Combined pectoralis and serratus anterior plane blocks with or without liposomal bupivacaine for minimally invasive thoracic surgery: A randomized clinical trial.

BACKGROUND: Minimally invasive thoracic surgery is associated with substantial pain that can impair pulmonary function. Fascial plane blocks may offer a favorable alternative to opioids, but conventional local anesthetics provide a limited duration of analgesia. We therefore tested the primary hypothesis that a mixture of liposomal bupivacaine and plain bupivacaine improves the overall benefit of analgesia score (OBAS) during the first three postoperative days compared to bupivacaine alone. Secondarily, we tested the hypotheses that liposomal bupivacaine improves respiratory mechanics, and decreases opioid consumption. METHODS: Adults scheduled for robotically or video-assisted thoracic surgery with combined ultrasound-guided pectoralis II and serratus anterior plane block were randomized to bupivacaine or bupivacaine combined with liposomal bupivacaine. OBAS was measured on postoperative days 1-3 and was analyzed with a linear mixed regression model. Postoperative respiratory mechanics were estimated using a linear mixed model. Total opioid consumption was estimated with a simple linear regression model. RESULTS: We analyzed 189 patients, of whom 95 were randomized to the treatment group and 94 to the control group. There was no significant treatment effect on total OBAS during the initial three postoperative days, with an estimated geometric mean ratio of 0.93 (95% CI: 0.76, 1.14; p = 0.485). There was no observed treatment effect on respiratory mechanics, total opioid consumption, or pain scores. Average pain scores were low in both groups. CONCLUSIONS: Liposomal bupivacaine did not improve OBAS during the initial postoperative three days following minimally invasive thoracic procedures. Furthermore, there was no improvement in respiratory mechanics, no reduction in opioid consumption, and no decrease in pain scores. Thus, the data presented here does not support the use of liposomal bupivacaine over standard bupivacaine to enhance analgesia after minimally invasive thoracic surgery. SUMMARY STATEMENT: For minimally invasive thoracic procedures, addition of liposomal bupivacaine to plain bupivacaine for thoracic fascial plane blocks does not improve OBAS, reduce opioid requirements, improve postoperative respiratory mechanics, or decrease pain scores.

Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial.

Importance: Endotracheal tubes are typically inserted in the operating room using direct laryngoscopy. Video laryngoscopy has been reported to improve airway visualization; however, whether improved visualization reduces intubation attempts in surgical patients is unclear. Objective: To determine whether the number of intubation attempts per surgical procedure is lower when initial laryngoscopy is performed using video laryngoscopy or direct laryngoscopy. Design, Setting, and Participants: Cluster randomized multiple crossover clinical trial conducted at a single US academic hospital. Patients were adults aged 18 years or older having elective or emergent cardiac, thoracic, or vascular surgical procedures who required single-lumen endotracheal intubation for general anesthesia. Patients were enrolled from March 30, 2021, to December 31, 2022. Data analysis was based on intention to treat. Interventions: Two sets of 11 operating rooms were randomized on a 1-week basis to perform hyperangulated video laryngoscopy or direct laryngoscopy for the initial intubation attempt. Main Outcomes and Measures: The primary outcome was the number of operating room intubation attempts per surgical procedure. Secondary outcomes were intubation failure, defined as the responsible clinician switching to an alternative laryngoscopy device for any reason at any time, or by more than 3 intubation attempts, and a composite of airway and dental injuries. Results: Among 8429 surgical procedures in 7736 patients, the median patient age was 66 (IQR, 56-73) years, 35% (2950) were women, and 85% (7135) had elective surgical procedures. More than 1 intubation attempt was required in 77 of 4413 surgical procedures (1.7%) randomized to receive video laryngoscopy vs 306 of 4016 surgical procedures (7.6%) randomized to receive direct laryngoscopy, with an estimated proportional odds ratio for the number of intubation attempts of 0.20 (95% CI, 0.14-0.28; P < .001). Intubation failure occurred in 12 of 4413 surgical procedures (0.27%) using video laryngoscopy vs 161 of 4016 surgical procedures (4.0%) using direct laryngoscopy (relative risk, 0.06; 95% CI, 0.03-0.14; P < .001) with an unadjusted absolute risk difference of -3.7% (95% CI, -4.4% to -3.2%). Airway and dental injuries did not differ significantly between video laryngoscopy (41 injuries [0.93%]) vs direct laryngoscopy (42 injuries [1.1%]). Conclusion and Relevance: In this study among adults having surgical procedures who required single-lumen endotracheal intubation for general anesthesia, hyperangulated video laryngoscopy decreased the number of attempts needed to achieve endotracheal intubation compared with direct laryngoscopy at a single academic medical center in the US. Results suggest that video laryngoscopy may be a preferable approach for intubating patients undergoing surgical procedures. Trial Registration: ClinicalTrials.gov Identifier: NCT04701762.

Implementing an Interdisciplinary Procedure Curriculum.

INTRODUCTION: This curriculum was designed to improve access to procedures for our internal medicine residents. METHODS: We created an interdisciplinary procedure course (IDPC) composed of two simulation sessions and a one-week procedural rotation supervised by multiple specialties including nephrology, cardiology, cardiothoracic anesthesiology, general anesthesiology, and interventional radiology. After the course, residents completed two surveys documenting the number of procedures and their level of confidence on a Likert scale (1 = very unconfident to 5 = very confident) prior to and after completing the curriculum. RESULTS: Sixteen residents participated in the course from September 2021 to June 2022. The collective number of procedures performed by these 16 residents increased from 176 to 343 after a one-week rotation. For arterial lines, the proportion of residents that reported an improvement in confidence scores was 0.44 (95% confidence interval 0.23 to 1, p-value of 0.60). The proportion of residents that had an increase in their confidence performing central lines was 0.63 (95% confidence interval 0.39 to 1, p-value of 0.23). For intubations, the proportion of residents that reported an improvement in confidence was 0.94 (95% confidence interval 0.72 to 1, p-value of 0.0006). CONCLUSION: By collaborating with multiple specialties, residents almost doubled the number of procedures performed during training and reported an increased level of confidence in procedural performance for airway intubation. We learned residents want to improve their access to procedures and described a curriculum that was easily implemented.

Serratus anterior and pectoralis plane blocks for robotically assisted mitral valve repair: a randomised clinical trial.

BACKGROUND: Minimally invasive cardiac surgery provokes substantial pain and therefore analgesic consumption. The effect of fascial plane blocks on analgesic efficacy and overall patient satisfaction remains unclear. We therefore tested the primary hypothesis that fascial plane blocks improve overall benefit analgesia score (OBAS) during the initial 3 days after robotically assisted mitral valve repair. Secondarily, we tested the hypotheses that blocks reduce opioid consumption and improve respiratory mechanics. METHODS: Adults scheduled for robotically assisted mitral valve repairs were randomised to combined pectoralis II and serratus anterior plane blocks or to routine analgesia. The blocks were ultrasound-guided and used a mixture of plain and liposomal bupivacaine. OBAS was measured daily on postoperative Days 1-3 and were analysed with linear mixed effects modelling. Opioid consumption was assessed with a simple linear regression model and respiratory mechanics with a linear mixed model. RESULTS: As planned, we enrolled 194 patients, with 98 assigned to blocks and 96 to routine analgesic management. There was neither time-by-treatment interaction (P=0.67) nor treatment effect on total OBAS over postoperative Days 1-3 with a median difference of 0.08 (95% confidence interval [CI]: -0.50 to 0.67; P=0.69) and an estimated ratio of geometric means of 0.98 (95% CI: 0.85-1.13; P=0.75). There was no evidence of a treatment effect on cumulative opioid consumption or respiratory mechanics. Average pain scores on each postoperative day were similarly low in both groups. CONCLUSIONS: Serratus anterior and pectoralis plane blocks did not improve postoperative analgesia, cumulative opioid consumption, or respiratory mechanics during the initial 3 days after robotically assisted mitral valve repair. CLINICAL TRIAL REGISTRATION: NCT03743194.

Effectiveness of Simulation- Versus Didactic Video-Based Learning to Teach Advanced Lung Isolation Techniques.

OBJECTIVES: Mastery of lung isolation is crucial for optimal cardiothoracic anesthesia education. The authors tested the hypothesis that simulation- is more effective than didactic video-based learning (cognitive, affective, and psychomotor) to teach anesthesiology fellows advanced lung isolation techniques. DESIGN: A prospective randomized study. SETTING: At a single academic heart center, simulation laboratory. PARTICIPANTS: Thirty anesthesiology fellows with equivalent prior experience in basic lung isolation techniques. INTERVENTIONS: Randomized participants received 1 of 2 structured educational interventions of equivalent duration designed to teach advanced lung isolation skills, a simulation workshop, or a video-based didactic session. MEASUREMENTS AND MAIN RESULTS: To assess Bloom's taxonomy domains, performance measurements included pre- and postintervention cognitive tests and affective surveys and a postintervention psychomotor task (time to complete lung isolation). Changes in test and survey scores and time to completion were compared using the Mann-Whitney U test; p values < 0.05 were considered significant. Improvements in lung isolation learning assessments were greater in the simulation group, but significant differences only existed in the affective domain. Specifically, affective survey score increases were greater in the simulation group (simulation- versus video-based didactic: +19.0 v +4.0; p ≤ 0.001), whereas there was no significant difference in cognitive pre- to posttest scores (simulation- versus video-based: +28.6 v +19.1, p = 0.23), and time to achieve lung isolation (simulation- versus video-based: 32 v 36 seconds, p = 0.46). CONCLUSIONS: Although greater affective learning of advanced lung isolation skills occurred with simulation-based compared to didactic video-based education, the authors found no differences between the teaching approaches in cognitive and psychomotor learning among anesthesiology fellows.

New Opportunities in Heart Failure with Preserved Ejection Fraction: From Bench to Bedside and Back.

Heart failure with preserved ejection fraction (HFpEF) is a growing public health problem in nearly 50% of patients with heart failure. Therefore, research on new strategies for its diagnosis and management has become imperative in recent years. Few drugs have successfully improved clinical outcomes in this population. Therefore, numerous attempts are being made to find new pharmacological interventions that target the main mechanisms responsible for this disease. In recent years, pathological mechanisms such as cardiac fibrosis and inflammation, alterations in calcium handling, NO pathway disturbance, and neurohumoral or mechanic impairment have been evaluated as new pharmacological targets showing promising results in preliminary studies. This review aims to analyze the new strategies and mechanical devices, along with their initial results in pre-clinical and different phases of ongoing clinical trials for HFpEF patients. Understanding new mechanisms to generate interventions will allow us to create methods to prevent the adverse outcomes of this silent pandemic.

Acoustic Noise-Based Detection of Ferroresonance Events in Isolated Neutral Power Systems with Inductive Voltage Transformers.

Power-quality events and operation transients in power systems (PS) with isolated neutral can saturate inductive voltage transformers (IVT), which, when interacting with the overhead and underground cable capacitances, can cause ferroresonance events in the local PS. This abnormal operating mode can partially or totally damage the transformers and switchgears within the affected PS. Distribution system operators (DSO) can minimize these effects by detecting ferroresonance events accurately and fast enough and changing the mode of operation accordingly. Direct detection methods, i.e., based on voltage measurements, are reliable, but the massive deployment of this solution is relatively expensive; i.e., power quality analyzers cost thousands of USD. Alternatively, indirect detection methods are also available, e.g., IVT vibration measurements with accelerometers costing hundreds of USD, but their reliability depends on the installation method used. This manuscript proposes using the acoustic noise caused by magnetostriction forces within the IVT core during ferroresonance events to detect their occurrence. Compared to other indirect methods, electret condenser microphones with preamplifying stage cost less than USD 10 and are less sensitive to the installation procedure. The proposed method is validated experimentally, and its performance compared to IVT vibration measurements one by using the same detection methodology.

When echocardiography fails, intravascular ultrasound as an alternative for adequate graft patency in hybrid elephant trunk surgery.

Aortic pathology is a common cardiovascular disease in the US. Transesophageal Echocardiogram is an invaluable imaging modality in the management of aortic pathology in perioperative setting. Intravascular ultrasound can assess coronary obstruction during coronary interventions and can be used in endovascular aneurysm repair. A 54-year-old male underwent Hybrid Elephant Trunk Surgery, for complex open aorta repair. There was functional confirmation graft patency via the femoral arterial line tracing, there was surgical confirmation via visual and physical inspection of graft, but there was lacking anatomical confirmation. Epiaortic ultrasound reassured the graft patency at level of the arch. However, transesophageal echocardiogram was not reassuring for adequate anatomical confirmation of patency. Intravascular ultrasound was used for anatomical confirmation of graft patency and position. This technology provides real time graft patency and is a great tool in open aorta reconstruction surgery.

Cervical kyphoscoliosis / Cifoescoliosis cervical

Cervical kyphoscoliosis is an uncommon spinal deformity. Kyphosis or outward curvature of cervical-spine (Image A) has led to a fixed flexion state resulting in suspension of patient's head in the air while lying on the imaging table. Additionally, dextroscoliosis or rightward convexity of the cervical vertebral axis has resulted in a persistent leftward head tilt (Image B). Head and neck radiation and trauma can lead to cervical kyphoscoliosis. In addition to the cosmetic deformity, patients present with myelopathic sensorimotor symptoms such as weakness and tingling of upper extremities. The Poisson effect states that flexion of the spine lengthens and stretches the spinal canal, reduces its area and narrows its lumen. This causes spinal cord impingement and myelopathy.

La cifoescoliosis cervical es una deformidad de la columna vertebral poco frecuente. La cifosis o la curvatura hacia fuera de la columna cervical (imagen A) ha dado lugar a un estado de flexión fija que provoca la suspensión de la cabeza del paciente en el aire mientras está tumbado en la mesa de diagnóstico por imagen. Además, la dextroscoliosis o convexidad hacia la derecha del eje vertebral cervical ha dado lugar a una inclinación persistente de la cabeza hacia la izquierda (Imagen B). La radiación de cabeza y cuello y los traumatismos pueden provocar cifoescoliosis cervical. Además de la deformidad estética, los pacientes presentan síntomas sensoriomotores mielopáticos como debilidad y hormigueo en las extremidades superiores. El efecto Poisson establece que la flexión de la columna vertebral alarga y estira el canal espinal, reduce su área y estrecha su lumen. Esto provoca el pinzamiento de la médula espinal y la mielopatía.

Extracorporeal CO2 removal and renal replacement therapy in acute severe respiratory failure in COVID-19 pneumonia: Case report.

The COVID-19 pandemic significates an enormous number of patients with pneumonia that get complicated with severe acute respiratory distress syndrome (ARDS), some of them with refractory hypercapnia and hypoxemia that need mechanical ventilation (MV). Those patients who are not candidate to extracorporeal membrane oxygenation (ECMO), the extracorporeal removal of CO2 (ECCO2 R) can allow ultra protective MV to limit the transpulmonary pressures and avoid ventilatory induced lung injury (VILI). We report a first case of prolonged ECCO2 R support in 38 year male with severe COVID-19 pneumonia refractory to conventional support. He was admitted tachypneic and oxygen saturation 71% without supplementary oxygen. The patient's clinical condition worsens with severe respiratory failure, increasing the oxygen requirement and initiating MV in the prone position. After 21 days of protective MV, PaCO2 rise to 96.8 mmHg, making it necessary to connect to an ECCO2 R system coupled continuous veno-venous hemodialysis (CVVHD). However, due to the lack of availability of equipment in the context of the pandemic, a pediatric gas exchange membrane adapted to CVVHD allowed to maintain the removal of CO2 until completing 27 days, being finally disconnected from the system without complications and with a satisfactory evolution.

Acuphagia: Anesthetic implications / Acufagia: implicaciones para la anestesia

Acuphagia, the practice of inappropriate consumption of non-nutritive sharp metallic substances, is a rare form of pica and can lead to devastating consequences.1 Panel A demonstrates an ingested serrated knife in the right upper abdominal quadrant (Image 1). Panel B exhibits distended bowel loops, pneumatosis intestinalis and pneumoperitoneum on radiological imaging (Image 2).

La acuphagia, la práctica del consumo inadecuado de sustancias metálicas cortantes no nutritivas, es una forma rara de pica y puede tener consecuencias devastadoras. 1 El panel A muestra un cuchillo dentado ingerido en el cuadrante abdominal superior derecho ( Imagen 1). El panel B muestra asas intestinales distendidas, neumatosis intestinal y neumoperitoneo en las imágenes radiológicas ( Imagen 2 ).

Point-of-Care Ultrasound to Identify Landmarks of the Proximal Humerus: Potential Use for Intraosseous Vascular Access.

OBJECTIVES: The inability to identify landmarks is an absolute contraindication for intraosseous access. The feasibility of landmark identification using ultrasound (US) has been demonstrated on human cadavers. We aimed to study the feasibility of point-of-care US in identifying proximal humerus landmarks in living human patients. METHODS: This was a prospective cohort study conducted from May 3 to June 7, 2017, after approval from the Institutional Review Board at the Cleveland Clinic. Sixty upper extremities of 30 consenting participants across 3 distinct body mass index (BMI) groups (normal, obese, and morbidly obese) were alternately examined with a 12 L-RS linear US transducer (GE Healthcare, Chicago, IL) by 2 investigators. Six anatomic landmarks were identified: the humeral shaft, the surgical neck of the humerus, the lesser tubercle, the greater tubercle, the inter tubercular sulcus, and the target site for needle insertion on the greater tubercle. Rates of successful identification of all 6 landmarks as defined by independent agreement between the investigators were reported as estimated incidence rates with 95% bootstrap confidence interval (CI) sampling at the participant level. RESULTS: Ultrasound had an overall success rate of 0.87 (95% CI, 0.78-0.95) in identifying all 6 landmarks with slight variability among various BMI groups. After excluding the surgical neck, the overall success rate improved to 0.93 (95% CI, 0.87-0.98), with minimum variability across BMI groups and no change in the ability to identify the target site. CONCLUSIONS: Ultrasound is reliable in identifying proximal humerus intraosseous landmarks, with reasonable accuracy across various BMI groups.

Cardiac conduction defects and complete heart block in myotonic dystrophy / Defectos de conduccion cardiaca y bloqueo cardiaco completo en la distrofìa miotonica

Classic myotonic dystrophy is a multisystem disorder that results from RNA toxicity and is one of the commonest adult onset muscular dystrophies. Patients often present with muscle stiffness from myotonia and dysphagia or dysarthria from laryngopharyngoesophageal muscle weakness. Benign electrocardiogram changes such as first degree atrioventricular block are commonly present and rarely merit further work up. Occasionally, patients develop advanced conduction defects which can unexpectedly progress to complete heart block perioperatively

La distrofia miotonica clásica es un trastorno multi-sistémico que resulta de la toxicidad del RNA y es una de las distrofias musculares más comunes en adultos. Los pacientes suelen presentar rigidez muscular por la miotonía, así como disfagia o disartria por debilidad muscular laringo-faríngea-esofágica. Los cambios benignos en el electrocardiograma, como el bloqueo auriculoventricular de primer grado, suelen estar presentes y rara vez merecen un análisis más profundo. Ocasionalmente, los pacientes desarrollan defectos de conduccion avanzados que pueden progresar inespera-damente para completar el bloqueo cardiaco perioperatorio.

Regional Anesthesia in Cardiac Surgery: An Overview of Fascial Plane Chest Wall Blocks.

Optimal analgesia is an integral part of enhanced recovery after surgery (ERAS) programs designed to improve patients' perioperative experience and outcomes. Regional anesthetic techniques in a form of various fascial plane chest wall blocks are an important adjunct to the optimal postoperative analgesia in cardiac surgery. The most common application of fascial plane chest wall blocks has been for minimally invasive cardiac surgical procedures. An abundance of case reports has been described in the anesthesia literature and reports appear promising, yet higher-level safety and efficacy evidence is lacking. Those providing anesthesia for minimally invasive cardiac procedures should become familiar with fascial plane anatomy and block techniques to be able to provide enhanced postsurgical analgesia and facilitate faster functional recovery and earlier discharge. The purpose of this review is to provide an overview of contemporary fascial plane chest wall blocks used for analgesia in cardiothoracic surgery. Specifically, we focus on relevant anatomic considerations and technical descriptions including pectoralis I and II, serratus anterior, pectointercostal fascial, transverse thoracic muscle, and erector spine plane blocks. In addition, we provide a summary of reported local anesthetic doses used for these blocks and a current state of the literature investigating their efficacy, duration, and comparisons with standard practices. Finally, we hope to stimulate further research with a focus on delineating mechanisms of action of novel emerging blocks, appropriate dosing regimens, and subsequent analysis of their effect on patient outcomes.