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Perioperative cardiac arrest (POCA) is a catastrophic complication that requires immediate recognition and correction of the underlying cause to improve patient outcomes. While the hypoxia, hypovolemia, hydrogen ions (acidosis), hypo-/hyperkalemia, and hypothermia (Hs) and toxins, tamponade (cardiac), tension pneumothorax, thrombosis (pulmonary), and thrombosis (coronary) (Ts) mnemonic is a valuable tool for rapid differential diagnosis, it does not cover all possible causes leading to POCA. To address this limitation, we propose using the preload-contractility-afterload-rate and rhythm (PCARR) construct to categorize POCA, which is comprehensive, systemic, and physiologically logical. We provide evidence for each component in the PCARR construct and emphasize that it complements the Hs and Ts mnemonic rather than replacing it. Furthermore, we discuss the significance of utilizing monitored variables such as electrocardiography, pulse oxygen saturation, end-tidal carbon dioxide, and blood pressure to identify clues to the underlying cause of POCA. To aid in investigating POCA causes, we suggest the Anesthetic care, Surgery, Echocardiography, Relevant Check and History (A-SERCH) list of actions. We recommend combining the Hs and Ts mnemonic, the PCARR construct, monitoring, and the A-SERCH list of actions in a rational manner to investigate POCA causes. These proposals require real-world testing to assess their feasibility.

Pulmonary embolism (PE) embodies a large healthcare burden globally and is the third leading cause of morbidity and mortality worldwide. Submassive (intermediate-risk) PE accounts for 40% of this burden. However, the optimal treatment pathway for this population remains complex and ill-defined. Catheter-directed interventions (CDIs) have shown promise in directly impacting morbidity and mortality while demonstrating a favorable success rate, safety profile, and decreased length of stay (LOS) in the intensive care unit and hospital. This retrospective review included 22 patients (50% female) with submassive PE who underwent mechanical thrombectomy (MT). A total of 45% had a contraindication to thrombolytics, the mean pulmonary embolism severity index was 127, 36% had saddle PE, the average decrease in mean pulmonary artery pressure (PAP) was 7.2 mmHg following MT, the average LOS was 6.9 days, the 30-day mortality rate was 9%, the major adverse event (MAE) rate was 9%, and the readmission rate was 13.6%. A total of 82% had successful removal of thrombus during MT with no major bleeding complications, intracranial hemorrhage events, or device-related deaths. Acknowledging the limitation of our small sample size, our data indicate that MT in the intermediate-high-risk submassive pulmonary embolism (PE) cohort resulted in a decreased hospital length of stay (LOS) and in-hospital mortality compared to standard anticoagulation therapy alone. [ABSTRACT FROM AUTHOR]

Venous air embolism (VAE) is a well-described phenomenon that may have life-threatening cardiopulmonary and neurological consequences. Accidental administration of air during resuscitation while using a rapid infuser is rare. Furthermore, there is a paucity of published data describing the intraoperative management of VAE during emergent nonseated neurological surgery. We report a 22-year-old previously healthy female who experienced a motor vehicle accident with severe facial and head trauma, and mixed subdural and epidural hematomas with an 8 mm midline shift. Computed tomography revealed significant air entrainment in the right heart and main pulmonary artery, with venous air tracking from the right axillary vein. Given her age, lack of preexisting cardiac comorbidities, hemodynamic stability, and critical cerebral herniation risk, further cardiac evaluation was deferred, and the patient was transferred to the operating room for emergent decompressive craniotomy. Intraoperatively, she experienced acute decrease in mean arterial pressure and end-expiratory carbon-dioxide with loss of pulse oximetry waveform concerning for obstructive VAE physiology. She was responsive to fluid resuscitation and epinephrine administration and did not experience any recurrence of obstructive VAE. This challenging case report describes positive neurologic and hemodynamic outcomes after resuscitation-associated VAE and cardiopulmonary collapse during emergency neurosurgery. Comprehensive evaluation of risk, urgency of procedure, and need for diagnostic monitoring and treatment should be personalized. [ABSTRACT FROM AUTHOR]

Background and Objectives: Venous air embolism (VAE) can cause significant morbidity and mortality. Prevention and management of VAE include cessation of air entrainment, positioning changes, and hemodynamic support. The degree to which position change and cardiac output (CO) moderate resolution of intracardiac air has not been rigorously studied using contemporary transesophageal echocardiography (TEE)., Methods: This observational cohort-type study aimed to identify the effect of supine vs sitting positioning on the movement and resolution of intracardiac air. In 20 patients undergoing seated neurosurgery, central venous air aspiration catheters were placed through the median basilic vein. TEE was used to estimate the time required for clearance of agitated microbubbles from the right atrium and ventricle in both the supine and sitting position. Estimates of CO were also obtained echocardiographically in each position., Results: Average clearance time was faster in the sitting vs the supine position with no significant difference in CO. A negative correlation between CO and right atrial clearance time across all patients was demonstrated with a Pearson coefficient of -0.4 (95% CI -0.07, -0.65) with P = .02., Conclusion: During VAE, both patient position and CO can significantly affect how bubbles move through intracardiac chambers. However, augmenting CO during VAE may be clinically more feasible, efficient, and productive than changing positioning-especially during crises unless the changing in position is intended to halt the entrainment of air. Further TEE studies of intravascular air movement affected by other position changes (lateral, reverse Trendelenburg) and vasopressors should be considered., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Interest in remimazolam has surged in recent years, thanks to its advantageous pharmacologic profile. This ultra-short-acting benzodiazepine is noted for its rapid onset and termination of action, organ-independent elimination, availability of a reversal agent, and excellent hemodynamic stability. Although the use of remimazolam has been explored in various anesthesia settings and procedures, data on its application in cardiovascular anesthesia and catheterization laboratory procedures remain limited. This review evaluates the latest literature to assess remimazolam's role in cardiovascular anesthesia across different settings and procedures. The analysis shows that remimazolam offers anesthesia without significant hemodynamic instability and a reduced need for vasopressors, with an incidence of perioperative adverse events comparable to that of other agents. These findings are relevant for both the induction and maintenance of general anesthesia in catheterization laboratory procedures and general anesthesia in elective cardiac surgery. Although further research is needed to fully understand remimazolam's role in cardiovascular anesthesia, its favorable hemodynamic and safety profile suggests that it is a promising option for cardiac anesthesiologists in both the catheterization laboratory and the operating room., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose of Review: 5-Aminolevulinic acid hydrochloride (5-ALA), available under the trade name Gleolan, is an orally administered fluorophore drug used to enhance visual differentiation of cancerous tissue from healthy tissue, primarily during surgical resection of high-grade gliomas. Although given preoperatively, 5-ALA has important implications for anesthetic care throughout the perioperative period. This article reviews pharmacology, safety concerns, and perioperative considerations for patients who receive oral 5-ALA., Recent Findings: Although approved for clinical use by the United States Food and Drug Administration in 2017, studies and case reports published since then have further delineated side effects of this medication and its mechanisms and pharmacokinetics., Summary: Mitigating the possible side effects of 5-ALA requires an understanding of its basic mechanism as well as focused perioperative planning and communication. Administration of this medication may result in nausea, vomiting, photosensitivity, increase in serum concentration of liver enzymes, and hypotension. Patients who receive 5-ALA must be protected from prolonged light exposure during the first 48 h after consumption and administration of other photosensitizing agents should be avoided (Supplemental Video File/Video abstract)., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: High-stakes yet clinically infrequent procedures are challenging to teach. Escape rooms may offer an innovative solution through game-based learning. There is limited guidance on how to design an escape room focused on physical puzzles. We designed and implemented a procedure-focused escape room to teach high-stakes procedures to anesthesiology residents., Methods: We selected 5 procedural skills relevant to anesthesiology residents through a modified Delphi technique: fiberoptic intubation, rapid infuser setup, intraosseous line placement, flexible bronchoscopy, and supraglottic airway exchange. We designed associated skills stations and linked them in sequence using an elaborate series of puzzles, locks, keys, and codes. The total cost of puzzle equipment was $169.53. After pilot testing, we implemented the escape room from July to November 2022. We assessed residents using a single group pretest-posttest study design., Results: Forty-three of 55 (78%) eligible anesthesiology residents participated in the escape room. Thirty-one residents completed the surveys. Resident self-efficacy significantly improved for each of the 5 procedures. Twenty-six of 27 (96%) residents preferred the escape room over a typical procedural skills workshop., Conclusions: This pilot study demonstrated the feasibility of a procedure-focused escape room for teaching high-stakes technical skills. We identified 3 lessons in procedure-focused escape room design: set participant caps intentionally, optimize resource usage, and maximize reproducibility. Participating in a single escape room session significantly increased resident self-efficacy. Residents strongly preferred the escape room format over a traditional procedural skills workshop., (© 2024 Society for Education in Anesthesia.)

Background: Social media remains a growing platform for physicians to facilitate learning, network, and disseminate information. The Coronavirus Disease 2019 (COVID-19) pandemic has challenged traditional medical student recruitment and outreach. Instagram is a platform that can be used by residency programs to increase engagement and as a potential recruitment tool. The authors present social media failed and successful strategies used to increase engagement and gain new followers., Methods: In June 2020, an initiative began to use Instagram on a more frequent and intentional basis. Three different strategies were implemented during the pandemic: mirroring Twitter posts, increasing multimedia, and leveraging Instagram Stories. The outcomes of interest included number of followers and engagement on posts. Data were collected October 2020., Results: After June 1, 2020, the @mayoanesthesia account gained 1000 followers through 127 days, an average of 4.26 new followers each day. Before June 1, there were 24 total posts over 3.3 years with a total of 458 followers. Three different strategies were implemented at different times during the pandemic. During the mirroring Twitter posts period, the mean number of interactions per post was 14.5. During the second phase after separating the Twitter and Instagram strategy, the mean number of interactions per post increased to 57.8., Conclusion: Residency programs can creatively, yet methodically, use Instagram posts to increase social media engagement during resident recruitment season during the COVID-19 pandemic and likely beyond., Competing Interests: Conflicts of interest: The authors have no financial conflicts of interest to report., (© 2021 Society for Education in Anesthesia.)