Quality Improvement in Anesthetic Management of Patients with Left Ventricular Assist Device Support Presenting for Non-Cardiac Surgery: A Single Center Experience.

With the growing number of left ventricular assist device (LVAD) recipients requiring non-cardiac surgery and the limited availability of cardiac anesthesiologists, our study reviewed non-cardiac surgeries in HeartMate III patients with LVAD at our institution. We focused on anesthesiologist roles, detailing patient characteristics, anesthetic management, and outcomes and identifying improvement opportunities in this specialized care setting. A retrospective chart review was conducted of all patients with LVAD who underwent non-cardiac surgery at our institution between 2017 and 2022. Patient demographics, surgical characteristics, anesthetic management, and 30-day mortality rates were also assessed. A total of 23 patients were identified, with 17 (73.9%) males and a median age of 61 [53.5, 67.5] years. Cardiac anesthesiologists were present in nine (39.1%) cases. Elective surgeries were more common (73.9%), with intermediate-risk surgeries accounting for 52.2% of all surgeries. General anesthesia was administered to 18 patients (78.3%), with a median duration of 40 [24, 63.5] min. A single patient required reoperation because of bleeding, and two patients (8.7%) experienced 30-day mortality. Despite guidelines lacking detail, involving non-cardiac anesthesiologists in certain cases is essential. Sharing our experience aims to enhance the evolving discourse on non-cardiac surgeries for patients with LVAD, improving their outcomes and safety.

Patient-Reported Quality of Recovery after Sedation for Endoscopy in the Elderly.

INTRODUCTION: Although sedation is critical in minimizing discomforts in patients, conflicting data regarding the safety of sedation among the elderly population exist. This prospective study aimed to compare the quality of recovery (QoR) from gastrointestinal endoscopy performed under sedation between elderly and younger patients. METHODS: We included 177 patients aged 40-64 (group 1, n = 66), 65-79 (group 2, n = 76), and ≥80 (group 3, n = 35) years. QoR was assessed 1 day after the procedure using the quality of recovery 15 (QoR-15) questionnaire, which is a 15-item questionnaire with scores ranging from 0 to 150. Patient demographic, procedural, and sedation data were collected, and neurocognitive function was assessed before and a day after sedation. RESULTS: Groups 1 and 3 differed according to the Mini-Cog test and 3-word memory test performed before the procedure (p < 0.001). QoR-15 scores between groups were not different (139 ± 19 group 1, 141 ± 17 group 2, and 147 ± 26 group 3; p > 0.05). Patients in groups 3 and 2 were administered lower doses of propofol and midazolam than those in group 1. The incidence of oxygen desaturation (SaO2 <90% for >30 s) was lower in groups 1 and 2 than in group 3 (p = 0.01). CONCLUSIONS: As indicated by the QoR-15 questionnaire, the QoR from sedation was not significantly different between the study groups.

Extracorporeal membrane oxygenation in obstetric patients: An Israeli nationwide study.

BACKGROUND: The leading causes of maternal mortality include respiratory failure, cardiovascular events, infections, and hemorrhages. The use of extracorporeal membrane oxygenation (ECMO) as rescue therapy in the peripartum period for cardiopulmonary failure is expanding in critical care medicine. METHODS: This retrospective observational study was conducted on a nationwide cohort in Israel. During the 3-year period, between September 1, 2019, and August 31, 2022, all women in the peripartum period who had been supported by ECMO for respiratory or circulatory failure at 10 large Israeli hospitals were identified. Indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and complications were collected. RESULTS: During the 3-year study period, in Israel, there were 540 234 live births, and 28 obstetric patients were supported by ECMO, with an incidence of 5.2 cases per 100 000 or 1 case per 19 000 births (when excluding patients with COVID-19, the incidence will be 2.5 cases per 100 000 births). Of these, 25 were during the postpartum period, of which 16 (64%) were connected in the PPD1, and 3 were during pregnancy. Eighteen patients (64.3%) were supported by V-V ECMO, 9 (32.1%) by V-A ECMO, and one (3.6%) by a VV-A configuration. Hypoxic respiratory failure (ARDS) was the most common indication for ECMO, observed in 21 patients (75%). COVID-19 was the cause of ARDS in 15 (53.7%) patients. The indications for the V-A configuration were cardiomyopathy (3 patients), amniotic fluid embolism (2 patients), sepsis, and pulmonary hypertension. The maternal and fetal survival rates were 89.3% (n = 25) and 100% (n = 28). The average ECMO duration was 17.6 ± 18.6 days and the ICU stay was 29.8 ± 23.8 days. Major bleeding complications requiring surgical intervention were observed in one patient. CONCLUSIONS: The incidence of using ECMO in the peripartum period is low. The maternal and neonatal survival rates in patients treated with ECMO are high. These results show that ECMO remains an important treatment option for obstetric patients with respiratory and/or cardiopulmonary failure.

Simulation training results in performance retention for the management of airway fires: A prospective observational study.

Given the severity of the consequences of operating room fires, it is recommended that every anaesthesiologist master fire safety protocols and periodically participate in operating room fire drills. The aim of the present study was to evaluate skill retention one year after an airway fire training programme. Anaesthesiology residents were evaluated using an airway fire simulation-based scenario one year after an educational programme that included a one-h long problem-based learning session, a simulation-based airway fire drill with debriefing, and a formal group discussion. The same simulation scenario was used for both the initial training and the one-year assessment. Thirty-eight anaesthesiology residents participated as pairs in the initial training programme. Of these, 36 participated in the evaluation a year later. Performance after one year was better than performance during the initial simulation. Time to removal of tracheal tube was 7.0 (4.0-12.8) s (median (interquartile range)) at the one-year assessment compared with 22.0 (18.5-52.5) s at the time of initial training (P < 0.001). Performance improvement was also demonstrated by a higher incidence of performance of crucial action items (cessation of airway gases, removal of sponges and pouring of saline), as well as shorter duration of time necessary to perform these tasks. After controlling the fire, the time to re-establish ventilation by bag-mask ventilation or intubation was shorter at one year: 18.0 (11.0-29.0 ) s, compared with initial training 54.0 s (36.2-69.8) s (P = 0.001). We conclude that skills are effectively retained for a year after an airway fire management training session.

Influence of anesthesia on hemodynamic assessment of mitral stenosis severity.

BACKGROUND: The treatment of choice for severe rheumatic mitral stenosis (MS) is balloon mitral valvuloplasty (BMV). Assessment of MS severity is usually performed by echocardiography. Before performing BMV, invasive hemodynamic assessment is also performed. The effect of anesthesia on the invasive assessment of MS severity has not been studied. The purpose of the present study was to assess changes in invasive hemodynamic measurement of MS severity before and after induction of general anesthesia. METHODS: The medical files of 22 patients who underwent BMV between 2014 and 2020 were reviewed. Medical history, laboratory, echocardiographic and invasive measurements were collected. Anesthesia induction was performed with etomidate or propofol. Pre-procedural echocardiographic measurements of valve area using pressure half time, and continuity correlated well with invasive measurements using the Gorlin formula. RESULTS: After induction of anesthesia the mean mitral valve gradient dropped by 2.4 mmHg (p = 0.153) and calculated mitral valve area (MVA) increased by 0.2 cm2 (p = 0.011). A wide variability in individual response was observed. While a drop in gradient was noted in 14 patients, it increased in 7. Gorlin derived MVA rose in most patients but dropped in 4. Assuming a calculated MVA of 1.5 cm2 and below to define clinically significant MS, 4 patients with pre-induction MVA of 1.5 cm2 or below had calculated MVA above 1.5 cm2 after induction. CONCLUSIONS: The impact of general anesthesia on the hemodynamic assessment of MS is heterogeneous and may lead to misclassification of MS severity.