ABSTRACT
Objectives: Hospital resource usage is under constant review, and the extent and intensity of postoperative care requirements for vascular surgical procedures has been especially relevant in the setting of the COVID-19 (coronavirus disease 2019) pandemic and its impact on staffed intensive care unit (ICU) beds. We evaluated the feasibility of regional anesthesia and low-intensity postoperative care for patients undergoing transcarotid artery revascularization (TCAR) at our institution. Methods: All patients at high risk for carotid endarterectomy undergoing TCAR at a single institution from 2018 to 2020 were reviewed. Perioperative management was standardized by the use of an institutional protocol that included hemodynamic parameters and requisite medications, anticoagulation and/or antiplatelet regimens, neurovascular examination guidelines, and nursing instructions. The anesthetic modality was at the surgeon’s preference. Patients were transferred to the postanesthesia care unit (PACU) for 2 hours (with a 1:1 or 1:2 nursing ratio) followed by the step-down unit (1:4 nursing ratio) for 4 hours, followed by transfer to the floor (1:6 ratio) or, alternatively, were transferred to the ICU (1:1 ratio). Intravenous (IV) blood pressure medications could be administered in all environments, except for the floor. The recovery location and length of stay were recorded. Results: A total of 83 patients had undergone TCAR during the study period. The mean age was 72 ± 9 years, 59% were men, and 36% were symptomatic. Regional anesthesia was used for 84%, with none converted to general anesthesia intraoperatively. Postoperatively, only seven patients (8%) had required monitoring in the ICU overnight (decided perioperatively). This was mostly for patients with prior neurologic symptoms but for one patient was because of a postoperative neurologic event and for another patient because of pulseless electrical activity arrest. Of the 83 patients, 76 (92%) had been monitored in the PACU, with 8 transferred to the floor after 4 hours and 13 discharged directly from the PACU (owing to limited bed availability). Of the patients in the PACU, 55 were transferred to the step-down unit after 2 hours and discharged from there. Six patients had required IV antihypertensive agents, and eight had required IV vasoactive support postoperatively. The mean length of stay in the ICU was 3.7 days (range, 1-15 days). The mean length of hospital stay was 1.8 ± 2.3 days (3.7 ± 5.4 days for those requiring the ICU and 1.4 ± 1.2 days for those not requiring the ICU). The incidence of stroke, death, and myocardial infarction was 2.4%. There was one postoperative stroke considered to be a recrudescence of a prior stroke, and one respiratory arrest fatality in a frail patient with a neck hematoma, both of whom had been treated under general anesthesia. Conclusions: Using perioperative care protocols, TCAR can safely be performed while avoiding both general anesthesia and an ICU stay for most patients.
ABSTRACT
Introduction: ST-segment elevation myocardial infarction (STEMI) is an emergency presentation of an acutely occluded coronary artery. Following the announcement of the COVID-19 pandemic (March 11, 2020), a global decrease in STEMI incidence has been observed. Incidence, characteristics, and outcomes for STEMI activation patients were investigated in the 5 years prior (“reference period”) to and 1 year into the pandemic (“pandemic period”). We assessed the hypothesis that pandemic period STEMI activations will have more severe infarction (elevated troponin I), a higher percentage of true STEMI, and worse outcomes (higher case fatality rate). Methods: STEMI activation incidence was obtained from an institutional database (reference period n = 430;pandemic period n = 31). Patient characteristics and outcomes were obtained retrospectively from electronic health records (EHRs). True STEMI was adjudicated based on chest pain, EKG, troponins, and angiogram. Results: Monthly STEMI activations declined significantly in the first year of the pandemic (2.50 ± .68 vs. 7.17 ± .41, P = <.001). No significant difference in demographic characteristics (age, BMI,and male-to-female ratio) were observed. True STEMI percentage was higher during the pandemic (80.65% vs. 70.93%), but not statistically significant. Peak troponin levels for true STEMI were significantly higher during the pandemic (98.83 ± 25.82 vs. 51.44 ± 4.11, P = .003). There was no significant difference in 30-day and 90-day case fatality rates. Conclusions: STEMI activation incidence declined significantly during the pandemic;interestingly, the proportion of these which were true STEMIs remained consistent. True STEMIs during the pandemic had higher troponin levels suggesting larger infarct, but there was no significant difference in case fatality. In conclusion, fewer patients presented with STEMI while case fatality remained unchanged despite more severe infarct occurrence during the pandemic.