Comparison of visual estimation and quantitative measurement of left ventricular ejection fraction in untrained perioperative echocardiographers.

BACKGROUND: Perioperative evaluation of the left ventricular systolic function is essential information to help diagnose and manage life-threatening perioperative emergencies. Although quantifying the left ventricular ejection fraction (LVEF) is recommended to determine the left ventricular function, it may not always be feasible in emergency perioperative settings. This study compared the visual estimation of LVEF (eyeballing) by noncardiac anesthesiologists with the quantitative LVEF measured using a modified Simpson's biplane method. METHODS: Transesophageal echocardiographic (TEE) studies of 35 patients were selected and 3 different echocardiographic views (the mid-esophageal four chamber view, the mid-esophageal two chamber view, and the transgastric mid-papillary short axis view) were recovered from each study and displayed in random order. Two cardiac anesthesiologists certified in perioperative echocardiography independently measured LVEF using the modified Simpson method and categorized LVEF into five grades: hyperdynamic LVEF, normal, mildly reduced LVEF, moderately reduced LVEF and severely reduced LVEF. Seven noncardiac anesthesiologists with limited experience in echocardiography also reviewed the same TEE studies and estimated the LVEF and graded LV function. The precision of the LV function classification and the correlation between visual estimation of LVEF and quantitative LVEF were calculated. The agreement of measurements between the two methods was also assessed. RESULTS: Pearson's correlation between the LVEF estimated by the participants and the quantitative LVEF using the modified Simpson method was 0.818 (p < 0.001). Of a total of 245 responses, 120 (49.0%) responses were correct grading of the LV function. Participants were able to classify the LV function more accurately in the LV function grades 1 and 5 (65.3%). The 95% level of agreement of the Bland-Altman method was - 11.3-24.5. -21.9-22.6, - 23.1-26.5, - 20.5-22.0 and - 26.6-11.1 for LV grade 1 to 5, respectively. CONCLUSION: Visual estimation of LVEF in perioperative TEE has acceptable accuracy in untrained echocardiographers and can be used for rescue TEE.

Learning curve for the acquisition of 20 standard two-dimensional images in advanced perioperative transesophageal echocardiography: a prospective observational study.

BACKGROUND: Learning to perform intraoperative transesophageal echocardiography takes time and practice. We aimed to determine the cumulative success rate in the first 20 intraoperative transesophageal echocardiography cases performed by trainee anesthesiologists with no transesophageal echocardiography experience. METHODS: This prospective observational study included nine anesthesiologists (four cardiovascular and thoracic anesthesia fellows and five short-course perioperative intraoperative transesophageal echocardiography trainees). Overall, 180 studies self-performed by the trainees were reviewed by certified reviewers. A study was considered successful when at least 15 qualified images were collected within 30 min. The cumulative success of each trainee was used as a surrogate of a basic two-dimensional intraoperative transesophageal echocardiography learning curve. RESULTS: The participants comprised three male and six female anesthesiologists aged 29-43 years with 2-13 years of work experience. Most studies (146/180, 81.11%) were completed within 30 min, and the cumulative success rate was 70-90% (average 82.78 ± 6.71%). The average cumulative success rate in the short-course group (85 ± 7.07%) was higher than that in the official cardiovascular and thoracic fellow trainee group (80 ± 7.07%). The recommended caseload for a 80-100% success rate was 18-20 cases (95% confidence interval, 0.652-0.973). The CUSUM method analysis confirmed that the lower decision limit was crossed after 20 TEE studies among those achieved competence. CONCLUSIONS: We recommended a 18-20 caseload for a target success rate of 80-100% in studies performed by trainees with no previous experience. Our findings will enable the development of programs to train anesthesiologists in intraoperative transesophageal echocardiography.

Lung ultrasound is non-inferior to bronchoscopy for confirmation of double-lumen endotracheal tube positioning: a randomized controlled noninferiority study.

BACKGROUND: Appropriate placement of left-sided double-lumen endotracheal tubes (LDLTs) is paramount for optimal visualization of the operative field during thoracic surgeries that require single lung ventilation. Appropriate placement of LDLTs is therefore confirmed with fiberoptic bronchoscopy (FOB) rather than clinical assessment alone. Recent studies have demonstrated lung ultrasound (US) is superior to clinical assessment alone for confirming placement of LDLT, but no large trials have compared US to the gold standard of FOB. This noninferiority trial was devised to compare lung US with FOB for LDLT positioning and achievement of lung collapse for operative exposure. METHODS: This randomized, controlled, double-blind, noninferiority trial was conducted at the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand from October 2017 to July 2019. The study enrolled 200 ASA classification 1-3 patients that were scheduled for elective thoracic surgery requiring placement of LDLT. Study patients were randomized into either the FOB group or the lung US group after initial blind placement of LDLT. Five patients were excluded due to protocol deviation. In the FOB group (n = 98), fiberoptic bronchoscopy was used to confirm lung collapse due to proper positioning of the LDLT, and to adjust the tube if necessary. In the US group (n = 97), lung ultrasonography of four pre-specified zones (upper and lower posterior and mid-axillary) was used to assess lung collapse and guide adjustment of the tube if necessary. The primary outcome was presence of adequate lung collapse as determined by visual grading by the attending surgeon on scale from 1 to 4. Secondary outcomes included the time needed to adjust and confirm lung collapse, the time from finishing LDLT positioning to the grading of lung collapse, and intraoperative parameters such has hypotension or hypertension, hypoxia, and hypercarbia. The patient, attending anesthesiologist, and attending thoracic surgeon were all blinded to the intervention arm. RESULTS: The primary outcome of lung collapse by visual grading was similar between the intervention and the control groups, with 89 patients (91.8%) in the US group compared to 83 patients (84.1%) in the FOB group (p = 0.18) experiencing adequate collapse. This met criteria for noninferiority per protocol analysis. The median time needed to confirm and adjust LDLT position in the US group was 3 min (IQR 2-5), which was significantly shorter than the median time needed to perform the task in the FOB group (6 min, IQR 4-10) (p = 0.002). CONCLUSIONS: In selected patients undergoing thoracic surgery requiring LDLT, lung ultrasonography was noninferior to fiberoptic bronchoscopy in achieving adequate lung collapse and reaches the desired outcome in less time. TRIAL REGISTRATION: This study was registered at clinicaltrials.gov, NCT03314519 , Principal investigator: Kasana Raksamani, Date of registration: 19/10/2017.

How postgraduate trainees from different health professions experience the learning climate within an operating theater: a mixed-methods study.

BACKGROUND: The learning climate within a learning environment is a key factor to determine the potential quality of learning. There are different groups of postgraduate trainees who study primarily in the operating theater (OT), which is a complex, high-stake environment. This study created and validated an interprofessional measure of the OT educational climate and explored how postgraduate trainees from different health professions experienced the learning climate within the operating theater. METHODS: An explanatory, sequential mixed-method design was used. The quantitative phase used and validated a newly developed questionnaire, the Operating Theater Educational Climate Test (OTECT), to evaluate the perceptions of anesthesia residents, surgical residents and student registered nurse anesthetists. In the qualitative phase, three mono-professional focus groups participants' opinions on the factors influencing their learning climate were explored. RESULTS: The OTECT questionnaire was found to be valid. The questionnaire response rate was 78.9% (142 respondents from 180). Questionnaire results indicated similar perceptions of the OT learning climate by learners from all disciplines. Focus groups revealed three major influencing factors on the experienced learning climate: 1) nature of work in the OT, 2) the role of the supervisor, and 3) the interprofessional dimension of work in the OT. CONCLUSIONS: The OT learning climate was perceived similarly by trainees from three health profession. The high stakes nature of the OT inhibited learning most as it impacted both trainees and supervisors. The results can be applied to improve the overall learning environment in the OT for all groups of learners.

The Changes in Cortisol Levels during Cardiac Surgery: A Randomized Double-Blinded Study between Two Induction Agents Etomidate and Thiopentone.

OBJECTIVE: To study the changes in cortisol levels during and after cardiac surgery after an inductive dose of either etomidate or thiopentone and their consequences. MATERIAL AND METHOD: A prospective, randomized, double-blinded study was conducted in 26 patients undergoing elective cardiac surgery. They received either etomidate or thiopentone for induction. Serum cortisol levels were measured preoperatively, and then at 2-, 4-, 8-, and 24-hour All of the patients received standard anesthesia and surgery. The data also included patients perioperative management and outcome. RESULTS: There is no difference in patients' characteristics. The baseline plasma morning cortisols in the two groups were comparable (11.7 ± 7.5 mcg/dL in etomidate group vs. 12.0 ± 8.2 mcg/dL in thiopentone group). In both groups, during surgery, the cortisol levels rose to higher levels and reached peak levels at four to eight hours and related to surgical stress. At all times, the etomidate group had lower cortisol levels but only at 8-hour the etomidate group had significantly lower cortisol level (39.9 ± 14.2 vs. 65.9 ± 20.0 mcg/dL). At 24 hours, in both groups, cortisol levels were lower than at 8-hour but did not return to normal baseline levels. There were no differences in the dose of inotropic use and ICU stay. However surprisingly the etomidate group had shorter hospital stay. CONCLUSION: A single dose of etomidate usedfor induction in elective cardiac patients can partially and reversibly inhibit of the cortisol synthesis for, at least, 24 hours, but its association with any hemodynamic consequences cannot be concluded. REGISTRATION: ClinicalTrials.gov as NCT01495949.

Ninety days mortality after thoracic endovascular aortic repair.

BACKGROUND: The thoracic endovascular aortic repair (TEVAR) has become popular due to its favorable immediate outcome. However, the outcome in longer duration is still questionable. The aim of the present study was to analyze the incidence and risk factors associated with 90 days mortality after TEVAR. MATERIAL AND METHOD: After the Siriraj Institutional Review Board, Thailand approved and waived the needfor the informed consent, the database that included 160 consecutive patients having TEVAR procedures between December 2006 and December 2010 was examined Patients' characteristics, including operative procedures and anesthesia techniques were studied. The mortality and complications were extracted and analyzed. Major adverse events and the others factors were analyzed to determine the risk factors. Other complications such as bleeding, endoleak, infection, and reintervention were examined and analyzed. RESULTS: One hundred sixty patients underwent TEVAR. They included 118 male (74%) and 42 female (26%) with mean age of 65. Perioperative mortality (within 24 hours postoperatively) was 1 (0.6%), 30 days mortality was 7 (4.4%) and the overall 90 days mortality was 10 (6.25%). Causes of death included sepsis [4 patients (2.5%)], multi-organ failure [3 patients (1.9%)], ischemic heart disease [1 patient (0.6%)], uncontrolled bleeding [1 patient (0.6%)], and graft ruptured [1 patient (0.6%)]. The risk factor related to mortality was postoperative neurological morbidity (OR 6.77, 95% CI = 1.08-42.36, p = 0.4). General anesthesia with endotracheal tube was used in the majority of the patients (92.5%), with no statistical significance in anesthesia-related mortality. Major adverse events including pneumonia 11.9%, cardiac arrhythmia 11.3%, graft infection 7.5%, neurological complication 7.0% (ischemic stroke 9 andparaplegia 1), renal failure 3.8%, and myocardial ischemia 0.6%. CONCLUSION: The incidence of 90 days mortality after TEVAR was 6.25% (10 from 160). The risk factor associated with mortality was the development of neurologic complication postoperatively.

An Equivalence Trial Comparing Labetalol and Diltiazem in Controlling Emergence Hypertension after Supratentorial Tumor Surgery.

BACKGROUND: Hypertension and tachycardia during emergence from anesthesia for craniotomy could increase risks of cerebral complications. Several anesthetic, sedative, and antihypertensive drugs have been suggested that may be successful at suppressing these unwanted hemodynamic consequences. OBJECTIVE: To study the equivalent efficacy and side effects of two antihypertensive drugs, diltiazem and labetalol. MATERIAL AND METHOD: A block randomized control trial was performed in 184 patients who developed emergence hypertensive response after craniotomyfor supratentorial tumor removal. Systolic blood pressure (SBP) of each patient was suppressed by 2.5 mg of study drugs and repeated with fix dosage of 2.5 mg every two to three minutes to maintain SBP lower than 140 mmHg with a cumulative dose within 20 mg. Data regarding demographic, successful rate in controlling hypertension, drug dosage, and incidence of side effects were analyzed. RESULTS: The success rate of treatment of labetalol was equivalent to diltiazem (87.1% and 80.2% respectively) [p = 0.003, 95% CI = 6.88 (-2.06 to 15.8)]. There was no statistical significant difference on dosage of drugs used or incidence ofside effect (hypotension, bradycardia, heart block, and bronchospasm). Median (minimum-maximum) dosage of labetalol and diltiazem were 10 mg (2.5-20 mg) and 10 mg (2.5-20 mg) respectively. The expense for labetalol was 1/6 of diltiazem. CONCLUSION: Labetalol has equivalent efficacy to diltiazem. Both drugs used low median dosage giving low incidence of side-effects. Labetalol is a good alternative drug to control hypertensive response during emergence from anesthesia for post-craniotomy.

Pain management after cardiac surgery: are we underestimating post sternotomy pain?

OBJECTIVE: Good pain management can improve the outcome of patient care after cardiac surgery. The intensity of pain after cardiac surgery is often underrated. Inadequate pain control can result in increased morbidity and length of hospital stay as well as lead to chronic pain. Therefore, the authors conducted a study to identify the prevalence and risk factors of moderate to severe pain after cardiac surgery including treatment and complication. MATERIAL AND METHOD: The present study was prospectively performed in the patients undergoing cardiac surgery with median sternotomy in Siriraj Hospital, a tertiary care center between July 2009 and November 2010. Pain was assessed by numerical rating scale (NRS, 0-10) whilst NRS >4 was defined as moderate to severe pain. Pain score was recorded until 48 hours after surgery. Demographic data, history ofprevious cardiac and non-cardiac surgery, chronic pain history, details of the operation, and intra-and postoperative analgesia were recorded, including complication ofpain treatment. In addition, pain expectation and experience were compared and the patient satisfaction was evaluated RESULTS: Two hundred ninety patients were enrolled, 95.5% ASA physical status III, with mean duration of surgery 243.8 minutes (95-600) and cardiopulmonary bypass time 112.8 minutes (33-500). The prevalence of moderate to severe pain in the patients after cardiac surgery was 61.4%. The duration of cardiopulmonary bypass less than 60 minutes decreased numbers of patients with moderate to severe pain with adjusted OR ratio of 0.40, 95% CI = 0.16,1.004, (p<0.001). Complications of pain treatment were respiratory depression (0.7%), nausea (25.6%), vomiting (11.4%), pruritus (4.1%), and urinary retention (0.3%). The majority of the patients were satisfied with pain control (81.4%). CONCLUSION: The prevalence of moderate to severe pain in the present study was high and duration of cardiopulmonary bypass was the only factor affected Still, most patients were satisfied with the pain treatment.

Transcatheter aortic valve implantation (TAVI): first case in Thailand.

Aortic valve replacement (AVR) is the standard treatment for patients with symptomatic severe aortic stenosis (AS). However many patients are not offered surgery due to high surgical risk for open AVR. Transcatheter aortic valve implantation has been an alternative to open heart surgery in patients with symptomatic severe aortic stenosis (AS) who are not suitable for open surgery. The first transcatheter aortic valve implantation in Thailand via the transapical route is described. An 87-year-old woman with symptomatic severe AS, calcified aorta and peripheral arterial disease, who was at high surgical risk, was successfully treated, and had good functional and haemodynamic results at six-months follow-up.