Intraoperative vasoplegia: methylene blue to the rescue!

PURPOSE OF REVIEW: To evaluate the efficacy, dosing, and safety of methylene blue (MTB) in perioperative vasoplegic syndrome (VS). RECENT FINDINGS: Vasoplegic syndrome is a state of persistent hypotension with elevated cardiac output, low filling pressures, and low systemic vascular resistance (SVR). It occurs in up to 25% of patients undergoing cardiac surgery with cardiopulmonary bypass, can last up to 72 h, and is associated with a high mortality rate. MTB has been found to increase SVR and decrease vasopressor requirements in vasoplegic syndrome by inhibiting nitric oxide synthase, thus limiting the generation of nitric oxide, while inhibiting activation of soluble guanylyl cyclase and preventing vasodilation. MTB has been used in postgraft reperfusion during liver transplantation and anaphylaxis in a limited number of cases. Additionally, this medication has been used in septic shock with promising results, but similar to the cardiac surgical population, the effects of MTB administration on clinical outcomes has yet to be elucidated. SUMMARY: MTB should be considered during vasoplegic syndrome in cardiac surgery with cardiopulmonary bypass and usage may be more effective in an early critical window, prior to end-organ hypoperfusion. Other perioperative scenarios of MTB use show promise, but additional studies are required to develop formative conclusions.

Outcomes in Patients Undergoing Cardiac Surgery Who Decline Transfusion and Received Erythropoietin Compared to Patients Who Did Not: A Matched Cohort Study.

BACKGROUND: Erythropoiesis-stimulating agents, such as erythropoietin (EPO), can be used to treat preoperative anemia. Some studies suggest an increased risk of mortality and thrombotic events, and use in cardiovascular surgery remains off-label. This study compares outcomes in cardiac surgery patients declining blood transfusion who received EPO with a matched cohort who did not. METHODS: After institutional review board approval, we conducted a retrospective review of all patients who decline blood transfusion who underwent cardiac surgery and received EPO between January 1, 2004, and June 15, 2015, at a single institution. Control patients who did not receive EPO and were not transfused allogeneic red blood cells perioperatively were identified during the same period. Two controls were matched to each EPO patient using an optimal matching algorithm based on age, date of surgery, gender, operative procedure, and surgeon. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) and baseline characteristics remaining unbalanced in the matched cohorts were controlled for in assessing patient outcomes. The primary outcome was a composite of mortality and thrombotic events, and secondary outcomes included change in hemoglobin (Hb) from baseline to discharge, acute kidney injury (AKI), sternal wound infection, atrial fibrillation, time to extubation, intensive care unit, and hospital length of stay (LOS). RESULTS: Fifty-three patients who decline transfusion and received EPO were compared to 106 optimally matched control patients who did not receive EPO or red blood cell transfusion in the perioperative period. The median additive EuroSCORE was similar between the EPO and control group [6 (4, 9) vs 5 (3, 7), respectively; P = .39]. There was no difference in the primary outcome (P = .12) and mortality was zero in both groups. The EPO group had a higher mean preoperative Hb (13.91 g/dL vs 13.31; P = .02) and a smaller change in Hb from baseline (-2.65 vs -3.60; P = .001). The incidence of AKI (47.17% vs 41.51%; P = .49) was similar and there was no significant difference in all other outcomes, including time to extubation, hospital LOS, or intensive care unit LOS. CONCLUSIONS: In this retrospective matched cohort study of patients declining transfusion and receiving EPO matched to control patients, there were no clinically meaningful differences in the outcomes.

Diversity in the American Society of Anesthesiologists Leadership.

BACKGROUND: Women and minorities are underrepresented in US academic medicine. The Sullivan Commission on Diversity in the Healthcare Workforce emphasized the importance of diverse leadership for reducing health care disparities. The objective of this study was to evaluate the demographics of the American Society of Anesthesiologists leadership. We hypothesized that the percentage of women and underrepresented minorities is less than that of their respective proportions in the general physician workforce. METHODS: An electronic survey was developed by the authors and mailed to 595 members of the American Society of Anesthesiologists leadership who had valid email addresses, including the members of the 2014 House of Delegates and state society leaders who were not the members of the House of Delegates. Univariate statistics were used to characterize survey responses and the probability distributions were estimated using the binomial distribution. A one-sample t test was used to compare the percentage of women and minorities in the survey pool to that of the corresponding percentages in the general physician workforce (38.0% women and 8.9% minorities), and the US population (51.0% women and 32.0% minorities). RESULTS: The survey response rate was 54%. A total of 21.1% (95% confidence interval: 16.4%-25.7%) of respondents were women and 6.0% (95% confidence interval: 3.3%-8.7%) were minorities. The proportion of women in the American Society of Anesthesiologist leadership was lower than the general medical workforce and the US population (P < .001 for both); the proportion of underrepresented minorities was lower than the US population (P < .001). CONCLUSIONS: Women and minorities are underrepresented in the leadership of the American Society of Anesthesiologists. Efforts should be made to increase the diversity of the American Society of Anesthesiologists leadership with the goal of reducing overall anesthesia workforce disparities.

Evaluation of the Foundation for Anesthesia Education and Research Medical Student Anesthesia Research Fellowship Program Participants' Scholarly Activity and Career Choices.

BACKGROUND: The Foundation for Anesthesia Education and Research Medical Student Anesthesia Research Fellowship (MSARF) program is an 8-week program that pairs medical students with anesthesiologists performing anesthesia-related research. This study evaluated the proportion of students who published an article from their work, as well as the percentage of students who entered anesthesiology residency programs. METHODS: A list of previous MSARF participants (2005 to 2012), site, and project information was obtained. Searches for publications were performed using PubMed. The primary outcome was the publication rate for MSARF projects. The MSARF abstract-to-publication ratio was compared with the percentage of abstracts presented at biomedical meetings that resulted in publication as estimated by a Cochrane review (44%). For students who had graduated from medical school, match lists from the students' medical schools were reviewed for specialty choice. RESULTS: Forty-two percent of the 346 MSARF projects were subsequently published. There was no difference between the MSARF abstract-to-publication ratio and the publication rate of articles from abstracts presented at scientific meetings (P = 0.57). Thirty percent (n = 105; 95% CI, 25 to 35%) of all the MSARF students were authors on a publication. Fifty-eight percent of the students for whom residency match data (n = 255) were available matched into anesthesiology residencies (95% CI, 52 to 64%). CONCLUSIONS: The MSARF program resulted in many students being included as a co-author on a published article; the majority of these students entered anesthesiology residency programs. Future research should determine whether the program has a long-term impact on the development of academic anesthesiologists.

Resection of portovenous structures to obtain microscopically negative margins during pancreaticoduodenectomy for pancreatic adenocarcinoma is worthwhile.

Locally advanced pancreatic adenocarcinoma may require resections of the portal vein and/or its major tributaries to achieve tumor extirpation, albeit with the potential for increased morbidity and mortality. However, major venous resections can impart complete tumor extirpation and thereby a survival advantage compared with resections with residual microscopic disease. This study was undertaken to determine if resection of the portal vein and/or its splenic or superior mesenteric venous (SMV) tributaries is a worthwhile endeavor. Since 1995, patients undergoing pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma have been prospectively followed. The impact of portovenous resections (portal vein, SMV, and/or splenic vein) on survival was evaluated using survival curve analysis (Mantel-Cox test). Margins were codified as R0 or R1 and data are presented as median, mean +/- SD where appropriate. For 220 patients undergoing PD for pancreatic adenocarcinoma, survival was 17 months. Patients undergoing R0 resections had improved survival relative to patients undergoing R1 resections (20 vs 13 months, P < 0.03). Concomitant portovenous resections were undertaken in 48 patients. There was no difference in survival after PD without portovenous resection (17 months) versus PD with portovenous resection (18 months). Resections with complete tumor extirpation (i.e., R0 resections) provide superior long-term survival; all efforts to obtain R0 resections should be undertaken. Portovenous resections during pancreaticoduodenectomy can be undertaken safely and are worthwhile when complete tumor extirpation is attainable.