Incidence of sedation-related adverse events during ERCP with anesthesia assistance: a multicenter observational study.

BACKGROUND AND AIMS: Anesthesia assistance is commonly used for ERCP. General anesthesia (GA) may provide greater airway protection but may lead to hypotension. We aimed to compare GA versus sedation without planned intubation (SWPI) on the incidence of hypoxemia and hypotension. We also explored risk factors for conversion from SWPI to GA. METHODS: This observational study used data from the Multicenter Perioperative Outcomes Group. Adults with American Society of Anesthesiologists physical status class I to IV undergoing ERCP between 2006 and 2019 were included. We compared GA and SWPI on incidence of hypoxemia (oxygen saturation <90% for ≥3 minutes) and hypotension (mean arterial pressure <65 mm Hg for ≥5 minutes) using joint hypothesis testing. The association between anesthetic approach and outcomes was assessed using logistic regression. The noninferiority delta for hypoxemia and hypotension was an odds ratio of 1.20. One approach was deemed better if it was noninferior on both outcomes and superior on at least 1 outcome. To explore risk factors associated with conversion from SWPI to GA, we constructed a logistic regression model. RESULTS: Among 61,735 cases from 42 institutions, 38,830 (63%) received GA and 22,905 (37%) received SWPI. The GA group had 1.27 times (97.5% confidence interval, 1.19-1.35) higher odds of hypotension but .71 times (97.5% confidence interval, .63-.80) lower odds of hypoxemia. Neither group was noninferior to the other on both outcomes. Conversion from SWPI to GA occurred in 6.5% of cases and was associated with baseline comorbidities and higher institutional procedure volume. CONCLUSIONS: GA for ERCP was associated with less hypoxemia, whereas SWPI was associated with less hypotension. Neither approach was better on the combined incidence of hypotension and hypoxemia.

The effects of diabetes mellitus on gastric emptying: A prospective observational cohort study.

STUDY OBJECTIVE: Our goal was to evaluate the effect of diabetic severity and duration on preoperative residual gastric volume. Secondarily we compared ultrasonic estimates of residual gastric volume with actual volume determined by aspiration during endoscopy. DESIGN: This was a prospective, observational cohort study that included adults with a history of diabetes mellitus and/or opioid use scheduled for gastrointestinal endoscopic procedures. SETTING: Endoscopy unit at Cleveland Clinic Main Campus from 2017 to 2019. PARTICIPANT: Adults scheduled for upper endoscopy with or without colonoscopy. INTERVENTION AND MEASUREMENTS: Residual gastric volumes were primarily determined by aspiration during endoscopy, and secondarily estimated with ultrasound. We evaluated the relationship between gastric residual volume and preoperative HBA1C concentration and duration of diabetes. Secondarily, we conducted an agreement analysis between the two gastric volume measurement techniques. MAIN RESULTS: Among 145 enrolled patients, 131 were diabetic and 17 were chronic opioid users. Among 131 diabetic patients, the mean ± SD HbA1c was 7.2 ± 1.5% and the median (Q1, Q3) duration of diabetes was 8.5 (3, 15) years. Neither HbA1c nor duration of diabetes was associated with residual gastric volume. The adjusted mean ratio of residual gastric volume was 1.07 (98.3% CI: 0.89, 1.28; P = 0.38) for 1% increase in HbA1c concentration, and 0.84 (98.3% CI: 0.63, 1.14; P = 0.17) for each 10-year increase induration of diabetes. The median [Q1-Q3] absolute difference between gastric ultrasound measurement and endoscopic measurement was 25 [15, 65] ml. CONCLUSIONS: In this prospective observational cohort study, neither the duration nor severity of diabetes influenced preoperative residual gastric volume. Gastric ultrasound can help identify patients who have excessive residual volumes despite overnight fasting.

Association of Intraoperative Tidal Volumes and Acute Kidney Injury After Noncardiac Surgery.

BACKGROUND: Patients with acute lung injury who received lower tidal volume (VT) ventilation had significantly fewer days with acute kidney injury (AKI) when compared to those receiving higher VTs. There is a paucity of studies on the relationship between intraoperative VTs and postoperative AKI in patients undergoing noncardiac surgery. We therefore sought to assess the association of mean delivered intraoperative VT per kilogram based on predicted body weight (PBW) and postoperative AKI. METHODS: This retrospective cohort study was conducted in a large tertiary multispecialty academic medical center. Adult patients who underwent noncardiac surgery between January 2005 and July 2016 under general anesthesia with endotracheal intubation and mechanical ventilation were included. A total of 41,224 patients were included in the study.The relationship between mean intraoperative VT per PBW and AKI was assessed using logistic regression, adjusting for prespecified potential confounding variables. The secondary outcomes were postoperative major pulmonary complications, myocardial injury after noncardiac surgery (MINS), and in-hospital mortality. RESULTS: The incidence of AKI was 10.9% in the study population. Postoperative renal replacement therapy was required in 0.1% of patients. Higher delivered mean intraoperative VT per PBW was significantly associated with increased odds of AKI. The estimated odds ratio for each 1 mL increase in VT per kilogram of PBW (1 unit) was 1.05 (95% confidence interval [CI], 1.02-1.08; P = .001), after adjusting for potential confounding variables. A higher delivered mean intraoperative VT per PBW was significantly associated with increased odds of postoperative myocardial injury and was not significantly associated with major postoperative pulmonary complications or in-hospital mortality after noncardiac surgery. CONCLUSIONS: In adult patients undergoing noncardiac surgery, higher delivered mean intraoperative VTs per PBW are associated with an increased odds of developing AKI.

Nonoperating Room Anesthesia: Anesthesia in the Gastrointestinal Suite.

Exponential growth in endoscopy suite procedures due to technological advances requires teamwork between anesthesiologists, endoscopists, nursing teams, and technical and support staff. The current standard of care for moderate sedation includes a combination of anxiolytic drugs and analgesic drugs and sometimes are not adequate to ensure patient safety, efficiency, and comfort. The use of anesthesia services can improve safety, recovery, turnovers, and efficiency. The article discusses comprehensive preoperative evaluation, optimization of comorbidities, and intraoperative airway management strategies to deliver safe and efficient anesthesia, given the need to share the airway and allow the use of carbon dioxide in the gastrointestinal suite.

Nil per os guidelines: what is changing, what is not, and what should?

Preoperative nil per os (NPO) guidelines have been in existence since the recognition of the risk of perioperative aspiration. These guidelines aim at reducing the risk for gastric content aspiration to the lowest possible, to avoid associated morbidity, unplanned hospital and/or an intensive care admission. Thus, such guidelines are not only considered for patients having major surgeries, but more so in those having ambulatory surgery including those performed at non-operating room anesthesia locations. NPO guidelines have always been controversial due to the paucity of data in support of one recommendation versus another and have seen multiple changes and updates by the issuing national anesthesiology societies as new evidence emerges. At the present time, they have become increasingly permissive, such that the ingestion of clear fluids is now encouraged up to two hours before elective surgery. This has added more fuel to the already heated controversies regarding NPO guidelines and contributed to the experienced variability among different local NPO policies adopted by different clinicians. In this article, we attempt to discuss many of these controversies, including the relationship between NPO duration and the risk of aspiration, NPO and the choice of airway device, NPO and operating room efficiency and NPO for procedural sedation.

Non-Operating Room Anesthesia in the Endoscopy Unit.

The term, non-operating room anesthesia, describes a location remote from the main operating suites and closer to the patient, including areas that offer specialized procedures, like endoscopy suites, cardiac catheterization laboratories, bronchoscopy suites, and invasive radiology suites. There has been an exponential growth in such procedures and they present challenges in both organizational aspects and administration of anesthesia. This article explores the requirements for the location, preoperative evaluation and patient selection, monitoring, anesthesia technique, and postoperative management at these sites. There is a need to better define the role of the anesthesia personnel at these remote sites.

Surgical options for refractory ventricular tachycardia.

Ventricular tachycardia (VT) is most often treated with antiarrhythmic drug therapy. When standard drugs fail, percutaneous, endocardial ablation guided by electroanatomic mapping is usually curative. Occasionally, these options are either unsuccessful or are not feasible, and surgical ablation is required. Surgical ablation of VT employs electroanatomic mapping and a variety of ablation strategies and technologies. The specific approach (endocardial vs. epicardial, beating heart vs. arrested) and ablation device must be tailored to the patient's anatomy and presentation. We present three cases to illustrate the range of surgical options available for ablation of VT arising from different anatomic foci.

Intraoperative electro-anatomical mapping and beating heart ablation of ventricular tachycardia.

In most cases ventricular tachycardia is responsive to antiarrhythmic drug therapy. If antiarrhythmic drugs fail, then percutaneous, endocardial ablation guided by electro-anatomical mapping is usually curative. Occasionally neither of these therapies is successful and surgical ablation is required. Challenges encountered in surgical ablation include application of reliable intraoperative real-time electro-anatomical mapping to identify the focus of ventricular tachycardia and the need for technology that enables ablation on the beating heart. We present a case demonstrating the feasibility of surgical cryoablation of ventricular tachycardia arising from the right ventricle using intraoperative real-time epicardial and endocardial electro-anatomical mapping and argon-based cryoablation.

Deep sternal wire infection resulting in severe pulmonary valve endocarditis.

Right-sided infective endocarditis is uncommon, comprising less than 5% of all cases of endocarditis. This is primarily seen in patients with drug abuse, long-term intravenous catheters, and congenital malformations, or a combination of these. Isolated pulmonary valve endocarditis is difficult to recognize due to its rarity, minimal cardiac manifestations, and predominance of pulmonary infections secondary to embolization of the vegetations. We describe an unusual case of chronic sternal wound infection and migration of an infected braided sternal wire causing right ventricular outflow tract and pulmonary valve endocarditis, which necessitated a complicated reoperation including pulmonary valve replacement with a homograft.

Surgery for permanent atrial fibrillation: impact of patient factors and lesion set.

BACKGROUND: Whether a complete Cox-maze procedure is needed to ablate permanent atrial fibrillation in patients undergoing concomitant cardiac surgery is unknown. Our objective was to assess the effectiveness of different lesion sets in such patients. METHODS: From November 1991 to January 2004, 575 patients underwent surgical treatment of permanent atrial fibrillation (duration > 6 months); mitral valve disease was the primary indication for surgery in 74%. Procedures included pulmonary vein isolation alone (n = 68, 12%), pulmonary vein isolation with left atrial connecting lesions (n = 265, 46%), and Cox-maze (n = 242, 42%). Rhythm documented on 5,120 postoperative electrocardiograms was used to estimate time-related prevalence of, and risk factors for, atrial fibrillation. RESULTS: Prevalence of postoperative atrial fibrillation peaked at 46% two weeks after operation, declining to 24% at one year. Patient-related risk factors for increased prevalence included older age (p < 0.0001), larger left atrium (p < 0.0001), and longer duration of preoperative atrial fibrillation (p = 0.0008). The Cox-maze procedure and lesion sets resembling it created with alternative energy sources had a similarly low prevalence of late postoperative atrial fibrillation; in contrast, pulmonary vein isolation and lesion sets that did not include a lesion to the mitral anulus were less effective. CONCLUSIONS: This study suggests that in cardiac surgical patients with permanent atrial fibrillation the left atrial lesion set should include wide pulmonary vein isolation, at least one connection between right and left pulmonary veins, and a connection to the mitral anulus. Availability of alternative energy sources to create lesions sets has virtually eliminated the need for the cut-and-sew Cox-maze procedure.