A Narrative Review for Perioperative Physicians of the 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants.

In 2017 the American College of Cardiology issued an Expert Consensus Decision Pathway dedicated specifically to the management of bleeding in patients on anticoagulants. The consensus document is both timely and important as indications for more novel anticoagulants expand rapidly. The document reviews in detail recommendations for interruption, management and re-initiation of anticoagulation in bleeding scenarios. Numerous points within the document are relevant to perioperative physicians managing patients on anticoagulation with either bleeding complications or undergoing surgical procedures. The intent of this narrative review is to highlight the salient points within the expert consensus for perioperative physicians.

Survey of anesthesiologists' practices related to steep Trendelenburg positioning in the USA.

BACKGROUND: Steep Trendelenburg during surgery has been associated with many position-related injuries. The American Society of Anesthesiology practice advisory recommends documentation, frequent position checks, avoiding shoulder braces, and limiting abduction of upper extremities to avoid brachial plexopathy. We conducted a web-based survey to assess anesthesiologists' practices, institutional policies, and complications encountered when using steep Trendelenburg. METHODS: Two thousand fifty randomly selected active members of the American Society of Anesthesiology were invited via email to participate in a 9-item web-based survey. Results are reported as absolute numbers and proportions with 95% confidence interval (CI). RESULTS: Survey response rate was 290 of 2050 (14.1%). 44.6% (95% CI, 38.9-50.3) of the respondents documented anesthesia start and finish, 73.9% (95% CI, 68.8-79) frequently checked positioning during surgery, 30.8% (95% CI, 25.4-36.2) reported using shoulder braces, 66.9% (95% CI, 61.5-72.3) tucked patients' arms to the side, 54.0% (95% CI, 48.2-59.8) limited fluid administration, and more than two-thirds did not limit the duration or inclination angle. Notably, 63/290 (21.7%) reported a complication and only 6/289 (2.1%) had an institutional policy. The most common complication was airway and face edema, second was brachial plexus injury, and third was corneal abrasions. Most institutional policies, when present, focused on limiting duration of steep Trendelenburg and communication with surgical team. Only 1/6 policies required avoiding use of shoulder braces. CONCLUSION: Based on survey results, practices related to steep Trendelenburg varied among USA anesthesiologists. Differences included protective measures, documentation, positioning techniques, fluid management, and institutional guidelines. The singular commonality found among all respondents was lack of institutional policies. Survey results highlighted the need for institutional policies and more education.

Factors Associated with Safe Extubation in the Operating Room After On-Pump Cardiac Valve Surgery.

BACKGROUND: Extubation in the operating room (OR) after cardiac surgery remains controversial due to safety concerns. Its feasibility had been suggested in select patients after off-pump surgery. AIM: To review the outcomes of patients extubated in the OR after on-pump cardiac valve surgery (cohort of interest) in comparison with patients extubated conventionally in the intensive care unit (ICU) (control). We hypothesized that the timing of extubation was not associated with postoperative complications. METHODS: Retrospective review of 272 consecutive patients who had undergone cardiac valve surgery at Jackson Memorial Hospital, Miami, Florida between January 1, 2009 and December 30, 2013. RESULTS: Compared with the control group, patients extubated in the OR had shorter cardiopulmonary bypass (CPB) (87 vs. 113 min, p < 0.0001) and aortic cross-clamp times (60 vs. 78 min, p < 0.0001), lower transfusion requirements (41.38% vs. 57.01%, p = 0.0342), shorter ICU (four vs. five days, p = 0.0002), and hospital stays (7.8 vs. 10 days, p = 0.0151). Mortality, overall rates of complications in all categories, ICU readmissions, and reintubations were similar in both groups. Each additional minute of CPB decreased the odds of extubation in the OR by a factor of 0.988 (odds ratio = 0.988; 95%CI: 0.980, 0.997). Pulmonary perfusion and ventilation during CPB increased the likelihood of extubation in the OR by a factor of 2.45 (odds ratio = 2.453; 95%CI: 1.247, 4.824). CONCLUSIONS: In select patients, extubation in the OR after on-pump valve surgery is safe. It is facilitated by shorter duration of CPB and pulmonary perfusion and ventilation during CPB. doi: 10.1111/jocs.12736 (J Card Surg 2016;31:274-281).

Factors which predict safe extubation in the operating room following cardiac surgery.

BACKGROUND: Extubation in the operating room (OR) after cardiac surgery is hampered by safety concerns, psychological reluctance, and uncertain economic benefit. We have studied the factors affecting the feasibility of extubation in the OR after cardiac surgery and its safety. METHODS: The outcomes of 78 patients extubated in the OR after open heart surgery were retrospectively compared to a matched control group of 80 patients with similar demographics, co-morbidities, and operative procedures, that were performed over the same time period, but extubated in the intensive care unit (ICU) following a standard weaning protocol. Variables collected included the incidence of subsequent unplanned tracheal reintubation in the ICU, postoperative complications, need for mediastinal re-exploration, surgical and OR times, and ICU and hospital lengths of stay. RESULTS: Out of a total of 372 cardiac procedures performed during the designated time frame, 78 (21%) resulted in extubation in the OR, mostly after off-pump coronary revascularization (41%) and aortic valve replacement (19.4%). Preoperative hypertension, EF ≥30%, off-bypass revascularization and shorter surgical times increased the likelihood of extubation in the OR. Extubation in the OR did not increase perioperative morbidity and mortality rates, but decreased the length of ICU and hospital stays. The incidence of unanticipated subsequent tracheal intubation in the ICU was comparable to noncardiac high-risk procedures (2.5%). CONCLUSIONS: Extubation in the OR can be safely performed in a select group of cardiac surgery patients without any increase in postoperative morbidity or mortality. The proposed mathematical model performed reasonably well in predicting a successful extubation in the OR.

Incidental finding of a left atrial thrombus during surgical management of a massive pulmonary embolism.

A 58-year-old male presented with a hemodynamically significant pulmonary embolism. Computed tomography angiogram revealed a saddle embolus in the main pulmonary artery with extensive clot burden affecting all lobes and right heart strain. Transthoracic echocardiogram displayed a dilated right ventricle with reduced systolic function. The patient was scheduled for pulmonary embolectomy. The intraoperative transesophageal echocardiogram (TEE) demonstrated a mobile left atrial thrombus that was missed on previous imaging. After removal of the thrombi, TEE showed a patent foramen ovale (PFO). The left atrial thrombus passed across the PFO secondary to increased right heart and pulmonary pressures.

The mechanism of chronic nicotine exposure and nicotine withdrawal on pain perception in an animal model.

It has been demonstrated that smoking is associated with an increase in postoperative and chronic pain. The changes in the pain-related neural pathways responsible for these effects are unknown. Additionally, the effects of nicotine withdrawal, resulting from smoking abstinence preoperatively, has not been evaluated in terms of its impact on pain sensation. In this study, an animal model has been used to assess these effects. A rat model of long-term nicotine exposure was used. Von Frey mechanical sensory tests were performed. Western Blot and immunohistological analysis were conducted on spinal cord samples. Mechanical sensory thresholds increased in the initial period (1-3 weeks), indicating hyposensitivity. Long-term (410 weeks) and under nicotine withdrawal, the mechanical sensory thresholds decreased, indicating hyperalgesia. During short-term nicotine exposure, glutamate decarboxylase 67 (GAD67), GAD65, and µ-opioid receptors (MOR) up-regulated. Beta-endorphins down-regulated. Increased γ -aminobutyric acid (GABA) and MOR appear responsible for the hyposensitivity since the GABA receptor antagonist, bicuculline and opioid receptor antagonist, naloxone decreased the mechanical thresholds of nicotine-induced hyposensitivity. In long-term nicotine exposure, the expression of GAD67, MOR, and GABA decreased. Baclofen, a derivative of GABA, reversed the hyperalgesia seen with nicotine withdrawal. Therefore, nicotine acts as an analgesic when used acutely or short-term. Long-term exposure or nicotine withdrawal (similar to smoking cessation) results in hyperalgesia. Nicotine appears to alter pain sensitivity by affecting the expression of GAD65, GAD67, MOR, endorphins, and GABA. This may partially explain the increased pain and opioid use seen in chronic smokers in the postoperative period.

Intravenous thrombolytic therapy for patients with ventricular assist device thrombosis: An attempt to avoid reoperation.

A growing number of patients are undergoing prolonged management of advanced heart failure with the use of continuous flow left ventricular assist devices (LVADs). Subsequently, an increasing number of patients are presenting with complications associated with these devices. Based on an analysis of three major LVAD institutions, the number of patients developing LVAD pump thrombosis may be much higher than originally projected. [1],[2] The management of this highly feared complication continues to be challenging, as the population of LVAD patients is very heterogeneous and heavily burdened with comorbidities. The standard protocol of increasing anticoagulation may fail to achieve successful resolution of thrombus. Difficulty and poor prognosis may make reoperation less than desirable. Here, we present a case of successful thrombolysis following intravenous administration of tissue plasminogen activator in the Intensive Care Unit setting.

Pulmonary Perfusion and Ventilation during Cardiopulmonary Bypass Are Not Associated with Improved Postoperative Outcomes after Cardiac Surgery.

OBJECTIVES: Clinical trials of either pulmonary perfusion or ventilation during cardiopulmonary bypass (CBP) are equivocal. We hypothesized that to achieve significant improvement in outcomes both interventions had to be concurrent. DESIGN: Retrospective case-control study. SETTINGS: Major academic tertiary referral medical center. PARTICIPANTS: Two hundred seventy-four consecutive patients who underwent open heart surgery with CBP 2009-2013. INTERVENTIONS: The outcomes of 86 patients who received pulmonary perfusion and ventilation during CBP were retrospectively compared to the control group of 188 patients. MEASUREMENTS AND MAIN RESULTS: Respiratory complications rates were similar in both groups (33.7 vs. 33.5%), as were the rates of postoperative pneumonia (4.7 vs. 4.3%), pleural effusions (13.9 vs. 12.2%), and re-intubations (9.3 vs. 9.1%). Rates of adverse postoperative cardiac events including ventricular tachycardia (9.3 vs. 8.5%) and atrial fibrillation (33.7 vs. 28.2%) were equivalent in both groups. Incidence of sepsis (8.1 vs. 5.3%), postoperative stroke (2.3 vs. 2.1%), acute kidney injury (2.3 vs. 3.7%), and renal failure (5.8 vs. 3.7%) was likewise comparable. Despite similar transfusion requirements, coagulopathy (12.8 vs. 5.3%, p = 0.031) and the need for mediastinal re-exploration (17.4 vs. 9.6%, p = 0.0633) were observed more frequently in the pulmonary perfusion and ventilation group, but the difference did not reach the statistical significance. Intensive care unit (ICU) and hospital stays, and the ICU readmission rates (7.0 vs. 8.0%) were similar in both groups. CONCLUSION: Simultaneous pulmonary perfusion and ventilation during CBP were not associated with improved clinical outcomes.

Magnets and implantable cardioverter defibrillators: what's the problem?

A growing number of surgical patients present to the operating room with implantable cardioverter defibrillators (ICD). Peri-operative care of these patients dictates that ICD function be suspended for many surgical procedures to avoid inappropriate, and possibly harmful, ICD therapy triggered by electromagnetic interference (EMI). An alternative to reprogramming the ICD is the use of a magnet to temporarily suspend its function. However, this approach is not without complications. We report a case where magnet use failed to inhibit ICD sensing of EMI, and a shock was delivered to the patient. Measures to decrease EMI, controversies regarding magnet use, and expert recommendations are discussed.

Deep hypothermic circulatory arrest with lung perfusion/ventilation in a patient with acute type a aortic dissection.

A 50-year-old black male presented with acute type A aortic dissection. Surgical repair was performed under deep hypothermic circulatory arrest (DHCA) with lung perfusion/ventilation throughout the procedure. Details of the lung perfusion technique and its potential benefits and drawbacks are discussed.

An unusual case of tracheoesophageal fistulae.

Acquired tracheoesophageal fistulae (TEF) are commonly due to malignancy (M. F. Reed and D. J. Mathisen, 2003). We present the case of a patient with a deceptive history for TEF and report an approach that provides adequate oxygenation, ventilation, surgical exposure, and postoperative analgesia with excellent outcome.