Comparison of Clinical Outcomes Between General Anesthesiologists and Cardiac Anesthesiologists in the Management of Left Ventricular Assist Device Patients in Noncardiac Surgeries and Procedures.

OBJECTIVE: To describe the authors' experience and comparative results after introducing noncardiac fellowship-trained anesthesiologists to a service previously managed by fellowship-trained cardiac anesthesiologists caring for left ventricular assist device (LVAD) patients undergoing low-risk noncardiac procedures with anesthesia. DESIGN: A retrospective chart review. SETTING: Single-site academic medical center in the United States. INTERVENTIONS: Anesthesia and intraoperative therapy. MEASUREMENTS AND MAIN RESULTS: After initiating a brief training period for the noncardiac fellowship-trained anesthesiologists and blending the noncardiac anesthesiologists into the care of LVAD patients, the electronic medical records of 158 patients with an LVAD who underwent noncardiac procedures were reviewed. The cases were managed by either cardiac-trained anesthesiologists or noncardiac-trained anesthesiologists. Their performance was evaluated on the basis of technique and outcome. The parameters for technique were the use of intubation and mechanical ventilation, use of vasoactive medications, type of vasoactive medications administered, use of invasive monitoring, and type and amount of intravenous fluid administration. The outcomes examined included occurrence of intraoperative mean blood pressure <55 mmHg, intraoperative cardiac arrest, intraoperative device malfunction, thromboembolic complications, inability to complete procedure due to intraoperative nonsurgical complication, unplanned postoperative intensive care unit admission, unplanned hospital readmission within 30 days, and the 30-day postoperative mortality rate. This analysis demonstrated no statistically significant associations between the type of anesthesiologist and the use of fluid, amount of fluid given, use of vasopressors, or use of invasive monitoring devices. There were no significant differences in specific patient outcomes by anesthesia provider type. CONCLUSIONS: Patients with LVADs can be managed by either a noncardiac or a cardiac fellowship-trained anesthesiologist with similar technique and outcome during low-risk noncardiac procedures and surgeries.

Examination of intra-operative core temperature in joint arthroplasty: a single-institution prospective observational study.

PURPOSE: Peri-operative hypothermia is associated with increased blood loss, delayed wound healing, and surgical site infections. However, it is not known when or how rapidly hypothermia develops during arthroplasty. This study observed patients undergoing lower extremity arthroplasty to identify the times of greatest heat loss or gain. METHODS: This single-institution prospective observational study enrolled 120 patients undergoing elective knee or hip arthroplasty for peri-operative temporal temperature measurements at ten prespecified intervals. Incidence of hypothermia was the primary outcome. A secondary aim was to identify patient and operative factors associated with hypothermia. Descriptive statistics were calculated for fixed time variables. Associations for the occurrence of hypothermia over time were conducted using generalized linear mixed models with a logit link and a random subject effect to account for repeated measures on the same individual over time. RESULTS: Most patients, 72.6%, experienced hypothermia with 20.6% hypothermic for over one hour and 47.1% hypothermic after surgery. In the multivariable model, increased odds of hypothermia were associated with female gender (P = 0.017), knee arthroplasty (P < 0.001), neuraxial anaesthesia (P < 0.001), lower patient pre-operative temperature (P < 0.001), and lower operating room temperature (P = 0.042). A 0.5 °C decrease in patient pre-operative temperature or operating room temperature was associated with a 97 and 11% increase in the odds of hypothermia, respectively, controlling for other factors. CONCLUSION: In our series, peri-operative hypothermia remains common for patients undergoing arthroplasty. Female gender, low pre-operative temperature, knee arthroplasty, and neuraxial anesthesia were associated with hypothermia. Further preventative strategies and studies on interventions to reduce hypothermia are needed.

Comparison of Lumbar Epidurals and Lumbar Plexus Nerve Blocks for Analgesia Following Primary Total Hip Arthroplasty: A Retrospective Analysis.

BACKGROUND: Total hip arthroplasty (THA) is associated with significant postoperative pain. Both lumbar epidurals and lumbar plexus nerve blocks have been described for postoperative pain control, but it is unclear if one technique is more beneficial. METHODS: Using electronic medical records, a randomly selected, cohort of 58 patients with lumbar epidurals were compared with 58 patients with lumbar plexus nerve blocks following primary THA. The primary end point was 48-hour postoperative opiate consumption. Secondary end points included time of first ambulation, distance ambulated, level of assistance with ambulation, presence of side effects, and time to discharge. Descriptive statistics were calculated to characterize subjects in the different block-type groups. Comparisons in morphine consumption were conducted using linear mixed models. Primary and secondary end points were examined in multivariable models. RESULTS: Patients with lumbar plexus blocks consumed less opiates at 24, 36, and 48 hours relative to patients that received lumbar epidural catheters (P = .047, .002, and .002, respectively). Patients with lumbar plexus blocks ambulated earlier (24.6 ± 2.01 hours vs 31.7 ± 3.01 hours) and farther relative to patients with epidurals (P < .001 for both) and had discharge orders written earlier (58.2 ± 6.68 hours vs 73.6 ± 6.35 hours). CONCLUSION: In comparison to lumbar epidural catheters, lumbar plexus nerve blocks are an effective pathway for postoperative pain control following primary THA. Furthermore, this clinical pathway expedites physical rehabilitation and is more compatible with postoperative prophylactic anticoagulants.

Regional anesthesia in patients with pre-existing neurologic disease.

PURPOSE OF REVIEW: Regional anesthesia is controversial in patients with pre-existing neurologic disease. This study reviews the published evidence regarding the utilization and outcomes of regional anesthetics in this population. RECENT FINDINGS: Although publications are sparse, neuraxial and peripheral regional techniques have been successfully described in patients with spinal cord injury, multiple sclerosis, Guillain-Barre disease, neurofibromatosis, diseases of the neuromuscular junction, and Charcot-Marie Tooth disease without neurologic complications. Ultrasound guidance may aid in reduction in local anesthetic dose, anatomical evaluation and avoidance of needle trauma. SUMMARY: Regional anesthesia can be safely utilized in patients with pre-existing neurological disease and may have benefits over general anesthesia; however, a conservative approach is warranted. In addition, further publications regarding regional techniques in this population are needed.

Positive or Negative? Implementation Processes and Pitfalls of Preoperative SARS-CoV-2 Testing at a Single Academic Institution.

BACKGROUND: Preoperative screening and testing for SARS-CoV-2 are important aspects of reopening perioperative and procedural sites to elective cases after the initial wave of the novel coronavirus pandemic. However, given that modern healthcare has never experienced a pandemic of this magnitude, rapid operationalization of mass testing presents unique challenges. We aim to highlight our experiences and challenges for preoperative SARS-CoV-2 testing. METHODS: We describe implementation of widespread screening tools and preoperative polymerase chain reaction (PCR) testing in a single, academic medical center. RESULTS: As of August 2020, we have been able to achieve an over 90% success rate in preoperative SARS-CoV-2 PCR testing for both outpatient and inpatient procedures. However, there are certain challenges in obtaining high levels of compliance both on individual and institutional levels. CONCLUSIONS: Instituting preoperative SARS-CoV-2 testing and maintaining high levels of compliance is possible in the midst of a fluctuating pandemic.

Retrospective Evaluation of the Perioperative Management of Patients Undergoing Total Pancreatectomy With Islet Autotransplantation: Single Institution Review.

OBJECTIVE: The aim of this retrospective descriptive study was to examine associations with the perioperative management of patients undergoing total pancreatectomy with islet autotransplantation, which may impact complication rate and hospital length of stay. METHODS: We retrospectively collected data on 165 patients, and 161 patients were included in the final analysis. Data collected included preoperative, intraoperative, and postoperative patient and procedural characteristics. RESULTS: Approximately 46.6% of patients experienced 1 or more complications. The occurrence of complications was associated with postoperative day 1 hemoglobin levels, use of intraoperative goal-directed therapy, estimated intraoperative blood loss, and total amount of intraoperative insulin given. Hospital length of stay was significantly associated with number of complications, use of goal-directed therapy, procedure duration, and postoperative day 1 hemoglobin levels. CONCLUSIONS: Overall, our retrospective descriptive study adds to the emerging body of literature determining optimal perioperative management of patients undergoing total pancreatectomy with islet autotransplantation.

Enhanced Recovery After Surgery Protocols Are Valuable in Pancreas Surgery Patients.

BACKGROUND: There is increasing interest in implementing comprehensive perioperative protocols, including preoperative optimization and education, perioperative goal-directed fluid management, and postoperative fast tracking, to enhance recovery after surgery. Data on the outcomes of these protocols in pancreatic surgery, however, are limited. STUDY DESIGN: A retrospective review of a prospectively maintained pancreas surgery database at a single institution from August 2012 to April 2015 was undertaken. An enhanced recovery protocol was initiated in October 2014, and patients were divided into groups according to preprotocol or postprotocol implementation. Preoperative, intraoperative, and postoperative data were tabulated. Statistical analysis was performed with Student's t-test and Fisher's exact tests, as well as equality of variances where appropriate, using SAS System software (SAS Institute). RESULTS: Three hundred and seventy-eight patients (181 men, mean age 54 years, BMI 28 kg/m(2)) underwent elective pancreatic surgery during the study period, 297 patients preprotocol and 81 postprotocol. There were no significant differences in preoperative or intraoperative characteristics. Mean postoperative length of stay was significantly lower in the Enhanced Recovery After Surgery group (7.4 vs 9.2 days; p < 0.0001). Hospital costs were similarly lower in the Enhanced Recovery After Surgery group ($23,307.90 vs $27,387.80; p < 0.0001). Readmission (29% vs 32%) and pancreatic fistula (26% vs 28%) rates were similar between groups. Delayed gastric emptying was lower in the Enhanced Recovery After Surgery group (26% vs 13%; p = 0.03). CONCLUSIONS: Implementation of an enhanced recovery after pancreatic surgery protocol significantly decreased length of stay and hospital cost without increasing readmission or morbidity. Despite patient complexity and the potential need for individualization of care, enhanced recovery protocols can be valuable and effective in high-risk patient populations, including pancreatic surgery patients.

Intraoperative goal-directed hemodynamic management in free tissue transfer for head and neck cancer.

BACKGROUND: The purpose of this study was to determine the effect of algorithmic physiologic management on patients undergoing head and neck free tissue transfer and reconstruction. METHODS: Ninety-four adult patients were randomized to treatment and control groups. The blood pressure of the control group was managed consistent with contemporary standards. The treatment group was managed using an algorithm based on blood pressure and calculated physiologic values derived from arterial waveform analysis. Primary outcome was intensive care unit (ICU) length of stay. RESULTS: ICU length of stay was decreased in the treatment group (33.7 vs 58.3 hours; p = .026). The complication rate was not increased in the treatment group. CONCLUSION: The goal-directed hemodynamic management algorithm decreased the ICU length of stay. Judicious use of vasoactive drugs and goal-directed fluid administration has a role in improving perioperative outcomes for patients undergoing head and neck free tissue transfer. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1974-E1980, 2016.

Hip Hemiarthroplasty in Two Patients with Severe Aortic Stenosis: Ethical Questions from an Anesthesiologist's Perspective.

As the population ages, geriatric patients with preexisting cardiac disease are presenting for noncardiac surgery in escalating numbers. The decision to proceed with surgery in such patients often is multifactorial. With this in mind, we describe 2 patients with severe aortic stenosis who required hip operations: one urgent and one elective. Both patients had different anesthetic plans and did well intraoperatively. However, both patients died postoperatively because of their comorbidities. Although published guidelines are sparse, we hope this report will increase awareness and discussion about caring for geriatric patients with severe aortic stenosis.

Characteristics and intraoperative treatments associated with head and neck free tissue transfer complications and failures.

OBJECTIVE: To investigate the association between perioperative patient characteristics and treatment modalities (eg, vasopressor use and volume of fluid administration) with complications and failure rates in patients undergoing head and neck free tissue transfer (FTT). STUDY DESIGN: A retrospective review of medical records. SETTING: Perioperative hospitalization for head and neck FTT at 1 tertiary care medical center between January 1, 2009, and October 31, 2011. SUBJECTS AND METHODS: Consecutive patients (N=235) who underwent head and neck FTT. Demographic, patient characteristic, and intraoperative data were extracted from medical records. Complication and failure rates within the first 30 days were collected RESULTS: In a multivariate analysis controlling for age, sex, ethnicity, reason for receiving flap, and type and volume of fluid given, perioperative complication was significantly associated with surgical blood loss (P=.019; 95% confidence interval [CI], 1.01-1.16), while the rate of intraoperative fluid administration did not reach statistical significance (P=.06; 95% CI, 0.99-1.28). In a univariate analysis, FTT failure was significantly associated with reason for surgery (odds ratio, 5.40; P=.03; 95% CI, 1.69-17.3) and preoperative diagnosis of coronary artery disease (odds ratio, 3.60; P=.03; 95% CI, 1.16-11.2). Intraoperative vasopressor administration was not associated with either FTT complication or failure rate. CONCLUSIONS: FTT complications were associated with surgical blood loss but not the use of vasoactive drugs. For patients undergoing FTT, judicious monitoring of blood loss may help stratify the risk of complication and failure.