Capillary leak and endothelial permeability in critically ill patients: a current overview.

Capillary leak syndrome (CLS) represents a phenotype of increased fluid extravasation, resulting in intravascular hypovolemia, extravascular edema formation and ultimately hypoperfusion. While endothelial permeability is an evolutionary preserved physiological process needed to sustain life, excessive fluid leak-often caused by systemic inflammation-can have detrimental effects on patients' outcomes. This article delves into the current understanding of CLS pathophysiology, diagnosis and potential treatments. Systemic inflammation leading to a compromise of endothelial cell interactions through various signaling cues (e.g., the angiopoietin-Tie2 pathway), and shedding of the glycocalyx collectively contribute to the manifestation of CLS. Capillary permeability subsequently leads to the seepage of protein-rich fluid into the interstitial space. Recent insights into the importance of the sub-glycocalyx space and preserving lymphatic flow are highlighted for an in-depth understanding. While no established diagnostic criteria exist and CLS is frequently diagnosed by clinical characteristics only, we highlight more objective serological and (non)-invasive measurements that hint towards a CLS phenotype. While currently available treatment options are limited, we further review understanding of fluid resuscitation and experimental approaches to target endothelial permeability. Despite the improved understanding of CLS pathophysiology, efforts are needed to develop uniform diagnostic criteria, associate clinical consequences to these criteria, and delineate treatment options.

Preoperative anemia is associated with increased radical cystectomy complications.

PURPOSE: The impact of anemia in postoperative complications following radical cystectomy (RC) is not completely elucidated and its association with direct hospital costs has not been characterized in depth. Our goal is to determine the association between anemia, 90-day surgical complications and the expenditure attributed to preoperative anemia in patients undergoing RC. MATERIALS AND METHODS: We captured all patients who underwent RC between 2003 and 2017 using the Premier Hospital Database (Premier Inc, Charlotte, NC). Patient, hospital and surgical characteristics were evaluated. Anemia was defined by a corresponding diagnostic code that was present on admission prior to RC. Unadjusted patients' demographic characteristics with and without anemia, hospital and surgeon characteristics were compared, and multivariable regression models were developed to evaluate 90-day complications and total direct hospital costs. RESULTS: The cohort included 83,470 patients that underwent RC between 2003 and 2017 and 11% were found to be anemic. On multivariable analysis, preoperative anemia more than doubled the odds of having a complication (odds ratio 2.19 (1.89-2.53)) and significantly increased the risk of major complications (odds ratio 1.51 (1.31-1.75)) at 90-days after RC. Anemic patients had significantly higher 90-days total direct costs due to higher laboratory, pharmacologic, radiology and operating room costs. CONCLUSIONS: Anemic cystectomy patients face a 50% increase in the risk of major complications within the first 90-days after surgery. This increased risk persisted after adjusting for patient, hospital and surgical factors. Our study suggests hematocrit level prior to RC may be used as a pre-exisitng condition for increased risk of surgical complications.

Use of Transversus Abdominis Plane (TAP) Blocks for Postoperative Pain Management in a Patient With an Open Abdomen: A Case Report and Review of Literature.

In light of the superior analgesia and opioid sparing effects provided by transversus abdominis plane (TAP) blocks, numerous new techniques and applications have evolved. However, TAP blocks are still underutilized in the critical care setting, and PubMed­listed reports on the relevance of TAP integrity for TAP block efficacy are lacking. Here, we report bilateral TAP blocks delivering quick, potent and durable pain relief to a patient with open abdomen (OA) after prior management with opioids and epidural anesthesia had failed. Extending TAP block application to OA patients even in the post­operative setting might hence reduce opioid consumption and quicken reconvalescence.

Anesthetic management of a patient with left ventricular assist device undergoing robotic laparoscopic prostatectomy: a case report.

BACKGROUND: Patients with left ventricular assist devices (LVAD) require specific anesthetic and hemodynamic considerations. We report the specific anesthetic preparation and management in this scenario. CASE PRESENTATION: We present the case of a 66-year-old male with a HeartMate II LVAD undergoing robotic prostatectomy for prostate cancer in the steep Trendelenburg position. We employed central venous and radial arterial access, LVAD pump parameters, near-infrared sensor of cerebral oximetry, and transesophageal echocardiography for monitoring. Hemodynamics were managed with nicardipine, dobutamine, epinephrine, and phenylephrine during abdominal insufflation, operative positioning, and desufflation. The patient had a successful procedure, was discharged on postoperative day 2, and achieved surgical cure of his prostate cancer. DISCUSSION: By presenting the first detailed account of anesthetic management in this scenario, we provide a clinical vignette for use by the clinical anesthesiologist in his or her preparation prior to caring for this type of patient.

Reduction in Cardiac Arrhythmias Within an Enhanced Recovery After Surgery Program in Colorectal Surgery.

BACKGROUND: Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway designed to achieve early recovery by preserving preoperative organ function and minimizing the stress response following surgery. Few studies have assessed the association between ERAS and postoperative cardiac complications. The goal of this study is to evaluate the impact of ERAS on postoperative cardiac complications. MATERIALS AND METHODS: A retrospective review of a prospectively maintained database of colorectal patients who underwent surgery at a tertiary colorectal cancer referral center was carried out. Preoperative, intraoperative, and postoperative factors including demographics, comorbidities, medications, and fluid administration were recorded. The primary outcome was postoperative cardiac arrhythmia, and secondary outcomes included other postoperative complications. RESULTS: A total of 800 patients who underwent elective colorectal surgery were identified. Four hundred seventeen patients (52%) were in the control group and 383 patients (48%) were in the ERAS group. Patients in both groups were similar with regard to demographics and clinical characteristics. There were significantly higher rates of cardiac arrhythmia in the control group (5.3%) compared with the ERAS group (1.8%), p = 0.009. Multivariable analysis revealed that ERAS was an independent predictor of decreased postoperative cardiac arrhythmia (OR 0.30, 95%CI 0.17-0.55, p < 0.001) while older age was an independent predictor of increased postoperative cardiac arrhythmia (OR 1.08, 95%CI 1.02-1.13, p = 0.008). Patients receiving lower amounts of intravenous fluids had significantly decreased postoperative cardiac arrhythmia (OR = 0.25, 95%CI 0.09-0.67, p = 0.006). CONCLUSIONS: ERAS and goal-directed fluid therapy are associated with significant reductions in postoperative cardiac arrhythmias.

Implementation of a Perioperative Venous Thromboembolism Prophylaxis Program for Patients Undergoing Radical Cystectomy on an Enhanced Recovery After Surgery Protocol.

BACKGROUND: Novel venous thromboembolism (VTE) prophylaxis programs, including postdischarge pharmacologic prophylaxis, have been associated with decreased VTE rates. Such practices have not been widely adopted in managing radical cystectomy (RC) patients. OBJECTIVE: To evaluate the effect of a perioperative VTE prophylaxis program on VTE rates after RC. DESIGN, SETTING, AND PARTICIPANTS: Single-institution, nonrandomized, pre- and post-intervention analysis of 319 patients undergoing RC at Brigham and Women's Hospital between July 2011 and April 2017. Patient and outcome data were prospectively collected as part of the American College of Surgeons National Surgical Quality Improvement Program. INTERVENTION: Before June 2015, patients only received postoperative pharmacologic and mechanical VTE prophylaxis in the inpatient setting. Starting June 2015, a perioperative VTE prophylaxis program was implemented as part of an enhanced recovery after surgery (ERAS) protocol, including a 28-d course of postdischarge enoxaparin. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcome was 30-d postoperative VTE rate. Secondary outcomes were perioperative bleeding rates, 30-d complication, readmission, and mortality rates, and length of stay. Univariate analysis was performed comparing outcomes between pre- and post-intervention cohorts. RESULTS AND LIMITATIONS: Of the 319 patients who underwent RC, 210 (66%) were in the pre- and 109 (34%) in the post-intervention cohort. VTE rate was significantly lower in the post-intervention cohort (n=1, 0.9% vs n=13, 6.2%; p=0.04). Rates of perioperative bleeding (35% vs 33%; p=0.80) and 30-d readmissions related to bleeding (1% vs 3.7%; p=0.19) did not differ significantly. Single-institution data limits generalizability, and patient compliance with postdischarge enoxaparin was unknown. CONCLUSIONS: Implementation of a perioperative VTE prophylaxis program as part of an ERAS protocol that includes extended postdischarge pharmacologic prophylaxis was associated with decreased rate of VTE events after RC. Perioperative bleeding and readmissions related to bleeding did not increase with this intervention. PATIENT SUMMARY: This study evaluated whether clotting complication rates after radical cystectomy (RC) for bladder cancer can be reduced by implementing a new postoperative care pathway. This pathway reduced rates of clotting complications without increasing bleeding rates and should be considered for all patients undergoing RC.

Cytoreductive Surgery and HIPEC in an Enhanced Recovery After Surgery Program: A Feasibility Study.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have historically been associated with high morbidity given the physiologic insult of an extensive operation. Enhanced Recovery after Surgery (ERAS) pathways have been successful in improving postoperative outcomes for many procedures but have not been well studied in these cases. We examined the feasibility and effect of ERAS pathway implementation for patients undergoing CRS/HIPEC. MATERIALS AND METHODS: Patients with peritoneal carcinomatosis who underwent CRS/HIPEC between October 2015 to September 2018 were identified. Patient characteristics, disease pathology, and perioperative outcome data were obtained. Primary outcomes were hospital length of stay (LOS), 30-d readmissions, renal dysfunction, and complications. RESULTS: Of the 31 patients who were included, 11 (35.5%) patients underwent CRS/HIPEC prior to the implementation of the ERAS pathway, and 20 (64.5%) patients underwent CRS/HIPEC according to the ERAS guidelines. There were no significant differences in the baseline clinical or pathologic characteristics between groups. There was a significant decrease in LOS with ERAS pathway management from 9 d to 6 d (P = 0.002). No patients from either cohort experienced acute kidney injury. There was no significant difference in 30-d readmission rates or complications. CONCLUSIONS: In this feasibility study, ERAS pathway utilization significantly decreased postoperative LOS for patients undergoing CRS/HIPEC, without evidence of increased complications or readmissions. ERAS programs should be considered for integration into future CRS/HIPEC protocols.

Implementation of liposomal bupivacaine transversus abdominis plane blocks into the colorectal enhanced recovery after surgery protocol: a natural experiment.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs are now standard of care for colorectal surgery. Efforts have been aimed at decreasing postoperative opioid consumption. The goal of this study is to evaluate the effect of liposomal bupivacaine transversus abdominis plane (TAP) blocks on opioid use and its downstream effect on rates of ileus and hospital length of stay (LOS). METHODS: We performed a retrospective pre- and postintervention time-trend analysis (2016-2018) of ERAS patients undergoing laparoscopic colorectal surgery at two academic medical centers within the same hospital system. The intervention was liposomal bupivacaine TAP blocks versus standard local infiltration with bupivacaine with a primary outcome of total morphine milligram equivalents (MME) administered within 72 h of surgery. Secondary outcomes included hospital LOS and rate of postoperative ileus. RESULTS: There were 556 patients included at the control hospital, and 384 patients were included at the treatment hospital. Patients at both hospitals were similar with regard to age, body mass index, comorbidities, and surgical indication. In an adjusted time-trend analysis, the treatment hospital was associated with a significant decrease in MME administered (- 15.9 mg, p = 0.04) and hospital LOS (- 0.8 days, p < 0.001). There was no significant decrease in the rate of ileus at the treatment hospital (- 6.9%, p = 0.08). CONCLUSIONS: In a time-trend analysis, the addition of liposomal bupivacaine TAP blocks into the ERAS protocol resulted in significantly reduced opioid use and shorter hospital LOS for patients undergoing surgery at the treatment hospital. Liposomal bupivacaine TAP blocks should be considered for inclusion in the standard ERAS protocol.

Enhanced Recovery After Surgery: Are the Principles Applicable to Adult and Geriatric Acute Care and Trauma Surgery?

The incorporation of enhanced recovery after surgery (ERAS) fundamentals into perioperative medicine has improved the patient care experience and hastened recovery time while reducing hospital costs. Research studies have shown that incorporating ERAS principles in the adult or geriatric acute care surgery populations minimizes time to resumption of preoperative activity and reduces hospital length of stay. ERAS principles are widely applicable to these patient cohorts and may be applicable in trauma patients. Increased physician and nursing education to promote widespread utilization of enhanced recovery protocols will further improve quality of health care administered in the twenty-first century.

Providing Transthoracic Echocardiography Training for Intensive Care Unit Trainees: An Educational Improvement Initiative.

OBJECTIVE: Transthoracic echocardiography (TTE) is important in the management of critically ill patients, yet it has not been incorporated into many residency programs' curricula. Our objective is to determine if trainees undergoing a 60-minute training session on TTE have improved knowledge, ultrasound skills, and increases the utilization of TTE during their rotation in the intensive care unit (ICU). We will also compare the results of participants with prior TTE exposure to TTE-naïve trainees. Our hypothesis is that after the training, participants' will have improved knowledge and ultrasound skills compared to before training. Our secondary hypotheses are that TTE-naïve trainees will have greater improvements in knowledge scores compared to those who have had prior TTE experience and trainees will increase their use of TTE in the ICU. DESIGN: Single-center, prospective trial. SETTING: Brigham and Women's Hospital (academic hospital). PARTICIPANTS: Residents and fellows rotating through the ICU, at any level of postgraduate training. RESULTS: Forty-two trainees participated in the study. Statistically significant improvement after training was observed for all multiple choice questions (MCQ) and practical assessments (p < 0.001). When assessing the differences in score improvement between TTE-experienced versus TTE-naïve users, mean score improvements were notably higher for TTE-naïve participants (MCQ: 28.2 ± 11.6; echo clinical: 48.6 ± 23.4) compared to TTE-experienced users (MCQ: 18.6 ± 13.5, p = 0.01; echo clinical: 38.3 ± 30.2, p = 0.04). CONCLUSIONS: A short didactic presentation on TTE use may be useful in teaching ICU trainees basic TTE skills and encouraging the use of bedside TTE in the ICU.

A Comparison of Web-Based with Traditional Classroom-Based Training of Lung Ultrasound for the Exclusion of Pneumothorax.

BACKGROUND: Lung ultrasound (LUS) is a well-established method that can exclude pneumothorax by demonstration of pleural sliding and the associated ultrasound artifacts. The positive diagnosis of pneumothorax is more difficult to obtain and relies on detection of the edge of a pneumothorax, called the "lung point." Yet, anesthesiologists are not widely taught these techniques, even though their patients are susceptible to pneumothorax either through trauma or as a result of central line placement or regional anesthesia techniques performed near the thorax. In anticipation of an increased training demand for LUS, efficient and scalable teaching methods should be developed. In this study, we compared the improvement in LUS skills after either Web-based or classroom-based training. We hypothesized that Web-based training would not be inferior to "traditional" classroom-based training beyond a noninferiority limit of 10% and that both would be superior to no training. Furthermore, we hypothesized that this short training session would lead to LUS skills that are similar to those of ultrasound-trained emergency medicine (EM) physicians. METHODS: After a pretest, anesthesiologists from 4 academic teaching hospitals were randomized to Web-based (group Web), classroom-based (group class), or no training (group control) and then completed a posttest. Groups Web and class returned for a retention test 4 weeks later. All 3 tests were similar, testing both practical and theoretical knowledge. EM physicians (group EM) performed the pretest only. Teaching for group class consisted of a standardized PowerPoint lecture conforming to the Consensus Conference on LUS followed by hands-on training. Group Web received a narrated video of the same PowerPoint presentation, followed by an online demonstration of LUS that also instructs the viewer to perform an LUS on himself using a clinically available ultrasound machine and submit smartphone snapshots of the resulting images as part of a portfolio system. Group Web received no other hands-on training. RESULTS: Groups Web, class, control, and EM contained 59, 59, 20, and 42 subjects. After training, overall test results of groups Web and class improved by a mean of 42.9% (±18.1% SD) and 39.2% (±19.2% SD), whereas the score of group control did not improve significantly. The test improvement of group Web was not inferior to group class. The posttest scores of groups Web and class were not significantly different from group EM. In comparison with the posttests, the retention test scores did not change significantly in either group. CONCLUSIONS: When training anesthesiologists to perform LUS for the exclusion of pneumothorax, we found that Web-based training was not inferior to traditional classroom-based training and was effective, leading to test scores that were similar to a group of clinicians experienced in LUS.

Tale of two sites: capillary versus arterial blood glucose testing in the operating room.

INTRODUCTION: Pre- and intraoperative glycemic control has been identified as a putative target to improve outcomes of surgical patients. Glycemic control requires frequent monitoring of blood glucose levels with appropriate adjustments. However, monitoring standards have been called into question, especially in cases in which capillary samples are used. Point-of-care testing (POCT) using capillary samples and glucometers has been noted to give relatively accurate results for critically ill patients. However, the package inserts of most glucometers warn that they should not be used for patients in shock. This has led clinicians to doubt their accuracy in the operating room. The accuracy of capillary samples when tested in patients undergoing surgical procedures has not been proven. This study aims to determine the accuracy of intraoperative blood glucose values using capillary samples relative to arterial samples. METHODS: A prospective study was conducted by collecting paired capillary and arterial samples of patients undergoing major operations at a tertiary medical center from August 2009 to May 2011. Subjects were a convenience sample of patients who had arterial lines and needed glucose testing while undergoing the procedure. Precision Xceed Pro (Abbott) handheld glucometers were used to obtain the blood glucose values. Our primary outcome of interest was the degree of correlation between capillary and arterial blood glucose values or the degree to which arterial glucose levels can be predicted by capillary glucose samples. We used linear regression and the Student t tests for statistical analyses. RESULTS: Seventy-two-paired samples were collected. Of the cases, 54% were major abdominal operations, whereas 24% were vascular operations. The mean values ± standard deviation for glucose levels were 146 ± 35 mg/dL (capillary) and 147 ± 36 mg/dL (arterial). The mean time ± standard deviation between the collection of both samples was 3.5 ± 1.3 minutes. The regression coefficient showed a strong positive correlation of .91 between capillary glucose values and arterial values (P < .001) although correlation was less stringent at the hyperglycemic range of values. The R(2) statistic was 84%. Differences in values between capillary and arterial samples would not have altered the diagnosis of hypo- and hyperglycemia using typical thresholds. CONCLUSIONS: Capillary samples collected intraoperatively are strongly correlated with arterial samples. Glucose monitoring in the operating room can be safely performed by collecting capillary samples for POCT. However, clinicians should still be cautious when interpreting glucose levels that are high, either by repeating the blood glucose test or by having samples sent to the laboratory.