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Introduction: Heater-cooler units (HCUs) are frequently incorporated into extracorporeal membrane oxygenation (ECMO) circuits to help maintain patient normothermia. However, these devices may be associated with increased cost and infection risk. This study describes our institution's experience managing adult ECMO patients without the routine use of in-circuit HCUs., Methods: We performed a retrospective analysis of adult patients treated with veno-venous (VV) or veno-arterial (VA) ECMO at our institution. The primary outcomes were rates of HCU use and the relative duration of the ECMO treatment course in which patients maintained normothermia (36-37.5°C), with and without HCUs. Secondary outcomes of mortality and ECMO-related complications were planned across HCU and non-HCU groups; exploratory analyses were performed across a 75% "ECMO time in normothermia" threshold., Results: Among a cohort of 71 patients, zero (0%) were managed with in-circuit HCUs. A majority of ECMO patient-hours were spent in the normothermic range. Median and mean percentages of ECMO normothermia time were 75% (IQR 49%-81%) and 62% (SD ± 27%). Twenty-nine patients (40%) met the threshold of 75% ECMO normothermia time, as used to evaluate secondary outcomes. At this threshold, mortality risk was significantly higher among the non-normothermic cohort; other ECMO-related complications did not vary significantly., Conclusions: In the absence of HCU use, the majority of ECMO patient-hours were spent in normothermia. However, only a minority of patients achieved normothermia for at least 75% of their ECMO course. In-circuit HCUs may be required to maintain high percentages of normothermic time in adult EMCO patients., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Intraoperative hemorrhage in cardiac surgery increases risk of morbidity and mortality. Low pre-operative and perioperative levels of fibrinogen, a key clotting factor, are associated with severity of hemorrhage and increased transfusion of blood components. The ability to supplement fibrinogen during hemorrhagic resuscitation is delayed 45-60 min because cryoprecipitated antihemophilic factor (cryo AHF) is stored frozen, due to a short post-thaw shelf life. Pathogen Reduced Cryoprecipitated Fibrinogen Complex (INTERCEPT Fibrinogen Complex, IFC) can be kept thawed, at room temperature, for up to 5 days, making it possible to be immediately available for hemorrhaging patients. This trial will investigate if earlier correction of acquired hypofibrinogenemia with IFC in hemorrhaging cardiac surgery patients reduces the total number of perioperatively transfused allogeneic blood products (red blood cells, plasma, and platelets) as compared to cryo AHF., Methods: This is a single center, prospective, cluster randomized trial with an adaptive design. Acquired hypofibrinogenemia will be assessed by rotational thromboelastometry (ROTEM) and the threshold for cryo AHF/IFC transfusion defined as FIBTEM A10 ≤ 10 mm in bleeding patients. IFC/cryo AHF will be randomized by 1-month blocks. Cardiac surgery patients will be enrolled in the study if they have an eligible procedure and at least one dose of a cryo AHF/IFC product (approximately 2 g fibrinogen) is transfused. Data from the electronic health record, including the blood bank and lab information systems, will be prospectively collected from the health system's data warehouse., Discussion: This trial aims to provide evidence of the clinical efficacy of utilizing readily available thawed IFC during acute bleeding in the cardiac surgery setting compared to traditional cryo AHF., Trial Registration: ClinicalTrials.gov NCT05711524. Feb 3, 2023., (© 2024. The Author(s).)

Patient safety huddles are brief, multidisciplinary conversations that focus on a specific topic or event. Huddles have been shown to improve communication among healthcare providers in a variety of settings, including the intensive care unit (ICU). This paper presents key features of patient safety huddles and describes the ways in which huddle techniques may be particularly relevant to the practice of critical care., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Sternal pain after cardiac surgery results in considerable discomfort. Single-injection parasternal fascial plane blocks have been shown to reduce pain scores and opioid consumption during the first 24 h after surgery, but the efficacy of continuous infusion has not been evaluated. This retrospective cohort study examined the effect of a continuous infusion of local anaesthetic through parasternal catheters on the integrated Pain Intensity and Opioid Consumption (PIOC) score up to 72 h., Methods: We performed a retrospective analysis of patients undergoing cardiac surgery with median sternotomy at a single academic centre before and after the addition of parasternal nerve catheters to a standard multimodal analgesic protocol. Outcomes included PIOC score, total opioid consumption in oral morphine equivalents, and time-weighted area under the curve pain scores up to 72 h after surgery., Results: Continuous infusion of ropivacaine 0.1% through parasternal catheters resulted in a significant reduction in PIOC scores at 24 h (-62, 95% confidence interval -108 to -16; P <0.01) and 48 h (-50, 95% CI -97 to -2.2; P =0.04) compared with no block. A significant reduction in opioid consumption up to 72 h was the primary factor in reduction of PIOC., Conclusions: This study suggests that continuous infusion of local anaesthetic through parasternal catheters may be a useful addition to a multimodal analgesic protocol in patients undergoing cardiac surgery with sternotomy. Further prospective study is warranted to determine the full benefits of continuous infusion compared with single injection or no block., (© 2024 The Authors.)

Artificial intelligence- (AI) and machine learning (ML)-based applications are becoming increasingly pervasive in the healthcare setting. This has in turn challenged clinicians, hospital administrators, and health policymakers to understand such technologies and develop frameworks for safe and sustained clinical implementation. Within cardiac anesthesiology, challenges and opportunities for AI/ML to support patient care are presented by the vast amounts of electronic health data, which are collected rapidly, interpreted, and acted upon within the periprocedural area. To address such challenges and opportunities, in this article, the authors review 3 recent applications relevant to cardiac anesthesiology, including depth of anesthesia monitoring, operating room resource optimization, and transthoracic/transesophageal echocardiography, as conceptual examples to explore strengths and limitations of AI/ML within healthcare, and characterize this evolving landscape. Through reviewing such applications, the authors introduce basic AI/ML concepts and methodologies, as well as practical considerations and ethical concerns for initiating and maintaining safe clinical implementation of AI/ML-based algorithms for cardiac anesthesia patient care., Competing Interests: Declaration of competing interest Michael Mathis reports research support from the US National Institutes of Health (NIDDK R01133226; NHLBI R01167790) and Chiesi USA. Jiapeng Huang is supported by the National Institute of Environmental Health Sciences (P30ES030283), the National Heart, Lung, and Blood Institute (R01HL158779), the National Institute of Allergy and Infectious Diseases (R01AI172873), the American Heart Association (23CSA1052735)., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used for patients with cardiogenic shock. Although Impella or intra-aortic balloon pump (IABP) is frequently used for left ventricular unloading (LVU) during VA-ECMO treatment, there are limited data on comparative outcomes. We compared outcomes of Impella and IABP for LVU during VA-ECMO., Methods and Results: Using the Nationwide Readmissions Database between 2016 and 2020, we analyzed outcomes in 3 groups of patients with cardiogenic shock requiring VA-ECMO based on LVU strategies: extracorporeal membrane oxygenation (ECMO) only, ECMO with IABP, and ECMO with Impella. Of 15 980 patients on VA-ECMO, IABP and Impella were used in 19.4% and 16.4%, respectively. The proportion of patients receiving Impella significantly increased from 2016 to 2020 (6.5% versus 25.8%; P -trend<0.001). In-hospital mortality was higher with ECMO with Impella (54.8%) compared with ECMO only (50.4%) and ECMO with IABP (48.4%). After adjustment, ECMO with IABP versus ECMO only was associated with lower in-hospital mortality (adjusted odds ratio [aOR], 0.83; P =0.02). ECMO with Impella versus ECMO only had similar in-hospital mortality (aOR, 1.09; P =0.695) but was associated with more bleeding (aOR, 1.21; P =0.007) and more acute kidney injury requiring hemodialysis (aOR, 1.42; P <0.001). ECMO with Impella versus ECMO with IABP was associated with greater risk of acute kidney injury requiring hemodialysis (aOR, 1.49; P =0.002), higher in-hospital mortality (aOR, 1.32; P =0.001), and higher 40-day mortality (hazard ratio, 1.25; P <0.001)., Conclusions: In patients with cardiogenic shock on VA-ECMO, LVU with Impella, particularly with 2.5/CP, was not associated with improved survival at 40 days but was associated with increased adverse events compared with IABP. More data are needed to assess Impella platform-specific comparative outcomes of LVU.

Background: Previous studies have shown that women have worse outcomes for cardiogenic shock (CS) than men. Patients who receive care in CS "hubs" have also been shown to have improved outcomes when compared to those treated at "spokes." This study aimed to examine the presence of sex disparities in the outcomes of CS in relation to hospital type., Methods: Hospitalizations of adults with a diagnosis of CS were identified using data from the 2016-2019 Nationwide Readmissions Database. CS "hubs" were defined as any centers receiving at least 1 interhospital transfer with CS, while those without such transfers were classified as "spokes." Data were combined across years and multivariable logistic regression modeling was used to evaluate the association of sex with in-hospital mortality, invasive procedures, and transfer to hubs., Results: There were a total of 618,411 CS hospitalizations (62.2% men) with CS related to acute myocardial infarction comprising 15.3 to 17.3% of women hospitalizations and 17.8 to 20.3% of men hospitalizations. In-hospital mortality was lower at hubs (34.5% for direct admissions, 31.6% for transfers) than at spokes (40.3%, all P < .01). Women underwent fewer invasive procedures (right heart catheterization, percutaneous coronary intervention, mechanical circulatory support) and had higher mortality than men. Female sex was independently associated with decreased transfers to hubs (odds ratio, 0.93; 95% CI, 0.89-0.96) and increased mortality (odds ratio, 1.09; 95% CI, 1.05-1.12)., Conclusions: Women with CS were less likely to be treated at a hub or transferred to a hub, had higher in-hospital mortality, and had a lower likelihood of receiving CS-related procedures than men. Further research is needed to understand sex-specific gaps in CS outcomes., (© 2023 The Author(s).)