David Bronheim

Hemothorax and Subclavian Artery Laceration during “J” Wire Change of a Right Internal Jugular Vein Catheter

CENTRAL venous cannulation via the right internal jugular vein is commonly used in the treatment of the critically ill patient. Although complications such as carotid artery puncture or pneumothorax have been reported, 1 that of hemothorax is relatively uncommon. We describe a case of a hemothorax and subclavian artery laceration that was recognized while changing an 8.5-French introducer to a 7.0-French triple-lumen catheter using a J wire.

Preoperative arterial pulse pressure has no apparent association with perioperative mortality after lower extremity arterial bypass.

BACKGROUND: Arterial pulse pressure hypertension is associated with perioperative morbidity and mortality in cardiac surgery patients. However, its association with perioperative mortality in other high-risk surgical populations has not been determined. In this study, we tested the hypothesis that increased preoperative arterial pulse pressure is associated with 30-day and 1-year all-cause mortality after lower extremity arterial bypass surgery. METHODS: A retrospective review of patients who had infrainguinal arterial bypass surgery at a single center over a 6-year period (January 2002 to January 2008) was performed (n = 556). Mean, systolic, and diastolic arterial blood pressure were determined from a single noninvasive oscillometric blood pressure cuff reading in the operating room before the administration of anesthetic drugs. Pulse pressure was calculated from this measurement in a retrospective manner by subtracting diastolic pressure from systolic pressure. Mortality for all subjects was determined using the social security death index. Comorbid conditions, preoperative medications, and anesthetic techniques were recorded. Univariate and multivariate analyses were performed to evaluate the association between arterial pulse pressure and the primary outcome variables, and all-cause 30-day and 1-year mortality. RESULTS: Of the 556 patients, a large percentage had elevated pulse pressure (44.9% had pulse pressure ≥80). Thirty-day mortality was 5.1% and 1-year mortality was 17.8%. There was no apparent association between preoperative pulse pressure and 30-day (P = 0.35) or 1-year (P = 0.14) all-cause mortality. Independent predictors of 30-day mortality were age ≥80 years (P = 0.02), ASA physical status ≥IV (P = 0.04), baseline creatinine >2.0 mg/dL (P < 0.0001), and emergency surgery (P = 0.009). The same variables were associated with 1-year mortality, as were the Lees Revised Cardiac Risk Index score, female gender, and gangrene or ulcer as an indication for surgery. CONCLUSION: Our results suggest that increased preoperative arterial pulse pressure might not be associated with all-cause mortality after lower extremity arterial bypass surgery.

Indication for surgery, the revised cardiac risk index, and 1-year mortality.

BACKGROUND Patients who undergo vascular surgery are at increased risk of perioperative cardiovascular morbidity and mortality. The Revised Cardiac Risk Index (RCRI) is a validated and widely used bedside tool for estimating the risk of a perioperative major adverse myocardial event. We hypothesized that inclusion of the indication for surgery would add independent and prognostic information to the RCRI in predicting all-cause 30-day and 1-year mortality in open infrainguinal vascular surgical procedures. METHODS This was a retrospective study of 603 patients who underwent open infrainguinal bypass vascular surgery between January 2002 and January 2008 at a tertiary care medical center. RCRI and indication for surgery were determined. The primary outcomes of interest were all-cause 30-day mortality (which included all in-hospital mortality, regardless of time) and all-cause 1-year mortality. RESULTS Overall 30-day mortality was 32 (5.3%). Independent risk factors for early death were RCRI score, being of age ≥80 years, American Society of Anesthesiologists Physical Status classification = 4, and emergency surgery. Overall 1-year mortality, including early deaths, was 114 (18.9%). Indication for surgery, RCRI score, age, American Society of Anesthesiologists Physical Status classification = 4, female sex, and emergency surgery were all independent predictors of 1-year mortality. CONCLUSIONS The RCRI score was associated with both 30-day and 1-year mortality in patients undergoing lower extremity bypass surgery. Indication for surgery was predictive of 1-year mortality but not of 30-day mortality.

Statins and the perioperative period.

Recent studies on the effects of statin use on perioperative morbidity and mortality suggest that statins may reduce risk during the perioperative period. However, studies published thus far either were retrospective nonrandomized studies or included small numbers of patients. Individually, none offered authoritative recommendations. However, in almost every study, preoperative statin use was associated with a substantial improvement in perioperative outcome. Thus, pending the publication of a large, prospective randomized trial, the preponderance of the evidence at this time suggests that perioperative statin usage may improve outcome in high-risk patients undergoing major surgery. Furthermore, even if statins are definitively found to be effective, additional studies will be necessary to establish the optimal timing of initiation, drug dosages, and length of therapy.

Case 1—1993 The role of erythropoietin in Jehovah's Witnesses requiring cardiac surgery

Case 1 * A 46-year-old female Jehovah’s Witness presented for cardiac surgery. She had a history of rheumatic heart disease, which consisted of moderate-to-severe aortic regurgitation and mild aortic stenosis, moderate-to-severe mitral regurgitation, severe tricuspid regurgitation, and pulmonary hypertension. The patient was also in chronic atria1 fibrillation. Her preoperative medical regimen consisted of digoxin, furosemide, verapamil, captopril, and coumadin. Preoperative laboratory studies were significant for a hemoglobin of 12.2 g/dL and hematocrit of 35.9%. In view of the relatively low hematocrit and the patient’s refusal to accept any blood products, the surgery was postponed and she was treated with oral iron and 10,000 units of r-erythropoietin by subcutaneous daily injection. She was rescheduled to undergo aortic valve replacement, mitral valve replacement, and tricuspid valvuloplasty 3 weeks later. At that time, the hemoglobin had risen to 14.7 g/dL, and the hematocrit to 42.6%. Coumadin had been discontinued 4 days prior to surgery. The PT was 13.6111.9 set, and the patient received 20 mg of vitamin K, intramuscularly (IM), on the day prior to surgery. The patient was premeditated with morphine, 5 mg, and scopolamine, 0.3 mg IM, and was transferred to the operating room while receiving O2 via nasal cannula. Her initial vital signs were a blood pressure (BP) 105/50 mmHg and heart rate (HR) of 85 beatsimin, in atria1 fibrillation. Peripheral venous, radial artery, and pulmonary artery (PA) catheters were placed. The patient’s baseline mean PA pressure (PAP) was 42 mmHg, central venous pressure (CVP) 23 mmHg, and cardiac output (CO) by thermodilution was 3.1 L/min. Following a smooth induction and maintenance of anesthesia with fentanyl, metocurine, and oxygen, her mean PAP was 16 mmHg. A transesophageal echocardiogram (TEE) probe was placed after induction. The patient was on total cardiopulmonary bypass (CPB) for 3 hours 52 minutes, during which time she underwent aortic and mitral valve replacements with St. Jude prostheses and DeVega tricuspid annuloplasty. Cardiotomy suction was used to return blood to the

Adenosine for the treatment of paroxysmal supraventricular tachycardia under general anesthesia in a patient with wolff-parkinson -white syndrome

Abstract Adenosine is an endogenous purine nucleoside natural to all cells in the body. It has been approved recently for use for acute intravenous therapy of paroxysmal supraventricular tachycardia (PSVT) caused by atrioventricular (AV) node reentry or reentry including the AV node and accessory pathways as in a patient with Wolff-Parkinson-White (WPW) syndrome. 1 After an intravenous (IV) bolus of 6 mg, PSVT will convert to a normal sinus rhythm (NSR) in about 60% of patients within 1 minute. 2 If the initial bolus is unsuccessful, the dysrhythmia will convert to a NSR in a majority of the remaining patients following an additional dose of 12 mg for a cumulative effectiveness of 93%. 2 Its short half-life may prove useful in PSVT therapy during the perioperative period. A case is described in which adenosine was used to convert a PSVT to NSR in a patient with the WPW syndrome while receiving general anesthesia.

Does β Selectivity Really Affect Outcome

To the Editor: We read with great interest the October 2013 article1 entitled “Selective β1-Antagonism with Bisoprolol is Associated with Fewer Postoperative Strokes than Atenolol or Metoprolol,” where the authors describe a decrease in the risk of stroke in patients receiving bisoprolol versus those receiving the less selective β-antagonists, atenolol and metoprolol. Although the results are noteworthy, it remains unclear to us that the outcomes reflect relative β selectivity. Previously published studies have demonstrated an association between the time of initiation of β-blocker therapy and outcome, with higher morbidity and mortality being associated with the initiation of β-blockade nearer the time of surgery. Flu et al.2 showed significantly fewer cardiovascular events as well as significantly lower mortality in patients who were initiated on β-antagonists more than 1 week preoperatively compared with that in patients who were initiated on β-antagonists less than 1 week before surgery. Ellenberger et al.3 in a 2011 issue of AnESthESiOlOgy, a study in which the author of this article was an active participant, similarly described worse outcomes in patients receiving acute β-blockade in comparison with the outcomes in patients receiving chronic therapy. in this current study, the authors note the lack of evidence of β-blocker usage in 35% of their patients before hospitalization, which was consistent with their previous data demonstrating that approximately 30% of their patients were started on β-antagonists between the time of admission and surgery. Unfortunately, they failed to quantify in the published article whether metoprolol, atenolol, and bisoprolol usage were proportionately similar in this higher-risk group. One may speculate or perhaps even assume that in anticipation of the need for intravenous β-blocker therapy perioperatively, these 30% of patients, whose outcomes are predictably worse, would be much more likely to receive either metoprolol or atenolol. Both of these have an intravenous formulation; bisoprolol does not. The authors even comment that only a small number of patients received more than one of these drugs, suggesting that our assumption is in fact correct. With this as a premise, we wonder whether this bias for initiating therapy near the time of surgery with metoprolol and atenolol versus bisoprolol was the reason behind the higher stroke rate and not differences in cerebral blood flow occurring as a consequence of β-receptor selectivity. Fortunately, the relative effects of β selectivity versus time of initiation could be clarified either by removing all patients not on chronic therapy from the analysis or by demonstrating no relation between time of initiation of β-blocker therapy and choice of medication. Furthermore, in this published study, the average dosages of β-blockers given are not noted. This is relevant because the PeriOperative iSchemic Evaluation (POiSE) study4 demonstrated that hypotension secondary to metoprolol was associated with an increased incidence of stroke. in the POiSE study, the dosages of metoprolol given were relatively high. in contrast, Wallace et al.5 demonstrated that lower doses of metoprolol proved to have better outcomes, so a comparison of the relative doses of β-blockers may be relevant. Finally, one can just as easily speculate that metoprolol’s variable metabolism, which may result in relative overdosing or underdosing, may be the cause of the differences and not its β selectivity.6 Although we have concerns that this study does not truly demonstrate the advantages of β selectivity, others have demonstrated improvements in outcomes with bisoprolol when given well before the perioperative period.7 Also, as demonstrated in this study, Wallace et al.8 have also noted the relative advantages of atenolol versus metoprolol. Many have assumed that these differences in outcomes were related to the initiation of therapy and the variable metabolism of metoprolol. The authors’ suggestion that β selectivity alone may be the source of improvement clearly warrants further investigation.

Management of the Organ Donor

Advances in immunosuppressive therapy have led to increased use of organ transplantation to treat end- organ failure. This has led to a consistent shortage of transplantable organs, with many patients dying while awaiting heart, liver, or lung transplantation. Traditional donor criteria are expanding and increase the pool of available donor organs. The organ procurement process often begins with the diagnosis of brain death, which must be made by clinical criteria and is usually con firmed by clinical testing. Because brain-dead patients suffer a variety of hemodynamic, cardiac, endocrine, respiratory, and hematologic abnormalities, manage ment in the intensive care unit demands meticulous attention and expertise. Living and, occasionally, non- heart-beating donors are also a source of donor organs. Management of the various types of donors in the operating room requires specific skills and knowledge. The persistent need for donor organs requires that poten tial organ donors be recognized and appropriately man aged to maximize the pool of available organs for the ever- increasing number of potential organ recipients.

Does the choice of muscle relaxants really affect postoperative recovery time

Unfortunately, we were not able to include two of Dr. Lang’s references in our article (4), because we could not reference abstracts more than 3 yr old (5,6). His other reference simply states that there were no complaints to the manufacturer of chloroprocaine in Switzerland during the previous 4 yr, and no findings of thrombophlebitis. However, there was no mention of the criteria for thrombophlebitis and whether the investigators actively looked for it. In summary, chloroprocaine may have a role in IVRA. Until there are further studies of chloroprocaine for IVRA in the literature, we believe that prilocaine is the safest local anesthetic for IVRA.