Update in lung transplantation: anesthetic considerations.

The field of lung transplantation (LTx) has expanded rapidly since its inception in the early 1960s with the work of James Hardy and colleagues at the University of Mississippi from the work of local single specialty physicians into an international multidisciplinary specialty. Advancements throughout the next several decades have led to the completion of over 70,000 lung transplants worldwide. The unique challenges presented by patients with end-stage lung disease have both evolved and remained consistent since then, yet these challenges are being answered with major improvements and advancements in perioperative care in the 21st century. The current practice of LTx medicine is fundamentally multidisciplinary, and members of the LTx team includes surgeons, physicians, and allied health staff. The integration of anesthesiologists into the LTx team as well as the multidisciplinary nature of LTx necessitates anesthetic considerations to be closely incorporated into emerging surgical, medical, and systems techniques for patient care. This review discusses a host of emerging strategies across the spectrum of LTx, including efforts to expand the donor pool, utilization of perioperative extracorporeal life support, perioperative echocardiography, and anesthetic techniques to mitigate primary graft dysfunction that have all contributed to improved long term outcomes in LTx patients.

Outcomes of Lung Transplantation in Patients With Combined Pulmonary Fibrosis and Emphysema: A Single-Center Experience.

BACKGROUND: Combined pulmonary fibrosis and emphysema (CPFE) is a distinct clinical entity that can progress to end-stage lung disease. Patients with CPFE may develop pulmonary hypertension and face a predicted 1-year mortality of 60%. Lung transplantation is the only curative therapeutic option for CPFE. This report describes our experience after lung transplantation in patients with CPFE. METHODS: This retrospective, single-center study describes short- and long-term outcomes for adult patients who underwent lung transplant for CPFE. RESULTS: The study included 19 patients with explant pathology-proven diagnosis of CPFE. The patients were transplanted between July 2005 and December 2018. Sixteen recipients (84%) had pulmonary hypertension before transplant. Of the 19 patients, 7 (37%) had primary graft dysfunction at 72 hours post-transplant. 1-, 3-, and 5-year freedom from bronchiolitis obliterans syndrome was 100%, 91% (95% CI, 75%-100%), and 82% (95% CI, 62%-100%), respectively. One-, 3-, and 5-year survival was 94% (95% CI, 84%-100%), 82% (95% CI, 65%-100%), and 74% (95% CI, 54%-100%), respectively. CONCLUSION: Our experience demonstrates the safety and feasibility of lung transplant for patients with CPFE. Significant morbidity and mortality without lung transplant coupled with favorable post-transplant outcomes merit prioritization of CPFE in the Lung Allocation Score algorithm for lung transplant candidacy.

Perioperative Circulatory Support and Management for Lung Transplantation: A Case-Based Review.

Lung transplantation (LTx) historically was performed with cardiopulmonary bypass (CPB) or Off-pump. Recent data suggest an increased interest in extracorporeal membrane oxygenation (ECMO) as perioperative circulatory support by many lung transplantation centers worldwide. However, there are no established guidelines for anesthetic management for LTx. We present a patient with a history of systemic sclerosis and interstitial lung disease complicated by acute onset of systemic pulmonary hypertension and right heart failure undergoing LTx. We aim to discuss perioperative circulatory support, including ECMO bridge to LTx, and how best to consider the varied intraoperative strategies of CPB vs ECMO vs off-pump during LTx, intraoperative maintenance, and coagulation management.

Intraoperative Epicardial Ultra-High Frequency Ultrasound in Coronary Artery Bypass Grafting Surgery.

The use of intraoperative epicardial ultrasound in order to aid physicians and surgeons in open cardiac surgery has been established for quite some time. Recently, the development of ultra-high frequency ultrasound (UFHUS), 50-70 megahertz (MHz) technology has resulted in high-resolution imaging capabilities previously unavailable for clinical use. This report is the first to describe the use of intraoperative UFHUS epicoronary scanning to assess coronary anatomy and visualize cardioplegia flow within native coronary vessels.

Pericardiectomy for Constrictive Pericarditis: Analysis of Outcomes.

Constrictive pericarditis is caused by pericardial inflammation and fibrosis, leading to diastolic heart failure. The diagnosis requires a high index of suspicion because it often can mimic restrictive myocardial disease and cardiac tamponade and can be associated with severe tricuspid regurgitation and chronic liver disease. Patients who remain undiagnosed can experience a 90% mortality rate, and for those who undergo pericardiectomy, the survival rate varies significantly, depending on the underlying etiology and preoperative functional class of the patient. In this article, the authors review the pathophysiology, echocardiographic findings, management, and surgical outcomes of constrictive pericarditis to aid the cardiothoracic anesthesiologist in the perioperative management of this disorder.

Detrimental Effects of Filling Laryngotracheal Airways To Excessive Pressure (DEFLATE-P): a quality improvement initiative.

BACKGROUND: This quality improvement (QI) project was performed at a single center to determine the incidence of postoperative complications associated with use of cuffed airway devices. An educational program was then completed that involved training our anesthesia providers about complications related to excessive cuff pressure and how to utilize a quantitative cuff pressure measurement device (manometer). The impact of this educational initiative was assessed by comparing the incidence of postoperative complications associated with the use of airway devices before and after the training period. METHODS: After approval by our institution's Institutional Review Board, a pre-intervention (baseline) survey was obtained from 259 adult patients after having undergone surgery with general anesthesia with the use of an endotracheal tube (ETT) or laryngeal mask airway (LMA). Survey responses were used to determine the baseline incidence of sore throat, hoarseness, and dysphagia. Once these results were obtained, education was provided to the anesthesia department members addressing the complications associated with excessive cuff pressures, appropriate cuff pressures based on manufacturer recommendations, and instructions on the use of a quantitative monitor to determine cuff pressure (manometry). Clinical care was then changed by requiring intraoperative cuff pressure monitoring throughout our institution for all surgical patients. After this educational period, 299 patients completed the same survey describing postoperative airway complications. RESULTS: The use of manometry reduced the incidence of moderate-to-severe postoperative sore throat in the pre- vs. post-intervention groups (35 patients vs 31 patients, p = 0.045), moderate to severe hoarseness (30 patients vs 13, patients p = 0.0001), and moderate-to-severe dysphagia (13 patients vs 5 patients, p = 0.03). CONCLUSION: Caring for patients in the perioperative setting frequently entails placement of an airway device. This procedure is associated with several potential complications, including sore throat, coughing, and vocal cord damage. Our quality improvement initiative has shown that intraoperative management of intra-cuff pressure based on manometry is feasible to implement in clinical practice and can reduce postoperative airway complications.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2019.

This highlights in our specialty for 2019 begin with the ongoing major developments in transcatheter valve interventions. Thereafter, the advances in left ventricular assist devices are reviewed. The recent focus on conduit selection and robotic options in coronary artery bypass surgery are then explored. Finally, this special articles closes with a discussion of pulmonary hypertension in noncardiac surgery, anesthetic technique in cardiac surgery, as well as postoperative pneumonia and its outcome consequences.

Anesthetic management of lung transplantation: impact of presenting disease.

PURPOSE OF REVIEW: Recent literature has described the emerging role of anesthesiologists as key members of the lung transplantation team and the impact of anesthetic management on outcomes. This review examines the impact of presenting cause of end-stage lung disease (ESLD) on anesthetic management. RECENT FINDINGS: The four primary causes of ESLD are suppurative, obstructive, or restrictive processes, and pulmonary hypertension. Our recent review of perioperative literature revealed new data regarding preoperative risk stratification, intraoperative management, and postoperative use of extracorporeal membrane oxygenation (ECMO) support. Major studies specifically about anesthetic management are lacking; however, the principles studied are readily applicable to the design of a perioperative care plan. The most compelling data have resulted in a revolutionary change in terms of intraoperative support and postoperative planning for pulmonary hypertension patients. Historically treated with cardiopulmonary bypass, significant data have been reported describing the successful use of ECMO both as an intraoperative support with superior outcomes, as well as postoperative support for improved stability during biventricular remodeling post graft implantation. SUMMARY: The application of these updated findings should assist anesthesiologists as they develop internal protocols and external guidelines to integrate within multidisciplinary teams caring for the lung transplant patient.

Reducing Iatrogenic Pneumothoraces: Using Real-Time Ultrasound Guidance for Pleural Procedures.

OBJECTIVES: Awareness of the impact of bedside ultrasound to reduce iatrogenic pneumothoraces while performing bedside pleural procedures has increased but with little understanding in how ultrasound is used for these procedures. DESIGN AND SETTING: We conducted a retrospective chart review at a tertiary referral center in the United States from January 1, 2014, to March 31, 2017. Our study assessed adverse effect rates between real-time ultrasound-guided and ultrasound-marked thoracenteses and thoracostomy tube placements. PATIENTS: Three-hundred ninety-four ICU patients were included in this study. MEASUREMENTS AND MAIN RESULTS: There was a significant difference in the rate of adverse effects between real-time ultrasound-guided (0.63% [95% CI, 0.11-3.4%]) and ultrasound-marked (6.89% [95% CI, 4.15-11.24%]; p ≤ 0.01) procedures. More specifically, the rate of pneumothoraces was different between the two procedures (0.63% [95% CI, 0.11-3.4%] vs 4.43% [95% CI, 2.35-8.21%]; p = 0.02). In patients mechanically ventilated, there was a significant difference in overall adverse effect rates between groups of ultrasound use (p = 0.01). CONCLUSIONS: The use of real-time ultrasound guidance was associated with a lower rate of iatrogenic pneumothoraces.

Ultrasound-guided Percutaneous Peripheral Nerve Stimulation for the Treatment of Complex Regional Pain Syndrome Type 1 Following a Crush Injury to the Fifth Digit: A Rare Case Report.

This case report presents an application of percutaneous peripheral nerve stimulation to the left ulnar nerve to treat a patient with complex regional pain syndrome type 1 following a crush injury to the left fifth digit. Conventional treatment had failed to ameliorate the patient's condition. After a successful seven-day trial with an ulnar peripheral nerve catheter, which followed an unsuccessful capsulectomy of the metacarpophalangeal and proximal interphalangeal joints of the left fifth digit with tenolysis of the flexor tendons, the patient underwent an uneventful implantation of a percutaneous peripheral nerve stimulator parallel with the trajectory of the left ulnar nerve just distal to the ulnar tunnel. Two weeks after implantation of the percutaneous peripheral nerve stimulator, the patient reported a reduction in the pain, with the intensity score coming down from 7 out of 10 to 0-1 out of 10 on the numeric rating scale (NRS). The patient was able to initiate pain-free active motion of her left fifth digit. At the 3-month follow-up consultation, the patient reported maintenance of the reduction of pain in her left upper extremity with the implanted percutaneous peripheral nerve stimulator, as well as improved performance in her daily activities. Despite the success achieved in this particular case, further clinical series involving larger numbers of patients are warranted in order to assess the definitive role of percutaneous peripheral nerve stimulation for the treatment of neuropathic pain of the upper and lower extremities, which has been previously unresponsive to medical and/or surgical treatment.

Echocardiographic evaluation of aorta to right atrial fistula secondary to ruptured sinus of valsalva aneurysm.

We present the case of a 37 year old male who presented with new onset dyspnea, tachycardia, palpitations, and chest tightness. His initial work up demonstrated a dilated pulmonary artery with reflux of contrast dye in to the IVC. Transthoracic echocardiogram identified a "windsock" appearance indicating Sinus of Valsalva aneurysm (SVA) and severe aortic regurgitation. As a result, the patient was taken for emergent surgery where the windsock tissue was surgically repaired with bovine pericardial patch. This case illuminates the uncommon occurrence of SVA and the ability to recognize these findings on multiple imaging modalities including transthoracic, transesophageal two and three dimensional echocardiography as well as direct surgical field visualization.