Citrate does not change viscoelastic haemostatic assays after cardiopulmonary bypass.

Context: Viscoelastic hemostatic assays (VHA) are commonly used to identify specific cellular and humoral causes for bleeding in cardiac surgery patients. Cardiopulmonary bypass (CPB) alterations to coagulation are observable on VHA. Citrated VHA can approximate fresh whole blood VHA when kaolin is used as the activator in healthy volunteers. Some have suggested that noncitrated blood is more optimal than citrated blood for point-of-care analysis in some populations. Aims: To determine if storage of blood samples in citrate after CPB alters kaolin activated VHA results. Settings and Design: This was a prospective observational cohort study at a single tertiary care teaching hospital. Methods and Material: Blood samples were subjected to VHA immediately after collection and compared to samples drawn at the same time and stored in citrate for 30, 90, and 150 min prior to kaolin activated VHA both before and after CPB. Statistical Analysis Used: VHA results were compared using paired T-tests and Bland-Altman analysis. Results: Maximum clot strength and time to clot initiation were not considerably different before or after CPB using paired T-tests or Bland-Altman Analysis. Conclusions: Citrated samples appear to be a clinically reliable substitute for fresh samples for maximum clot strength and time to VHA clot initiation after CPB. Concerns about the role of citrate in altering the validity of the VHA samples in the cardiac surgery population seem unfounded.

Decline in Functional Status While on the Waiting List Predicts Worse Survival After Lung Transplantation.

OBJECTIVES: To determine if decreases in the Karnofsky Performance Score (KPS) while on the waitlist predict decreased survival after lung transplantation (LTx). DESIGN: A retrospective evaluation of the United Network for Organ Sharing database. The KPS was evaluated at the time of listing for transplant and at the time of transplantation. Group I consisted of patients having a decrease in KPS during the time on the waiting list (from the time of listing to the time of transplant), and Group II consisted of patients whose KPS stayed the same or increased during the same period. The authors used propensity-score weighting for comparisons of these groups. SETTING: Retrospective observational database review. PARTICIPANTS: Adult patients undergoing lung transplantation. INTERVENTIONS: None. Patients were stratified according to a change in their KPS. MEASUREMENTS AND MAIN RESULTS: Patient and graft survival of patients with decreasing or not decreasing KPS were compared. Of the 27,558 subjects included in the analysis, 17,986 (65%) had worsening KPS, which was associated with worse graft (p = 0.0003) and patient (p = 0.0019) survival after LTx. Using multivariate regression, a decrease in KPS of ≥40 was associated with decreased survival, and an increase of ≥40 was associated with improved survival (HR = 1.245, 95% CI [1.181-1.312], p < 0.0001 and HR = 0.866, 95% CI [0.785, 0.955], respectively). Among patients with a KPS <40 at the time of transplant, those with a decrease in KPS of ≥40 had decreased graft and patient survival compared with those with a smaller decrease (p = 0.0002 and p = 0.0021, respectively). CONCLUSIONS: Deterioration of KPS on the waiting list for LTx is associated with significantly greater postoperative mortality in patients after LTx. These results should be taken into consideration when allocating organs. Strategies to increase or to prevent a decrease in KPS before LTx should be evaluated.

A Sharp Right Turn: A Case of Aortic to Right Atrial Fistula During Transcatheter Aortic Valve Replacement.

BACKGROUND Aorto-atrial fistulas (AAFs) are rare lesions typically associated with paravalvular abscesses or aortic aneurysms. Iatrogenic AAFs have been described after cardiac surgery. While these lesions are often asymptomatic, they can cause shunting and volume overload. Diagnosis of AAFs can be challenging. Transesophageal echocardiography plays a critical role in their diagnosis. CASE REPORT A 91-year-old man undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis had extreme tortuosity of the aorta and iliofemoral vessels. The patient developed a fistula from the non-sinus of Valsalva to the right atrium during the procedure. After the procedure, the patient developed stroke and retroperitoneal hematoma. CONCLUSIONS This case represents the first full report of an aorta to right atrial fistula after TAVR. The anatomy of the aortic root in relation to the right atrium and ventricle may make aorta to right ventricle fistulas more common than aorta to right atrial fistulas. This patient's vascular tortuosity may have played a role in the development of this lesion. Blood flow in an aorta to right atrial fistula occurs during both systole and diastole, making both right and left ventricle overload possible. Echocardiography is essential to the diagnosis of these lesions. Both vascular injury and landing zone rupture are possible during TAVR, although the observed timing and anatomy of this lesion suggest that it was caused during retrograde access of the left ventricular outflow tract via the ascending aorta.

Problem-Based Learning Discussion to Introduce Quality Improvement to Residents in the Perioperative Setting.

INTRODUCTION: Quality improvement (QI) is a growing and critical part of perioperative medical practice. However, there are few examples of educational tools to introduce new learners from anesthesiology to QI. This may contribute to a lack of enthusiasm to learn about and apply these concepts. METHODS: This problem-based learning discussion (PBLD) was designed to teach anesthesiology residents about QI in a way allowing for the application of core concepts in a group setting. We created this PBLD using available literature on QI in the perioperative setting. Basic concepts and terminology necessary for new learners to communicate about QI were specifically addressed. Feedback from staff anesthesiologists and resident participants in the PBLD was used to tailor it to the needs of the target learners and to reach the educational objectives. RESULTS: We delivered this PBLD in two separate learning sessions both to board-certified anesthesiologists (N = 10) and to resident anesthesiologists (N = 19) at our institution. The exercise was reviewed anonymously, and qualitative feedback was used to improve updated versions. Respondents felt that the PBLD would be improved by avoiding jargon-based humor, considering the systemic implications of QI, and limiting the overall length of the learning tool. The PBLD has been adopted as a starting point for discussions about QI in our training program. DISCUSSION: We feel this PBLD can introduce new learners to the learning objectives. This tool has provided an alternative to lectures or computer-based modules for teaching QI.

Postoperative Thyroid Storm After Evacuation of a Complete Hydatidiform Mole: A Case Report.

Gestational trophoblastic disease can lead to excess thyroid hormone release and rarely, thyroid storm. We present a case of complete molar pregnancy with hyperthyroidism that was not identified or treated before surgical evacuation of uterine contents. Untreated hyperthyroidism preoperatively led to unanticipated thyroid storm immediately after emergence from anesthesia. It is important for anesthesia providers to recognize the link between gestational trophoblastic disease and thyrotoxicosis, and appreciate the severe consequences than can occur if left untreated. Anesthesia providers should strongly consider preoperative consultation and treatment. Being prepared to treat intraoperative symptoms and thyroid storm is paramount.

Desperate Times Call for Deliberate Measurement: A Review of COVID-19 Aerosol Barrier Devices and a Perspective from a Military Treatment Facility.

The threat of shortages of personal protective equipment have led to innovations in protective barriers to limit the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Those performing aerosolizing procedures such as endotracheal intubation have been designated by the Centers for Disease Control as increased risk of contracting COVID-19. Evaluation of aerosolizing containing barriers for intubation has been limited to date. Some have raised concerns about the universal use of these devices and their possible iatrogenic side effects. It is clear that in time periods of atypical practice that quality and outcome review are critical to addressing novel problems as they arise. An unusual set of injury patterns associated with videolaryngoscopy lead to further evaluation and reconsideration of these devices in our own military department. We review the current literature on this topic and provide a perspective from a single large academic military treatment facility.

Leveraging the Existing Anesthesia Information Management System to Improve Anesthesia Quality Assurance Outcome Reporting.

INTRODUCTION: Tracking measures of quality over time has been shown to improve care within institutions and across health systems. Perioperative quality assurance (QA) tracking by anesthesia departments in the Military Health System (MHS) has not used a uniform system integrated into the workflow of anesthesia providers. The purpose of this study was to demonstrate that the use of the embedded QA outcome reporting feature in the anesthesia information management system (AIMS) increased the rate of reporting compared to the current paper reporting system in a military anesthesia department. MATERIALS AND METHODS: An electronic outcome reporting mechanism embedded in the AIMS was activated as an alternative to paper QA outcome reporting. The proportion of anesthesia cases per month in a 12-month period with a reported QA outcome was compared to the previous year in which only the paper reporting system was used. The total number of cases in each time period with an outcome reported was compared using chi square for proportions, and systems were evaluated using the Statistical Process Control methodology. This project was evaluated and determined to be exempt from review by our institutional review board. RESULTS: There was a 389.8% increase in the number of cases with a QA outcome reported after the implementation of the outcome reporting function integrated into the AIMS (χ2 = 207.72; P <.001, Table I). Systems before and after the intervention were stable, and special cause variation was noted only at the point of implementation of the electronic reporting system. Anesthesia providers were surveyed and felt that the addition of QA reporting to the AIMS made QA reporting more likely. CONCLUSIONS: The use of an electronic QA outcome reporting method integrated into the AIMS dramatically increased the likelihood that a QA outcome would be reported. The decreased administrative burden of the integrated outcome reporting system was likely the primary reason for this increase. This study was limited by the fact that it was done in a single institution; however, the size and timing of the increase clearly indicate that the intervention was the reason for improved reporting. Electronic health record upgrades should consider incorporating QA reporting into the AIMS across the MHS. These measures could allow for system-wide improvement, evaluation, and evidence-based education on their own, but also by facilitating participation in the American Society of Anesthesiologists' Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry. This report serves as a valuable example to institutions and perioperative leaders in the MHS of how to improve the robustness of perioperative QA reporting such that it could be used to validate and improve the value of care.

Retrieval of a Esophageal pH Monitoring Probe Dislodged Into the Laryngopharynx: A Case Report.

Esophageal pH monitoring via wireless probes is used to evaluate chest pain and atypical symptoms and diagnose gastroesophageal reflux. These probes are commonly placed during esophagogastroduodenoscopy performed by gastroenterologists in an ambulatory anesthesia setting. Dislodgment and aspiration of these probes can cause morbidity, require surgical removal, and involve the anesthesia provider in prolonged emergency care. We present a case of a probe dislodgment where aspiration was avoided and describe how retrieval of this device is different from typical hypopharyngeal foreign body removal.