Ashraf Fayad

Ultrasound-Guided Subclavian Vein Catheterization: A Systematic Review and Meta-Analysis.

Objective:Although ultrasound guidance for subclavian vein catheterization has been well described, evidence for its use has not been comprehensively appraised. Thus, we conducted a systematic review and meta-analysis to determine whether ultrasound guidance of subclavian vein catheterization reduces catheterization failures and adverse events compared to the traditional “blind” landmark method. All forms of ultrasound were included (dynamic 2D ultrasound, static 2D ultrasound, and Doppler). Data Sources:Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL (from inception to September 2014). Study Selection:Randomized controlled trials of ultrasound compared to landmark technique for subclavian catheterization in adult populations were considered. Outcomes of interest included safety and failure of catheterization. Data Extraction:Adverse event data were analyzed according to Peto’s method and expressed as odd ratios and 95% CIs. Failure of catheterization was analyzed with inverse variance random effects modeling and expressed as risk ratios and 95% CI. Data Synthesis:Six hundred and one studies were reviewed and 10 met inclusion criteria (n = 2,168 participants). Six used dynamic 2D ultrasound (n = 719), one used static 2D ultrasound (n = 821), and three used Doppler-guided insertion techniques (n = 628). Overall complication rates were reduced with ultrasound use compared to the landmark group (odd ratio, 0.53; 95% CI, 0.41–0.69). Subgroup analysis demonstrated that dynamic 2D ultrasound reduced inadvertent arterial puncture, pneumothorax, and hematoma formation. No difference in failure of catheterization was noted between the ultrasound group and the landmark method (risk ratio, 0.85; 95% CI, 0.48–1.51). Subgroup analysis of dynamic 2D ultrasound demonstrated a significant decrease in failed catheterization (risk ratio, 0.24; 95% CI, 0.06–0.92). Conclusions:Ultrasound-guided subclavian catheterization reduced the frequency of adverse events compared with the landmark technique. Our findings support the use of dynamic 2D ultrasound for subclavian catheterization to reduce adverse events and failed catheterization.

Acute diastolic dysfunction in thoracoabdominal aortic aneurysm surgery

PurposeTo report transesophageal echocardiographic (TEE) findings consistent with intraoperative acute diastolic dysfunction in a series of patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair.MethodsA series of nine consecutive patients underwent TAAA repair with intraoperative TEE monitoring. Surgical repair was performed with the adjunct of a left atrio-femoral bypass. Invasive arterial and venous pressures were monitored. Intraoperative TEE was utilized to assess the diastolic function before, and during aortic cross clamping. Diastolic dysfunction was defined as a mitral inflow pulsed wave Doppler (E: A ratio) < 1.ResultsAll patients demonstrated an E: A ratio > 1 (1.3 ± 0.08) before aortic cross clamping. During cross clamp, the E: A ratio decreased to < 1 (0.75 ± 0.05) in six of nine patients consistent with diastolic dysfunction. The three patients who did not develop E: A changes were receiving ß-blockers preoperatively. Patients with diastolic dysfunction were treated with nitroglycerin infusions, which resulted in restoration of their E: A ratios < 1 (1.2 ± 0.09). Three of the patients with intraoperative diastolic dysfunction developed postoperative myocardial infarction.ConclusionsChronic diastolic dysfunction is a well-known entity. This report describes acute diastolic dysfunction, which was observed frequently in patients undergoing TAAA during aortic cross clamp. Further research is required to confirm this phenomenon and determine its possible association with increased postoperative cardiac morbidity.RésuméObjectifPrésenter les résultats de ľéchocardiographie transœsophagienne (ETO) compatibles avec une dysfonction peropératoire diastolique aiguë chez une série de patients opérés pour un anévrysme aortique thoraco-abdominal (AATA).MéthodeNeuf patients consécutifs ont subi la réparation ďun AATA sous monitorage peropératoire avec ETO. Une dérivation auriculo-fémorale gauche et un monitorage endovasculaire des pressions artérielle et veineuse ont été utilisés. ĽETO peropératoire a servi à évaluer la fonction diastolique avant et pendant le clampage de la crosse aortique. La dysfonction diastolique était une onde Doppler pulsée ďentrée mitrale (ratio E: A) < 1.RésultatsTous les patients ont démontré un ratio E: A > 1 (1,3 ± 0,08) avant le clampage de la crosse aortique. Pendant le clampage, le ratio E: A a baissé à < 1 (0,75 ± 0,05) chez six des neuf patients, indiquant une dysfonction diastolique. Les trois autres patients avaient reçu des ß bloquants préopératoires. La dysfonction diastolique a été traitée avec une perfusion de nitroglycérine, ce qui a restauré le ratio E: A < 1 (1,2 ± 0,09). Trois des patients qui ont présenté une dysfonction diastolique peropératoire ont subi un infarctus du myocarde postopératoire.ConclusionLa dysfonction diastolique chronique est bien connue. Nous avons décrit une dysfonction diastolique aiguë observée souvent pendant le clampage de la crosse aortique chez des patients opérés pour un AATA. Il faut encore confirmer ce phénomène et déterminer son lien possible avec la hausse de la morbidité cardiaque postopératoire.

Focused ultrasound is the next step in perioperative care

In this issue of the Journal, two different investigators report the use of bedside ultrasound for focused cardiac examination as well as for focused thoracic and abdominal examinations in patients undergoing non-cardiac surgery. These ultrasound observations led to a change in patient management, and it is expected that more widespread use of this tool in our practice will likely have a significant impact on perioperative care. This paradigm change implies that consideration should be given to incorporating an ultrasound curriculum within our anesthesiology training programs. The first case involves a previously healthy 29-yr-old pregnant woman who developed preeclampsia complicated by HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. Following Cesarean delivery, the patient remained anuric and was transferred to the intensive care unit. A bedside cardiac ultrasound was performed using a validated pulsed wave tissue Doppler technique to estimate filling pressures and evaluate cardiac function. The patient was found to be responsive to passive leg raising and fluid therapy, and ultrasound confirmed the absence of fluid overload; however, a few hours later, she was found to be anemic. At that point, abdominal ultrasound was used to diagnose an intra-abdominal hematoma. Based on these findings, a decision was made to transfuse blood and explore the abdomen surgically. Postoperatively, the patient became hypoxic, and a repeated lung ultrasound showed comet-tail artifacts of B-lines, which is suggestive of an alveolar-interstitial syndrome. The absence of elevated filling pressure on cardiac ultrasound suggested non-cardiogenic pulmonary edema and the possibility of acute respiratory distress syndrome. The other case involves a 58-yr-old man who was scheduled for elective nasal polyp excision. The patient was known to have aortic stenosis and was ‘‘cleared’’ preoperatively by a cardiologist and a cardiac surgeon. A preoperative anesthesia evaluation of cardiac function with bedside ultrasound revealed an unsuspected large pericardial effusion with signs of pericardial tamponade and right atrial and right ventricular collapse. The case was cancelled and the patient underwent percutaneous pericardial drainage. The clinical presentation and pericardial fluid analysis led to the diagnosis of ChurgStrauss syndrome complicated by progressive pericardial effusion. The patient was discharged from hospital several days later, and his nasal polyps were treated medically. These two cases effectively illustrate the gradual integration of bedside ultrasound as a point-of-care examination performed by the anesthesiologist for conditions that are not uncommon in the perioperative setting. Ultrasound was used in a goal-oriented approach to answer a specific question, and it involved more than solely examination of the heart. As anesthesiologists and critical care physicians, we strive to maintain adequate oxygen delivery; ultrasound can play a role in identifying A. Denault, MD, PhD (&) Department of Anesthesia, Montreal Heart Institute, 5000 Belanger Street, Montreal, QC H1S 1T8, Canada e-mail: andre.denault@gmail.com

Perioperative Diastolic Dysfunction in Patients Undergoing Noncardiac Surgery Is an Independent Risk Factor for Cardiovascular Events: A Systematic Review and Meta-analysis.

Background:The prognostic value of perioperative diastolic dysfunction (PDD) in patients undergoing noncardiac surgery remains uncertain, and the current guidelines do not recognize PDD as a perioperative risk factor. This systematic review aimed to investigate whether existing evidence supports PDD as an independent predictor of adverse events after noncardiac surgery. Methods:Ovid MEDLINE, PubMed, EMBASE, the Cochrane Library, and Google search engine were searched for English-language citations in April 2015 investigating PDD as a risk factor for perioperative adverse events in adult patients undergoing noncardiac surgery. Two reviewers independently assessed the study risk of bias. Extracted data were verified. Random-effects model was used for meta-analysis, and reviewers’ certainty was graded. Results:Seventeen studies met eligibility criteria; however, 13 contributed to evidence synthesis. The entire body of evidence addressing the research question was based on a total of 3,876 patients. PDD was significantly associated with pulmonary edema/congestive heart failure (odds ratio [OR], 3.90; 95% CI, 2.23 to 6.83; 3 studies; 996 patients), myocardial infarction (OR, 1.74; 95% CI, 1.14 to 2.67; 3 studies; 717 patients), and the composite outcome of major adverse cardiovascular events (OR, 2.03; 95% CI, 1.24 to 3.32; 4 studies; 1,814 patients). Evidence addressing other outcomes had low statistical power, but higher long-term cardiovascular mortality was observed in patients undergoing open vascular repair (OR, 3.00; 95% CI, 1.50 to 6.00). Reviewers’ overall certainty of the evidence was moderate. Conclusion:Evidence of moderate certainty indicates that PDD is an independent risk factor for adverse cardiovascular outcomes after noncardiac surgery.

Thoracic endovascular stent graft with a bird’s beak sign

A 21 yr-old male patient, with closed chest injury, presented for endovascular repair of a traumatic descending thoracic aortic pseudo-aneurysm. The preoperative computed tomography scan demonstrated the presence of a pseudo-aneurysm just distal to the left subclavian artery. It was also noted that the junction between the aortic arch and descending aorta was abnormally at a sharp right angle. Following induction of anesthesia, a transesophageal echocardiography (TEE) probe was inserted. The aortic pseudo-aneurysm was identified and the TEE deployment zone measurements were obtained. A Zenith (Cook, Inc., Bloomington, IN, USA) thoracic endovascular graft was deployed at the aortic arch proximal to the left subclavian artery, but distal to the left common carotid artery. Upper esophageal TEE views of the aortic arch demonstrated a type I1 endoleak with a right angle present between the graft and the aortic wall, leading to a bird’s beak sign formation2 (Figures 1, 2 and 3). Further ballooning of the proximal end of the graft minimized the endoleak, based on the Images in Anesthesia

Postoperative real-time electrocardiography monitoring detects myocardial ischemia: a case report.

PurposeThis case report outlines the utility and challenges of remote continuous postoperative electrocardiography ECG) monitoring, which is routed through a secure smartphone to provide real-time detection and management of myocardial ischemia.Clinical featuresA 42-yr-old male with previous myocardial infarction and angioplasty underwent a radical prostatectomy. At three hours and 45 min postoperatively, remote real-time ECG monitoring was initiated upon the patient’s arrival on a regular surgical ward. Monitor alerts were routed to a study clinician’s smartphone. About six hours postoperatively, alarms were received and horizontal ST segment depressions were observed. A 12-lead ECG validated the ST segment changes, prompting initiation of a metoprolol iv and a red blood cell transfusion. Approximately seven hours and 30 min postoperatively, the ST segments normalized. The patient was discharged on postoperative day 3 and followed for four years without any sequelae.ConclusionThis case report illustrates the use of remote ECG monitoring and clinician response in real time with the use of a smartphone. With each alert, a small ECG strip is transmitted to the smartphone for viewing. In our view, this technology and management system provides a possible means to interrupt myocardial ischemic cascades in real time and prevent postoperative myocardial infarction.RésuméObjectifCette présentation de cas décrit l’utilité et les défis d’un monitorage électrocardiographique (ECG) postopératoire continu à distance, dont le signal est acheminé via un téléphone intelligent sécurisé pour permettre la détection et la prise en charge en temps réel de l’ischémie myocardique.Éléments cliniquesUn homme de 42 ans présentant des antécédents d’infarctus du myocarde et d’angioplastie a subi une prostatectomie radicale. Trois heures et 45 minutes après l’opération, un monitorage ECG en temps réel a été lancé à distance, soit à l’arrivée du patient dans un service régulier de chirurgie. Les alertes du moniteur ont été acheminées vers le téléphone intelligent d’un clinicien de l’étude. Après environ six heures postopératoires, des signaux ont été reçus et des sous-décalages horizontaux du segment ST observés. Un ECG à 12 dérivations a permis de valider les changements au segment ST, incitant l’amorce d’une iv de métoprolol et une transfusion d’érythrocytes. Approximativement sept heures et 30 minutes après l’opération, les segments ST se sont normalisés. Le patient a reçu son congé au 3ème jour postopératoire, puis il a été suivi pendant quatre ans sans séquelles.ConclusionCette présentation de cas illustre l’utilisation d’un monitorage ECG à distance et la réponse du clinicien en temps réel à l’aide de son téléphone intelligent. Lors de chaque alerte, une petite bande de rythme ECG est transmise au téléphone intelligent pour être visionnée. Selon nous, cette technologie et ce système de gestion offrent une possibilité d’interrompre les cascades d’ischémie myocardique en temps réel et de prévenir l’infarctus du myocarde postopératoire.

Echocardiography images of endovascular mal-aligned stent grafts.

CAN J ANESTH 55: 5 www.cja-jca.org May, 2008 A 64 yr-old male patient presented for endovascular repair of a descending thoracic aortic aneurysm. The preoperative computed tomography scan demonstrated an enlargement of the proximal descending aorta at the tracheal bifurcation level (5.8 × 6.1 cm). The rest of the descending aorta was also dilated and tortuous. Following induction of anesthesia, a transesophageal echocardiography (TEE) probe was inserted. Intraoperative TEE identifies the deployment aortic zone, and provides a sensitive means of detecting endoleaks.1 An initial stent graft was deployed proximal to the left subclavian artery. A second stent graft overlapping the distal end of the first was required to cover the descending aortic thoracic aneurysm. Intraoperative Images in Anesthesia

Comparative Effectiveness and Harms of Intraoperative Transesophageal Echocardiography in Noncardiac Surgery: A Systematic Review:

Intraoperative use of transesophageal echocardiography (TEE) has become commonplace in high-risk noncardiac surgeries but the balance of benefits and harms remains unclear. This systematic review investigated the comparative effectiveness and harms of intraoperative TEE in noncardiac surgery. We searched Ovid MEDLINE, PubMed, EMBASE, and the Cochrane Library from 1946 to March 2017. Two reviewers independently screened the literature for eligibility. Studies were assessed for the risk of selection bias, confounding, measurement bias, and reporting bias. Three comparative and 13 noncomparative studies were included. Intraoperative TEE was employed in a total of 1912 of 3837 patients. Studies had important design limitations. Data were not amenable to quantitative synthesis due to clinical and methodological diversity. Reported incidence of TEE complications ranged from 0% to 1.7% in patients undergoing various procedures (5 studies, 540 patients). No serious adverse events were observed for mixed surgeries (2 studies, 197 patients). Changes in surgical or medical management attributable to the use of TEE were noted in 17% to 81% of patients (7 studies, 558 patients). The only randomized trial of intraoperative TEE was grossly underpowered to detect meaningful differences in 30-day postoperative outcomes. There is lack of high-quality evidence of effectiveness and harms of intraoperative TEE in the management of non-cardiac surgeries. Evidence, however, indicates timely evaluation of cardiac function and structure, and hemodynamics. Future studies should be comparative evaluating confounder-adjusted impact on both intraoperative and 30-day postoperative clinical outcomes.

Postoperative Home Monitoring After Joint Replacement: Feasibility Study

Background We conducted a prospective observational study of patients undergoing elective primary hip or knee replacements to examine the feasibility of a postoperative home monitoring system as transitional care to support patients following their surgery in real time. Objective The primary outcome was the mean percentage of successful wireless transmissions from home of blood pressure levels, heart rate, oxygen saturation levels, and pain scores until postoperative day 4 with a feasibility target of ≥90%. Methods Patients with an expected length of stay ≤1 day, age 18-80 years, Revised Cardiac Risk Index ≤ class 2, and caretakers willing to assist at home were eligible. Patient satisfaction, as a secondary outcome, was also evaluated. Wireless monitoring equipment (remote patient monitoring, Telus Canada) was obtained and a multidisciplinary care team was formed. Results We conducted the study after obtaining Research Ethics Board approval; 54 patients completed the study: 21 males, 33 females. In total, we evaluated 9 hips, 4 hip resurfacing, 26 total knees, and 15 hemi-knees. The mean transmission rate was 96.4% (SD 5.9%; 95% CI 94.8-98.0). The median response to “I would recommend the Remote Monitoring System program to future patients” was 4.5 (interquartile range 4-5), with 1 being “strongly disagree” and 5 “strongly agree.” At 30 days postop, there was no mortality or readmission. Conclusions This is an evolving new paradigm for postoperative care and the first feasibility study on monitoring biometrics after primary hip or knee replacement. Postoperative home monitoring combines current technology with real-time support by a multidisciplinary transitional care team after discharge, facilitating postsurgical care with successful wireless transmission of vitals. The postoperative home monitoring implementation is, therefore, generalizable to other surgical discharges from hospitals. Trial Registration ClinicalTrials.gov NCT02143232; https://clinicaltrials.gov/ct2/show/NCT02143232 (Archived by WebCite at http://www.webcitation.org/71ugAhhIk)

Postoperative Home Monitoring After Joint Replacement: A Retrospective Outcome Study Comparing Cases With Matched Historical Controls (Preprint)

Background A retrospective cohort study was conducted in patients undergoing postoperative home monitoring (POHM) following elective primary hip or knee replacements. Objective The objectives of our study were to compare the cost per patient, readmissions rate, emergency room visits, and mortality within 30 days to the historical standard of care using descriptive analysis. Methods After Research Ethics Board approval, patients who were enrolled and had completed a POHM study were individually matched to historical controls by age, American Society of Anesthesiology class, and procedure at a ratio 1:2. Results A total of 54 patients in the study group and 107 in the control group were eligible for the analysis. Compared with the historical standard of care, the average cost per case was Can