROUND: The World Symposium of Pulmonary Hypertension in 2018, updated the definition of pulmonary hypertension (PH) as mean pulmonary artery pressures (PAP) > 20 mmHg. Pulmonary venous hypertension secondary to left-heart disease, constitutes the most common cause of PH, and the determination of a co-existent pre-capillary (primary) PH becomes paramount, particularly at the moment of evaluating and managing patients with heart failure. Pulmonary artery pressures above the systemic pressures define supra-systemic PH and generally leads to frank right ventricular failure and high mortality. CASE PRESENTATION: We present the perioperative management of a patient with rheumatic mitral valve disease, initially found to have severe PH due to pulmonary venous hypertension, who underwent percutaneous mitral balloon valvuloplasty complicated with mitral chordae rupture, severe mitral regurgitation and supra-systemic PH. Multiple medical therapies and an intra-aortic balloon pump were used as means of non-surgical management of this complication. CONCLUSIONS: This case report illustrates the perioperative implications of combined pre- and post-capillary PH and supra-systemic PH, as this has not been widely discussed in previous literature. A thorough literature review of the clinical characteristics of PH, methods to determine co-existent pre- and post-capillary PH components, as well as concomitant right ventricular failure is presented. Severe PH has known detrimental effects on the hemodynamic status of patients, which can ultimately lead to a decrease in effective cardiac output and poor tissue perfusion.

Dynamic anterior mediastinal mass compression of the superior vena cava during airway stent deployment.

Mediastinal masses carry the intrinsic potential for life-threatening perioperative complications that directly impact anesthetic management, since well-recognized cardiopulmonary failure either chronic or acute may occur. A 48-year-old patient with known airway collapse due to an anterior mediastinal mass presents for airway stent insertion, that upon manipulation of the airway, a sudden and reproducible cardiovascular collapse ensued, due to dynamic compression of the superior vena cava, witnessed via endobronchial ultrasound. Close communication with the procedural team before and during manipulation of the patient's airway plays a paramount role to assure positive clinical outcomes.

PRO: The pulmonary artery catheter has a paramount role in current clinical practice.

Ever since its clinical introduction, the utilization of the pulmonary artery catheter (PAC) has been surrounded by multiple controversies, mostly related to imprecise clinical indications and the complications derived from its placement. Currently, one of the most important criticisms of the PAC is the ambiguity in the interpretation of its hemodynamic measurements and therefore, in the translation of this data into specific therapeutic interventions. The popularity of the PAC stems from the fact that it provides hemodynamic data that cannot be obtained from clinical examination. The assumption is that this information would allow better understanding of the individual's hemodynamic profile which would trigger therapeutic interventions that improve patient outcomes. Nevertheless, even with the current diversity of hemodynamic devices available, the PAC remains a valuable tool in a wide variety of clinical settings. The authors present a review exposing the benefits of the PAC, current clinical recommendations for its use, mortality and survival profile, its role in goal-directed therapy, and other applications of the PAC beyond cardiac surgery and the intensive care unit.

CON: Pulmonary artery catheter use should be forgone in modern clinical practice.

The pulmonary artery catheter (PAC) and its role in the practice of modern medicine remains to be questioned and has experienced a substantial decline in its use in the most recent decades. The complications associated to its use, the lack of consistency of the interpretation provided by the PAC among clinicians, the development of new hemodynamic methods, and the deleterious cost profile associated to the PAC are some of the reasons behind the decrease in its use. Since its introduction into clinical practice, the PAC and the data obtained from its use became paramount in the management of critically ill patients as well as for the high-risk/invasive procedures. Initially, many clinicians were under the impression that regardless the clinical setting, acquiring the information provided by the PAC justified its use, until a growing body of evidence demonstrated its lack of mortality and morbidity improvement, as well as several reports of the presence of difficulties-some of them fatal-during its insertion. The authors present an updated review discussing the futility of the PAC in current clinical practice, the complications associated to its insertion, the lack of mortality benefit in critically ill patients and cardiac surgery, as well as present alternative hemodynamic methods to the PAC.

Perioperative care of heart transplant recipients undergoing non-cardiac surgery.

The life expectancy of patients with end-stage heart disease undergoing Orthotopic Heart Transplantation (OHT) has increased significantly in the recent decades since its original introduction into the medical practice in 1967. Substantial advances in post-operative intensive care, surgical prophylaxis, and anti-rejection drugs have clearly impacted survivability after OHT, therefore the volume of patients presenting for non-cardiac surgical procedures is expected to continue to escalate in the upcoming years. There are a number of caveats associated with this upsurge of post-OHT patients requiring non-cardiac surgery, including presenting to healthcare facilities without the resources and technology necessary to manage potential perioperative complications or that may not be familiar with the care of these patients, facilities in which a cardiac anesthesiologist is not available, patients presenting for emergency procedures and so forth. The perioperative care of patients after OHT introduces several challenges to the anesthesiologist including preoperative risk assessments different to the general population and intraoperative management of a denervated organ with altered response to medications and drug-drug interactions. The present review aims to synopsize current data of patients presenting for non-cardiac surgery after OHT, surgical aspects of the transplant that may impact perioperative care, physiology of the transplanted heart as well as anesthetic considerations.

Failure to Clear Intermediate Lactate Levels in Ward Patients With Admission Blood Cultures Did Not Increase the Risk of Intensive Care Unit Transfer or In-Hospital Mortality: A Retrospective Cohort Study.

Introduction A sepsis bundle instituted by the Centers for Medicare and Medicaid Services, known as SEP-1, mandates remeasuring lactate concentrations in patients with suspected sepsis who have an initial lactate level ≥ 2.0 mmol/L to identify those at risk of mortality or clinical deterioration. However, in the group with an intermediate lactate level (2.0 - 3.9 mmol/L), evidence for the predictive utility for such practice is lacking. The objective of this retrospective cohort study was to evaluate the potential utility of repeating the blood lactate measurement for the premonitory detection of clinical deterioration in patients admitted to a ward with a diagnosis of suspected sepsis and an initial intermediate lactate level. Methods Using electronic health records, we retrospectively evaluated all non-hospice adult patients admitted from the emergency department to a ward of an academic medical center between October 1, 2017, and November 30, 2019, in whom a blood culture was obtained on admission as part of their workup for suspected sepsis. Patient demographics, the times and values of lactate concentrations, the occurrence of subsequent intensive care unit (ICU) transfer during the admission, and hospital mortality were determined. We computed the relative risk of ICU transfer (i.e., clinical deterioration) and hospital mortality in patients whose initial lactate was in the intermediate range who failed to reduce their lactate concentration by at least 10% within six hours. We hypothesized that failure to clear the lactate would be associated with an increased risk of ICU transfer and hospital mortality. Results We studied 12,157 patients, of whom 25 hospice patients were excluded. Of the remaining 12,132 patients, 1,416 (11.7%) were initially admitted to an intensive care unit, and 10,716 (88.3%) were admitted to a ward. Repeat lactate determinations were performed in 10.7%, 77.1%, and 90.2% of the ward patients with initial normal (< 2.0 mmol/L), intermediate (2.0 - 3.99 mmol/L), and high (≥ 4.0 mmol/L) admission lactate concentrations, respectively. There was no increase in the relative risk of ICU transfer (relative risk [RR] = 0.90, 95% CI, 0.53 - 1.28, P = 0.55) or hospital mortality (RR = 1.23, 95% CI, 0.85 - 1.79, P = 0.27) within the intermediate lactate level group among those whose lactate remained within 10% of the initial value (i.e., no change) or increased by more than 10%, compared to those in whom the level decreased by more than 10%. Conclusions Failure to reduce lactate concentrations in ward patients admitted with possible sepsis and an intermediate lactate level was not associated with an increased risk of ICU transfer or mortality. These results call into question the mandate in SEP-1 to routinely repeat the lactate determination in patients presenting with an intermediate concentration.

Parallel veno-venous and veno-arterial extracorporeal membrane circuits for coexisting refractory hypoxemia and cardiovascular failure: a case report.

BACKGROUND: The complexity of extracorporeal membrane oxygenation (ECMO) techniques continues to evolve. Different cannulation methods and configurations have been proposed as a response to a challenging cardiovascular and pulmonary physiology of the patients. The use of parallel ECMO circuits represents a unique and novel approach for patients with refractory respiratory failure and cardiovascular collapse with very large body surface areas. CASE PRESENTATION: We present the case of a 25-year-old morbidly obese male patient admitted for severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia, requiring institution of double cannulation for veno-venous ECMO. Since his hypoxemia persisted, likely due to insufficient flows given his large body surface area, an additional drainage venous cannula was implemented to provide higher flows, temporarily addressing his oxygenation status. Unfortunately, the patient developed concomitant cardiogenic shock refractory to inotropic support and extracorporeal fluid removal, further worsening his oxygenation status, thus the decision was to institute four-cannulation/parallel-circuits veno-venous and veno-arterial ECMO, successfully controlling both refractory hypoxemia and cardiogenic shock. CONCLUSIONS: Our case illustrates a novel and complex approach for combined severe ARDS and cardiovascular collapse through the use of parallel veno-venous and veno-arterial ECMO circuits, and exemplifies the expansion of ECMO techniques and its life-saving capabilities when conservative approaches are futile.

Expert Consensus Decision Pathway of the American College of Cardiology on Management of Bleeding in Patients With Oral Anticoagulants: A Review of the 2020 Update for Perioperative Physicians.

The use and evolution of oral anticoagulation therapies continue to advance for multiple reasons, including a growing segment of older patients with associated chronic prothrombotic illnesses including cardiovascular, pulmonary, hematologic and oncologic conditions. Correlated to this increased use of oral anticoagulants is bleeding complications associated with their use. Based on these trends, it is expected that perioperative physicians will be facing more and more of these patients requiring scheduled, urgent or emergent surgical procedures During May 2020, the American College of Cardiology updated its Expert Consensus Decision Pathway devoted to the approach of bleeding in patients on oral anticoagulants. This updated version emphasized the expanding role of the direct-acting oral anticoagulants in other conditions beyond nonvalvular atrial fibrillation, such as venous thromboembolism. Several details discussed within this most recent update are pertinent to perioperative physicians, who frequently deal with bleeding in the setting of anticoagulation. The purpose of this narrative review is to highlight and expand on these salient points because they relate to perioperative management.

Intraoperative Focused Cardiac Ultrasound for Assessment of Hypotension: A Systematic Review.

Focused cardiac ultrasound (FoCUS) has become a valuable tool to assess unexplained hypotension in critically ill patients. Due to increasing availability of transthoracic echocardiography (TTE) equipment in the operating room, there is a widespread interest in its usefulness for intraoperative diagnosis of hypotension as an alternative to transesophageal echocardiography (TEE). The objective of this systematic review is to evaluate the utility of intraoperative FoCUS to assess patients experiencing unexplained hypotension while undergoing noncardiac surgery. We performed a systematic literature search of multiple publication databases for studies that evaluated the utility of intraoperative FoCUS for assessment and management of unexplained hypotension in patients undergoing noncardiac surgery, including retro- and prospective clinical studies. A summary of the study findings, study quality, and assessment of level of evidence is presented. We identified 2227 unique articles from the literature search, of which 27 were potentially relevant, and 9 were included in this review. The number of patients pooled from these studies was 255, of whom 228 had intraoperative diagnoses with the aid of intraoperative FoCUS. The level of evidence of all studies included was very low according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines. This systematic review has demonstrated that FoCUS may be a useful, noninvasive method to differentiate causes of intraoperative hypotension and guide correcting interventions, although the quality of evidence is very low. Further prospective high-quality studies are needed to investigate whether intraoperative FoCUS has a diagnostic utility that is associated with improved outcomes.

Management of Respiratory Distress Syndrome due to COVID-19 infection.

The management of Acute Respiratory Distress Syndrome (ARDS) secondary to the novel Coronavirus Disease 2019 (COVID-19) proves to be challenging and controversial. Multiple studies have suggested the likelihood of an atypical pathophysiology to explain the spectrum of pulmonary and systemic manifestations caused by the virus. The principal paradox of COVID-19 pneumonia is the presence of severe hypoxemia with preserved pulmonary mechanics. Data derived from the experience of multiple centers around the world have demonstrated that initial clinical efforts should be focused into avoid intubation and mechanical ventilation in hypoxemic COVID-19 patients. On the other hand, COVID-19 patients progressing or presenting into frank ARDS with typical decreased pulmonary compliance, represents another clinical enigma to many clinicians, since routine therapeutic interventions for ARDS are still a subject of debate.

Incorporating Perioperative Point-of-Care Ultrasound as Part of the Anesthesia Residency Curriculum.

OBJECTIVE: The purposes of this study were to establish whether implementing a curriculum of perioperative point-of-care ultrasound (POCUS) of the heart and lungs for current in-training anesthesia residents during their required month of cardiac anesthesia was feasible and whether an evaluation tool would demonstrate improvement in the residents' baseline knowledge of POCUS. DESIGN: Single-center, prospective, cohort, and observational study. SETTING: A tertiary-care, university-affiliated hospital. PARTICIPANTS: The study comprised 16 anesthesia residents on their third postgraduate training year during their required cardiac anesthesia rotation. INTERVENTIONS: The implementation of a curriculum to educate anesthesia residents in perioperative POCUS of the heart and lungs on patients undergoing elective cardiothoracic procedures that included both theoretical and practical approaches. A 21-question, multiple-choice, electronic-generated test was developed to gauge performance improvement from before ("pretest") to after ("posttest") the 4-week period. MEASUREMENTS AND MAIN RESULTS: Of the 16 residents, 13 (81.3%) showed improved scores between the pretest and posttest periods after the 4-week rotation. The difference between pretest and posttest mean score was 5 (p = 0.001). CONCLUSIONS: This study demonstrates that integrating a curriculum dedicated to perioperative POCUS of the heart and lungs as part of the goals and objectives during the rotation of cardiac anesthesia is feasible and that anesthesia residents who received the training proposed by the authors improved their cognitive and technical skills.

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.

Emergent airway management in a patient with in situ tracheal stent: A lesson learned.

The prevalence of in situ tracheal stents has increased in the past two decades for the management of malignant and benign central airway diseases for either palliation or definitive therapy. Recent placement of a tracheal stent has been associated with edema of the upper airway; therefore, these patients are at a great risk for airway collapse, especially within the days most recent to the procedure. The authors present the case of a morbidly obese patient with a tracheal stent admitted to the Intensive Care Unit who developed acute respiratory failure and was found to be "unable to ventilate, unable to intubate." Surgical airway approach through a cricothyroidotomy failed to provide a patent airway and the patient subsequently developed cardiac arrest and expired. The presence of tracheal stent poses a high challenge during emergent airway interventions; thus, carefully planned airway manipulation in such patients is paramount in order to avoid catastrophic outcomes.