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To describe perfusionist perspectives regarding waste anesthetic gas (WAG) management during cardiopulmonary bypass (CPB) and compare results to existing American Society of Extracorporeal Technology (AmSECT) guidelines and the 2016 National Institute of Occupational Safety and Health Survey of healthcare workers and anesthesia care providers. We developed a questionnaire with 26 questions covering institutional demographics, use of anesthetic gases, scavenging systems, and air monitoring practices. Web-based survey. Self-identified board-eligible perfusionist members of AmSECT, the American Academy of Cardiovascular Perfusion, and the Maryland and Wisconsin State Perfusion Societies in 2022. None. Of the 4,303 providers sent the survey, 365 (8.5%) participated. Although 92% of the respondents (335/364) routinely administered inhaled anesthetics via the oxygenator, only 73.2% (259/354) routinely scavenged WAG during CPB cases. Only 6.6% of the respondents (22/336) conducted environmental monitoring for WAG levels. Cited reasons for not scavenging waste gases included a lack of applicable protocols and waste gas scavenging systems, excessive cost, and no need for scavenging. Our findings identify a gap between AmSECT guidelines and current perfusionist behavior and suggest potential strategies for reducing WAG leakage during CPB. Effective management should incorporate hazard awareness training, availability of standard procedures to minimize exposure, scavenging systems, regular equipment inspection, and prompt attention to spills and leaks. In high-risk environments, environmental surveillance for waste gas levels would also contribute to waste gas safety. A comprehensive approach to managing waste anesthetic gases will reduce WAG leakage, help improve health care worker safety, and prevent potential adverse effects of exposure. [Display omitted] [ABSTRACT FROM AUTHOR]

• Peripartum use of mechanical circulatory support increased from 2002 – 2014. • Overall mortality for pregnant women receiving mechanical support has not decreased. • The most common type of mechanical support used was an intra-aortic balloon pump. • Probability of death increased when mechanical support was used on or after day 6. To systematically explore the relationship among the use of mechanical circulatory support (MCS), the timing of placement, and outcomes in pregnancy. Using the National Inpatient Sample and National Readmissions Database, the authors performed a retrospective, cohort analysis of peripartum women who received MCS. United States hospitals. A weighted sample of women who received MCS during the antepartum, delivery, or postpartum period between 2002 and 2014. MCS There were 1,386 women who received MCS during their admission. These women were older and had more comorbidities than women without MCS. The mean time from admission to device placement was 5.4 days for all women, and MCS use was highest in urban teaching hospitals. Overall, peripartum use of MCS has increased since 2002, but mortality did not change during the same period. After adjusting for potential confounders, the odds ratio for mortality when MCS was placed within 6 days of admission was 0.48 (95% confidence interval 0.23-0.98) with the adjusted probability of death rising from 18.6% to 32.5% when the device was placed on or after day 6. Similar to trends in the general population, use of MCS has increased in the peripartum period. Women receiving MCS were generally older and had more comorbidities than those not receiving MCS. Increased time to device placement may worsen mortality. Further research will help identify appropriate candidates and factors that improve survival. [ABSTRACT FROM AUTHOR]

Nondepolarizing neuromuscular blocking agents (NMBAs) are associated with perioperative complications in noncardiac surgery; however, little is known about their effect on cardiac surgery. This study assessed the effect of neuromuscular blockade (NMB) on the incidence of postoperative pulmonary complications (PPCs) after cardiac surgery and operating conditions. Prospective, randomized clinical trial with blinded outcomes assessment. University hospital, single institution. Adult patients having cardiac surgery requiring cardiopulmonary bypass. One hundred patients were randomized to receive succinylcholine (group SUX) for intubation with no further NMB administered or cisatracurium (group CIS) for intubation and maintenance NMB. The primary outcome was a composite incidence of PPCs in the 72 hours after elective cardiac surgery. PPCs included failure to extubate within 24 hours, need for reintubation, pneumonia, aspiration, unanticipated need for noninvasive respiratory support, acute respiratory distress, and mortality from respiratory arrest. The secondary outcome was the adequacy of operating conditions as assessed by blinded surgeon survey (including a rating of surgical conditions on a Likert scale from 1 = poor to 5 = excellent), anesthesiologist report, and patient questionnaire. The composite incidence of PPCs did not differ between groups (8 of 50 patients in both groups; 16%). Mean surgeon rating of surgical conditions was lower in the SUX group (4.65 ± 0.85 v 4.96 ± 0.20, p = 0.02). Although avoiding nondepolarizing NMBA is feasible, doing so worsened operating conditions and did not reduce the incidence of postoperative pulmonary complications. [ABSTRACT FROM AUTHOR]

Background In some institutions, the current blood ordering practice does not discriminate minimally invasive endovascular aneurysm repair (EVAR) from open procedures, with consequent increasing costs and likelihood of blood product wastage for EVARs. This limitation in practice can possibly be addressed with the development of a reliable prediction model for transfusion risk in EVAR patients. We used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to create a model for prediction of intraoperative blood transfusion occurrence in patients undergoing EVAR. Afterward, we tested our predictive model on the Vascular Study Group of New England (VSGNE) database. Methods We used the ACS NSQIP database for patients who underwent EVAR from 2011 to 2013 (N = 4709) as our derivation set for identifying a risk index for predicting intraoperative blood transfusion. We then developed a clinical risk score and validated this model using patients who underwent EVAR from 2003 to 2014 in the VSGNE database (N = 4478). Results The transfusion rates were 8.4% and 6.1% for the ACS NSQIP (derivation set) and VSGNE (validation) databases, respectively. Hemoglobin concentration, American Society of Anesthesiologists class, age, and aneurysm diameter predicted blood transfusion in the derivation set. When it was applied on the validation set, our risk index demonstrated good discrimination in both the derivation and validation set (C statistic = 0.73 and 0.70, respectively) and calibration using the Hosmer-Lemeshow test ( P = .27 and 0.31) for both data sets. Conclusions We developed and validated a risk index for predicting the likelihood of intraoperative blood transfusion in EVAR patients. Implementation of this index may facilitate the blood management strategies specific for EVAR. [ABSTRACT FROM AUTHOR]

Objectives Septic cardiomyopathy is a well-described consequence of septic shock and is associated with increased sepsis-related mortality. The myocardial performance index (MPI), a parameter derived from echocardiographic tissue Doppler measurements, allows for a more sensitive assessment of global cardiac function than do traditional metrics for cardiac function. The authors hypothesized that changes in left ventricular MPI in patients with severe sepsis would be associated with a higher 90-day mortality. Design Prospective, observational study. Setting Intensive care units of a tertiary medical center. Participants The study comprised 47 patients admitted with new diagnoses of severe sepsis or septic shock. Interventions All patients underwent transthoracic echocardiograms with assessment of MPI at enrollment and 24 hours later. Hemodynamic data and information on sepsis-related mortality were collected. In the primary analysis, the association between change in MPI from enrollment to 24 hours and sepsis-related 90-day mortality was assessed. Measurements and Main Results Of the 47 patients enrolled, 30 demonstrated an improvement in MPI from 0 to 24 hours (“improved” group), and MPI worsened in the remaining 17 patients (“worsened” group). Despite no significant differences in ejection fraction or severity of illness, the median MPI at enrollment in the “improved” group was higher than baseline values in the “worsened” group (p = 0.005). A worsening MPI over the 24-hour study interval was associated with increased mortality at 90 days (p = 0.04), which remained significant (hazard ratio 3.72; 95% confidence interval 1.12-12.41; p = 0.03) after adjusting for severity of illness (Acute Physiology and Chronic Health Evaluation II score), intravenous fluids, and vasopressor use. Conclusions In patients admitted to the intensive care unit with a diagnosis of severe sepsis or septic shock, a worsening MPI during the first 24 hours after intensive care unit admission was associated with higher 90-day mortality. [ABSTRACT FROM AUTHOR]

Objective The method of protamine administration may influence adverse reactions. The authors investigated the effects of 3 different methods of protamine administration on cardiopulmonary function. Design Prospective, randomized clinical study. Setting Single university hospital. Participants Human volunteer patients. Interventions Ninety-five patients undergoing cardiac surgery were randomized prospectively into 3 groups. Group central vein control (CVC) and group central vein (CV) received protamine via a central vein over 10 minutes and 2 minutes, respectively. Group ascending aorta (AA) received protamine via the ascending aorta over 2 minutes. Hemodynamic parameters were assessed at 7 intraoperative time points, and pulmonary parameters were assessed at 4 intraoperative time points. Measurements and Main Results The groups were similar regarding preoperative demographics, intraoperative care, and baseline cardiopulmonary function. However, both the CVC and CV groups exhibited decreased blood pressure and impaired pulmonary oxygenation after protamine administration; these changes were not observed in the AA group. Within-group changes in mean arterial blood pressure after protamine administration were significant in the AA group (mean increase 6.5 mmHg; p = 0.01) but not in the CVC (mean decrease 3.1 mmHg, p = 0.13) or CV (mean decrease 4.3 mmHg, p = 0.14) groups. Within-group changes in arterial oxygenation after protamine administration were significant in the CVC (mean decrease 85 mmHg; p<0.001) and CV (mean decrease 47 mmHg; p = 0.009) groups but not in the AA group (mean decrease 8 mmHg; p = 0.82). Conclusions The results indicated that administration of protamine via the ascending aorta may be the preferred route. The potential ability of administering protamine via the ascending aorta to prevent cardiopulmonary instability in patients undergoing cardiac surgery deserves further clinical investigation. [ABSTRACT FROM AUTHOR]

Objective To investigate the impact of a sequence of educational interventions in a one-day course on focused transthoracic echocardiography (FOTE) by anesthesia and critical care practitioners. Design A prospective analysis of the educational data. Setting Educational setting in two academic medical centers and a medical meeting workshop organized by one of these institutions. Participants Fifty-six anesthesia and critical care providers, divided into three groups, participated separately in a FOTE training course. Interventions All participants received a sequence of educational intervention as follows: A standardized, multiple-choice pretest; a lecture on cardiac and lung ultrasound; and a FOTE “hands-on” training session. The same standardized test was administered and graded as a posttest. Measurements and Main Results Fifty-six professionals attended the course in three separate groups: The first were cardiothoracic anesthesia fellows (n = 16) (group 1), the second included critical care practitioners (n = 21) (group 2), and the third were general anesthesiologists (n = 19) (group 3). Parasternal views were most difficult to obtain for all groups (58.1, 63.8, and 58%, respectively). The mean written test scores increased from 14.9±2 to 21.0±2.3 in group 1; from 12.3±3.8 to 19.2±3.7 in group 2; 12±3.5 to 21±2.4 in group 3, (p = 0.0003, 0.00005, 0.0001, respectively). Conclusions A FOTE training course improves image acquisition skills and knowledge to the same level independently of professional background and level of experience in critical care ultrasound. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this review was to evaluate new computer software available for 3-dimensional right ventricular (RV) volume estimation. Description: Based on 2-dimensional echocardiography, various algorithms have been used for RV volume estimation. These are complex, time-consuming techniques and are prone to significant error. The current clinical paradigm of RV volume assessment is based on the visual quantitative assessment of chamber size and the use of tricuspid annular and RV internal diameters as a surrogate measure of RV volume. Hence, there is a need for a practical method for the intraoperative assessment of RV volume. Evaluation: The evaluation consists of an objective review of the capabilities of this software and its potential application in the operating room. The authors also performed a detailed review of the potential limitations and possible improvements. Conclusions: This new software has the potential to be incorporated into the existing workflow environment of the ultrasound systems in the future, making it clinically feasible to perform perioperative RV volume analysis. [ABSTRACT FROM AUTHOR]

Purpose: The authors analyze a commercially available software package capable of geometrically reconstructing the mitral valve (MV) dynamically throughout systole. Description: Three-dimensional echocardiography has revolutionized the understanding of MV geometry. Advanced quantification software can be used to assess geometric changes in the MV, which have been shown to have important implications for MV surgery. Evaluation: The authors performed geometric analysis on 24 patients, with both anatomically normal and abnormal MVs to assess the feasibility of this new software. The application of this new software is briefly reviewed. Conclusion: This new software, despite its limitations, allows an improved perspective on MV geometry with implications for MV repair and surgical decision making. [ABSTRACT FROM AUTHOR]

Objective: This study was designed to test the hypothesis that simulator-based transesophageal echocardiographic training was a more effective method of training anesthesia residents with no prior experience in echocardiography as compared with conventional methods of training (books, articles, and web-based resources). Study Design: A prospective randomized study. Setting: An academic medical center (teaching hospital). Participants: The participants consisted of first-year anesthesia residents. Intervention: The study design was composed of 2 groups: a control group (group 1, conventional group) and a study group (group 2, simulator group). The residents belonging to group 2 (simulator group) received a 90-minute simulator-based teaching session moderated by a faculty experienced in transesophageal echocardiography. Residents belonging to group 1 (conventional group) were asked to review the guidelines of the comprehensive intraoperative transesophageal echocardiographic examination published by the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. They also were encouraged to use other learning resources (eg, textbooks, electronic media, and web-based resources) to understand the underlying concepts of echocardiography. Written pre- and post-test was administered to both groups. Measurements and Main Results: The groups were compared for the pretest scores by the nonparametric Mann-Whitney U test. Pre- and post-test scores were compared with a Wilcoxon paired test in the individual groups. The results showed a statistically significant difference between the scores of the 2 groups with better scores in the simulation group in the post-training test. Conclusion: The simulator-based teaching model for transesophageal echocardiography is a better method of teaching the basic concepts of transesophageal echocardiography like anatomic correlation, structure identification, and image acquisition. [ABSTRACT FROM AUTHOR]

We present the case of a 78-year-old woman who presented with acute anterior myocardial infraction. An intraoperative transesophageal echocardiogram revealed an akinetic apex with hyperkinesis of the basal segments causing systolic anterior motion of the mitral valve. The patient was immediately placed on cardiopulmonary bypass. Her postoperative course was uneventful. We present transesophageal and transthoracic echocardiographic videos showing this unique complication and describing the challenge of managing a patient who required opposing therapies. [ABSTRACT FROM AUTHOR]