Anesthetic Management of Middle Aortic Syndrome in an Adult: A Case Report.

Middle aortic syndrome (MAS) is a rare disorder characterized by narrowing of the aorta. Depending on the location and extent of aortic narrowing, surgical management may be necessary to prevent long-term sequelae, such as stroke and congestive heart failure. We report a case of MAS and discuss the unique intraoperative anesthetic considerations including hemodynamic monitoring proximal and distal to the aortic narrowing, minimizing the risk of spinal cord ischemia, and utilization of intraoperative dobutamine stress testing to guide surgical management.

Association between body mass index and difficult intubation with a double lumen tube: A retrospective cohort study.

STUDY OBJECTIVE: Obesity, defined by the World Health Organization as body mass index (BMI) ≥ 30.0 kg/m2, is associated with adverse outcomes and challenges during surgery. Difficulties during endotracheal intubation, occur in 3-8% of procedures and are among the principal causes of anesthetic-related morbidity and mortality. Endotracheal intubation can be challenging in obese patients due to an array of anatomic and physiologic factors. Double lumen tubes (DLTs), the most commonly used airway technique to facilitate anatomic isolation of the lungs for one lung ventilation. However, DLTs can be difficult to properly position and are also more likely to cause airway injuries and bleeding when compared to conventional single lumen tubes. We investigated the association between BMI and difficult tracheal DLT intubation. DESIGN: Retrospective cohort study. SETTING: Operating room. PATIENTS: We analyzed electronic records of adults having cardiac and thoracic surgery requiring general anesthesia and endotracheal intubation with DLT at the Cleveland Clinic between 2008 and 2021. MEASUREMENTS: BMI, preoperative airway abnormalities and difficult intubation, defined as more than one intubation attempt, was assessed using multivariable logistic regression. MAIN RESULTS: Among 8641 analyzed anesthetics requiring DLT, 1459 (17%) were difficult intubations. After adjusting for confounders, each 5 kg/m2 increase in BMI was associated with a marginal increase of difficult intubation, odds ratio (OR) 1.06 (95% Confidence Interval [CI]: 1.002, 1.11; P = 0.040). Difficult intubation was not associated with airway abnormalities, estimated OR 0.85 (95% CI: 0.62, 1.17; P = 0.321). There was no interaction between known airway abnormalities and BMI (P = 0.894). CONCLUSIONS: Difficult intubations with DLT remain common, but BMI is a weak predictor thereof. For example, an increase in BMI from 20 to 40 kg/m2 corresponds to an increase in average absolute risk for difficult intubation from 16 to 19%, which probably is not clinically meaningful.

Recommendations for Multimodality Cardiovascular Imaging of Patients with Hypertrophic Cardiomyopathy: An Update from the American Society of Echocardiography, in Collaboration with the American Society of Nuclear Cardiology, the Society for Cardiovascular Magnetic Resonance, and the Society of Cardiovascular Computed Tomography.

Hypertrophic cardiomyopathy (HCM) is defined by the presence of left ventricular hypertrophy in the absence of other potentially causative cardiac, systemic, syndromic, or metabolic diseases. Symptoms can be related to a range of pathophysiologic mechanisms including left ventricular outflow tract obstruction with or without significant mitral regurgitation, diastolic dysfunction with heart failure with preserved and heart failure with reduced ejection fraction, autonomic dysfunction, ischemia, and arrhythmias. Appropriate understanding and utilization of multimodality imaging is fundamental to accurate diagnosis as well as longitudinal care of patients with HCM. Resting and stress imaging provide comprehensive and complementary information to help clarify mechanism(s) responsible for symptoms such that appropriate and timely treatment strategies may be implemented. Advanced imaging is relied upon to guide certain treatment options including septal reduction therapy and mitral valve repair. Using both clinical and imaging parameters, enhanced algorithms for sudden cardiac death risk stratification facilitate selection of HCM patients most likely to benefit from implantable cardioverter-defibrillators.

Near-Infrared Spectroscopy (NIRS) for Cerebral and Tissue Oximetry: Analysis of Evolving Applications.

THE USE OF NEAR-INFRARED SPECTROSCOPY (NIRS) has increased significantly worldwide in the past decade. This technology, first described more than 40 years ago, is based on the fact that near-infrared light is able to penetrate biologic tissue and can obtain real-time, noninvasive information on tissue oxygenation and metabolism. In the clinical setting, NIRS has been able to provide clinicians potentially valuable information in patients with impaired microcirculations (systemic and cerebral). Near-infrared spectroscopy has progressed beyond assessment of brain oxygenation to monitor local tissue and muscle oxygenation and perfusion. This review analyzes the published data and provides the clinician a comprehensive account of the perioperative utility of NIRS in cardiac, vascular and thoracic surgery, as well as its increasing role in tissue/muscle oxygenation monitoring.

Academic faculty demonstrate higher well-being than residents: Pennsylvania anesthesiology programs' results of the 2017-2018 ACGME well-being survey.

STUDY OBJECTIVE: Physician burnout and suicide are at epidemic proportions. There is very little data directly comparing resident versus faculty well-being. The 2017-2018 ACGME resident and faculty surveys mark the first time that well-being questions were included. The purpose of this study was to determine whether responses to ACGME well-being questions would differ significantly between anesthesiology residents and academic anesthesiology faculty. DESIGN: 2017-2018 ACGME well-being survey responses. SETTING: All eight Pennsylvania anesthesiology residency programs. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS: The authors compared the 5-point Likert scale responses (1 = Never through 5 = Very Often) between residents (371/384 responses, 97%) and faculty (277/297 responses, 93%) for each of the twelve well-being questions. Responses were also dichotomized as being ≥4 versus <4 for categorical comparisons. MAIN RESULTS: Faculty responded higher than residents both by mean scores and percent of scores ≥ 4 for 6/12 questions (questions 1 (p < 0.001), 2 (p < 0.001), 4 (p < 0.001), 5 (p < 0.001), 8 (p < 0.001), and 11 (p = 0.001)). Residents responded categorically higher for question 9 (p = 0.022) although this was not considered statistically significant. Residents responded lowest for "Reflected on how your work helps make the world a better place" (question 1), whereas the lowest faculty responses were for questions 1, 9, and 10. Both had high responses for "Had an enjoyable interaction with a patient" (question 11). CONCLUSIONS: Pennsylvania academic anesthesiology faculty survey responses demonstrated a higher level of well-being compared to their residents. The variation in scoring suggests that anesthesiology residents and faculty have differing perceptions of various well-being domains. Information from well-being surveys can help provide programs with focus areas that they can intervene on to improve physician well-being.

Retrograde Venous Bullet Embolization to the Hepatic Inferior Vena Cava Located with Intraoperative Transesophageal Echocardiography.

The authors present a case in which a GSW to the chest led to a retrograde venous bullet embolization. The fragment originated in the right atrium and embolized to the hepatic IVC, which was located with intraoperative TEE.

Moderate Aortic Stenosis and Coronary Artery Bypass Grafting: Clinical Update for the Perioperative Echocardiographer.

Incidental aortic stenosis in the setting of coronary artery bypass surgery may be a perioperative challenge. The accurate assessment of the degree of aortic stenosis remains an important determinant. Although severe aortic stenosis is an indication for valve replacement, current guidelines advise a balanced approach to the management of moderate aortic stenosis in this setting. Multiple factors should be considered in a team discussion to balance risks versus benefits for the various management options in the given patient. The rapid progress in aortic valve technologies also offer alternatives for definitive management of moderate aortic stenosis in this setting that will likely become even safer in the near future.

Optimal perioperative medical management of the vascular surgery patient.

Perioperative medical management of patients undergoing vascular surgery can be challenging because they represent the surgical population at highest risk. ß-Blockers should be continued perioperatively in patients already taking them preoperatively. Statins may be used in the perioperative period in patients who are not on statin therapy preoperatively. Institutional guidelines should be used to guide insulin replacement. Recent research suggests that measurement of troponins may provide some risk stratification in clinically stable patients following vascular surgery. Multimodal pain therapy including nonopioid strategies is necessary to improve the efficacy of pain relief and decrease the risk of side effects and complications.

Cerebral near-infrared spectroscopy in perioperative management of left ventricular assist device and extracorporeal membrane oxygenation patients.

PURPOSE OF REVIEW: Neurologic injury remains a common complication in patients undergoing mechanical support for cardiac and respiratory failure with either left ventricular assist devices (LVAD) or extracorporeal membrane oxygenation (ECMO). Cerebral near-infrared spectroscopy (NIRS) has been recognized clinically as a valid, continuous, and practical monitor of cerebral perfusion in cardiac surgery. Recently, interest in utilizing this technology to monitor patients while undergoing LVAD and ECMO placement and their resultant care has expanded. The purpose of this review is to discuss the practical approaches to using cerebral NIRS for LVAD and ECMO implantation. RECENT FINDINGS: Recent studies suggest that implementation of cerebral NIRS monitoring during LVAD and ECMO implantation may reduce the perioperative neurological complications. In addition, cerebral NIRS can function as a first-alert monitor to warn of problems with oxygenation, ventilation, mixed venous oxygen saturation, and cardiac output. SUMMARY: Despite an overall small body of literature, early evidence suggests a possible beneficial effect of utilizing cerebral NIRS during LVAD and ECMO implantation. Prospective randomized studies are needed to develop algorithm-based therapies centered on NIRS monitoring. On the basis of potential benefits and minimal risks in relation to cerebral NIRS, it is recommended that it be utilized during the operative and immediate postoperative period in the LVAD and ECMO patient population.

An overview of end-of-life issues in the intensive care unit.

The population of the earth is aging, and as medical techniques, pharmaceuticals, and devices push the boundaries of human physiological capabilities, more humans will go on to live longer. However, this prolonged existence may involve incapacities, particularly at the end-of-life, and especially in the intensive care unit. This arena involves not only patients and families, but also care givers. It involves topics from economics to existentialism, and surgery to spiritualism. It requires education, communication, acceptance of diversity, and an ultimate acquiescence to the inevitable. Here, we present a comprehensive overview of issues in the care of patients at the end-of-life stage that may cause physicians and other healthcare providers, medical, ethical, social, and philosophical concerns in the intensive care unit.