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Prevention quality indicators (PQIs) are used in hospital discharge data sets to identify quality of care for ambulatory care-sensitive conditions, such as diabetes. We examined the impact of clinical integration efforts on diabetes-related PQIs in a large community-based health care organization. Inpatient and observation hospitalizations from nine acute care hospitals were trended over 5 years (2012-2016). Using established technical specifications, annual hospitalizations rates were calculated for four diabetes-related PQIs: uncontrolled diabetes, short-term complications, long-term complications, and lower extremity amputations. The mean (±standard error of the mean) annual hospitalization rate for uncontrolled diabetes and short-term complications gradually increased from 1.3 ± 1.1 and 3.2 ± 2.5 per 1,000 discharges to 2.4 ± 1.7 (p < .001) and 7.1 ± 3.2 (p < .001) per 1,000 discharges, respectively. Conversely, the annual hospitalization rate for long-term complications and lower extremity amputations gradually decreased from 12.6 ± 1.1 and 88.6 ± 1.0 per 1,000 discharges to 6.5 ± 1.0 (p = .004) and 82.2 ± 1.0 per 1,000 discharges (p < .001). Trends generally persisted across payers, age, sex, and race. There was an inverse correlation between county income-per-capita and hospitalization rate for short-term complications (p = .04), long-term complications (p = .03), and lower extremity amputations (p < .001). Study limitations included use of administrative data, evolving coding practices, and ecological fallacy. Ambulatory-based efforts to optimize diabetes care can prevent long-term complications and reduce avoidable hospitalizations.

How to cite this article Liora Y, Wells C, Subramaniam K. Preinduction-focused Transthoracic Echocardiography by Anesthesiologists in Cardiac Surgical Patients: “Checks and Balances” Approach improves Patient Care!. J Perioper Echocardiogr 2017;5(1):1-2.

End-stage liver disease with severe portopulmonary hypertension (PPHTN), which is refractory to vasodilator therapies, is a contraindication for isolated liver transplantation (LT) because of the high mortality rate. Combined heart, lung, and liver transplantation (CHLLT) and combined lung and liver transplantation (CLLT) can be lifesaving options for these patients; however, these procedures have rarely been performed. A 52-year-old man had end-stage liver disease due to hepatitis C and PPHTN; the latter showed a suboptimal response to pulmonary vasodilator therapy with continuous intravenous treprostinil sodium and oral sildenafil citrate and was considered a contraindication to isolated LT. His preoperative left ventricular function was normal, and he had mild to moderate right ventricular dysfunction. He underwent CLLT, which consisted of sequential double-lung transplantation under cardiopulmonary bypass followed by standard LT under venovenous bypass. Re-exploration of the chest cavity was necessary because of bleeding, and respiratory failure developed; however, the patient recovered, was discharged home on day 26, and remained well 1 year after CLLT with the standard immunosuppressants (similar to those used for heart and lung transplantation). For PPHTN, combined thoracic organ and liver transplantation has been reported in only 10 patients. Six of these patients, including our case, underwent CLLT, whereas 4 patients underwent CHLLT. Notably, 2 of the 6 CLLT patients expired within 24 hours of transplantation because of acute right heart failure. CHLLT should be considered for patients with refractory PPHTN. The assessment of preoperative cardiac function is a vital part of the decision to include heart transplantation in CLLT.

Objectives This study was conducted to evaluate the safety and efficacy of high-dose tranexamic acid (TA) compared with aprotinin in patients who underwent thoracic aortic surgery with deep hypothermic circulatory arrest (DHCA). Design A retrospective study. Participants Eighty-four patients underwent thoracic aortic surgery with DHCA arrest between July 2006 and December 2007. Antifibrinolytic efficacy and perioperative outcomes were compared between the groups by appropriate statistical tests. Measurements and Main Results Demographic data, comorbid conditions, aortic pathology, surgical procedures, and operative data were comparable between groups. The use of blood products tended to be more in the TA group, despite the fact that the aprotinin group had longer CPB duration. Thirty-day mortality was 5 of 48 (10.4%) in the aprotinin group versus 5 of 36 (13.9%) in the TA group (p = 0.44). Neurologic, cardiac, and respiratory dysfunctions were comparable as well as intensive care unit and hospital stay. Serum creatinine increased significantly postoperatively in both groups, with more patients in the aprotinin group developing stage 1 postoperative renal dysfunction based on Acute Kidney Insufficiency Network criteria. Multivariate logistic regression analysis identified risk factors for postoperative renal dysfunction including preoperative creatinine clearance, blood transfusion, and sepsis. Throughout the study, both drugs were available for use, allowing selective bias for providers. Conclusions Aprotinin appeared more effective in reducing blood product use after thoracic aortic surgery in this limited cohort. Aprotinin use also appeared to be associated with postoperative renal dysfunction. The choice of antifibrinolytic appeared to not be associated with cardiac, neurologic, or respiratory outcomes or survival after thoracic aortic surgery requiring DHCA.

One of the commonly accepted goals of general anesthesia is the achievement of decreased consciousness and the prevention of intraoperative awareness. Intraoperative awareness and recall can have serious psychological effects on the patient as well as legal consequences for the provider. As such, it is imperative to maintain vigilance in the operating room in order to avoid preventable anesthesia awareness, as well as to be prepared to address such events when they arise.

In recent years, an increasing proportion of elderly patients have been referred for repeat cardiac surgery despite the higher morbidity and mortality associated with redo procedures. This patient population requires additional considerations when planning their anesthetic and perioperative care, based on the higher incidence of preexisting conditions in elderly patients as well as the greater surgical risk associated with sternal reentry.

End-stage liver disease with severe portopulmonary hypertension (PPHTN), which is refractory to vasodilator therapies, is a contraindication for isolated liver transplantation (LT) because of the high mortality rate. Combined heart, lung, and liver transplantation (CHLLT) and combined lung and liver transplantation (CLLT) can be lifesaving options for these patients; however, these procedures have rarely been performed. A 52-year-old man had end-stage liver disease due to hepatitis C and PPHTN; the latter showed a suboptimal response to pulmonary vasodilator therapy with continuous intravenous treprostinil sodium and oral sildenafil citrate and was considered a contraindication to isolated LT. His preoperative left ventricular function was normal, and he had mild to moderate right ventricular dysfunction. He underwent CLLT, which consisted of sequential double-lung transplantation under cardiopulmonary bypass followed by standard LT under venovenous bypass. Re-exploration of the chest cavity was necessary because of bleeding, and respiratory failure developed; however, the patient recovered, was discharged home on day 26, and remained well 1 year after CLLT with the standard immunosuppressants (similar to those used for heart and lung transplantation). For PPHTN, combined thoracic organ and liver transplantation has been reported in only 10 patients. Six of these patients, including our case, underwent CLLT, whereas 4 patients underwent CHLLT. Notably, 2 of the 6 CLLT patients expired within 24 hours of transplantation because of acute right heart failure. CHLLT should be considered for patients with refractory PPHTN. The assessment of preoperative cardiac function is a vital part of the decision to include heart transplantation in CLLT.

How to cite this article Subramaniam K, Wells CMQ. Intraoperative Transesophageal Echocardiography: A Safeguard for Cardiovascular Surgery!. J Perioper Echocardiogr 2014;2(2):49-50.

Acute aortic syndrome is a modern term that describes the acute presentation of patients with characteristic “aortic” pain caused by one of the life-threatening thoracic aortic conditions including aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer (Fig. 2.1). This entity involves acute lesions of the aorta involving the tunica media and can be distinguished by their etiopathogenesis and characteristic appearance using various diagnostic imaging modalities. Recent advances in imaging techniques and therapeutic interventions have increased awareness of these pathological conditions and emphasized the importance of early diagnosis and treatment.