Echocardiographic and Point-of-Care Ultrasonography (POCUS) Guidance in the Management of the ECMO Patient.

Veno-arterial (V-A) and Veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) support is increasingly utilized for acute cardiogenic shock and/or respiratory failure. Echocardiography and point-of-care ultrasonography (POCUS) play a critical role in the selection and management of these critically ill patients, however, there are limited guidelines regarding their application. This comprehensive review describes current and potential application of echocardiography and POCUS for pre-ECMO assessment and patient selection, cannulation guidance with emphasis on dual-lumen configurations, diagnosis of ECMO complications and trouble-shooting of cannula malposition, diagnosis of common cardiac or pulmonary pathologies, and assessment of ECMO weaning appropriateness including identification of the aortic mixing point in V-A ECMO.

Ultrafiltration in cardiac surgery: Results of a systematic review and meta-analysis.

Background: Ultrafiltration is used with cardiopulmonary bypass to reduce the effects of hemodilution and restore electrolyte balance. We performed a systematic review and meta-analysis to analyze the effect of conventional and modified ultrafiltration on intraoperative blood transfusion.Methods: Utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement, we systematically searched MEDLINE, EMBASE, Web of Science, and Cochrane Library to perform a meta-analysis of studies of randomized controlled trials (RCTs) and observational studies evaluating conventional ultrafiltration (CUF) and modified ultrafiltration (MUF) on the primary outcome of intraoperative red cell transfusions.Results: A total of 7 RCTs (n = 928) were included, comparing modified ultrafiltration (n = 473 patients) to controls (n = 455 patients) and 2 observational studies (n = 47,007), comparing conventional ultrafiltration (n = 21,748) to controls (n = 25,427). Overall, MUF was associated with transfusion of fewer intraoperative red cell units per patient (n = 7); MD -0.73 units; 95% CI -1.12 to -0.35 p = 0.04; p for heterogeneity = 0.0001, I2 = 55%) compared to controls. CUF was no difference in intraoperative red cell transfusions compared to controls (n = 2); OR 3.09; 95% CI 0.26-36.59; p = 0.37; p for heterogeneity = 0.94, I2 = 0%. Review of the included observational studies revealed an association between larger volumes (>2.2 L in a 70 kg patient) of CUF and risk of acute kidney injury (AKI).Conclusion: The results of this systematic review and meta-analysis suggest that MUF is associated with fewer intraoperative red cell transfusions. Based on limited studies, CUF does not appear to be associated with a difference in intraoperative red cell transfusion.

Anesthetic Management for Open Thoracoabdominal and Abdominal Aortic Aneurysm Repair.

Open thoracoabdominal and abdominal aortic aneurysm repairs are some of the most challenging cases for anesthesiologists because of the potential for rapid blood loss combined with clamping and reperfusion, potential use of left heart bypass, the potential need for lung isolation, and potential placement and management of a spinal drain. In addition, patients often present with other significant comorbidities and a detailed understanding of the disease process, the complex physiology throughout the case, and the intricacies of organ protection are critical.

A complication of ECMO cannula placement resulting in hemodynamic and oxygenation alterations: A case report.

Veno-veno extracorporeal membrane oxygenation (VV ECMO) is used as a bridge to recovery in acute respiratory distress syndrome (ARDS) patients who have reversible lung failure. We present a complication of ECMO cannula placement/position resulting in hemodynamic and oxygenation alterations. These demonstrate principles related to the interaction of the VV ECMO circuit and patient cardio-pulmonary physiology. Consideration and comprehension of pulmonary shunt fraction, ECMO cannula recirculation ratio and ECMO blood flow to cardiac output (CO) ratio are central to continuous assessment and diagnosis of cardio-pulmonary changes encountered during management of VV ECMO.

The Epiaortic Ultrasound Diagnosis of Iatrogenic Subadventitial Hematoma.

Iatrogenic aortic injury is a rare but potentially lethal complication of cardiac surgery. While sometimes resulting in aortic dissection or intramural hematoma, injury more frequently results in subadventitial hematoma, a more benign pathology. Here, we describe a case where intraoperative transesophageal echocardiography (TEE) identified such a hematoma but was unable to rule out dissection. Epiaortic ultrasound was subsequently performed, which definitively demonstrated the absence of a dissection flap or extraluminal flow. Per our review, this is the first report documenting the successful use of epiaortic imaging to identify subadventitial hematoma in the setting of inconclusive TEE findings.

Mentoring Fellows in Adult Cardiothoracic Anesthesiology for Academic Practice in the Contemporary Era-Perspectives From Mentors Around the United States.

This special article presents perspectives on the mentoring of fellows for academic practice in adult cardiothoracic anesthesiology. A comprehensive mentoring model should address the areas of clinical care, educational expertise and exposure to scholarly activity. The additional value of educational exposure to patient safety, quality improvement and critical care medicine in this model is also explored.

Near Total Occlusion of Right Ventricle by Cardiac Mass.

The incidence of primary cardiac tumors is very rare (0.02%) with the majority being benign. Angiosarcoma is the most common malignant cardiac tumor. However, regardless of the histological nature of cardiac tumors, they can cause life-threatening mechanical obstruction. We present a case of urgent surgical removal of a right ventricular (RV) mass. Echocardiography was instrumental for confirmation of the diagnosis, delineation of the anatomical extent of the tumor, evaluation for associated structural involvement and assessment of repair along with constant hemodynamic monitoring.

Blood utilization in revision versus first-time cardiac surgery: an update in the era of patient blood management.

BACKGROUND: Relative to first-time (primary) cardiac surgery, revision cardiac surgery is associated with increased transfusion requirements, but studies comparing these cohorts were performed before patient blood management (PBM) and blood conservation measures were commonplace. The current study was performed as an update to determine if this finding is still evident in the PBM era. STUDY DESIGN AND METHODS: Primary and revision cardiac surgery cases were compared in a retrospective database analysis at a single tertiary care referral center. Two groups of patients were assessed: 1) those having isolated coronary artery bypass (CAB) or valve surgery and 2) all other cardiac surgeries. Intraoperative and whole hospital transfusion requirements were assessed for the four major blood components. RESULTS: Compared to the primary cardiac surgery patients, the revision surgery patients required approximately twofold more transfused units intraoperatively (p < 0.0001) and approximately two- to threefold more transfused units for the whole hospital stay (p < 0.0001). Intraoperative massive transfusion (>10 red blood cell [RBC] units) was substantially more frequent with revision versus primary cardiac surgery (2.6% vs. 0.1% [p < 0.0001] for isolated CAB or valve and 6.1% vs. 1.9% [p < 0.0001] for all other cardiac surgeries). Revision surgery was an independent risk factor for both moderate (6-10 RBC units) and massive intraoperative transfusion. CONCLUSIONS: In the era of PBM, with restrictive transfusion strategies and a variety of methods for blood conservation, revision cardiac surgery patients continue to have substantially greater transfusion requirements relative to primary cardiac surgery patients. This difference in transfusion requirement was greater than what has been previously reported in the pre-PBM era.

Defining the Role of Intraoperative Transesophageal Echocardiography During Radical Nephrectomy With Inferior Vena Cava Tumor Thrombectomy for Renal Cell Carcinoma.

OBJECTIVE: To determine the impact of transesophageal echocardiography on the surgical management of patients undergoing nephrectomy and inferior vena cava tumor thrombectomy for renal cell carcinoma. MATERIALS AND METHODS: We retrospectively analyzed intraoperative records of 67 patients with renal cell carcinoma and level II-IV invasion of the inferior vena cava who underwent nephrectomy with tumor thrombectomy between 2007 and 2015. Based on preoperative imaging, patients were categorized according to vena cava thrombus level. Diagnostic utility and impact on surgical management were extracted from the operative note, anesthesia record, and intraoperative echocardiography report. RESULTS: Twelve of 34 patients (35%) with level II thrombus, 14 of 18 (78%) with level III thrombus, and 15 of 15 (100%) with level IV thrombus had intraoperative transesophageal echocardiography. With increasing level of tumor thrombus, the diagnostic yield and surgical impact increased. Echocardiography provided new diagnostic information in 7 of 12 (58%) patients with level II thrombus and altered surgical management in 16%. Among level III thrombus patients, echocardiography provided new diagnostic information in 12 of 14 (86%) and altered surgical management in 21%. Echocardiography provided new diagnostic information and impacted surgical management in all 15 (100%) patients with a level IV thrombus. CONCLUSION: The diagnostic yield of intraoperative transesophageal echocardiography increases in patients with greater vena caval tumor thrombus extension. This information has a significant influence on surgical decision-making.