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Dysgeusia, or foul taste, is a rarely reported side effect in patients who have undergone deep brain stimulation (DBS) in the thalamus for essential tremor. This retrospective study evaluated the incidence, nature, neurophysiological and anatomical location of dysgeusia following DBS. Of 52 patients who had undergone DBS for essential tremor, eight (15%) reported dysgeusia, which was described as a "metallic," "sour," "foul," or "cold" taste in the mouth. Dysgeusia was separate and distinguishable from paresthesia. Dysgeusia was more frequently reported with bilateral than unilateral DBS implants (6 of 27 (22%) vs. 2 of 25 (8%) patients, respectively). The anatomical locations of the contacts causing dysgeusia were measured on postoperative MRI, and compared to those from seven control patients who did not experience dysgeusia after receiving bilateral DBS implants. Leads causing dysgeusia were more posterior than non-dysgeusia-associated leads (4.5 ± 1.2 vs. 5.7 ± 1.8 mm anterior to the posterior commissure, respectively, P < .001). Intraoperative microelectrode recording indicated that these contacts were in the sensory region of the thalamus. Intraoperative testing found that low sensory threshold for paresthesia predicted the development of dysgeusia postoperatively (1.5 ± 0.5 V vs. 3.3 ± 1.9 V; P < .05). These data indicate that taste perception can be altered in the human through DBS, with posterior leads likely within the sensory region of the thalamus. Dysgeusia can be reduced by changing stimulation parameters, or surgical revision of the lead., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The stereotactic accuracy of intraoperative imaging is critical to clinical outcome, particularly in "asleep" deep brain stimulation (DBS) surgery that typically forgoes neurophysiological techniques. Different intraoperative imaging modalities and associated accuracies have been reported, including magnetic resonance imaging (MRI), computed tomography (CT), and O-arm., Objective: To analyze intraoperative O-arm imaging accuracy and to evaluate the utility of microelectrode mapping., Methods: O-arm images of DBS electrodes were collected during implantation in the subthalamic nucleus in patients with Parkinson disease. Images were fused to postoperative MRI and postoperative CT scans. Stereotactic coordinates for the electrode tip were measured independently. Radial distances between the images were compared. The impact of microelectrode mapping on final DBS electrode positioning was also evaluated., Results: In 71 consecutive DBS electrodes, the average radial error of the electrode tip between the O-arm and MRI was 1.55 ± 0.58 mm. The average radial error between the O-arm and CT was 1.03 ± 0.61 mm. Thus, the O-arm images accurately depicted the position of the electrode. However, in 14% of cases, microelectrode mapping revised the DBS electrode position beyond the preoperative direct target in combination with accurate intraoperative imaging., Conclusion: Intraoperative O-arm images reliably and accurately displayed the location of the DBS electrode compared with postoperative CT and MRI images. Microelectrode mapping provided superior subnuclear resolution to imaging. Both intraoperative imaging and microelectrode mapping are effective tools that can be synergistically combined for optimal DBS electrode placement., (Copyright © 2016 by the Congress of Neurological Surgeons)

Background: Patient handovers (handoffs) following surgery have often been characterized by poor teamwork, unclear procedures, unstructured processes, and distractions. A study was conducted to apply a human-centered approach to the redesign of operating room (OR)-to-ICU patient handovers in a broad surgical ICU (SICU) population. This approach entailed (1) the study of existing practices, (2) the redesign of the handover on the basis of the input of hand over participants and evidence in the medical literature, and (3) the study of the effects of this change on processes and communication., Methods: The Durham [North Carolina] Veterans Affairs Medical Center SICU is an 11-bed mixed surgical specialty unit. To understand the existing process for receiving postoperative patients in the SICU, ethnographic methods-a series of observations, surveys, interviews, and focus groups-were used. The handover process was redesigned to better address providers' work flow, information needs, and expectations, as well as concerns identified in the literature., Results: Technical and communication flaws were uncovered, and the handover was redesigned to address them. For the 49 preintervention and 49 postintervention handovers, the information transfer score and number of interruptions were not significantly different. However, staff workload and team behaviors scores improved significantly, while the hand over duration was not prolonged by the new process. Handover participants were also significantly more satisfied with the new handover method., Conclusions: An HCD approach led to improvements in the patient handover process from the OR to the ICU in a mixed adult surgical population. Although the specific handover process would unlikely be optimal in another clinical setting if replicated exactly, the HCD foundation behind the redesign process is widely applicable.

Since its inception, the pulmonary artery catheter has enjoyed widespread use in both medical and surgical critically ill patients. It has also endured criticism and skepticism about its benefit in these patient populations. By providing information such as cardiac output, mixed venous oxygen saturation, and intracardiac pressures, the pulmonary artery catheter may improve care of the most complex critically ill patients in the intensive care unit and the operating room. With its ability to transduce pressures through multiple ports, one of the primary clinical uses for pulmonary artery catheters is real-time intracardiac pressure monitoring. Correct interpretation of the waveforms is essential to confirming correct placement of the catheter to ensure accurate data are recorded. Major complications related to catheter placement are infrequent, but misinterpretation of monitored data is not uncommon and has led many to question the utility of the pulmonary artery catheter. The evidence to date suggests that the use of the catheter does not change mortality in many critically ill patients and may expose these patients to a higher rate of complications. However, additional clinical trials are needed, particularly in the most complex critically ill patients, who have generally been excluded from many of the research trials performed to date., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

The Society of Cardiovascular Anesthesiologists (SCA) introduced the FOCUS initiative (Flawless Operative Cardiovascular Unified Systems) in 2005 in response to the need for a rigorous scientific approach to improve quality and safety in the cardiovascular operating room (CVOR). The goal of the project, which is supported by the SCA Foundation, is to identify hazards and develop evidence-based protocols to improve cardiac surgery safety. A hazard is anything that has the potential to cause a preventable adverse event. Specifically, the strategic plan of FOCUS includes 3 goals: (1) identifying hazards in the CVOR, (2) prioritizing hazards and developing risk-reduction interventions, and (3) disseminating these interventions. Collectively, the FOCUS initiative, through the work of several groups composed of members from different disciplines such as clinical medicine, human factors engineering, industrial psychology, and organizational sociology, has identified and documented significant hazards occurring daily in our CVORs. Some examples of frequent occurrences that contribute to reduce the safety and quality of care provided to cardiac surgery patients include deficiencies in teamwork, poor OR design, incompatible technologies, and failure to adhere to best practices. Several projects are currently under way that are aimed at better understanding these hazards and developing interventions to mitigate them. The SCA, through the FOCUS initiative, has begun this journey of science-driven improvement in quality and safety. There is a long and arduous road ahead, but one we need to continue to travel.

Postoperative patient handovers are fraught with technical and communication errors and may negatively impact patient safety. We systematically reviewed the literature on handover of care from the operating room to postanesthesia or intensive care units and summarized process and communication recommendations based on these findings. From >500 papers, we identified 31 dealing with postoperative handovers. Twenty-four included recommendations for structuring the handover process or information transfer. Several recommendations were broadly supported, including (1) standardize processes (e.g., through the use of checklists and protocols); (2) complete urgent clinical tasks before the information transfer; (3) allow only patient-specific discussions during verbal handovers; (4) require that all relevant team members be present; and (5) provide training in team skills and communication. Only 4 of the studies developed an intervention and formally assessed its impact on different process measures. All 4 interventions improved metrics of effectiveness, efficiency, and perceived teamwork. Most of the papers were cross-sectional studies that identified barriers to safe, effective postoperative handovers including the incomplete transfer of information and other communication issues, inconsistent or incomplete teams, absent or inefficient execution of clinical tasks, and poor standardization. An association between poor-quality handovers and adverse events was also demonstrated. More innovative research is needed to define optimal patient handovers and to determine the effect of handover quality on patient outcomes.

Purpose: An unusual case of superior vena cava (SVC) syndrome caused by an infected right atrial-SVC junction thrombus may be diagnosed using transesophageal echocardiography., Clinical Features: A 59-yr-old male with end-stage renal disease requiring hemodialysis presented with fungemia and later developed facial and bilateral upper extremity edema. Transesophageal echocardiography revealed subtotal occlusion of the SVC at its junction with the right atrium. The mass was surgically removed with cardiopulmonary bypass support. Pathological examination of the mass confirmed the presence of a large fungal colony of Candida species mixed in the thrombus. The patient's signs and symptoms of SVC obstruction resolved, and he was discharged from the hospital four weeks later in stable condition., Conclusion: Although usually caused by extrinsic tumour compression, SVC syndrome can result from intravascular caval obstruction. This etiology should also be considered in the differential diagnosis, particularly in patients with intravascular devices. Transesophageal echocardiography is a valuable diagnostic tool in these cases.

Low circulating von Willebrand factor levels increase the risk of bleeding after cardiac surgery. Patients with blood group O may be at greatest risk owing to lower baseline levels of von Willebrand factor compared with patients with other blood groups, and perioperative hemodilution during cardiac surgery may reduce von Willebrand factor to critical levels in these patients. This study tested the hypothesis that patients with blood group O are at increased risk for postoperative bleeding following cardiac surgery, and determined whether the blood group affected perioperative assessment of primary hemostasis. Using multivariate linear regression models that included preoperative and intraoperative covariates, the risk factors for postoperative bleeding were evaluated in 877 patients undergoing primary, nonemergent coronary artery bypass surgery at a university hospital. In a subset of these patients, we measured perioperative in-vitro bleeding times (PFA-100 analyzer) to determine whether there were measurable differences in primary hemostasis between patients with blood type O and those with other blood groups. Patients with blood group O did not have increased bleeding after cardiac surgery compared with patients with other blood types. In addition, while blood group O patients had laboratory evidence for abnormal primary hemostasis before surgery, there were no measurable differences in postoperative primary hemostasis in patients with different blood types. In conclusion, although we identified clinical and procedural factors that were independently associated with bleeding, blood group was not one of these factors.

Pressure monitoring systems influence the contour of the displayed wave-forms and, on occasion, can introduce significant artifact in the pressure traces. It is important to understand the technical details of invasive pressure monitoring to interpret better the information presented. Careful observation of the arterial pressure waveform can provide information about ventricular function, the arterial system, and ventricular preload. In particular, systolic pressure variation during the respiratory cycle in mechanically ventilated patients is a clinically useful indicator of volume status. CVP monitoring is also used to assess intravascular volume, but this measurement is significantly influenced by ventricular compliance and intrathoracic pressure. Under most clinical circumstances, a trend in CVP values or its change with therapeutic maneuvers is more reliable than a single measurement. Like arterial pressure waveforms, CVP waveform morphology can provide important information about clinical pathophysiology.

Background: We hypothesized that time of day of surgery would influence the incidence of anesthetic adverse events (AEs)., Methods: Clinical observations reported in a quality improvement database were categorized into different AEs that reflected (1) error, (2) harm, and (3) other AEs (error or harm could not be determined) and were analyzed for effects related to start hour of care., Results: As expected, there were differences in the rate of AEs depending on start hour of care. Compared with a reference start hour of 7 am, other AEs were more frequent for cases starting during the 3 pm and 4 pm hours (p < 0.0001). Post hoc inspection of data revealed that the predicted probability increased from a low of 1.0% at 9 am to a high of 4.2% at 4 pm. The two most common event types (pain management and postoperative nausea and vomiting) may be primary determinants of these effects., Conclusions: Our results indicate that clinical outcomes may be different for patients anesthetized at the end of the work day compared with the beginning of the day. Although this may result from patient related factors, medical care delivery factors such as case load, fatigue, and care transitions may also be influencing the rate of anesthetic AEs for cases that start in the late afternoon.

Transesophageal echocardiography is a crucial tool in intraoperative evaluation of newly implanted/repaired heart valves because suspected valvular malfunction needs to be identified and sometimes surgically corrected. Although color Doppler is often adequate in evaluating the expected regurgitant jets, as well as excluding pathologic paravalvular leaks, spectral Doppler techniques are the most commonly used methods for estimating transvalvular gradients in the operating room. However, these methods are subject to a variety of confounding factors, including subvalvular gradients and pressure recovery. Other methods of valve area estimation should also be used when evaluating a prostethic aortic valve, including the continuity equation and the left ventricular outflow tract/aortic valve velocity ratio.

Cardiac anesthesiologists have the responsibility to detect myocardial ischemia in a timely manner, which can be a challenging task in the perioperative environment. Transesophageal echocardiography pulmonary artery catheterization, and electrocardiography are the 3 major methods available for monitoring perioperative ischemia. Echocardiography, the newest and most sophisticated method, has been shown to be highly sensitive for detecting ischemia associated with systolic dysfunction. Echocardiography can detect wall-motion abnormalities before electrocardiographic changes develop in patients who are likely to experience supply-mediated ischemia. Perioperative ischemia that occurs after bypass and is detected using transesophageal echocardiography has been found to be related to an adverse outcome. However, the use of echocardiography has some limitations, including the detection of abnormalities not induced by ischemia and the presence of ischemia in areas not visible in the view selected. Pulmonary artery catheterization can provide information about systolic dysfunction, diastolic dysfunction, and mitral regurgitation, but the sensitivity and safety of catheterization have been questioned. Electrocardiography can be a superb monitoring device as long as clinicians pay adequate attention to lead selection and placement, filter selection, and gain adjustment. The optimal monitoring approach should integrate all 3 available monitoring systems in order to increase the likelihood of detecting both supply- and demand-mediated ischemia.

Objective: To determine the effects of positive-pressure ventilation and experimentally induced pericardial effusion and tamponade on transmitral flow velocities in dogs., Design: Descriptive., Setting: University laboratory., Participants: Eleven tracheally intubated and mechanically ventilated dogs., Interventions: Experimental pericardial effusion and cardiac tamponade were created by pericardial injection of warm saline., Measurements and Main Results: Hemodynamic parameters and pericardial pressures were monitored in the 11 dogs. Pulsed-wave Doppler tracings of mitral valve flow were obtained at the leaflet tips along with hemodynamic measurements at 4 stages: control, effusion (no decrease in mean arterial pressure), tamponade (>or=40% decrease in mean arterial pressure), and tamponade relief (after evacuation of pericardial fluid). Maximal variation (36%) in transmitral flow velocity over the respiratory cycle during positive-pressure ventilation was seen in the control stage. In the effusion and tamponade stages, variation in transmitral flow velocity decreased progressively to 29% (p = 0.1804, not significant) and 16% (p < 0.0001), respectively., Conclusion: Intrathoracic pressure and lung volume changes caused by positive-pressure ventilation influence transmitral flow velocity patterns. Respiratory variation in transvalvular flow is pronounced during standard positive-pressure mechanical ventilation, decreases in the presence of pericardial effusion, and becomes almost nonexistent when cardiac tamponade is present. These findings show that the echocardiographic criteria used to diagnose cardiac tamponade based on mitral valve inflow patterns are different during positive-pressure ventilation from spontaneously breathing subjects., (Copyright 2003, Elsevier Science (USA). All rights reserved.)

Failure to suppress thrombin generation during cardiac surgery promotes fibrin generation, fibrinolysis, and a consumptive coagulopathy. Acquired deficiencies of antithrombin III may play a contributory role. We hypothesized that antithrombin III supplementation to normal physiologic concentrations would decrease thrombin generation and potentially reduce peri-operative bleeding. Twenty patients undergoing coronary artery bypass graft surgery were randomized for this prospective, double-blind, placebo-controlled study. Ten patients received antithrombin III supplementation (50 U/kg) by intravenous infusion prior to incision, and 10 patients received a placebo. Blood samples were obtained pre-operatively, at 1 and 2 h following initiation of cardiopulmonary bypass (CPB), and at 1, 3, and 24 h after completion of CPB. Samples were analyzed for antithrombin III, thrombin-antithrombin III (TAT) complex, and D-dimer concentrations. Cumulative blood loss was recorded at 6 and 12 h after CPB. No statistically significant differences in patient demographics or total heparin dose administered were observed between groups. As expected, plasma antithrombin III concentrations were maintained near pre-operative values in the treatment group, but not in the placebo group. Despite this difference, no statistically significant alterations in generation of TAT complex, D-dimer, or blood loss occurred between groups. Antithrombin III supplementation to maintain normal physiologic concentrations during CPB did not alter significantly thrombin generation, fibrinolytic activity, or blood loss in adults undergoing elective cardiac surgery.

Carcinoma of the esophagus is a highly lethal disease in which surgical resection is part of every treatment regimen carried out with curative intent. The development of surgical resection of the esophagus for carcinoma has been a long and tortuous one. Its evolution depended not only on a thorough knowledge of surgical anatomy and technique, but also on important developments in endoscopy, radiology, anesthesia, nutrition, pulmonary physiology, and intensive care.

Study Objectives: To determine the usefulness of radioaerosol ventilation scans for the detection and localization of air leaks from the lungs or bronchial tree., Design: Selected patients with suspected air leaks underwent ventilation scans. Retrospective analysis of data was carried out., Setting and Patients: Twenty-eight hospitalized patients were included in the study., Interventions: Ventilation scintigraphy using 99mTc-DTPA (technetium aerosol) was carried out in patients with air leaks., Measurements and Results: Of the total group, there were 50% true-positive scans, 36% true-negative scans, and 14% false-negative scans giving a sensitivity of 78%, specificity of 100%, and accuracy of 86%., Conclusions: 99mTc-DTPA ventilation scintigraphy is useful in some patients with air leaks from the lung or tracheobronchial tree and may help to guide surgical intervention should this become necessary.

The first case of prosthetic valve thrombosis treated with an accelerated regimen of TPA is reported. The experience suggests that this therapeutic approach is feasible and may produce higher rates of patency for thrombosed prosthetic valves than other thrombolytic therapies currently available. This therapeutic strategy is worthy of further evaluation as a treatment for this disorder.

Lung cancer is the leading cause of cancer death in both men and women in the United States. Although lung cancer has been treated aggressively by surgery, radiation therapy, and chemotherapy, alone or in combination, survival is still in the 12% to 15% range at 5 years. All curative treatment plans for patients with non-small cell lung cancer include resectional surgery. Despite the dismal outlook there is hope, because improvements in outcome for patients undergoing surgical treatment have been realized. Definite progress has been made in reducing operative mortality and morbidity, helping to increase long-term survival. Advances that have contributed to these successes include improved preoperative evaluation in staging and patient selection criteria, the use of newer techniques such as video-assisted or open limited resections in selected instances, and the use of neoadjuvant therapy. These topics are addressed here, as are techniques for locally advanced tumors and options for palliation.

Objective: To evaluate postthoractomy analgesia in patients receiving lumbar epidural hydromorphone versus intrapleural bupivacaine., Design: A randomized, prospective, double-blind study., Setting: A university-affiliated medical center., Participants: Twenty patients undergoing lateral thoracotomy for either pulmonary wedge resection, lobectomy, or pneumonectomy., Intervention: Nine patients received epidural hydromorphone, and 11 patients received intrapleural bupivacaine in the postoperative period., Measurements and Main Results: Severity of pain was assessed using a visual analog pain scale (VAPS) (0 to 100 mm) at 1, 3, and 5 hours. Patients receiving epidural hydromorphone had a statistically significant improvement in VAPS scores. Patients who received intrapleural bupivacaine did not achieve a significant reduction in pain scores. Nine of 11 patients in the intrapleural bupivacaine group had "failed" postoperative analgesia as defined by a VAPS greater than 30. Only 3 of 9 patients in the continuous epidural hydromorphone group had "failed" analgesia., Conclusion: Epidural hydromorphone is superior to intrapleural bupivacaine in achieving satisfactory pain outcomes during the first 5 hours after thoracotomy.

A prospective analysis of placement of left-sided plastic double-lumen tubes in 100 patients is presented. Intubation of the left bronchus was successfully accomplished using only auscultation and clinical signs ("blind" placement) in 91 patients. Double-lumen tubes were positioned in less than five minutes in 84 patients. The most common problem encountered (30%) was initial intubation of the right main bronchus. Seven of these patients required bronchoscopic assistance to guide the tube into the left bronchus. There were four minor intraoperative complications due to DLT malposition that were recognized and corrected by withdrawing the tube slightly back in the bronchus. The plastic double-lumen tubes functioned properly during the procedure in all 100 patients.

A continuous, noninvasive device for blood pressure measurement using pulse transit time has been recently introduced. We compared blood pressure measurement determined using this device with simultaneous invasive blood pressure measurements in 35 patients undergoing general endotracheal anesthesia. Data were analyzed for accuracy and tracking ability of the noninvasive technique, and for frequency of unavailable pressure measurements by each method. A total of 25,133 measurements of systolic pressure, diastolic pressure, and mean arterial pressure (MAP) by each method were collected for comparison from 35 patients. Accuracy was expressed by reporting mean bias (invasive pressure minus noninvasive pressure) and limits of agreement between the two measurements. After correction for the offset found when measuring invasive and oscillometric methods of arterial pressure measurement, the mean biases for systolic, diastolic, and mean pressures by the pulse wave method were -0.37 mm Hg, -0.01 mm Hg, and -0.05 mm Hg, respectively (p < 0.001). The limits of agreement were: -29.0 to 28.2 mm Hg, -14.9 to 14.8 mm Hg, and -19.1 to 19.0 mm Hg, respectively (95% confidence intervals). When blood pressure measured invasively changed over time by more than 10 mm Hg, the noninvasive technique accurately tracked the direction of change 67% of the time. During the entire study, 3.2% of the invasive measurements were unavailable and 12.9% of the noninvasive measurements were unavailable. The continuous noninvasive monitoring technique is not of sufficient accuracy to replace direct invasive measurement of arterial blood pressure, owing to relatively wide limits of agreement between the two methods.(ABSTRACT TRUNCATED AT 250 WORDS)