Jordan E. Goldhammer

Tracheal Stenosis After Placement of Percutaneous Dilational Tracheotomy

Objectives: Percutaneous dilational tracheotomy procedures have been used successfully as a bedside alternative to open surgical tracheotomy. At our institution, we have seen patients with tracheal injuries following this procedure. In this paper, we review those cases to demonstrate that tracheal stenosis is a potential long‐term complication of percutaneous dilational tracheotomy.

Evidence for preoperative aspirin improving major outcomes in patients with chronic kidney disease undergoing cardiac surgery: a cohort study.

BACKGROUND Effects of aspirin on patients with chronic kidney disease (CKD) remains unclear. This study aimed to examine the effect of preoperative aspirin use on postoperative renal function and 30-day mortality in patients with CKD undergoing cardiac surgery. METHODS A retrospective cohort study was performed on consecutive patients (n = 5175) receiving cardiac surgery in 2 tertiary hospitals. Of all patients, 3585 met the inclusion criteria and underwent the analysis to determine the association of preoperative aspirin with incidence of acute kidney injury (AKI) and death based on estimated glomerular filtration rate (eGFR). RESULTS Of 3585 patients, 31.5% had CKD (eGFR < 60 mL/min/1.73 m2) at baseline and 27.6% had AKI postoperatively. The baseline eGFR had a nonlinear relationship with the incidence and stages of AKI. As eGFR decreased to 15 to 30 from more than or equal to 90 mL/min/1.73 m2, AKI and 30-day mortality increased to 50.5% from 23.5% and to 11.9% from 2.6%, respectively (P < 0.001). However, preoperative aspirin use was associated with a significant decrease in postoperative AKI and 30-day mortality in patients with CKD undergoing cardiac surgery, in particular, the survival benefit associated with aspirin was greater in patients with CKD (vs normal kidney function): 30-day mortality was reduced by 23.3%, 58.2%, or 70.0% for patients with baseline eGFR more than or equal to 90, 30 to 59, or 15 to 30 mL/min/1.73 m2, respectively (P trend < 0.001). CONCLUSIONS For patients with CKD undergoing cardiac surgery, preoperative aspirin therapy was associated with renal protection and mortality decline. The magnitude of the survival benefit was greater in patients with CKD than normal kidney function.

The Effect of Aspirin on Bleeding and Transfusion in Contemporary Cardiac Surgery

Objective Despite evidence that preoperative aspirin improves outcomes in cardiac surgery, recommendations for aspirin use are inconsistent due to aspirin’s anti-platelet effect and concern for bleeding. The purpose of this study was to investigate preoperative aspirin use and its effect on bleeding and transfusion in cardiac surgery. Methods This retrospective study involved consecutive patients (n=1571) who underwent CABG, valve, or combined CABG and valve surgery at a single center between March 2007 and July 2012. Of all patients, 728 met the inclusion criteria and were divided into two groups: those using (n=603) or not using (n=125) aspirin within 5 days of surgery. Data were collected on chest tube drainage, re-operation for bleeding, and transfusion of red blood cells (RBCs), fresh frozen plasma (FFP), and platelets. Results No significant difference was observed between the two groups in chest tube drainage or re-operation for bleeding. An increase in patients transfused with RBCs was observed in the aspirin group (61.9 vs 51.2%, adjusted OR 1.77, p=0.027); however, among those transfused RBCs, no significant difference in mean units transfused or massive transfusion was observed. No significant difference was seen in transfusion requirement of FFP or platelets. Conclusions In patients undergoing CABG, valve, or combined CABG/valve surgery, preoperative aspirin, within 5 days of surgery, was associated with an increased probability of receiving an RBC transfusion. Preoperative aspirin was not associated with an increase in chest tube drainage, re-operation for bleeding complications, or transfusion of FFP or platelets.

Intracardiac Thrombosis after Emergent Prothrombin Complex Concentrate Administration for Warfarin Reversal

458 August 2015 R ECENTLY published clinical practice guidelines recommend prothrombin complex concentrate (PCC) for urgent reversal of vitamin k antagonists.1,2 Both three-factor and four-factor PCC have been shown to be superior to fresh-frozen plasma for international normalized ratio normalization; with the added benefit of quicker access and administration, decreased transfusion-related morbidity, and fewer adverse events secondary to volume overload. A 74-yr-old, 67-kg female who previously received a mechanical mitral valve replacement was dosed 3,420 units of Profilnine (threefactor PCC) for urgent reversal of warfarin (international normalized ratio 5.5/prothrombin time 54.4) in preparation for emergent cervical spine surgery due to cord compression. Fifty-five minutes after PCC administration, the patient developed hypoxia and hemodynamic instability. Advanced cardiac life support was initiated. Emergent transesophageal echo revealed extensive thrombus of the mechanical mitral valve (fig. A) and the descending thoracic aorta (fig. B). Thromboembolic events, especially during anesthesia, are a rare but known side effect of PCC administration. A recently completed prospective, randomized, multicenter study comparing PCC with fresh-frozen plasma found thrombotic events occurred in 3.9% of patients treated with PCC.3 Rapid international normalized ratio normalization has been documented in doses ranging from 12.5 to 50 units/kg; however, a clinically effective yet safe dose of PCC before surgery has yet to be determined. When considering PCC administration, the patients’ native hemostatic mechanism must be considered. Patients with underlying thrombogenic potential may benefit from decreased PCC dose or alternative therapeutic options to avoid stroke, pulmonary embolism, myocardial ischemia, or death due to PCC-related thromboembolic events.

Preoperative Aspirin Does Not Increase Transfusion or Reoperation in Isolated Valve Surgery

OBJECTIVE Preoperative aspirin has been studied in patients undergoing isolated coronary artery bypass graft surgery. However, there is a paucity of clinical data available evaluating perioperative aspirin in other cardiac surgical procedures. This study was designed to investigate the effects of aspirin on bleeding and transfusion in patients undergoing non-emergent, isolated, heart valve repair or replacement. DESIGN Retrospective, cohort study. SETTING Academic medical center. PARTICIPANTS A total of 694 consecutive patients having non-emergent, isolated, valve repair or replacement surgery at an academic medical center were identified. INTERVENTIONS Of the 488 patients who met inclusion criteria, 2 groups were defined based on their preoperative use of aspirin: those taking (n = 282), and those not taking (n = 206) aspirin within 5 days of surgery. MEASUREMENTS AND MAIN RESULTS Binary logistic regression was used to examine relationships among demographic and clinical variables. No significant difference was found between the aspirin and non-aspirin groups with respect to the percentage receiving red blood cell (RBC) transfusion, mean RBC units transfused in those who required transfusion, massive transfusion of RBC, or amounts of fresh frozen plasma, cryoprecipitate, or platelets. Aspirin was not associated with an increase in the rate of re-exploration for bleeding (5.3% v 6.3%, p = 0.478). Major adverse cardiocerebral events (MACE), 30-day mortality, and 30-day readmission rates were not statistically different between the aspirin-and non-aspirin-treated groups. CONCLUSIONS Preoperative aspirin therapy in elective, isolated, valve surgery did not result in an increase in transfusion or reoperation for bleeding and was not associated with reduced readmission rate, MACE, or 30-day mortality.

Right Coronary Artery Occlusion After Tricuspid Ring Annuloplasty

THE DETECTION OF ISCHEMIA during cardiac surgery is not an uncommon finding; however, the interpretation of signs of ischemia is challenging secondary to both the diffuse etiologies associated with ischemic insult, and the limited intraoperative ability to differentiate and localize potential injury. This case presents a rare iatrogenic coronary artery injury and illustrates the challenges associated with the diagnosis and management of perioperative ischemia after cardiac surgery.

Use of Provider Debriefing to Improve Fast-Track Extubation Rates Following Cardiac Surgery at an Academic Medical Center

When used in appropriate patient populations, fast-track extubation (FTE) anesthetic techniques and intensive care unit (ICU) protocols safely reduce intubation times, ICU length of stay, and resource utilization. The authors hypothesized that perioperative provider debriefing on success or failure of FTE would improve FTE success. This retrospective observational study included consecutive patients undergoing elective coronary artery bypass graft (CABG), valve, or combined CABG/valve surgery between February 2015 and May 2016 (N = 313). Throughout the intervention period, a briefing was distributed on postoperative day 1 to the anesthesiology providers responsible for operative care of the patient detailing success or failure of FTE and perioperative characteristics. The preintervention FTE success rate of 55.6% significantly improved to 72.8% in the intervention group (P = .022). When combined with a continuous interdepartmental review process, provider debriefing improved FTE success. Perioperative provider debriefing requires minimal resources for implementation and can easily be replicated in other cardiac surgery centers.

Simultaneous Right-Sided and Left-Sided Infective Endocarditis – Management Challenges in a Multidisciplinary Setting☆☆☆

Cardiothoracic Section, Department of Anesthesiology, Wake Forest University School of Medicine, Winston Salem, NC Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA Adult Cardiothoracic Anesthesiology, Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA Division of Cardiac Anesthesia, Department of Anesthesiology, University of New Mexico, Albuquerque, NM

Learning Curve After Fellowship in the First 3 Years: The Junior Faculty Perspective, Lessons, Tips, and Tricks

A FELLOWSHIP TRAINEE one day, junior attending the next. Practice as junior faculty in the high-acuity setting of cardiothoracic anesthesiology can be a daunting task. The immediate years following graduate medical education (GME) need not strictly define your future career; a solid foundation can be laid for future progression across all potential tracts for career advancement: research, education, scholarship, leadership, and administration. After my fellowship in Adult Cardiothoracic Anesthesiology in the Department of Anesthesiology and Critical Care at the University of Pennsylvania, I began practice as a junior cardiothoracic anesthesiology attending at Thomas Jefferson University in the Clinical and Educational Scholarship Track, with primary appointment in the Department of Anesthesiology. The following are lessons, tips, and tricks to succeed in the first 3 years of junior attending practice of cardiothoracic anesthesiology.

Intranasal Medication Administration Using a Squeeze Bottle Atomizer Results in Overdosing if Deployed in Supine Patients

BACKGROUND: Vasoconstrictors and local anesthetics are commonly administered using a squeeze bottle atomizer to the nasal mucosa to reduce edema, limit bleeding, and provide analgesia. Despite widespread use, there are few clinical guidelines that address technical details related to safe administration. The purpose of this study was to quantify, via simulation, the amount of liquid delivered to the nasal mucosa when patients are in the supine and upright positions and administration parameters that would reliably provide the desired amount of medication per spray. METHODS: A convenience sample of 10 anesthesia residents was studied. Providers were instructed to use a 25-mL dip and tube nasal squeeze bottle to administer the test solution (sterile water) to a mannequin in the upright (90° elevation) and supine (0° elevation) position. After mannequin testing, additional testing was completed with the spray bottles at 0°, 15°, 30°, 45°, and 90° to determine the relationship between the angles of administration and the amount of liquid dispensed. RESULTS: The mean volume delivered per spray was substantially greater when administered in the supine position (0.56 ± 0.22 mL) compared with the upright position (0.041 ± 0.02 mL, difference = 0.52 mL, 95% confidence interval [CI], 0.37–0.67 mL, P < .001). Converting the administered volume to the dose of phenylephrine that would be administered using our standard 0.25% solution, an estimated additional 1300 mcg is delivered per spray in the supine position compared with the upright position (95% CI, 925–1675 mcg, P < .001). Administration with a delivery angle of ⩽30° resulted in significantly more volume than when the bottle was oriented at a 90° angle. The volume dispensed at 45° was not different from the volume delivered at 90° (0.032 ± 0.006 mL vs 0.030 ± 0.005 mL, P = .34). CONCLUSIONS: We found a 14-fold increase in the volume (ie, dose) delivered per spray when a nasal squeeze bottle was used with a mannequin in the supine position compared with the upright position. Given the reported toxicity from the use of intranasal medication and the inadvertent overdosing that occurs when squeeze bottle atomizers are used in clinical practice, our data suggest that all intranasal drugs should be administered with a precise, metered-dose device. If a metered-dose device is unavailable, the medication should be delivered at an angle of ≥45°; however, we recommend administering the drug with the patient in the sitting position and the bottle at 90° because only a small change in angle below 45° will result in a substantial increase in medication delivered.