Gregory M. Janelle

An accuracy evaluation of the T-Line Tensymeter (continuous noninvasive blood pressure management device) versus conventional invasive radial artery monitoring in surgical patients.

Continuous beat-to-beat arterial blood pressure (BP) monitoring with a simultaneous arterial waveform display is typically achieved with an invasive arterial catheter. We evaluated a noninvasive device, the T-Line® Tensymeter, that provides a calibrated arterial pressure waveform from which continuous BP measurements and heart rate may be computed by either a bedside host monitor or the tensymeter device itself. In 25 patients given general anesthesia, we measured systolic, mean, and diastolic BPs via the tensymeter and compared these measurements with those obtained from the contralateral radial artery catheter. Data were analyzed using the Bland Altman test to determine agreement between the two systems. The mean ± sd bias and precision (mm Hg) were as follows: 1.7 ± 7.0 and 5.7 ± 4.4 for systolic BP; 2.3 ± 6.9 and 5.7 ± 4.5 for diastolic BP; and 1.7 ± 5.3 and 4.0 ± 4.8 for mean BP. Noninvasive pressures from the tensymeter-produced arterial waveform agreed with simultaneous contralateral BPs measured from arterial catheters within an acceptable clinical range for a limited population of surgical patients studied over a systolic arterial BP range from 41 to 189 mm Hg without significant temporal performance degradation. The tensymeter may enable physicians to circumvent arterial cannulation in certain circumstances (such as with low- or intermediate-risk procedures) on patients when beat-to-beat BP measurement is desirable.

An unusual giant right coronary artery aneurysm resembles an intracardiac mass.

A 49-yr-old man with a history of Job’s Syndrome (Hyper IgE Syndrome), an immunologic disorder characterized by recurrent infections and connective tissue disorders, was referred to our institution for evaluation of a saccular aneurysm of the distal aortic arch and proximal descending thoracic aorta. After multiple cardiac imaging studies, including cardiac catheterization, transthoracic echocardiography, and magnetic resonance imaging, the diagnosis of an aortic root aneurysm was confirmed. In addition, a 5 4.5 cm right atrial rounded and homogenic mass was detected, occupying two-thirds of the right atrium and receiving feeding vessels from the right coronary artery (RCA). These findings suggested that this mass was most likely an angiosarcoma. In addition to the above findings, the imaging studies also showed diffuse aneurysmal coronary disease throughout the entire coronary bed. The patient was scheduled for resection of the right atrial tumor, RCA bypass, and aortic root aneurysm repair. After an uneventful anesthetic induction, a transesophageal echocardiogram (TEE) confirmed a right atrial homogenic mass with a well organized capsule attached to the anterolateral wall of the atrium

Inhibition of phosphodiesterase type III before aortic cross-clamping preserves intramyocardial cyclic adenosine monophosphate during cardiopulmonary bypass.

Inotropes are often used to treat myocardial dysfunction shortly after cardiopulmonary bypass (CPB). &bgr;-Adrenergic agonists improve contractility, in part by increasing cyclic adenosine monophosphate (cAMP) production, whereas phosphodiesterase type III inhibitors prevent its breakdown. CPB is associated with abnormalities at the &bgr;-receptor level and diminished adenyl cyclase activity, both of which tend to decrease cAMP. These effects may be increased in the presence of preexisting myocardial dysfunction. We tested the hypothesis that inhibition of phosphodiesterase type III before global myocardial ischemia and pharmacologic arrest results in the preservation of intramyocardial cAMP concentration during CPB. Twenty adult patients undergoing coronary artery bypass grafting with CPB were studied. After CPB was instituted, a myocardial biopsy was obtained from the apex of the left ventricle. Patients were randomized to receive either placebo or milrinone (50 &mgr;g/kg) through the bypass pump 10 min before aortic cross-clamping. Another myocardial biopsy was performed adjacent to the left ventricular apex just before weaning from CPB. Myocardial cAMP concentration was determined by radioimmunoassay. Myocyte protein content was determined by the Bradford method by using a commercial kit. There were no significant demographic differences between the groups; however, patients in the Milrinone group had a lower left ventricular ejection fraction than placebo (41% ± 13% vs 53% ± 7%;P < 0.05). Patients who received milrinone had larger cAMP concentrations at the end of CPB compared with placebo (21 ± 12.5 pmol/mg protein versus 12.8 ± 2.2 pmol/mg protein;P < 0.05). The administration of milrinone before aortic cross-clamping is associated with increased intramyocardial cAMP concentration at the end of CPB.

Noncardiogenic pulmonary edema and rhabdomyolysis after protamine administration in a patient with unrecognized Mcardle's disease

Noncardiogenic Pulmonary Edema and Rhabdomyolysis after Protamine Administration in a Patient with Unrecognized McArdles Disease Emilio Lobato;Gregory Janelle;Felipe Urdaneta;Mark Malias; Anesthesiology

Emergent limited perioperative transesophageal echocardiography: should new guidelines exist for limited echocardiography training for anesthesiologists?

Bedside limited echocardiography, or focused cardiac ultrasound, continues to gain popularity in many emergency rooms, intensive care units, and operating rooms as a rapid method of assessing unstable patients. Effective monitoring of cardiovascular function in conditions like cardiac arrest or near-arrest is the crucial step to guide successful resuscitative efforts. Transesophageal echocardiography (TEE) has emerged as one of the preferred cardiac diagnostic and monitoring modalities in the intraoperative setting due to the fact that it is less invasive than many other monitors, is immediately accessible, and allows for continuous real-time monitoring of cardiac function. However, the minimum training requirements needed for the anesthesia provider to obtain the competency, knowledge, and skills for basic certification in perioperative TEE far exceed those developed for other medical specialties. We believe there is an urgent need to develop (1) practical guidelines for emergent perioperative TEE use for anesthesiologists and (2) a requisite educational curriculum to teach the basic skills necessary to aid in the diagnosis and treatment of cardiac arrest or near-arrest scenarios. The measures elucidated in this report summarize the efforts of the Department of Anesthesiology at the University of Florida in establishing the necessary steps to make this process not only practical, but accessible to all trainees.We hope that these collective efforts will provide more trainees the confidence in utilizing TEE to aid in establishing a diagnosis in critical situations.

Imaging Artifacts in Echocardiography.

Artifacts are frequently encountered during echocardiographic examinations. An understanding of the physics and underlying assumptions of ultrasound processing involved with image generation is important for accurate interpretation of 2D grayscale, spectral Doppler, color flow Doppler, and 3D artifacts and their clinical implications.

Perioperative Ultrasound: The Future Is Now.

1734 www.anesthesia-analgesia.org June 2016 • Volume 122 • Number 6 Copyright

Expanding role of perioperative transesophageal echocardiography in the general anesthesia practice and residency training in the USA.

Purpose of review To review the perioperative use of noncardiac transesophageal echocardiography in anesthesiology and to explore the current mechanisms of teaching and certification. Recent findings Anesthesiologists frequently use echocardiography in many noncardiac situations with potential impact on outcomes. Certification has evolved to include those who use echocardiography in noncardiac situations. More advanced teaching tools have been developed for the learning of diagnostic and monitoring modality. Summary Transesophageal echocardiography can have many helpful uses in perioperative patient care. This study summarizes many noncardiac uses, certification, and echocardiography education for anesthesiologists.

Effects of Calcium Chloride on Grafted Internal Mammary Artery Flow After Cardiopulmonary Bypass

OBJECTIVE To examine the effects of calcium chloride (CaCl2) administration on blood flow through the grafted left internal mammary artery (IMA) after cardiopulmonary bypass (CPB). DESIGN Single-arm prospective study. SETTING University-affiliated hospital operating room. PARTICIPANTS Twenty adult patients scheduled for coronary artery bypass graft surgery with IMA graft. INTERVENTIONS IMA flow was measured noninvasively with a laser Doppler flow probe placed around the IMA, and measurements were recorded for 10 seconds and averaged. After separation from CPB under stable hemodynamics, baseline IMA flow was measured. CaCl2, 15 mg/kg, was administered intravenously over 1 minute. Blood pressure, left atrial pressure, heart rate, and IMA flow were then measured at 1, 5, and 10 minutes. Coronary perfusion pressure and IMA vascular resistance were calculated. MEASUREMENTS AND MAIN RESULTS After CaCl2 administration, IMA blood flow significantly decreased from baseline at 1, 5, and 10 minutes (from 28+/-9 mL/min to 19+/-8 mL/min, 22+/-6 mL/min, and 25+/-4 mL/min), with gradual return toward baseline over time. Blood pressure, coronary perfusion pressure, and IMA vascular resistance significantly increased at 1 and 5 minutes after CaCl2. Left atrial pressure and heart rate remained unchanged. No systolic regional wall motion abnormalities were detected on transesophageal echocardiography. CONCLUSIONS CaCl2, administered as a bolus dose after separation from CPB, transiently but significantly reduces IMA flow and can potentially trigger vasospasm, increasing the risk for myocardial ischemia or infarction in susceptible patients. Further studies are needed to determine whether this effect also occurs with nitrosodilators or phosphodiesterase inhibitors.

What Is the PROPPR Transfusion Strategy in Trauma Resuscitation

A massive transfusion protocol is increasingly used in trauma patients. However, the ideal ratio of plasma to other factors has been the subject of significant debate.1–5 The current published data and clinical practice are based primarily on retrospective database analyses. The Pragmatic Randomized