PERSUADE Survey-PERioperative AnestheSia and Intensive Care Management of Left VentricUlar Assist DevicE Implantation in Europe and the United States.

OBJECTIVE: To comprehensively assess relevant institutional variations in anesthesia and intensive care management during left ventricular assist device (LVAD) implantation. DESIGN: The authors used a prospective data analysis. SETTING: This was an online survey. PARTICIPANTS: Participants were from LVAD centers in Europe and the US. INTERVENTIONS: After investigating initial interest, 91 of 202 European and 93 of 195 US centers received a link to the survey targeting institutional organization and experience, perioperative hemodynamic monitoring, medical management, and postoperative intensive care aspects. MEASUREMENTS AND MAIN RESULTS: The survey was completed by 73 (36.1%) European and 60 (30.8%) US centers. Although most LVAD implantations were performed in university hospitals (>5 years of experience), significant differences were observed in the composition of the preoperative multidisciplinary team and provision of intraoperative care. No significant differences in monitoring or induction agents were observed. Propofol was used more often for maintenance in Europe (p < 0.001). The choice for inotropes changed significantly from preoperatively (more levosimendan in Europe) to intraoperatively (more use of epinephrine in both Europe and the US). The use of quantitative methods for defining right ventricular (RV) function was reported more often from European centers than from US centers (p < 0.05). Temporary mechanical circulatory support for the treatment of RV failure was more often used in Europe. Nitric oxide appeared to play a major role only intraoperatively. There were no significant differences in early postoperative complications reported from European versus US centers. CONCLUSIONS: Although the perioperative practice of care for patients undergoing LVAD implantation differs in several aspects between Europe and the US, there were no perceived differences in early postoperative complications.

Airway and Hemodynamic Considerations for the Anesthetic Management of an Intraluminal Tracheal Plasmacytoma.

Central airway obstruction due to tracheal tumors presents unique challenges to the anesthesiologist. We present the case of a 44-year-old male taken to the OR for biopsy and resection of an undiagnosed tracheal mass. Intraoperative management was complicated by bleeding and significant hemodynamic instability, necessitating rapid surgical and anesthetic intervention. This ultimately led to abortion of surgical resection. Pathologic examination revealed a primary tracheal plasmacytoma, a rare type of tracheal tumor. Here, we describe anesthetic and hemodynamic considerations for a tracheal plasmacytoma. We discuss the approach to airway management in variable intrathoracic tracheal obstruction and the unpredictability of tracheal tumors.

Lidocaine Intraoperative Infusion Pharmacokinetics during Partial Hepatectomy for Living Liver Donation.

BACKGROUND: Postoperative pain associated with open partial hepatectomy can be intense and persistent. The multimodal approach used to lessen this problem includes an intraoperative intravenous infusion of lidocaine hydrochloride. Decreased hepatic metabolism after resection raises concerns about safe lidocaine dosing in this patient population. The hypothesis was that the elimination clearance of lidocaine and its metabolites, monoethylglycinexylidide and glycinexylidide, is reduced after a partial hepatectomy, as reflected by observed plasma concentrations that are higher and have a longer half-life than expected based on pharmacokinetic modeling (estimated for normal liver function). Secondarily, this study postulated that plasma concentrations of lidocaine, monoethylglycinexylidide, and glycinexylidide do not reach toxic concentrations with institutional protocol up to 24 h after surgery. METHODS: Blood samples were collected from 15 patients undergoing a partial hepatectomy for living liver donation, at the following specific time points: before and immediately after induction of anesthesia, during hepatectomy, 30 min after hepatectomy completion, at case end, and 24 h after the end of surgery. Plasma concentrations of lidocaine and metabolites were measured by liquid chromatography-mass spectrometry. The population lidocaine pharmacokinetics were estimated, and total body weight and the fraction of remaining liver mass as potential model covariates were evaluated. The detection of any lidocaine, monoethylglycinexylidide, or glycinexylidide toxic plasma concentrations at any time point during and after hepatectomy were also evaluated. RESULTS: The typical value for lidocaine elimination clearance was 0.55 ± 0.12 l/min (± standard error of the estimate) which, on average, was reduced to about one third of the baseline clearance, 0.17 ± 0.02 l/min, once the donor graft was surgically isolated, and remained so for 24 h according to the current data and model. The fraction of remaining liver was a significant covariate for the posthepatectomy lidocaine clearance' such that if 50% of the liver is removed the clearance is reduced by approximately 60%. Plasma concentrations of lidocaine and its metabolites remained below their theoretical combined toxic threshold concentrations throughout the surgical and postoperative course in all patients, with one exception obtained near induction of anesthesia. Plasma lidocaine concentrations decreased at case end and postoperatively, while metabolite concentrations continued to rise at the end of surgery with reduction postoperatively. Pharmacokinetic modeling revealed that the only significant covariate in the model was the fraction of liver remaining after isolation of the donor graft. CONCLUSIONS: Intravenous lidocaine infusions are an acceptable option for multimodal pain management in patients undergoing a hepatectomy for living donation if the lidocaine infusion is stopped when the liver resection is complete. Clearance of lidocaine is decreased proportionally to the remaining liver mass, which should guide lidocaine infusion administration or dosing adjustments for patients undergoing liver resection surgery.

The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2020 Part I - Lung Transplantation.

This special article focuses on the highlights in cardiothoracic transplantation literature in the year 2020. Part I encompasses the recent literature on lung transplantation, including the advances in preoperative assessment and optimization, donor management, including the use of ex-vivo lung perfusion, recipient management, including those who have been infected with coronavirus disease 2019, updates on the perioperative management, including the use of extracorporeal membrane oxygenation, and long-term outcomes.

The Year 2020 in Review: Noteworthy Literature for Thoracic Transplant Anesthesiologists.

The year 2020 was a monumental year in medicine, and this review focuses on selected articles for cardiothoracic anesthesiologists and perioperative physicians involved in the care of heart and lung transplant patients. In the field of lung transplantation, significant strides were made in our knowledge of risk stratification during the preoperative assessment of potential recipients, perioperative transfusion medicine, and the administration of coagulation factor concentrates. In addition, variations in perioperative management and outcomes between institutions were studied across an assortment of metrics regarding lung transplantation, including case volumes and anesthetic practices. Transitioning to topics in the field of heart transplantation, consideration was given to recipients with adult congenital heart disease, and separately, approaches to expanding the donor pool through donation after circulatory death. With regard to preoperative support, outcomes for the total artificial heart as well as the MitraClip as bridges to transplantation were published.

Anesthetic management of lung transplantation: Results from a multicenter, cross-sectional survey by the society for advancement of transplant anesthesia.

BACKGROUND: Current protocols for the perioperative care of lung transplant (LTX) recipients lack rigorous evidence and are often empiric, based upon institutional preferences. We surveyed LTX anesthesiologists to determine the most common practices. METHODS: We developed a survey of 40 questions regarding perioperative care of LTX recipients using Qualtrics software. The survey was sent out to members of the Society of Cardiovascular Anesthesiologists performing LTX at geographically diverse sites to facilitate data collection for as many practices as possible. RESULTS: The responses were center-weighed (127 responses, 85% from academic settings). The clamshell approach was commonly used (70%). Cardiopulmonary bypass was preferred by 56%, ex vivo lung perfusion utilized by 43%, and 49.4% indicated they use lungs from donation after circulatory determination of death. Most (69%) used oximetric pulmonary artery catheters, 60% used tissue oximetry, and 89.3% utilized transesophageal echocardiography. Inhaled nitric oxide was preferred by 48%, restrictive fluid management by 48%, and systemic analgesia advocated by 49% of participants. Inspired oxygen concentration <30% was applied to the new lung on reperfusion by 28% of the respondents. CONCLUSION: Variations in healthcare delivery and utilization for LTX recipients indicate gaps in knowledge and potential opportunities to improve the quality of care.

Statement From the Society for the Advancement of Transplant Anesthesia: White Paper Advocating Desirable Milestones and Competencies for Anesthesiology Fellowship Training in the Field of Lung Transplantation.

The clinical, educational, and research facets of lung transplantation have advanced significantly since the first lung transplant in 1963. The formation of the International Society for Heart and Lung Transplantation (ISHLT) and subsequent Registry has forged a precedent of collaborative teamwork that has significantly affected current lung transplantation outcomes. The Society for the Advancement of Anesthesia (SATA) is dedicated to developing educational platforms for all facets of transplant anesthesia. Additionally, we believe that the anesthetic training for lung transplantation has not kept pace with other advances in the field. As such, SATA presents for consideration these educational milestones and competencies for anesthetic fellowship training in the field of lung transplantation. The proposed milestones were designed on the framework of 6 core competencies created by the Accreditation Council on Graduate Medical Education. The milestones were identified by combining the expert opinion of our Thoracic Transplant Committee, our experience as educators, and literature review. We offer this White Paper to the anesthesiology and transplant communities as a starting point for the discussion and evolution of perioperative anesthetic care in the field of lung transplantation.

Anesthetic management of lung transplantation: impact of presenting disease.

PURPOSE OF REVIEW: Recent literature has described the emerging role of anesthesiologists as key members of the lung transplantation team and the impact of anesthetic management on outcomes. This review examines the impact of presenting cause of end-stage lung disease (ESLD) on anesthetic management. RECENT FINDINGS: The four primary causes of ESLD are suppurative, obstructive, or restrictive processes, and pulmonary hypertension. Our recent review of perioperative literature revealed new data regarding preoperative risk stratification, intraoperative management, and postoperative use of extracorporeal membrane oxygenation (ECMO) support. Major studies specifically about anesthetic management are lacking; however, the principles studied are readily applicable to the design of a perioperative care plan. The most compelling data have resulted in a revolutionary change in terms of intraoperative support and postoperative planning for pulmonary hypertension patients. Historically treated with cardiopulmonary bypass, significant data have been reported describing the successful use of ECMO both as an intraoperative support with superior outcomes, as well as postoperative support for improved stability during biventricular remodeling post graft implantation. SUMMARY: The application of these updated findings should assist anesthesiologists as they develop internal protocols and external guidelines to integrate within multidisciplinary teams caring for the lung transplant patient.

Mitigation of Primary Graft Dysfunction in Lung Transplantation: Current Understanding and Hopes for the Future.

Primary graft dysfunction (PGD) is a form of acute lung injury that develops within the first 72 hours after lung transplantation. The overall incidence of PGD is estimated to be around 30%, and the 30-day mortality for grade 3 PGD around 36%. PGD is also associated with the development of bronchiolitis obliterans syndrome, a specific form of chronic lung allograft dysfunction. In this article, we will discuss perioperative strategies for PGD prevention as well as possible future avenues for prevention and treatment.

Society of Cardiovascular Anesthesiologists Clinical Practice Improvement Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery Patients.

Bleeding after cardiac surgery is a common and serious complication leading to transfusion of multiple blood products and resulting in increased morbidity and mortality. Despite the publication of numerous guidelines and consensus statements for patient blood management in cardiac surgery, research has revealed that adherence to these guidelines is poor, and as a result, a significant variability in patient transfusion practices among practitioners still remains. In addition, although utilization of point-of-care (POC) coagulation monitors and the use of novel therapeutic strategies for perioperative hemostasis, such as the use of coagulation factor concentrates, have increased significantly over the last decade, they are still not widely available in every institution. Therefore, despite continuous efforts, blood transfusion in cardiac surgery has only modestly declined over the last decade, remaining at ≥50% in high-risk patients. Given these limitations, and in response to new regulatory and legislature requirements, the Society of Cardiovascular Anesthesiologists (SCA) has formed the Blood Conservation in Cardiac Surgery Working Group to organize, summarize, and disseminate the available best-practice knowledge in patient blood management in cardiac surgery. The current publication includes the summary statements and algorithms designed by the working group, after collection and review of the existing guidelines, consensus statements, and recommendations for patient blood management practices in cardiac surgery patients. The overall goal is creating a dynamic resource of easily accessible educational material that will help to increase and improve compliance with the existing evidence-based best practices of patient blood management by cardiac surgery care teams.

Society of Cardiovascular Anesthesiologists Clinical Practice Improvement Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery Patients.

Bleeding after cardiac surgery is a common and serious complication leading to transfusion of multiple blood products and resulting in increased morbidity and mortality. Despite the publication of numerous guidelines and consensus statements for patient blood management in cardiac surgery, research has revealed that adherence to these guidelines is poor, and as a result, a significant variability in patient transfusion practices among practitioners still remains. In addition, although utilization of point of care coagulation monitors and the use of novel therapeutic strategies for perioperative hemostasis, such as the use of coagulation factor concentrates, has increased significantly over the last decade, they are still not widely available in every institution. Therefore, despite continuous efforts, blood transfusion in cardiac surgery has declined only modestly over the last decade, remaining at 50% or greater in high-risk patients. Given these limitations and in response to new regulatory and legislature requirements, the Society of Cardiovascular Anesthesiologists has formed the Blood Conservation in Cardiac Surgery Working Group in order to organize, summarize, and disseminate the available best-practice knowledge in patient blood management in cardiac surgery. The current publication includes the summary statements and algorithms designed by the working group, after collection and review of the existing guidelines, consensus statements, and recommendations for patient blood management practices in cardiac surgery patients. The overall goal is creating a dynamic resource of easily accessible educational material that will help to increase and improve compliance with the existing evidence-based best practices of patient blood management by cardiac surgery care teams.

Anesthetic Considerations for Surgery on the Aortic Arch.

Aortic arch surgery requires meticulous teamwork in the true perioperative sense. Planning and communication at all phases from preoperative evaluation, through intraoperative management, to postoperative care should be well coordinated between surgical, anesthesia, perfusion, and intensive care unit teams. This review discusses intraoperative management from the anesthesiologist's perspective, with particular emphasis on transesophageal echo evaluation and coagulation management.

Transfemoral Transcatheter Aortic Valve Replacement for Mixed Aortic Valve Disease in Child's Class C Liver Disease Prior to Orthotopic Liver Transplantation: A Case Report.

The American Association for the Study of Liver Diseases practice guidelines list severe cardiac disease as a contraindication to liver transplantation. Transcatheter aortic valve replacement has been shown to decrease all-cause mortality in patients with severe aortic stenosis who are not considered candidates for surgical aortic valve replacement. We report our experience of liver transplantation in a patient with severe aortic stenosis and moderate aortic insufficiency who underwent transcatheter aortic valve replacement with Child-Pugh Class C disease at a Model For End-Stage Liver Disease score of 29. The patient had a difficult post procedure course that was successfully medically managed. After liver transplantation the patient was discharged to home on postoperative day 11. The combination of cardiac disease and end stage liver disease is challenging but these patients can have a successful outcome despite very severe illness.

Anesthesia for tracheobronchial surgery.

The airway is a crucial dynamic structure that spans different anatomical zones, including the intrathoracic, extrathoracic, tracheal, bronchial, and alveolar zones. Because of its vital role as the sole oxygen-conducting pathway to the alveoli, and hence to the human body, surgery involving any portion requires careful and specific planning by both the surgeon and the anesthesiologist. The review covers essential management points for proximal and distal tracheal procedures, including a discussion of tracheal stenting and tracheoplasty.