Should All Patients With Pulmonary Hypertension Undergoing Non-Cardiac Surgery Be Managed by Cardiothoracic Fellowship-Trained Anesthesiologists?

OBJECTIVES: To identify differences in practice patterns and outcomes related to the induction of general anesthesia for patients with pulmonary hypertension (PH) performed by anesthesiologists who have completed a cardiothoracic fellowship (CTA group) vs those who have not (non-CTA group). DESIGN: Retrospective study with propensity score matching. SETTING: Operating room. PARTICIPANTS: All adult patients with PH undergoing general anesthesia requiring intubation at a single academic center over 5 years. INTERVENTIONS: Patient baseline characteristics, peri-induction management variables, post-induction mean arterial pressure (MAP), and other outcomes were compared between CTA and non-CTA groups. METHODS AND MAIN RESULTS: Following propensity scoring matching, 402 patients were included in the final model, 100 in the CTA group and 302 in the non-CTA group. Also following matching, only cases of mild to moderate PH without right ventricular dysfunction remained in the analysis. Matched groups were overall statistically similar with respect to baseline characteristics; however, there was a greater incidence of higher ASA class (P = .025) and cardiology and thoracic procedures (P < .001) being managed by the CTA group. No statistical differences were identified in practice patterns or outcomes related to the induction of anesthesia between groups, except for longer hospital length of stay in the CTA group (P = .008). CONCLUSIONS: These results provide early evidence to suggest the induction of general anesthesia of patients with non-severe PH disease can be comparably managed by either anesthesiologists with or without a cardiothoracic fellowship. However, these findings should be confirmed in a prospective study.

Dollars for Diagnosis: A Single-Institutional Analysis of Billing for Intraoperative Transesophageal Echocardiography Examinations.

OBJECTIVES: The authors sought to identify correctable reasons for the failed completion of required billing elements necessary for the reimbursement of services for intraoperative transesophageal echocardiography (TEE). DESIGN: This was a retrospective study. SETTING: This study was completed at a single institution and large academic center. PARTICIPANTS: The patient population included all adult patients who underwent cardiac surgery at a single academic center over one year. INTERVENTIONS: This retrospective review of TEE documentation and billing data was performed for the all adults undergoing cardiac surgery over the course of one year. METHODS AND MAIN RESULTS: Documentation characteristics were compared between examinations that were reimbursed and those that were not. Out of 504 TEE examinations, 30% were not reimbursed. For these examinations, there was a lower compliance in the completion of minimum billing requirements, compared with those that were reimbursed; designation as "diagnostic" (29% v 93%, respectively, p < 0.0001), procedure note (70% v 99%, p < 0.0001), and procedure order (67% v 98%, p = 0.0002). The total estimated annual loss in revenue was $36,000. CONCLUSIONS: Understanding documentation requirements for TEE is an overlooked but important part of anesthesiology practice that may lead to substantial cost savings. Completion of a procedure note, procedure order, and documentation of an examination as "diagnostic" was associated with successful billing.

Brain death interval and relationship to outcomes of pediatric cardiac transplantation.

BACKGROUND: We sought to analyze brain death interval and outcomes of pediatric cardiac transplantation using national registry data. METHODS: We retrospectively evaluated a pediatric cohort from the UNOS registry from 2005 to 2014. We restricted the donor cohort to those with a primary central nervous system event as the cause of hospitalization. Brain death interval (BDI) was defined as the time between hospital admission and organ procurement. Primary outcomes were recipient and graft survival time. Logistical regression modeling was used for multivariable analysis. RESULTS: The donor cohort included 2565 cases. Multivariable analysis demonstrated no relationship between BDI and recipient or graft survival time. For patient survival time, the lowest HR was 0.94 (0.63-1.39), P = 0.531; for graft survival time, the lowest HR was 0.89 (0.53-1.49), P = 0.563. We obtained similar results using a non-restricted donor cohort. CONCLUSIONS: There was no clear relationship between BDI and recipient or graft survival after pediatric cardiac transplantation.