Anticoagulation with Argatroban in a Patient with Heparin-Induced Thrombocytopenia and Renal Insufficiency Undergoing Orthotopic Heart Transplantation.

Unfractionated heparin is the anticoagulant of choice for cardiac surgery that requires cardiopulmonary bypass. However, it can cause serious side effects like heparin-induced thrombocytopenia (HIT), an immune-mediated process where antibodies are directed against heparin and platelet 4 complexes. In such cases, alternative pharmacologic strategies are implemented to facilitate safe bypass conditions. A woman with severe decompensated heart failure was heparinized for intra-aortic balloon pump and subsequent LVAD placement. On day 6, a fall in platelets from 113,000 to 26,000 was noted. She was diagnosed with HIT. Heparin was discontinued and replaced with an argatroban infusion for the duration of her care until heart transplantation was completed. We review the mechanism, diagnosis, and complications of HIT. We discuss cardiopulmonary bypass and its relation to heparin, HIT, and heparin alternatives. We discuss argatroban's relevant pharmacology, clinical use, advantages, and disadvantages.

Anesthesia Resident Training Experience Minimally Impacts Emergence Time, Making Correlation of Resident Competency With This Operational Metric Difficult.

INTRODUCTION: Anesthesia residents are deemed competent based on subjective and objective metrics. Knowledge acquisition and procedural skill is often difficult to accurately measure. Inspecting tangible metrics of perioperative efficiency may provide a source for reliable evaluation. METHODS: Retrospective case-log database review yielded 3072 surgical cases involving residents over 5 years. Primary variable investigated was the time from surgery completion to exit from operating room. Other variables recorded included day of week, attending anesthesiologist name, attending surgeon name, patient age, sex, American Society of Anesthesiologists physical status (ASA PS) classification, and inpatient versus day surgery status. RESULTS: After controlling for procedure duration time, inpatient status, ASA PS, surgeon, and attending anesthesiologist, resident training time had high statistical significance. In the fully adjusted model, 1 year of resident training was associated with a reduction in emergence time by 28 seconds. A 1-hour increase in procedure time was associated with an increase in emergence time of 34 seconds. CONCLUSIONS: Although a statistically significant correlation between anesthesia resident training time and emergence time was demonstrated, the clinical significance is likely low given the relatively small amount of actual time saved. We caution the value of using perioperative metrics (e.g., emergence time) for evaluating anesthesia resident competency, until such metrics have undergone significant validation.

Operating room first case start times: a metric to assess systems-based practice milestones?

BACKGROUND: Resident competence in peri-operative care is a reflection on education and cost-efficiency. Inspecting pre-existing operating room metrics for performance outliers may be a potential solution for assessing competence. Statistical correlation of problematic benchmarks may reveal future opportunities for educational intervention. METHODS: Case-log database review yielded 3071 surgical cases involving residents over the course of 5 years. Surgery anticipated and actual start times were evaluated for delays and residents were assessed using the days of resident training performed at the time of each corresponding case. Other variables recorded included day of week, attending anesthesiologist name, attending surgeon name, patient age, sex, American Society of Anesthesiologists physical status classification (ASA PS), and in-patient versus day surgery status. Mixed-effect, multi-variable, linear regression determined independent determinants of delay time. RESULTS: The analysis identified day of the week (F = 25.65, P < 0.0001), days of training (F = 8.39, P = 0.0038), attending surgeon (F = 2.67, P < 0.0001), and anesthesiology resident (F = 1.67, P = 0.0012) as independent predictors of delay time for first-start cases, with an overall regression model F = 3.09, r2 = 0.186, and P < 0.0001. CONCLUSIONS: The day of the week and attending surgeon demonstrated significant impact of case delay compared to resident days trained. If a learning curve for first-case start punctuality exists for anesthesiology residents, it is subtle and irrelevant to operating room efficiency. The regression model accounted for only 19% of the variability in the outcome of delay time, indicating a multitude of additional unidentified factors contributing to operating room efficiency.

Using operating room turnover time by anesthesia trainee level to assess improving systems-based practice milestones.

BACKGROUND: Operating room (OR) metrics are frequently cited when optimizing cost efficacy and quality of care (Weiss et al, Characteristics of operating room procedures in U.S. hospitals, 2011: Statistical brief #170, 2013; Macario A, Anesthesiology 105:237-240, 2006; Childers et al, JAMA Surg 153:e176233, 2018). Little has been reported to evaluate how anesthesia trainees change anesthesia-related efficiencies in the OR. Statistical correlation may demonstrate awareness and implementation of efficient systems-based practice. METHODS: Utilizing computerized OR information systems, specific data regarding anesthesia controlled turnover times were collected (546 data points) over the course of 4 months. The type of surgery performed, patient's American Society of Anesthesiologists (ASA) physical status and OR turnover times were compared for clinical anesthesia (CA) trainee levels CA1, CA2, CA3 and CRNAs. Standard descriptive statistics were computed. Analysis of variance (ANOVA) was performed to compare the average turnover time. RESULTS: Average OR turnover time was 31 min ranging from 8 to 60 min. There was a significant difference between the OR turnover time of CA-1 (32 min) compared to CA-3 (29 min) (p = 0.017) and CA-1 compared to CRNA (30 min) (p = 0.016). OR turnover time was significantly shorter in CA-3 and CRNA. The analysis showed no differences between OR turnover time of ASA categories. CONCLUSIONS: These findings posit that trainees improve efficiency over time, but that education may for a time come at the expense of productivity. This trend may demonstrate a more profound understanding and mastery of a learner progressing in the graduate medical education system. This interplay plays a key role in clinical and academic shared success.

Crohn's disease-associated silent aspiration in the outpatient setting: Anesthesiologists beware.

Every anesthesia provider fears aspiration of gastric contents during an anesthetic, and it may occur even in the absence of overt signs such as coughing or choking. Whether the aspiration is frank or silent, catastrophic and deleterious consequences may ensue. Therefore, familiarity with risk factors for silent aspiration is essential. Crohn's disease reportedly delays gastric emptying making these patients more susceptible to silent aspiration during surgery. Anesthesia providers must be cognizant of this risk and vigilant in the recognition to formulate a specific treatment plan preoperatively. We present a case of an ambulatory surgical patient with suspected silent aspiration undiagnosed by the anesthesia care team before induction of anesthesia.

Near-Infrared Spectroscopy: The New Must Have Tool in the Intensive Care Unit?

Standard hemodynamic monitoring such as blood pressure and pulse oximetry may only provide a crude estimation of organ perfusion in the critical care setting. Near-infrared spectroscopy (NIRS) is based on the same principle as a pulse oximeter and allows continuous noninvasive monitoring of hemoglobin oxygenation and deoxygenation and thus tissue saturation "StO2" This review aims to provide an overview of NIRS technology principles and discuss its current clinical use in the critical care setting. The study selection was performed using the PubMed database to find studies that investigated the use of NIRS in both the critical care setting and in the intensive care unit. Currently, NIRS in the critical care setting is predominantly being used for infants and neonates. A number of studies in the past decade have shown promising results for the use of NIRS in surgical/trauma intensive care units during shock management as a prognostic tool and in guiding resuscitation. It is evident that over the past 2 decades, NIRS has gone from being a laboratory fascination to an actively employed clinical tool. Even though the benefit of routine use of this technology to achieve better outcomes is still questionable, the fact that NIRS is a low-cost, noninvasive monitoring modality improves the attractiveness of the technology. However, more research may be warranted before recommending its routine use in the critical care setting.

Anomalous Coronary Artery: Run of a Lifetime.

The anatomy of the coronary circulation is well described with incidence of congenital anomalies of approximately 0.3% to 1.0%. Although often incidental, 20% are life-threatening. A 25-year-old woman with syncopal episodes collapsed following a 10-km run. Coronary anatomy evaluation showed an anomalous left main coronary artery originating from the right sinus of valsalva and following a course between the aorta and the pulmonary outflow tract. Percutaneous coronary intervention was followed by eventual surgical revascularization. Abnormal course of coronary arteries plays a role in the pathogenesis of sudden death on exertion. Origin of the left main coronary from the right sinus of valsalva is a rare congenital anomaly. The expansion of the roots of the aorta and pulmonary trunk with exertion lead to compression of the coronary artery and syncope. Our patient raises awareness of a potentially fatal coronary artery path. Intraoperative identification of anomalous coronaries by utilizing intraoperative transesophageal echocardiography was critical.

Use of Methyl Tert-Butyl Ether for the Treatment of Refractory Intrahepatic Biliary Strictures and Bile Casts: A Modern Perspective.

Cholelithiasis is a prevalent problem in the United States with 14% or more adults affected. Definitive treatment of cholelithiasis is cholecystectomy. When cholecystectomy yields minimal resolution treatment options include expectant management of asymptomatic gallstones or endoscopic retrograde cholangiopancreatogram. We present a case of intrahepatic biliary casts where surgical option was not possible, interventional radiology was unsuccessful, and methyl tert-butyl ether was used to dissolve the biliary obstruction. Dissolution therapy of gallstones was first reported in 1722 when Vollisnieri used turpentine in vitro. While diethyl ether has excellent solubilizing capacity, its low boiling point limited its use surgically as it vaporizes immediately. Diethyl ether can expand 120-fold during warming to body temperature after injection into the biliary system making it impractical for routine use. The use of dissolution is out of favor due to the success of laparoscopic cholecystectomy. Epidemiological studies have shown the general population should have minimal concerns from passive exposure. Dissolution using MTBE remains a viable option if surgical or endoscopic options are not available. However, because of risks involved to both the patient and the staff, careful multidisciplinary team approach must be undertaken to minimize the risks and provide the best possible care to the patient.