Risk of cardiac events after elective versus urgent or emergent noncardiac surgery: Implications for quality measurement and improvement.

INTRODUCTION: Patient populations differ for elective vs urgent and emergent surgery. The effect of this difference on surgical outcome is not well understood and may be important for improving surgical safety. Our primary hypothesis was that there is an association of surgical acuity with risk of postoperative cardiac events. Secondarily, we examined elective vs urgent and emergent patients separately to understand patient characteristics that are associated with postoperative cardiac events. METHODS: We performed a retrospective cohort study of patients ≥65 years undergoing noncardiac elective or urgent/emergent surgery. Logistic regression estimated the association of surgical acuity with a postoperative cardiac event, which was defined as myocardial infarction or cardiac arrest within 30 days of surgery. For the secondary analysis, we modeled the outcome after stratifying by acuity. RESULTS: The study included 161,177 patients with 1014 cardiac events. The unadjusted risk of a postoperative cardiac event was 3.2 per 1000 among elective patients and 28.7 per 1000 among urgent and emergent patients (adjusted odds ratio 4.10, 95% confidence interval 3.56-4.72). After adjustment, increased age, higher baseline cardiac risk, peripheral vascular disease, hypertension, worse American Society of Anesthesiologist (ASA) physical classification, and longer operative time were associated with a postoperative cardiac event. Higher baseline cardiac risk was more strongly associated with postoperative cardiac events in elective patients. In contrast, worse ASA physical classification was more strongly associated with postoperative cardiac events in urgent and emergent patients. Black patients had higher odds of a postoperative cardiac event only in urgent and emergent patients compared to White patients. CONCLUSIONS: Quality measurement and improvement to address postoperative cardiac risk should consider patients based on surgical acuity.

Survey of Workplace Perceptions of Female Anesthesiologists.

BACKGROUND: Disparities encountered by men and women physicians are well documented. However, evidence is lacking concerning the effects of gender on daily practice in the specialty of anesthesiology. AIMS: To evaluate gender disparities perceived by female anesthesiologists. SETTING AND DESIGN: Anonymous, voluntary 30-question, electronic secure REDcap survey. MATERIALS AND METHODS: Survey link was sent via email, Twitter and the Facebook page, Physician Mom's Group. Instructions dictated that only female attending anesthesiologists participate and to partake in the survey one time. STATISTICAL ANALYSIS: Categorical variables were summarized using frequencies and percentages. Associations between categorical variables were tested using Chi-square test. Likert scale items were treated as continuous variables. T-tests were utilized to examine differences between those who reported burnout and those who did not. RESULTS: 502 survey responses were received and analyzed. Female leadership was valued by 78%, yet only 47% had leadership roles. Being female was identified by 51% as negatively affecting career advancement and 90% perceived that women in medicine need to work harder than men to achieve the same career goals. Sexual harassment was experienced by 55%. Nearly 35% of institutions did not offer paid maternity leave. Burnout was identified in 43% of respondents and was significantly associated with work-life balance not being ideal (P < 0.0001), gender negatively affecting career advancement (P < 0.0001), experiencing sexual harassment at work (P = 0.002), feeling the need to work harder than men (P = 0.0033), being responsible for majority of household duties (P = 0.0074), lack of weekly exercise (P = 0.0135) and lack of lactation needs at work (P = 0.0007). CONCLUSIONS: Understanding perceptions of female anesthesiologists may lead to actionable plans aimed at improving workplace equity or conditions.

Establishing a patient centered, outpatient total joint home recovery program within an integrated healthcare system.

Outpatient total joint home recovery (HR) is a rapidly growing initiative being developed and employed at high volume orthopedic centers. Minimally invasive surgery, improved pain control and home health services have made HR possible. Multidisciplinary teams with members ranging from surgeons and anesthesiologists to hospital administrators, physical therapists, nurses and research analysts are necessary for success. Eligibility criteria for outpatient total joint arthroplasty will vary between medical centers. Surgeon preference in addition to medical comorbidities, social support, preoperative patient mobility and safety of the HR location are all factors to consider when selecting patients for outpatient total joint HR. As additional knowledge is gained, the next steps will be to establish 'best practices' and speciality society-endorsed guidelines for patients undergoing outpatient total joint arthroplasty.

Miniaturized Echocardiography in the Cardiac Intensive Care Unit.

Miniaturized transesophageal echocardiography has become more common in cardiac intensive care units. There are potential benefits to this mode of technology, many of which have been described in the literature. However, image acquisition and quality have been cited as being less optimal when compared to traditional transesophageal echocardiography. This review will discuss the current options available for miniaturized transesophageal echocardiography along with a literature review of this emerging assessment modality.

Routine chest X-ray is unnecessary after ultrasound-guided central venous line placement in the operating room.

BACKGROUND: Central venous catheters (CVC) can be useful for perioperative monitoring and insertion has low complication rates. However, routine post insertion chest X-rays have become standard of care and contribute to health care costs with limited impact on patient management. METHODS: 200 patient charts who underwent pancreaticoduodenectomy with central line placement and early line removal were reviewed for clinical complications related to central line placement as well as radiographic evidence of malpositioning. A cost analysis was performed to estimate savings if CXR had not been performed across routine surgical procedures requiring central access. RESULTS: In 200 central line placements for Whipple procedures, 198 lines were placed in the right internal jugular and 2 were placed in the subclavian. No cases of pneumothorax or hemothorax were identified and 30 (15.3%) of CVCs were improperly positioned. Only 1 (0.5%) of these was deemed clinically significant and repositioned after the CXR was performed. CONCLUSION: Routine CXR consumes valuable time and resources (≅$155,000 annually) and rarely affects management. Selection should be guided by clinical factors.

Review of the evidence: best analgesic regimen for shoulder surgery.

Multimodal pain management has been advocated in patients experiencing acute pain after surgical procedures due to tissue damage and the subsequent inflammatory response. For patients undergoing shoulder surgeries, studies have definitively shown that interscalene blocks (ISBs) via single-injection or continuous infusion can reduce the total opioid consumption and can lower pain scores after surgery. In some cases, ISBs can be used as the sole anesthetic during shoulder surgeries and spare patients of receiving general anesthesia. However, clinicians should be fully aware of potential pulmonary complications of ISBs and weigh the risk-benefit ratio in patients with limited pulmonary reserve.

Case Report of Serratus Plane Catheter for Pain Management in a Patient With Multiple Rib Fractures and an Inferior Scapular Fracture.

We placed a superficial serratus anterior plane catheter in an elderly woman with dementia and elevated clotting times who presented with multiple rib fractures after a mechanical fall. She was not a surgical candidate, and treatment consisted of conservative management with physical therapy and pain control. She was not a candidate for a patient-controlled analgesia regimen because of her dementia. Given her elevated international normalized ratio, thoracic epidural and paravertebral analgesia was also contraindicated. We placed an ultrasound-guided serratus anterior plane catheter, allowing titratable continuous infusion in a trauma patient, resulting in excellent analgesia without adverse effects.

Ultrasound-Guided Genicular Nerve Thermal Radiofrequency Ablation for Chronic Knee Pain.

Osteoarthritis (OA) of the knee is one of the most common joint diseases affecting adults in the United States. For elderly patients with multiple medical comorbidities who do not wish to undergo total knee arthroplasty (TKA), lifestyle modification, pharmacologic management, and injections are the mainstay of therapy. Previously, pain management interventions were limited to intra-articular joint injections and viscosupplementation with hyaluronic acid. Fluoroscopic-guided techniques for radiofrequency ablation (RFA) of the genicular nerves have been previously described and a recent cadaveric study suggests that ultrasound-guided genicular nerve blocks can be performed accurately. We performed an ultrasound-guided radiofrequency ablation of the genicular nerves in 88-year-old woman who had deferred surgical management given her age. Following successful ultrasound guided diagnostic genicular nerve blocks, she proceeded to RFA using the same ultrasound guided technique. The procedure resulted in significant pain relief and improvement in overall function for greater than 6 months. The use of ultrasound provides a relatively rapid and noninvasive method to directly visualize genicular nerves and surrounding vasculature. Our case suggests that, for genicular nerve blockade and RFA, ultrasound may be a useful alternative to fluoroscopy. Not only did the procedure result in significant pain relief that has persisted for greater than 6 months but also more importantly her function status and quality of life were improved.

Pain management in critically ill patients: a review of multimodal treatment options.

Pain management for critically ill patients provides physicians with the challenge of maximizing patient comfort while avoiding the risks that arise with oversedation. Preventing oversedation has become increasingly important as we better understand the negative impact it has on patients' experiences and outcomes. Current research suggests that oversedation can result in complications such as thromboembolism, pulmonary compromise, immunosuppression and delirium. Fortunately, the analgesic options available for physicians to limit these complications are growing as more treatment modalities are being researched and implemented in the intensive care unit. Our goal is to outline some of the effective and widely utilized tools available to physicians to appropriately and safely manage pain while avoiding oversedation in the critically ill population.

Truncal blocks for perioperative pain management: a review of the literature and evolving techniques.

As the American healthcare system continues to evolve and reimbursement becomes tied to value-based incentive programs, perioperative pain management will become increasingly important. Regional anesthetic techniques are only one component of a successful multimodal pain regimen. In recent years, the use of peripheral and paraneuraxial blocks to provide chest wall and abdominal analgesia has gained popularity. When used within a multimodal regimen, truncal blocks may provide similar analgesia when compared with other regional anesthetic techniques. While there are other reviews that cover this topic, our review will also highlight the emerging role for serratus plane blocks, pectoral nerve blocks and quadratus lumborum blocks in providing thoracic and abdominal analgesia.

Management of Acute Kidney Injury and Acid-Base Balance in the Septic Patient.

Acute kidney injury (AKI) is an abrupt decrease in kidney function that takes place over hours to days. Sepsis is the leading cause of AKI and portends a particularly high morbidity and mortality, although the severity may vary from a transient rise in serum creatinine to end-stage renal disease. With regard to acid-base management in septic AKI, caution should be used with hyperchloremic crystalloid solutions, and dialysis is often used in the setting of severe acidosis. In the future, biomarkers may help clinicians identify AKI earlier and allow for potential interventions before the development of severe AKI.

Workup and Management of Persistent Neuralgia following Nerve Block.

Neurological injuries following peripheral nerve blocks are a relatively rare yet potentially devastating complication depending on the type of lesion, affected extremity, and duration of symptoms. Medical management continues to be the treatment modality of choice with multimodal nonopioid analgesics as the cornerstone of this therapy. We report the case of a 28-year-old man who developed a clinical common peroneal and lateral sural cutaneous neuropathy following an uncomplicated popliteal sciatic nerve block. Workup with electrodiagnostic studies and magnetic resonance neurography revealed injury to both the femoral and sciatic nerves. Diagnostic studies and potential mechanisms for nerve injury are discussed.

Right Breast Mastectomy and Reconstruction with Tissue Expander under Thoracic Paravertebral Blocks in a 12-Week Parturient.

Paravertebral blocks are becoming increasingly utilized for breast surgery with studies showing improved postoperative pain control, decreased need for opioids, and less nausea and vomiting. We describe the anesthetic management of an otherwise healthy woman who was 12 weeks pregnant presenting for treatment of her breast cancer. For patients undergoing breast mastectomy and reconstruction with tissue expanders, paravertebral blocks offer an anesthetic alternative when general anesthesia is not desired.

Management of intra-aortic balloon pumps.

Intra-aortic balloon pumps (IABPs) continue to be the most widely used cardiac support devices with an annual estimate of 200 000 IABPs placed worldwide. IABPs enhance myocardial function by maximizing oxygen supply and minimizing oxygen demand. The use of IABPs is not without risk, with major vascular injury, ischemia, and infection being the most common complications, especially in high-risk patients. While recent studies have questioned the use of IABPs in patients with cardiogenic shock secondary to myocardial infarction, these studies have limitations making it difficult to formulate definitive conclusions. This review will focus on the mechanisms of counterpulsation, the management of IABPs and the evidence supporting this ventricular support therapy.

Anesthetic implications of extended right hepatectomy in a patient with fontan physiology.

Patients who have undergone complete cavopulmonary anastomosis, the Fontan procedure, have passive venous blood flow from the superior and inferior vena cava into the pulmonary circulation without passing through the right ventricle. Although this procedure is an effective means of palliation, the resultant chronically increased central venous pressure, leads to several types of hepatic dysfunction including chronic congestion, cardiac cirrhosis, and even hepatocellular carcinoma. In this case report, we describe a patient with Fontan-associated hepatocellular carcinoma who successfully underwent a right hepatectomy.

An overview of cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion for the anesthesiologist.

Anesthesiologists face several perioperative challenges when patients need cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion. To adequately care for these patients, anesthesiologists must understand the goals and objectives of the operation in addition to having a basic knowledge of the chemotherapeutic drugs that are frequently used. Optimal anesthetic management of patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion requires control of a complex interplay of physiologic mechanisms, including hyperthermia, abdominal hypertension, electrolyte abnormalities, coagulopathies, increased cardiac index, oxygen consumption, and decreased systemic vascular resistance. As this surgery continues to gain popularity among oncologic surgeons, further studies that clearly define the chemistry, pharmacokinetics, pharmacodynamics, and end points of efficacy need to be performed to elucidate optimal perioperative management.

Lung ischemia reperfusion injury: a bench-to-bedside review.

Lung ischemia reperfusion injury (LIRI) is a pathologic process occurring when oxygen supply to the lung has been compromised followed by a period of reperfusion. The disruption of oxygen supply can occur either via limited blood flow or decreased ventilation termed anoxic ischemia and ventilated ischemia, respectively. When reperfusion occurs, blood flow and oxygen are reintroduced to the ischemic lung parenchyma, facilitating a toxic environment through the creation of reactive oxygen species, activation of the immune and coagulation systems, endothelial dysfunction, and apoptotic cell death. This review will focus on the mechanisms of LIRI, the current supportive treatments used, and the many therapies currently under research for prevention and treatment of LIRI.