Overcoming Challenges in the Management of Critical Events During Cardiopulmonary Bypass.

Critical events during cardiopulmonary bypass (CPB) can challenge the most experienced perfusionists, anesthesiologists, and surgeons and can potentially lead to devastating outcomes. Much of the challenge of troubleshooting these events requires a key understanding of these situations and a well-defined strategy for early recognition and treatment. Adverse situations may be anticipated prior to going on CPB. Atherosclerosis is pervasive, and a high plaque burden may have implications in surgical technique modification and planning of CPB. Hematologic abnormalities such as cold agglutinins, antithrombin III deficiency, and hemoglobin S have been discussed with emphasis on managing complications arising from their altered pathophysiology. Jehovah's witness patients require appropriate techniques for cell salvage to minimize blood loss. During initiation of CPB, devastating situations leading to acute hypoperfusion and multiorgan failure may be encountered in patients undergoing surgery for aortic dissection. Massive air emboli during CPB, though rare, necessitate an urgent diagnosis to detect the source and prompt management to contain catastrophic outcomes. Gaseous microemboli remain ubiquitous and continue to be a major concern for neurocognitive impairment despite our best efforts to improve techniques and refine the CPB circuit. During maintenance of CPB, adverse events reflect inability to provide optimal perfusion and can be ascribed to CPB machine malfunction or physiological aberrations. We also discuss critical events that can occur during perfusion and the need to monitor for organ perfusion in altered physiologic states emanating from hemodilution, hypothermia, and acid-base alterations.

Blood product storage: does age really matter?

Red blood cell transfusion therapy has been used with the ultimate goal of enhancing oxygen delivery to vital organs and tissue beds, thus enhancing cellular function. Red blood cell transfusion therapy is also a long-standing practice, and since the 1950s it has only grown in utilization, especially within the United States. Recently, transfusion therapy has come under increased scrutiny with a desire to develop evidence-based therapeutic guidelines that not only decrease undue risk to the patient but also decrease the overutilization of this high-cost, low-availability product. Despite the development and implementation of these guidelines, significant complications associated with red cell therapy persist and may be related to storage of blood products. Recently, within the transfusion literature, there has been a renewed focus on red cell storage lesions and their contributions to perioperative outcomes. Several meta-analyses, and now a recently launched, multinational randomized controlled trial, have been initiated to help bring clarity to whether or not the length of product storage has any effect on patient outcomes. This review will focus on the nature of storage lesions, complications associated with storage, as well as a brief review of some of the more provocative literature surrounding this controversial topic.

Teaching professionalism during anesthesiology training.

Recently, there has been a focus on the teaching of professionalism in postgraduate medical education. Many discussions and studies have been performed to help in teaching professionalism and in the evaluation of the effectiveness of this teaching process. Unfortunately, many anesthesiologists are unaware of the literature and the discussions that have taken place. This review article serves as a primer for those individuals faced with the task of instilling the concepts of professionalism, not only in trainees but also in anesthesiologists practicing today.