Adam S. Evans

Determination of Brain Death by Apnea Test Adapted to Extracorporeal Cardiopulmonary Resuscitation

d b WHEN CARDIOPULMONARY RESUSCITATION (CPR) has to be prolonged for more than 10 to 30 minutes, survival and neurologic outcomes are dismal.1 This has spurred the institution of rescue extracorporeal membrane oxygenation (ECMO), known as extracorporeal cardiopulmonary resuscitation (ECPR). In this situation, ECMO provides both circulatory and oxygenation support via a system called venoarterial ECMO (VA-ECMO). Vascular access is achieved via the jugular and/or femoral route, and venous blood is drained into the ECMO device, oxygenated, warmed, and pumped back into the arterial system (Fig 1). An added benefit is that ECPR can facilitate therapeutic interventions that potentially could reverse the cause of the cardiac arrest or collapse (eg, emergent coronary revascularization or relief of cardiac tamponade). ECPR also allows the provision of therapeutic hypothermia by precise blood temperature control. There is some evidence, most of it from Taiwan, that ECPR in patients suffering from in-hospital cardiac arrest improves both shortand long-term survival when compared with conventional CPR,2,3 although this finding has not been consistent.1 The Extraorporeal Life Support Organization, a worldwide registry of more han 170 centers,4 has reported a steady increase in the number of atients receiving ECPR over the last 2 decades (Table 1).5 Although ECPR potentially may enhance survival and neurologic outcome, a substantial proportion of patients will nonetheless sustain severe neurologic complications, and there is a 1 in 5 hance of brain death.5 The 3 clinical findings necessary to confirm brain death include coma with a known cause, the absence of brainstem reflexes, and apnea (Table 2). The definitive diagnosis of brain death during ECPR is technically and logistically challenging. Conventional apnea testing is not feasible because oxygenation and carbon dioxide elimination are accomplished by ECMO. The transportation of a patient to the radiology suite for

Ten Years After the IOM Report: Engaging Residents in Quality and Patient Safety by Creating a House Staff Quality Council

Ten years after the 1999 Institute of Medicine report, it is clear that despite significant progress, much remains to be done to improve quality and patient safety (QPS). Recognizing the critical role of postgraduate trainees, an innovative approach was developed at New York-Presbyterian Hospital, Weill Cornell Medical Center to engage residents in QPS by creating a Housestaff Quality Council (HQC). HQC leaders and representatives from each clinical department communicate and partner regularly with hospital administration and other key departments to address interdisciplinary quality improvement (QI). In support of the mission to improve patient care and safety, QI initiatives included attaining greater than 90% compliance with medication reconciliation and reduction in the use of paper laboratory orders by more than 70%. A patient safety awareness campaign is expected to evolve into a transparent environment where house staff can openly discuss patient safety issues to improve the quality of care.

Perspective: call to action: it is time for academic institutions to appoint a resident quality and patient safety officer.

In meeting the Accreditation Council for Graduate Medical Education (ACGME) core competency requirements, teaching hospitals often find it challenging to ensure effective involvement of housestaff in the area of quality and patient safety (QPS). Because housestaff are the frontline providers of care to patients, and medical errors occasionally occur based on their actions, it is essential for health care organizations to engage them in QPS processes.In early 2008 a Housestaff Quality Council (HQC) was established at New York-Presbyterian Hospital, Weill Cornell Medical Center, to improve QPS by engaging housestaff in policy and decision-making processes and to promote greater housestaff participation in QPS initiatives. It was quickly realized that the success of the HQC was highly contingent on alignment with the institutions overall QPS agenda. To this end, the position of resident QPS officer was created to strengthen the relationship between the hospitals strategic goals and the HQC. The authors describe the success of the resident QPS officers at their institution and observe that by appointing and supporting resident QPS officers, hospitals will be better able to meet their quality and safety goals, residency programs will be able to fulfill their required ACGME core competencies, and the overall quality and safety of patient care can be improved. Simultaneously, the creation of this position will help to create a new cadre of physician leaders needed to further the goals of QPS in health care.

The Effect of a Novel Housestaff Quality Council on Quality and Patient Safety

Article-at-a-Glance Background In 2008 New York-Presbyterian Hospital (NYP)/Weill Cornell Medical Center, New York City, the largest not-for-profit, nonsectarian hospital in the United States, created and implemented a novel approach—the Housestaff Quality Council (HQC)—to engaging housestaff in quality and patient safety activities. Methods The HQC represented an innovative collaboration between the housestaff, the Department of Anesthesiology, the Division of Quality and Patient Safety, the Office of Graduate Medical Education, and senior leadership. As key managers of patient care, the housestaff sought to become involved in the quality and patient safety decision- and policy-making processes at the hospital. Its members were determined to decrease or minimize adverse events by facilitating multimodal communication, ensuring smart work flow, and measuring outcomes to determine best practices. The HQC, which also included frontline hospital staff or managers from areas such as nursing, pharmacy, and information technology, aligned its initiatives with those of the division of quality and patient safety and embarked on two projects—medication reconciliation and use of the electronic medical record. More than three years later, the resulting improvements have been sustained and three new projects—hand hygiene, central line–associated bloodstream infections, and patient handoffs—have been initiated. Conclusions The HQC model is highly replicable at other teaching institutions as a complementary approach to their other quality and patient safety initiatives. However, the ability to sustain positive momentum is dependent on the ability of residents to invest time and effort in the face of a demanding residency training schedule and focus on specialty-specific clinical and research activities.

Trends in the Management of Patients With Left Ventricular Assist Devices Presenting for Noncardiac Surgery: A 10-Year Institutional Experience.

In our institution, the vast majority of patients presenting for noncardiac surgery (NCS) while supported by a left ventricular assist device (LVAD) are now cared for by noncardiac-trained anesthesiologists as the result of a decade of educational intervention to effect this transition. This represents a significant departure from the published experiences of other institutions. With institutional review board approval, we queried the database of our anesthesia record keeping system (CompuRecord) to determine various aspects of the perioperative management of these patients from July 1, 2003, through June 30, 2013, during which time 271 NCS procedures were performed on adult patients supported by LVADs. Over the entire study period (2003-2013), anesthetic care was provided by a cardiac anesthesiologist 47% of the time and by a noncardiac anesthesiologist 53% of the time. However, by the time period 2012-2013, 88% of the NCS procedures were staffed by a noncardiac anesthesiologist. Despite the prevalence of continuous flow devices in this series, the use of invasive blood pressure monitoring decreased dramatically by the later years of the study. Vasoactive and inotropic medications were rarely required intraoperatively. No intraoperative cardiac arrests, thromboembolic complications, or device malfunctions occurred. Our conclusion is that NCS procedures on LVAD-supported patients can be safely managed by educated noncardiac anesthesiologists.

The Role of Housestaff in Implementing Medication Reconciliation on Admission at an Academic Medical Center

Since 2006, the Joint Commission has required all hospitals to have a process in place for medication reconciliation (MR). Although it has been shown that MR decreases medical errors, achieving compliance has proven difficult for many health care institutions. This article describes a housestaff-championed intervention of a “hard stop” for on-admission MR orders that led to a statistically significant increase in compliance that was sustained at 6 months after intervention. Academic medical centers, which comprise large numbers of housestaff, can improve compliance with on-admission MR by engaging housestaff in the development of solutions and in communication to their peers, leading to sustained results.

Intraoperative echocardiography for patients undergoing lung transplantation.

• Volume 118 • Number 4 www.anesthesia-analgesia.org 725 INDEX CASE A 34-year-old woman with end-stage lung disease secondary to cystic fibrosis is undergoing bilateral lung transplantation. After reperfusion of the left-transplanted lung, transesophageal echocardiography (TEE) assessment reveals a large (45 × 4 mm) echogenic mass arising from the left upper pulmonary vein (PV) extending into the left atrium (LA). Perioperative care of a patient undergoing lung transplantation can be challenging, given the patient’s limited cardiopulmonary reserve, and potential for hemodynamic and respiratory instability. Practice Guidelines from the American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists recommend TEE in the management of patients undergoing lung transplantation,1 particularly for assessment of hemodynamic instability and evaluation of pulmonary vasculature anastomoses.2,3 This Echo Didactics describes a focused examination for patients undergoing lung transplantation.

Role of nutrition support in adult cardiac surgery: a consensus statement from an International Multidisciplinary Expert Group on Nutrition in Cardiac Surgery

Nutrition support is a necessary therapy for critically ill cardiac surgery patients. However, conclusive evidence for this population, consisting of well-conducted clinical trials is lacking. To clarify optimal strategies to improve outcomes, an international multidisciplinary group of 25 experts from different clinical specialties from Germany, Canada, Greece, USA and Russia discussed potential approaches to identify patients who may benefit from nutrition support, when best to initiate nutrition support, and the potential use of pharmaco-nutrition to modulate the inflammatory response to cardiopulmonary bypass. Despite conspicuous knowledge and evidence gaps, a rational nutritional support therapy is presented to benefit patients undergoing cardiac surgery.

An Anesthesiology Department Leads Culture Change at a Hospital System Level to Improve Quality and Patient Safety

At New York-Presbyterian Hospital, Weill Cornell Medical Center, an innovative approach to involving housestaff in quality and patient safety, policy and procedure creation, and culture change was led by the Department of Anesthesiology of the Weill Medical College of Cornell University. A Housestaff Quality Council was started in 2008 that has partnered with hospital leadership and clinical departments to engage the housestaff in quality and patient safety initiatives, resulting in measurable improvements in several patient care projects and enhanced working relationships among various clinical constituencies. Ultimately this attempt to change culture has found great success in fostering a relationship between the housestaff and the hospital in ways that have and will continue to improve patient care.

Nutrition and the Cardiac Surgery Intensive Care Unit Patient—An Update

ITHIN THE SPECIALTY of critical care medicine, a new subspecialty of cardiothoracic surgical critical care has emerged as a result of the unique physiologic changes and complications associated with cardiothoracic surgery. The demand for cardiovascular critical care is increasing with the aging of the population and is projected to increase markedly over the next 15 years worldwide. 1 New paradigms of nutritional and metabolic support have been introduced in the last decade in critically ill patients, focusing on early, combined enteral nutrition (EN) and parenteral nutrition (PN), intensive insulin therapy for tight glucose control, and specific nutrients to modulate system and organ functions. 2 Although most cardiac surgical patients stay in the intensive care unit (ICU) for 1 to 2 days and do not require nutritional support, a small percentage progress to a more complicated and prolonged course and are at higher risk for complications from catabolism related to their illness. In addition, more patients with advanced heart failure are being admitted to the cardiac surgical ICU for prolonged periods and are malnourished at baseline. 3 This article reviews the current evidence regarding nutrition and metabolic support in cardiac surgical patients in the ICU and provides a framework for a structured approach to improve outcomes in this high-risk population.