Dawit T. Haile

Pediatric airway management: current practices and future directions.

Management of a pediatric airway can be a challenge, especially for the nonpediatric anesthesiologists. Structured algorithms for an unexpected difficult pediatric airway have been missing so far. A recent step wise algorithm, based on the Difficult Airway society (DAS) adult protocol, is a step in the right direction. There have been some exciting advances in development of pediatric extra‐glottic devices for maintaining ventilation, and introduction of pediatric versions of new ‘non line of sight’ laryngoscopes and optical stylets. The exact role of these devices in routine and emergent situations is still evolving. Recent advances in simulation technology has become a valuable tool in imparting psychomotor and procedural skills to trainees and allied healthcare workers. Moving toward the goal of eliminating serious adverse events during the management of routine and difficult pediatric airway, authors propose that institutions develop a dedicated Difficult Airway Service comprising of a team of experts in advanced airway management.

Ebstein anomaly review: what’s now, what’s next?

Ebstein anomaly accounts for 1% of all congenital heart disease. It is a right ventricular myopathy with failure of tricuspid valve delamination and highly variable tricuspid valve morphology that usually results in severe regurgitation. It is the only congenital heart lesion that has a range of clinical presentations, from the severely symptomatic neonate to an asymptomatic adult. Neonatal operation has high operative mortality, whereas operation performed beyond infancy and into adulthood has low operative mortality. Late survival and quality of life for hospital survivors are excellent for the majority of patients in all age brackets. Atrial tachyarrhythmias are the most common late complication. There have been more techniques of tricuspid repair reported in the literature than any other congenital or acquired cardiac lesion. This is largely due to the infinite anatomic variability encountered with this anomaly. The cone reconstruction of Ebstein anomaly can achieve near anatomic restoration of the tricuspid valve anatomy. Early and intermediate results with these repairs are promising. Reduced right ventricular function continues to be a challenge for some patients, as is the need for reoperation for recurrent tricuspid regurgitation. The purpose of this article is to outline the current standard of care for diagnosis and treatment of Ebstein anomaly and describe innovative strategies to address poor right ventricular function and associated right-sided heart failure.

Optimal time for initiating extracorporeal membrane oxygenation.

The technical evolution of extracorporeal membrane oxygenation (ECMO) coincides with the vast improvement in intensive care medicine of the past 4 decades. Extracorporeal circulatory technology substitutes for acutely failed cardiac or pulmonary function until these organs regain sustainable function through goal-oriented intensive care practice. The technology has been validated to improve survival in select patients who would otherwise have 100% mortality. This is by far the most complex life-sustaining technology employed and thus can contribute significant risks such that the decision to institute ECMO requires prompt risk and benefit analysis. Delaying the institution of ECMO may cause irreversible pulmonary and cardiac injuries in addition to other organs. Therefore, the optimal time of initiating ECMO support is crucial to the survival of a critically ill patient.

Extracorporeal Membrane Oxygenation Support in Postcardiotomy Elderly Patients: The Mayo Clinic Experience

BACKGROUND We conducted a retrospective study to assess whether providing extracorporeal membrane oxygenation (ECMO) support to elderly patients (aged 70 years or more) who failed separation from cardiopulmonary bypass after cardiac surgery was a viable option. METHODS From 2003 to 2013, 45 patients aged 70 years or more underwent 47 runs of ECMO postoperatively. RESULTS There were 31 men (68.9%). The mean age was 76.8 years. Five patients were in cardiogenic shock preoperatively. Forty-four patients required venoarterial ECMO support for cardiogenic shock. Mean duration of support was 103.8 ± 74.3 hours. Twenty-one patients (46.6%) died while on ECMO support. Twenty-four patients (53.3%) were weaned off ECMO initially, and 11 patients were discharged from hospital. Inhospital mortality was 75.6%. Postoperative complications included acute kidney injury in 30 patients (44.4%), pneumonia in 12 (26.7%), and sepsis in 11 (24.4%). There were 30 deaths (88.2%) attributable to cardiac causes. Preoperative atrial fibrillation, chronic kidney injury, lactic acidosis on ECMO support, and persistent coagulopathy were associated with higher mortality. CONCLUSIONS Postcardiotomy ECMO support in elderly patients is associated with high postoperative morbidity and mortality. Nevertheless, it often provides the last line of therapy for these critically ill patients and may provide positive outcomes in selected subgroups.

Postcardiotomy ECMO Support after High‐risk Operations in Adult Congenital Heart Disease

BACKGROUND Cardiac operations in high-risk adult congenital heart disease (ACHD) patients may require mechanical circulatory support (MCS), such as extracorporeal membrane oxygenation (ECMO) or intraaortic balloon pump (IABP), to allow the cardiopulmonary system to recover. METHODS We reviewed records for all ACHD patients who required MCS following cardiotomy at our institution from 1/2001 to 12/2013. RESULTS During the study period, 2264 (mean age 39.1 years, females ∼54.1%) operations were performed in ACHD patients of whom 24 (1.1%) required postoperative MCS (14 males; median age 41 years, range 22-75). Preoperatively the 24 patients had a mean systemic ventricular ejection fraction of 47% (range 10-66%); 72% of these patients were in NYHA class III/IV heart failure. The common underlying diagnoses included pulmonary atresia with intact ventricular septum (20%), tetralogy of Fallot (16%), Ebstein anomaly (12%), cc-TGA (12%), septal defects (12%), and others (28%). Operations performed were valvular operations with/without maze (58.2%), Fontan conversion (21%), coronary bypass grafting with valvular operations (12.5%), and heart transplant (8.3%). Indications for MCS were left-sided (systemic) heart failure (32%), right-sided (subpulmonary) heart failure (24%), biventricular heart failure (36%), persistent arrhythmia (4%), and hypoxemia (4%). Forty-two percent were placed on ECMO only; in the second group, IABP was attempted and subsequently followed by ECMO initiation. The mean duration of MCS was 8.4 days (range 0.8-35.4). Common morbidities included coagulopathy (60%), renal failure (56%), and arrhythmia (48%). Overall, 46% of patients survived to hospital discharge. Deaths were due to either multi organ failure or the underlying cardiac disease; sepsis was the primary cause of death in one patient. Median follow-up for survivors was 41 months (maximum 106 months). NYHA functional class was I/II in all 8 late survivors. CONCLUSIONS Following complex operations in high-risk ACHD patients, MCS may be required. Despite significant morbidity, nearly half of patients survive to hospital discharge.

Improvement in Patient Transfer Process From the Operating Room to the PICU Using a Lean and Six Sigma–Based Quality Improvement Project

BACKGROUND AND OBJECTIVES Ineffective and inefficient patient transfer processes can increase the chance of medical errors. Improvements in such processes are high-priority local institutional and national patient safety goals. At our institution, nonintubated postoperative pediatric patients are first admitted to the postanesthesia care unit before transfer to the PICU. This quality improvement project was designed to improve the patient transfer process from the operating room (OR) to the PICU. METHODS After direct observation of the baseline process, we introduced a structured, direct OR-PICU transfer process for orthopedic spinal fusion patients. We performed value stream mapping of the process to determine error-prone and inefficient areas. We evaluated primary outcome measures of handoff error reduction and the overall efficiency of patient transfer process time. Staff satisfaction was evaluated as a counterbalance measure. RESULTS With the introduction of the new direct OR-PICU patient transfer process, the handoff communication error rate improved from 1.9 to 0.3 errors per patient handoff (P = .002). Inefficiency (patient wait time and non-value-creating activity) was reduced from 90 to 32 minutes. Handoff content was improved with fewer information omissions (P < .001). Staff satisfaction significantly improved among nearly all PICU providers. CONCLUSIONS By using quality improvement methodology to design and implement a new direct OR-PICU transfer process with a structured multidisciplinary verbal handoff, we achieved sustained improvements in patient safety and efficiency. Handoff communication was enhanced, with fewer errors and content omissions. The new process improved efficiency, with high staff satisfaction.

Patient-controlled analgesia-based pain control strategy for minimally-invasive pectus excavatum repair

The minimally‐invasive Nuss procedure has become the preferred technique for pectus excavatum repair. This procedure is still associated with significant postoperative pain, and an optimal pain‐management strategy is yet to be determined. The purpose of this study was to compare the efficacy of patient‐controlled analgesia (PCA) to thoracic epidural analgesia (TEA).

The intraoperative management of a patient with fontan physiology and an undiagnosed pheochromocytoma.

During the inspiratory phase of manual ventilation, the bag is squeezed with the open end of the bag partially or totally occluded by the anesthetist. During exhalation, the open end is released to allow the gases in the system to escape. This simple mechanism is extremely efficient for infants and small children. Several mechanical devices are available that can be placed in the tail of the bag to provide variable restriction similar to the above–described manual method and to prevent the bag from collapsing (1–3). However it may be tedious to ventilate the lungs manually by intermittent occlusion of the tail end. As an alternative to an intermittent occlusion method, an expiratory valve, which is available together with the pediatric circuit, is usually used for controlled ventilation. Furthermore, one may need to switch from controlled ⁄ assisted ventilation to spontaneous mode or vice versa. Fixation and removal of this valve from the tail end needs widening of the tail to insert the valve. This needs time and if the valve is repeatedly inserted and removed from the tail, this can tear off, rendering the bag worthless. This is specially a problem in developing countries where reusable circuits, albeit after proper cleaning and disinfection ⁄ sterilization are used to limit costs. To avoid this problem, we have devised a new technique. A sterile 5 cm length of 8.0 ⁄ 8.5 PVC tracheal tube (depending on external diameter of expiratory valve) is pushed into the tail of the bag after stretching it. This provides a patent and firm tail which can easily be used for spontaneous breathing and if required it easily accommodates the expiratory valve (Figure 1). This change in the bag does not alters the physical characteristics of the circuit, keeps the expiratory tail widely open for spontaneous respiration and allows easy removal and insertion of an expiratory valve. Rajesh Mahajan* , Vinod Kumar Grover† Sushil Kumar† *Department of Anaesthesia, ASCOMS, Jammu, India and †Department of Anaesthesia, PGIMER, Chandigarh, India (email: drmahajanr@rediffmail.com)

Cell-Based Therapy for Myocardial Dysfunction After Fontan Operation in Hypoplastic Left Heart Syndrome

Myocardial dysfunction after Fontan palliation for univentricular congenital heart disease is a challenging clinical problem. The medical treatment has a limited impact, with cardiac transplant being the ultimate management step. Cell-based therapies are evolving as a new treatment for heart failure. Phase 1 clinical trials using regenerative therapeutic strategies in congenital heart disease are ongoing. We report the first case of autologous bone marrow–derived mononuclear cell administration for ventricular dysfunction, 23 years after Fontan operation in a patient with hypoplastic left heart syndrome. The cells were delivered into the coronary circulation by cardiac catheterization. Ventricular size decreased and several parameters reflecting ventricular function improved, with maximum change noted 3 months after cell delivery. Such regenerative therapeutic options may help in delaying and preventing cardiac transplant.