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Arterial pressure monitoring and management are mainstays of haemodynamic therapy in patients having surgery. This article presents updated consensus statements and recommendations on perioperative arterial pressure management developed during the 11th POQI PeriOperative Quality Initiative (POQI) consensus conference held in London, UK, on June 4–6, 2023, which included a diverse group of international experts. Based on a modified Delphi approach, we recommend keeping intraoperative mean arterial pressure ≥60 mm Hg in at-risk patients. We further recommend increasing mean arterial pressure targets when venous or compartment pressures are elevated and treating hypotension based on presumed underlying causes. When intraoperative hypertension is treated, we recommend doing so carefully to avoid hypotension. Clinicians should consider continuous intraoperative arterial pressure monitoring as it can help reduce the severity and duration of hypotension compared to intermittent arterial pressure monitoring. Postoperative hypotension is often unrecognised and might be more important than intraoperative hypotension because it is often prolonged and untreated. Future research should focus on identifying patient-specific and organ-specific hypotension harm thresholds and optimal treatment strategies for intraoperative hypotension including choice of vasopressors. Research is also needed to guide monitoring and management strategies for recognising, preventing, and treating postoperative hypotension. [ABSTRACT FROM AUTHOR]

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery. [ABSTRACT FROM AUTHOR]

The use of transoesophageal echocardiography (TOE) has increased in the last 20 years and is now standard in perioperative monitoring during cardiac surgery. Because of the proximity of the oesophagus to the heart, TOE facilitates acquisition of high-resolution images. TOE probes have a multiplane transducer allowing image planes to be rotated from 0° to 180° thus enabling three-dimensional (3D) assessment of structures. Intraoperative TOE has been shown to improve outcomes in a variety of cardiac surgeries. It assists substantially in the planning, execution, and evaluation of surgical decision-making. In 15% of cardiac surgical procedures it modifies the planned operation. [ABSTRACT FROM AUTHOR]

Transcatheter aortic valve replacement (TAVR) has become an alternative treatment for patients with symptomatic aortic stenosis not eligible for surgical valve replacement due to a high periprocedural risk or comorbidities. However, there are several areas of debate concerning the pre-, intra- and post-procedural management. The standards and management for these topics may vary widely among different institutions and countries in Europe. Structured web-based, anonymized, voluntary survey. Distribution of the survey via email among members of the European Association of Cardiothoracic Anaesthesiology working in European centers performing TAVR between September and December 2018. Physicians. The survey consisted of 25 questions, including inquiries regarding number of TAVR procedures, technical aspects of TAVR, medical specialities present, preoperative evaluation of TAVR candidates, anesthesia regimen, as well as postoperative management. Seventy members participated in the survey. Reporting members mostly performed 151-to-300 TAVR procedures per year. In 90% of the responses, a cardiologist, cardiac surgeon, cardiothoracic anesthesiologist, and perfusionist always were available. Sixty-six percent of the members had a national curriculum for cardiothoracic anesthesia. Among 60% of responders, the decision for TAVR was made preoperatively by an interdisciplinary heart team with a cardiothoracic anesthesiologist, yet in 5 countries an anesthesiologist was not part of the decision-making. General anesthesia was employed in 40% of the responses, monitored anesthesia care in 44%, local anesthesia in 23%, and in 49% all techniques were offered to the patients. In cases of general anesthesia, endotracheal intubation almost always was performed (91%). It was stated that norepinephrine was the vasopressor of choice (63% of centers). Transesophageal echocardiography guiding, whether performed by an anesthesiologist or cardiologist, was used only ≤30%. Postprocedurally, patients were transferred to an intensive care unit by 51.43% of the respondents with a reported nurse-to-patient ratio of 1:2 or 1:3, to a post-anesthesia care unit by 27.14%, to a postoperative recovery room by 11.43%, and to a peripheral ward by 10%. The results indicated that requirements and quality indicators (eg, periprocedural anesthetic management, involvement of the anesthesiologist in the heart team, etc) for TAVR procedures as published within the European guideline are largely, yet still not fully implemented in daily routine. In addition, anesthetic TAVR management also is performed heterogeneously throughout Europe. [ABSTRACT FROM AUTHOR]

The use of transoesophageal echocardiography (TOE) has increased in the last 20 years and TOE is now a standard perioperative monitoring tool used for patients undergoing cardiac surgery. Because of the close proximity of the oesophagus to the heart, TOE facilitates the acquisition of high-resolution images. The TOE probe is a multiplane transducer. This means that the image planes can be rotated from 0 to 180 degrees, enabling three-dimensional assessment of the structure of interest. Intraoperative TOE has been shown to improve outcome in a variety of cardiac surgeries. TOE findings assist in the planning, execution and evaluation of surgery. TOE has a substantial impact on surgical decision-making. Intraoperative TOE modifies the planned surgical operation in 15% of cardiac surgical procedures. [ABSTRACT FROM AUTHOR]

Objective To derive and validate a clinical risk index that can predict readmission to the intensive care unit (ICU) after cardiac surgery. Design Retrospective nonrandomized study to determine the perioperative variables associated with risk of readmission to the ICU after cardiac surgery. Setting The study was carried out in a single university hospital. Participants This was an analysis of 4,869 consecutive adult patients. Interventions All patients underwent cardiac surgery at a single center and were discharged to the ward from the ICU during the index surgical admission. Measurements and Main Results A total of 156 patients (3.2%) were readmitted to the ICU during their index surgical admission. Risk factors associated with readmission were identified by performing univariate analysis followed by multivariate logistic regression. The final multivariable regression model was validated internally by bootstrap replications. Nine independent variables were associated with readmission: urgency of surgery, diabetes, chronic kidney disease stage 3 to 5, aortic valve surgery, European System for Cardiac Operative Risk Evaluation, postoperative anemia, hypertension, preoperative neurological disease, and the Intensive Care National Audit and Research Centre score. Our data also showed mortality (18% v 3.2%, p < 0.0001) was significantly higher in readmitted patients. The median duration of ICU stay (7 [4-17] v 1 [1-2] days, p < 0.0001) and hospital stay (20 [12-33] v 7 [5-10] days, p < 0.0001) were significantly longer in patients who were readmitted to ICU compared to those who were not. Conclusion From a comprehensive perioperative dataset, the authors have derived and internally validated a risk index incorporating 9 easily identifiable and routinely collected variables to predict readmission following cardiac surgery. [ABSTRACT FROM AUTHOR]

Objective Ongoing debate focuses on whether patients admitted to the hospital on weekends have higher mortality than those admitted on weekdays. Whether this apparent "weekend effect" reflects differing patient risk, care quality differences, or inadequate adjustment for risk during analysis remains unclear. This study aimed to examine the existence of a "weekend effect" for risk-adjusted in-hospital mortality after cardiac surgery. Design Retrospective analysis of prospectively collected cardiac registry data. Setting Ten UK specialist cardiac centers. Participants A total of 110,728 cases, undertaken by 127 consultant surgeons and 190 consultant anesthetists between April 2002 and March 2012. Interventions Major risk-stratified cardiac surgical operations. Measurements and Main Results Crude in-hospital mortality rate was 3.1%. Multilevel multivariable models were employed to estimate the effect of operative day on in-hospital mortality, adjusting for center, surgeon, anesthetist, patient risk, and procedure priority. Weekend elective cases had significantly lower mortality risk compared to Monday elective cases (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.42, 0.96) following risk adjustment by the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) and procedure priority; differences between weekend and Monday for urgent and emergency/salvage cases were not significant (OR 1.12, 95% CI 0.73, 1.72, and 1.07, 95% CI 0.79, 1.45 respectively). Considering only the logistic EuroSCORE but not procedure priority yielded 29% higher odds of death for weekend cases compared to Monday operations (OR 1.29, 95% CI 1.08, 1.54). Conclusions This study suggests that undergoing cardiac surgery during the weekend does not affect negatively patient survival, and highlights the importance of comprehensive risk adjustment to avoid detecting spurious "weekend effects." [ABSTRACT FROM AUTHOR]

Objectives The Intercollegiate Surgical Curriculum now recommends that cardiac surgical trainees should be able to understand and interpret transesophageal echocardiography images. However, cardiac surgical trainees receive limited formal transesophageal echocardiography training. The objective of this study was to assess the impact of simulation-based teaching versus more traditional operating room teaching on transesophageal echocardiography knowledge in cardiac surgical trainees. Methods A total of 25 cardiac surgical trainees with no formal transesophageal echocardiography learning experience were randomly assigned by computer to a study group receiving simulation-based transesophageal echocardiography teaching via the Heartworks (Inventive Medical, London, UK) simulator (n = 12) or a control group receiving transesophageal echocardiography teaching during elective cardiac surgery (n = 13). Each subject undertook a video-based test composed of 20 multiple choice questions on standard transesophageal echocardiography views before and after teaching. Results There was no significant difference in the pretest scores between the 2 groups ( P = .89). After transesophageal echocardiography teaching, subjects within each group demonstrated a statistically significant improvement in transesophageal echocardiography knowledge. Although the subjects within the simulation group outperformed their counterparts in the operating room teaching group in the post-test scores, this difference was not significant ( P = .14). Conclusions Despite the familiarity with transesophageal echocardiography images during surgery, subjects in the simulation group performed at least as well as those in the operating room group. Surgical trainees will benefit from formal transesophageal echocardiography teaching incorporated into their training via either learning method. [ABSTRACT FROM AUTHOR]

Objective To investigate the safety of a novel, miniaturized, monoplane transesophageal echocardiography probe (mTEE) and its potential as a hemodynamic monitoring tool. Design This was a retrospective analysis of the clinical evaluation of a disposable mTEE in ventilated patients with severe cardiogenic shock requiring hemodynamic support. mTEE assessment was performed by operators with mixed levels of TEE training. Information on hemodynamic interventions based on mTEE findings was recorded. Setting A tertiary university cardiac critical care unit. Participants Male and female critical care patients admitted to the unit with severe hemodynamic instability. Interventions Insertion of miniaturized disposable TEE probe and hemodynamic and other critical care interventions based on this and conventional monitoring. Measurements and Main Results In 41 patients (51.2% female, 73.2% after cardiac surgery), hemodynamic support probe insertion was accomplished without major complications. A total of 195 mTEE studies were performed, resulting in changes in therapy in 37 (90.2%) patients based on mTEE findings, leading to an improvement in hemodynamic parameters in 33 (80.5%) patients. Right ventricular (RV) failure was diagnosed in 25 patients (67.6%) and mTEE had a direct therapeutic impact on management of RV failure in 17 patients (68 %). Conclusions Insertion and operation of a novel, miniaturized transoesophageal echocardiography probe can be performed for up to 72 hours without major complications. Repeated assessment using this device provides complementary information to invasive monitoring in the majority of patients and has an impact on hemodynamic management. [ABSTRACT FROM AUTHOR]

Objective Pathology of the aortic valve and ascending thoracic aorta is an uncommon but life-threatening complication of pregnancy. Cardiac surgery during pregnancy is known to carry a high risk of mortality to both the mother and fetus. We present our experience of performing aortic surgery during the patients' pregnancy. Methods All patients undergoing aortic surgery during pregnancy at St George's Hospital, from January 2004 until October 2013, were identified. Surgery was performed using cardiopulmonary bypass at 36°C, with pulsatile perfusion at 70 mm Hg. Fetal blood flow parameters were serially monitored during surgery, via transabdominal and/or transvaginal Doppler ultrasonography. Surgery was performed in the second trimester when possible to allow completion of organogenesis and minimize hemodynamic compromise. Results Eleven patients underwent aortic surgery. The median age was 28 years (range, 26-31 years), with gestational age 19 weeks (range, 16-21 weeks). Six patients had aortic root dilatation with aortic regurgitation, and 5 had aortic stenosis, one of whom presented with acute type A dissection. Four patients had Marfan syndrome, and 2 had undergone previous cardiac surgery. The operative procedures were aortic root replacement (tissue valve, n = 5; homograft, n = 1), aortic valve replacement (n = 3), valve-sparing root replacement (n = 1), and aortic and mitral valve replacements (n = 1). Mean cardiopulmonary bypass and cross-clamp times were 105 and 89 minutes, respectively. There were no maternal deaths; 8 healthy babies were born at term, and 3 pregnancies resulted in intrauterine demise within 1 week of surgery. Conclusions Major aortic surgery during pregnancy carries a high risk to both mother and baby. With appropriate maternal and fetal monitoring, attention to cardiopulmonary bypass, pulsatile perfusion, near-normothermia, and avoidance of vasoconstrictors, these risks may be minimized. [ABSTRACT FROM AUTHOR]

Highlights from the article: 4 Junchen Zhu Yu Zhang Chen Lvlin Yan He Xiaoming Qing Levosimendan in patients with low cardiac output syndrome undergoing cardiac surgery: a systematic review and meta-analysis Anesthesia Critical Care and Pain Medicine 2018 13 B Cholley T Caruba S Grosjean J Amour A Ouattara J Villacorta Effect of Levosimendan on low cardiac output syndrome in patients with low ejection fraction undergoing coronary artery bypass grafting with cardiopulmonary bypass: the LICORN randomized clinical trial JAMA 318 6 2017 548 556

Abstract Objective To examine the influence of prolonged intensive care unit (ICU) stay on quality of life and recovery following cardiac surgery. Methods Quality of life was assessed using the Short Form 36 Health Survey (SF36). The Postoperative Quality of Recovery Scale was used to assess quality of recovery, disability, and cognition after ICU discharge over 12 months' follow-up. Prolonged ICU stay was defined as ≥3 postoperative days. Mortality and major adverse cardiac and cerebrovascular events were recorded up to 12 months. Results For quality of life, the physical component improved over time in both groups (P <.01 for both groups), as did the mental component (P <.01 for both groups). The long ICU group had lower physical and mental components over time (both P values <.01), but by 12 months the values were similar. The overall quality of recovery was lower for the long ICU group (P <.01). Likewise, we found higher rates of recovery in the normal ICU group than in the long ICU group in terms of emotive recovery (P <.01), activities of daily living (P <.01), and cognitive recovery (P =.03) but no differences in terms of physiologic (P =.91), nociceptive (P =.89), and satisfaction with anesthetic care (P =.91). Major adverse cardiac and cerebrovascular events (P <.01), 30-day mortality (P <.01), and length of ward stay (P <.01) were all higher with prolonged ICU stay. Conclusions Patients with prolonged ICU stay have lower quality of life scores; however, they achieve similar midterm quality of recovery, but with reduced survival, increased major adverse cardiac and cerebrovascular events, and longer hospital length of stay. [ABSTRACT FROM AUTHOR]

Abstract: We have investigated the role of Vitamin A (retinoid) proteins in hepatic retinoid processing under normal conditions and during chemical stress induced by 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), a chemical known to interfere with retinoid turnover and metabolism. Three separate studies were performed in wildtype control mice and transgenic mice that lack one or more isoforms of retinoic acid receptors (RAR), retinoid X receptors (RXR), or intracellular retinoid-binding proteins (CRABP I, CRABP II, CRBP I). Body and organ weight development was monitored from 2 weeks of age to adult, and hepatic levels of retinyl esters, retinol, and retinoic acid were investigated. In addition, hepatic concentrations of 9-cis-4-oxo-13,14-dihydro-retinoic acid, a recently discovered retinoid metabolite that has proven sensitive to both TCDD exposure and Vitamin A status, were also determined. Mice absent in the three proteins CRBP I, CRABP I, and CRABP II (CI/CAI/CAII−/−) displayed significantly lower hepatic retinyl ester, retinol, and all-trans-retinoic acid levels compared to wildtype mice, whereas the liver concentrations of 9-cis-4-oxo-13,14-dihydro-retinoic acid was considerably higher. After treatment with TCDD, hepatic total retinoids were almost entirely depleted in the CI/CAI/CAII−/− mice, whereas wildtype mice and mice lacking CRABP I, and CRABP II (CAI/CAII−/−) retained approximately 60–70% of their Vitamin A content compared to controls at 28 days. RAR and RXR knockout mice responded similarly to wildtype mice with respect to TCDD-induced retinoid disruption, with the exception of RXRβ−/− mice which showed no decrease in hepatic Vitamin A concentration, suggesting that the role of RXRβ in TCDD-induced retinoid disruption should be further investigated. Overall, the abnormal retinoid profile in the triple knockout mice (CI/CAI/CAII−/−), but not double knockout (CAI/CAII−/−) mice, suggests that a loss of CRBP I may account for the difference in retinoid profile in CI/CAI/CAII−/− mice, and is likely to result in an increased susceptibility to hepatic retinoid depletion following dioxin exposure. [Copyright &y& Elsevier]