The Vancouver 3M (Multidisciplinary, Multimodality, But Minimalist) Clinical Pathway Facilitates Safe Next-Day Discharge Home at Low-, Medium-, and High-Volume Transfemoral Transcatheter Aortic Valve Replacement Centers: The 3M TAVR Study.

OBJECTIVES: The authors sought to prospectively determine the safety and efficacy of next-day discharge using the Vancouver 3M (Multidisciplinary, Multimodality, but Minimalist) Clinical Pathway. BACKGROUND: Transfemoral transcatheter aortic valve replacement (TAVR) is an alternative to surgery in high- and intermediate-risk patients; however, hospital stays average at least 6 days in most trials. The Vancouver 3M Clinical Pathway is focused on next-day discharge, made possible by the use of objective screening criteria as well as streamlined peri- and post-procedural management guidelines. METHODS: Patients were enrolled from 6 low-volume (<100 TAVR/year), 4 medium-volume, and 3 high-volume (>200 TAVR/year) centers in Canada and the United States. The primary outcomes were a composite of all-cause death or stroke by 30 days and the proportion of patients successfully discharged home the day following TAVR. RESULTS: Of 1,400 screened patients, 411 were enrolled at 13 centers and received a SAPIEN XT (58.2%) or SAPIEN 3 (41.8%) valve (Edwards Lifesciences, Irvine, California). In centers enrolling exclusively in the study, 55% of screened patients were enrolled. The median age was 84 years (interquartile range: 78 to 87 years) with a median STS score of 4.9% (interquartile range: 3.3% to 6.8%). Next-day discharge home was achieved in 80.1% of patients, and within 48 h in 89.5%. The composite of all-cause mortality or stroke by 30 days occurred in 2.9% (95% confidence interval: 1.7% to 5.1%), with neither component of the primary outcome affected by hospital TAVR volume (p = 0.51). Secondary outcomes at 30 days included major vascular complication 2.4% (n = 10), readmission 9.2% (n = 36), cardiac readmission 5.7% (n = 22), new permanent pacemaker 5.7% (n = 23), and >mild paravalvular regurgitation 3.8% (n = 15). CONCLUSIONS: Adherence to the Vancouver 3M Clinical Pathway at low-, medium-, and high-volume TAVR centers allows next-day discharge home with excellent safety and efficacy outcomes.

Perioperative implications of sodium-glucose cotransporter-2 inhibitors: a case series of euglycemic diabetic ketoacidosis in three patients after cardiac surgery.

PURPOSE: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) comprise the newest class of oral hypoglycemic agents approved for treating type II diabetes mellitus (DM-II). Their use, however, has been associated with the rare development of euglycemic diabetic ketoacidosis (euDKA). We present three cases of euDKA that occurred following elective coronary artery bypass grafting surgery. The role of the anesthesiologist in the prevention, diagnosis, and management of this complication is also discussed. CLINICAL FEATURES: Three patients receiving chronic SGLT2i therapy for DM-II (discontinued one to two days preoperatively) underwent cardiac surgery. On the first postoperative day, each exhibited nausea, vomiting, and tachypnea. Although these nonspecific postoperative findings are common, our patients also exhibited anion gap metabolic acidosis (pH < 7.3, anion gap > 12 mmol·L-1) with lower than anticipated serum glucose levels of < 14 mmol·L-1. Serum and urine ketone analyses confirmed a diagnosis of euDKA. After insulin and dextrose infusions were initiated, rapid resolution of the metabolic abnormalities occured. CONCLUSIONS: Anesthesiologists should recognize that patients receiving SGLT2i preoperatively are at risk of developing euDKA. Hence, based on the pharmacokinetics of SGLT2i, discontinuing the medication at least two days prior to surgery should minimize the risk. Diagnosing euDKA is challenging and often delayed because of its nonspecific signs and symptoms. When suspected, serum and urine ketones should be monitored to reduce the time to diagnosis and treatment.

Point-of-care ultrasonography in Canadian anesthesiology residency programs: a national survey of program directors.

PURPOSE: Point-of-care ultrasonography (POCUS) is a useful tool with multiple perioperative applications relevant to the anesthesiologist. Nevertheless, the full scope of POCUS applications has yet to be formally incorporated into Canadian anesthesiology training. The purpose of this study was to determine the current state of POCUS training in Canadian anesthesiology residency programs. METHODS: We conducted a web-based survey of program directors from Royal College-accredited anesthesiology residency programs across Canada. Respondents were asked about POCUS training and assessment strategies at their institution as well as perceived barriers to POCUS education. We also elicited program directors' views on the importance of various POCUS applications as well as future direction of POCUS education within Canadian anesthesiology residency programs. RESULTS: Thirteen of 17 (76%) program directors responded to our survey. All respondents' residency programs provide some training in POCUS-facilitated vascular access, peripheral nerve blocks, neuraxial techniques, and transthoracic echocardiography. Nevertheless, training varies significantly for the other POCUS applications in our survey. The most frequently quoted teaching method employed is informal bedside teaching, followed by structured expert demonstration, hands-on scanning, and didactic lectures. The most frequently quoted barrier to teaching POCUS is the lack of trained staff. The majority of respondents agreed that competence in POCUS is important for graduating anesthesiology residents, and that POCUS should be incorporated into the National Curriculum for Canadian Anesthesiology Residency. CONCLUSION: Point-of-care ultrasonography training within Canadian anesthesiology residency programs is highly variable. Given the importance of POCUS abilities and their relevance to modern anesthesia practice, POCUS training and assessment within Canadian anesthesiology residency programs should be formalized.

Ultrasound-guided saphenous nerve block--within versus distal to the adductor canal: a proof-of-principle randomized trial.

PURPOSE: Reliable saphenous nerve blockade is a desirable complement to popliteal sciatic nerve blockade for foot and ankle surgery. We compared two promising ultrasound-guided techniques, the supine adductor canal (AC) technique and the prone peri-saphenous branch of the descending genicular artery (Peri-SBDGA) technique, using 8 mL of 2% lidocaine with epinephrine 1:400,000. METHODS: Following Research Ethics Board approval, we conducted a randomized single-blinded parallel-group trial in 102 patients undergoing foot and ankle surgery at a single centre. The primary endpoint was saphenous nerve ease of visualization (0 = not visible; 1 = visible with difficulty; and 2 = easily visible). Other endpoints included vascular landmark visualization (0 = not visible; 1= visible with colour flow Doppler; 2 = visible without colour flow Doppler), block success, onset, and complications. RESULTS: Ninety-one patients were eligible for analysis. Saphenous nerve visibility was not different between the groups (visibility score = 2: AC group, n = 24/49 [49%] vs Peri-SBDGA group, 20/42 [48%]; P = 1.00). Vascular landmark visibility was better in the AC group than in the Peri-SBDGA group (visibility score = 2: 41/49 [84%] vs 25/42 [60%], respectively; P = 0.018). Block success rates were similar (AC group, 41/49 [84%] vs Peri-SBDGA group, 34/42 [81%]; P = 0.79), as were median [interquartile range] onset times (AC group, 5 [5-10] min vs Peri-SBDGA group, 8 [5-11] min; P = 0.38). CONCLUSION: In this randomized trial, we found no differences in nerve visibility, block success rate, or onset between the AC and Peri-SBDGA techniques of ultrasound-guided saphenous nerve blockade, although the former technique provided superior vascular landmark visibility. Neither technique produced a sufficiently high success rate to provide reliable surgical anesthesia per se.

Acute Type A Dissection Repair in an Achondroplastic Dwarf: Anesthetic, Perfusion, and Surgical Concerns.

In this report we present a 43-year-old male with achondroplastic dwarfism who presented with acute Type A aortic dissection with aortic insufficiency. The patient underwent successful Bentall and hemiarch repair. Anesthetic, perfusion-related, and surgical planning and execution are presented.