Search

Study Objective: To determine the association of practitioner dashboard feedback of intraoperative glycemic and temperature control on maintenance of normoglycemia and normothermia., Design: Retrospective review., Setting: Single tertiary care institution., Patients: Patients over the age of 18 undergoing cardiac surgery from February 17, 2021 through February 16, 2023. During the study interval, 15 anesthesiologists providing care during 2255 procedures were analyzed: 1114 prior to the individual faculty dashboard distribution and 1141 after commencement of dashboard distribution., Interventions: On February 17, 2022, anesthesia faculty members began receiving monthly individualized dashboards indicating their personal intraoperative glycemic and temperature compliance rates., Measurements: Baseline patient demographic characteristics, surgical and cardiopulmonary bypass times, perioperative temperature and glucose concentrations, and the incidence of sternal wound infections. Glycemic compliance was defined as final serum glucose between 80 and 180 mg/dL. Temperature compliance was defined as an average temperature during the final 30 min of the surgical procedure between 35 and 37.3 °C inclusive., Main Results: Dashboard distribution was associated with a significant decrease in the average glucose concentration (median location shift by -6 mg% (95% confidence interval (CI) -8, -4), p < 0.001) from 157 mg/dL to 152 mg/dL and final glucose concentration (median location shift by -17 mg/dL (95% CI -19, -14, p < 0.001) from 161 mg/dL to 145 mg/dL. The intervention was associated with an improvement in glycemic compliance from 71.4% to 87.1% (odds ratio (OR): 2.71(95% CI 2.19, 3.37, p < 0.001)). There were no significant differences in final temperature (36.3 °C [Q1, Q3: 36.0, 36.6] vs. 36.3 °C [Q1, Q3: 36.0, 36.7] (p = 0.232)) with the intervention nor were there any statistically significant differences in temperature compliance (93.9% vs. 92.9%, OR: 0.79 (95% CI 0.55-1.14, p = 0.25). There were no statistically significant changes in the incidence of superficial, deep, or any wound infections with the intervention., Conclusions: Individualized practitioner dashboard distribution may be an effective tool to increase intraoperative glycemic control., Competing Interests: Declaration of competing interest The authors have no financial or personal relationships with other people or organizations that could inappropriately influence or bias this work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Patients with intermediate-risk pulmonary embolism (PE) and normotensive shock may have worse outcomes. However, diagnosis of normotensive shock requires invasive hemodynamics. Our objective was to assess the predictive value of McConnell's sign in identifying normotensive shock in patients with intermediate-risk PE., Methods: Patients with intermediate-risk PE who underwent percutaneous mechanical thrombectomy between August 2020 and April 2023 at a large academic public hospital were included in the study. Normotensive shock was defined as systolic blood pressure ≥ 90 mmHg without vasopressor support with pre-procedural invasive measures of cardiac index ≤2.2 L/min/m 2 and clinical evidence of hypoperfusion (i.e. elevated lactate, oliguria). The primary outcome was the association between McConnell's sign and normotensive shock., Results: Those with McConnell's sign (29/40, 72.5 %) had higher heart rate (114 vs 99 beats/min, p = 0.008), higher rates of elevated lactate (86 % vs 55 %, p = 0.038), lower cardiac index (1.9 vs 3.1 L/min/m 2 , p = 0.003), and higher rates of normotensive shock (76 % vs 27 %, p = 0.005). McConnell's sign had a sensitivity of 88 % and specificity of 53 % for identifying intermediate-risk PE patients with normotensive shock. Patients with McConnell's sign had an increased odds (odds ratio 8.38, confidence interval: 1.73-40.53, p = 0.008; area under the curve 0.70, 95 % confidence interval: 0.56-0.85) of normotensive shock., Conclusion: This is the first study to suggest that McConnell's sign may identify those in the intermediate-risk group who are at risk for normotensive shock. Larger cohorts are needed to validate our findings., Competing Interests: Declaration of competing interest Dr. Sripal Bangalore - Advisory board - Abbott Vascular, Boston Scientific, Biotronik, Amgen, Pfizer, Merck, REATA, Inari, Truvic, Argon. Dr. Allison Greco - Board Member of ABIM Critical Care., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

The Society of Cardiovascular Anesthesiologists (SCA) is committed to improving the quality, safety, and value that cardiothoracic anesthesiologists bring to patient care. To fulfill this mission, the SCA supports the creation of peer-reviewed manuscripts that establish standards, produce guidelines, critically analyze the literature, interpret preexisting guidelines, and allow experts to engage in consensus opinion. The aim of this report, commissioned by the SCA President, is to summarize the distinctions among these publications and describe a novel SCA-supported framework that provides guidance to SCA members for the creation of these publications. The ultimate goal is that through a standardized and transparent process, the SCA will facilitate up-to-date education and implementation of best practices by cardiovascular and thoracic anesthesiologists to improve patient safety, quality of care, and outcomes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 International Anesthesia Research Society.)

The lymphatic vasculature regulates lung homeostasis through drainage of fluid and trafficking of immune cells and plays a key role in the response to lung injury in several disease states. We have previously shown that lymphatic dysfunction occurs early in the pathogenesis of chronic obstructive pulmonary disease (COPD) caused by cigarette smoke (CS) and that this is associated with increased thrombin and fibrin clots in lung lymph. However, the direct effects of CS and thrombin on lymphatic endothelial cells (LECs) in COPD are not entirely clear. Studies of the blood vasculature have shown that COPD is associated with increased thrombin after CS exposure that causes endothelial dysfunction characterized by changes in the expression of coagulation factors and leukocyte adhesion proteins. Here, we determined whether similar changes occur in LECs. We used an in vitro cell culture system and treated human lung microvascular lymphatic endothelial cells with cigarette smoke extract (CSE) and/or thrombin. We found that CSE treatment led to decreased fibrinolytic activity in LECs, which was associated with increased expression of plasminogen activator inhibitor 1 (PAI-1). LECs treated with both CSE and thrombin together had a decreased expression of tissue factor pathway inhibitor (TFPI) and increased expression of adhesion molecules. RNA sequencing of lung LECs isolated from mice exposed to CS also showed upregulation of prothrombotic and inflammatory pathways at both acute and chronic exposure time points. Analysis of publicly available single-cell RNA sequencing of LECs as well as immunohistochemical staining of lung tissue from COPD patients supported these data and showed increased expression of inflammatory markers in LECs from COPD patients compared to those from controls. These studies suggest that in parallel with blood vessels, the lymphatic endothelium undergoes inflammatory changes associated with CS exposure and increased thrombin in COPD. Further research is needed to unravel the mechanisms by which these changes affect lymphatic function and drive tissue injury in COPD., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Trivedi, Lu, Summers, Kim, Rhee, Houghton, Byers, Lis and Reed.)

Competing Interests: Disclosures Dr Bangalore serves on the advisory board of Abbott Vascular, Boston Scientific, Biotronik, Amgen, Pfizer, Merck, Reata, Inari, and Truvic. The other authors report no conflicts.

Unprofessional behavior in the procedural arena is associated with worse patient outcomes. This is thought to be due to breakdowns in communication structures and team dynamics. Behavioral issues are often uncovered during the investigation of serious event reports. Understanding differences in behavior deviations enables leadership to best address each type with an appropriate response. This allows institutions to address reckless behavior and unprofessionalism, while concomitantly creating a culture that fosters trust to promote self-reporting and sharing of information. These are characteristics of high-reliability organizations that produce sustained excellence in patient outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Electrocardiography (ECG) electrodes require special expiration tracking after the manufacturer's packaging is opened. Compliance with this requirement, however, can be inconsistent. The authors tested the efficacy of a device that provides for expiration tracking of bulk-packaged electrodes to improve compliance., Methods: The device tested is a bin with an automated countdown timer that could be used for storing and dispensing open ECG electrodes. Seven operating rooms were inspected three times each before and after implementation of the device. Compliance with expiration dating of open electrodes was recorded for each inspection., Results: Compliance was found in 3 of the 21 (14.3%) baseline inspections. Following implementation of the devices, compliance was found in 20 of 21 (95.2%) inspections. This increase in compliance was statistically significant (p < 0.01)., Conclusion: A storage and dispensing device with automated countdown timer significantly improved compliance with expiration dating regulations for bulk-packaged ECG electrodes. It also has the potential to reduce supply cost, packaging waste, and inconvenience compared with individually wrapped electrodes., (Copyright © 2023 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Despite mounting evidence implicating inflammation in cardiovascular diseases, attempts at clinical translation have shown mixed results. Recent preclinical studies have reenergized this field and provided new insights into how to favorably modulate cardiac macrophage function in the context of acute myocardial injury and chronic disease. In this review, we discuss the origins and roles of cardiac macrophage populations in the steady-state and diseased heart, focusing on the human heart and mouse models of ischemia, hypertensive heart disease, and aortic stenosis. Specific attention is given to delineating the roles of tissue-resident and recruited monocyte-derived macrophage subsets. We also highlight emerging concepts of monocyte plasticity and heterogeneity among monocyte-derived macrophages, describe possible mechanisms by which infiltrating monocytes acquire unique macrophage fates, and discuss the putative impact of these populations on cardiac remodeling. Finally, we discuss strategies to target inflammatory macrophage populations.

Preventable medical errors in the operating room are most often caused by ineffective communication and suboptimal team dynamics. TeamSTEPPS is a government-funded, evidence-based program that provides tools and education to improve teamwork in medicine. The study hospital implemented TeamSTEPPS in the operating room and merged the program with a surgical safety checklist. Audits were performed to collect both quantitative and qualitative information on time out (brief) and debrief conversations, using a standardized audit tool. A total of 1610 audits over 6 months were performed by live auditors. Performance was sustained at desired levels or improved for all qualitative metrics using χ 2 and linear regression analyses. Additionally, the absolute number of wrong site/side/person surgery and unintentionally retained foreign body counts decreased after TeamSTEPPS implementation.

Objectives: The objective of this study was to assess the impact of robotic approaches on outcomes of coronary bypass surgery., Design: Retrospective national database analysis., Setting: United States hospitals., Participants: A weighted sample of 484,128 patients undergoing isolated coronary artery surgery identified from the Nationwide Inpatient Sample from 2008 through 2010., Interventions: Robotically assisted coronary artery bypass surgery versus conventional bypass surgery., Measurements and Main Results: Robotic approaches were used in 2,582 patients (0.4%). Patients undergoing robotic surgery were less likely to be female (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.57-0.87), present with acute myocardial infarction (OR 0.53, 95% CI 0.38-0.73), or have cerebrovascular disease (OR 0.41, 95% CI 0.23-0.71) compared to patients undergoing conventional surgery. In 59% of robotic cases, a single bypass was performed, and 2 bypasses were performed in 25% of cases. After adjusting for comorbidity, reduced postoperative stroke (0.0% v 1.5%, p = 0.045) and transfusion (13.5% v 24.4%, p = 0.001) rates were observed in patients who underwent robotic single-bypass surgery compared to conventional surgery. In patients undergoing multiple bypass grafts, higher mortality (1.1% v 0.5%), and cardiovascular complications (12.2% v 10.6%) were observed when robotic assistance was used, but the differences were not statistically significant (p = 0.5). The mean number of robotic cases carried out annually at institutions sampled was 6., Conclusions: Robotic assistance is associated with lower rates of postoperative complications in highly selected patients undergoing single coronary artery bypass surgery, but the benefits of this approach are reduced in patients who require multiple coronary artery bypass grafts., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Pemphigus vulgaris is an autoimmune disorder that causes blistering of the skin and mucous membranes. We present a patient with pemphigus vulgaris who required combined coronary artery bypass grafting and mitral valve repair. The challenges that we faced and modifications to the technique required in this situation are described and reviewed.

Purpose of Review: The fundamental advantage of point-of-care testing (POCT) is rapid acquisition of laboratory data. This is particularly advantageous in the operative arena because of the urgency of timeliness in anesthetic patient care. Technology is persistently evolving, such that it is imperative to regularly review available devices and investigate new devices that emerge each year. This review provides a comprehensive, current summary of POCT most pertinent to the anesthesiologist, and recent investigations that evaluate them., Recent Findings: Perioperative POCT includes arterial blood gas monitoring, chemistry, co-oximetry panels, parathyroid hormone assays, and coagulation testing. Parathyroid hormone assays continue to guide surgical resection of the parathyroid glands. Coagulation testing aids anesthesiologists in diagnosis of coagulopathy as well as therapeutic optimization of anticoagulants such as clopidogrel and aspirin., Summary: POCT, although generally found to be more expensive compared to laboratory testing, has been shown to quicken result time. POCT will continue to be useful in the realm of anesthesiology in management of the surgical patient to guide drug therapy, surgical strategy, and medical management. A major challenge to POCT continues to be developing platforms to configure, organize, and distribute laboratory results as well as minimizing cost.

We assessed blood-retinal barrier function by vitreous fluorophotometry in 24 patients with either cone or cone-rod dystrophy who were segregated into three subgroups. Compared with a normal population, the patients demonstrated increased vitreous fluorescence (breakdown of the blood-retinal barrier) that positively correlated with peripheral pigmentary changes and an appreciable reduction in electroretinographic scotopic b-wave amplitude. A unique subgroup of three women with supernormal electroretinographic scotopic b-wave amplitudes to a high-intensity stimulus had an abnormal increase in permeability of the blood-retinal barrier even without peripheral pigmentary fundus changes.