Marek Brzezinski

Radial Artery Cannulation: A Comprehensive Review of Recent Anatomic and Physiologic Investigations

Consistent anatomic accessibility, ease of cannulation, and a low rate of complications have made the radial artery the preferred site for arterial cannulation. Radial artery catheterization is a relatively safe procedure with an incidence of permanent ischemic complications of 0.09%. Although its anatomy in the forearm and the hand is variable, adequate collateral flow in the event of radial artery thrombosis is present in most patients. Harvesting of the radial artery as a conduit for coronary artery bypass grafting, advances in plastic and reconstructive surgery of the hand, and its use as an entry site for cardiac catheterization has provided new insight into the collateral blood flow to the hand and the impact of radial arterial instrumentation. The Modified Allen’s Test has been the most frequently used method to clinically assess adequacy of ulnar artery collateral flow despite the lack of evidence that it can predict ischemic complications in the setting of radial artery occlusion. Doppler ultrasound can be used to evaluate collateral hand perfusion in an effort to stratify risk of potential ischemic injury from cannulation. Limited research has demonstrated a beneficial effect of heparinized flush solutions on arterial catheter patency but only in patients with prolonged monitoring (>24 h). Conservative management may be equally as effective as surgical intervention in treating ischemic complications resulting from radial artery cannulation. Limited clinical experience with the ultrasound-guided arterial cannulation method suggests that this technique is associated with increased success of cannulation with fewer attempts. Whether use of the latter technique is associated with a decrease in complications has not yet been verified in prospective studies. Research is needed to assess the safety of using the ulnar artery as an alternative to radial artery cannulation because the proximity and attachments of the ulnar artery to the ulnar nerve may potentially expose it to a higher risk of injury.

Perioperative Cognitive Decline in the Aging Population

Elderly patients who have an acute illness or who undergo surgery often experience cognitive decline. The pathophysiologic mechanisms that cause neurodegeneration resulting in cognitive decline, including protein deposition and neuroinflammation, also play a role in animal models of surgery-induced cognitive decline. With the aging of the population, surgical candidates of advanced age with underlying neurodegeneration are encountered more often, raising concerns that, in patients with this combination, cognitive function will precipitously decline postoperatively. This special article is based on a symposium that the University of California, San Francisco, convened to explore the contributions of surgery and anesthesia to the development of cognitive decline in the aged patient. A road map to further elucidate the mechanisms, diagnosis, risk factors, mitigation, and treatment of postoperative cognitive decline in the elderly is provided.

Are we closing the gap in faculty development needs for feedback training

STUDY OBJECTIVE To determine needs, adequacy, types of resources, and challenges in teaching faculty how to provide feedback to residents. DESIGN Survey instrument. SETTING Academic medical center. PARTICIPANTS Of the 115 anesthesia residency program directors surveyed, 69 responses were received (60% response rate). MEASUREMENTS Percentages of respondents who indicated categories of need, adequacy, and types of resources for teaching faculty to give feedback to residents were recorded, as were narrative descriptions of challenges confronted by respondents. MAIN RESULTS While the percentage of programs with faculty development resources has increased from 20.2% in 1999 to 48% today, an overwhelming majority of program directors (90%) feel that faculty require more training in providing feedback to residents. The majority of program directors also want more resources to train their faculty in providing feedback. CONCLUSIONS While the perceived gap in providing training for faculty in giving feedback to anesthesia residents has narrowed, program director responses suggest a substantial unmet need remains. Innovative new approaches are in order.

Persistent left superior vena cava in a patient with a history of tetralogy of Fallot.

A 42-year-old female patient was referred to our institution with recent progressive dyspnea and fatigue. Her history was significant for 3 previous surgeries for repair of tetralogy of Fallot at age 3, 9, and 17. The patient was informed after the last surgery that she has a persistent left superior vena cava (PLSVC). Diagnostic work-up at our institution with chest wall echocardiogram, magnetic resonance imaging, and cardiac catheterization demonstrated severe pulmonary insufficiency, right ventricular dysfunction, and a patent foramen ovale (PFO). These imaging techniques also confirmed the presence of the PLSVC draining to the coronary sinus (CS). Electrophysiology study identified foci of ventricular tachycardia in the endocardial surface of the right ventricle. The patient was scheduled for an elective pulmonic valve replacement, closure of the PFO, and endocardial ablation for ventricular arrhythmia. Intraoperative transesophageal echocardiography revealed a normal sized left ventricle and an enlarged right ventricle, both with a good function. The CS was enlarged. The presence of the PLSVC was confirmed by injection of agitated normal saline as echo contrast into the left arm vein. Consistent with the diagnosis of PLSVC, the contrast was seen in the CS instead of draining into the right superior vena cava (Fig. 1) (video loop; see supplemental data at www.anesthesiaanalgesia.org). Other pathology confirmed included a PFO with bidirectional shunt and a severely incompetent pulmonic valve. No residual postoperative defects were demonstrated. The patient tolerated the procedure well, and her postoperative course was uncomplicated. Persistent LSVC, the most common anomaly of systemic venous return, is an uncommon congenital pathology with a prevalence of 0.3–0.5% in patients with normal heart and 1.3–4.5% in patients with congenital heart disease. Tetralogy of Fallot was found in up to 25% of patients with PLSVC (1). A failure of obliteration of the LSVC in late embryologic life results in a

Incidental cor triatriatum sinister during coronary artery bypass surgery

A 64-yr-old man presented for elective coronary artery bypass graft surgery. He gave a 2-wk history of chest pain but denied symptoms of dyspnea or orthopnea. His medical history was significant for myocardial infarction 7 yr earlier, hypertension, and noninsulin dependant diabetes mellitus. Cardiac catheterization demonstrated three-vessel coronary artery disease and left ventricular (LV) enddiastolic pressure of 18 mm Hg. The preoperative chest radiograph was normal. Preoperative echocardiography was not performed. Routine intraoperative transesophageal echocardiography (TEE) demonstrated a fenestrated membrane traversing the left atrium (LA) (Fig. 1A) (video loop available at www.anesthesia-analgesia.org). Diastolic flow across the membrane was nonturbulent. All four pulmonary veins entered the LA proximal to the membrane (Fig. 1B), and the left atrial appendage (LAA) was distal to the membrane (Fig. 1C). The LA was not enlarged and the atrial septum was intact. The remainder of the TEE examination was unremarkable. The echocardiography findings were discussed with the surgical team, and a decision was made to resect the membrane using a transseptal approach through a right atriotomy in addition to performing the coronary revascularization (Fig. 2A). The TEE examination after resection of the membrane showed oscillating strandlike remnants of the membrane attached to the LA wall (Fig. 2B). Cor triatriatum sinister is a rare congenital anomaly wherein, a fibromuscular membrane divides the LA into two chambers: the dorsal chamber receives the pulmonary veins and the ventral chamber contains the mitral valve and the LAA (1). Depending on the degree of communication between the chambers, the obstruction to left ventricular inflow can manifest clinically from infancy to late adulthood, with symptoms of pulmonary venous congestion that imitate mitral stenosis. The primary concern with cor triatriatum is the potential for LV inlet obstruction, leading to mitral stenosis physiology, although rarely pulmonary venous inflow can be compromised. The chest radiograph usually shows increased vascular markings, and a cardiac murmur is frequently noted. Some patients with cor triatriatum may remain asymptomatic, whereas others may have late onset of symptoms, possibly related to fibrosis and calcification of the membrane with associated atrial fibrillation or mitral regurgitation (2). Currently, TEE is the standard procedure for diagnosing this congenital anomaly (3), but its incidental intraoperative diagnosis presents a management dilemma because surgical excision exposes the patient to increased risk associated with an open-chamber procedure. Appropriate TEE assessment of this condition should include the following key steps. The anatomy of the LA membrane should be defined and flow obstruction should be assessed using color flow Doppler. When obstruction is suspected from these images and any discreet jets of abnormal transmembrane or pulmonary venous flow are identified, spectral Doppler measurements can help quantify the hemodynamic impairment. In addition, pulmonary venous and atrial septal anatomy should be evaluated, as these may be abnormal in this condition. Although the preferred management of “incidental” cor triatriatum remains anecdotal at best, a comprehensive and accurate TEE examination undoubtedly will aid clinical decision making.

Teaching in the ICU A Comprehensive Review

Teaching in the fast-paced, high-pressure environment of the ICU can be very demanding. Thus, the educator-intensivist must learn teaching strategies that are time-efficient, simple, and successful. In this article, we provide an overview of the current and relevant teaching theories and highlight potential obstacles and limitations to teaching in the ICU. In the second part, we discuss a sample of simple approaches to optimize the ICU-rotation curriculum as well as effective techniques to improve teaching, while not compromising quality of care.

Adult Extracorporeal Membrane Oxygenation An Update for Intensivists

Extracorporeal membrane oxygenation (ECMO), sometimes used interchangeably with extracorporeal life support, is a therapy that artificially supports pulmonary and/or cardiac organ systems. Venous blood is continuously withdrawn from a patient and passed across a membrane that can support both oxygenation and removal of carbon dioxide; blood is then reinfused back into the patient via venous or arterial access. A pump in the circuit can augment cardiac output, if necessary. Initial treatment with ECMO had discouraging outcomes, but recent experience with acute respiratory distress syndrome and the H1N1 influenza A pandemic in 2009 have led to a resurgence in popularity and additional research into this technique. At this time, treatment with ECMO is limited to highly specialized centers with well-trained practitioners. ECMO continues to be used primarily as a salvage technique in severe critical illness. This review will discuss the indications, complications, and types of ECMO. A guide to the clinical use...

Transesophageal Echocardiography of Pulmonary Thrombus Causing Complete Left Pulmonary Artery Occlusion

A 36-yr-old female patient was referred to our institution for management of a pulmonary embolism (PE) associated with respiratory failure. Her history was significant for an uncomplicated partial hysterectomy 6 months previously. One month later she presented to an outside hospital with dyspnea and chest pain. Computed tomography of the chest demonstrated a massive PE occluding the left pulmonary artery (LPA). Transthoracic echocardiography (TTE) revealed a moderately enlarged right ventricle (RV) with moderate decrease in contractility and an estimated RV systolic pressure of 58 mm Hg. Left ventricular (LV) function was normal. Her preoperative angiogram at our institution demonstrated complete occlusion of the LPA at its origin. The patient underwent pulmonary thromboendarterectomy with cardiopulmonary bypass (CPB). Intraoperatively, the entire LPA was found to be occluded with organized thrombus that was completely removed. Intraoperative pre-CPB transesophageal echocardiography (TEE) examination revealed signs of combined volume and pressure overload of the RV and moderate to severe RV dysfunction. The right atrium was massively enlarged and the interatrial septum was severely curved towards the left during systole and diastole. The interventricular septum displayed diastolic septal flattening (D-shaped ventricle). The LV function was normal. The modified midesophageal ascending aortic short axis (ME asc aortic SAX) view demonstrated a total occlusion of the LPA (Fig. 1) (video loop available at www. anesthesia-analgesia.org). The upper esophageal aortic arch short axis (UE aortic arch SAX) view further defined the contours and echogenic nature of the thrombus (Fig. 2). The post-CPB TEE examination confirmed a patent LPA. The postoperative ventilation/perfusion scan indicated differential perfusion in the left lung of only 3%. On the eleventh postoperative day, repeat TTE revealed a severely enlarged RV with global decrease in contractility with an estimated RV systolic pressure of 55 mm Hg. The LV function was normal. These presented images display thrombus in the LPA, a structure usually difficult to image secondary to interposition of left bronchus between the esophagus (TEE probe) and the LPA (1,2). Standard TEE imaging of the PA includes the UE aortic arch SAX view and the ME asc aortic SAX view, and should be complemented by evaluation for the presence of RV dysfunction and increased PA pressures in patients with suspected PE (1).

Enhancing Feedback on Professionalism and Communication Skills in Anesthesia Residency Programs

BACKGROUND: Despite its importance, training faculty to provide feedback to residents remains challenging. We hypothesized that, overall, at 4 institutions, a faculty development program on providing feedback on professionalism and communication skills would lead to (1) an improvement in the quantity, quality, and utility of feedback and (2) an increase in feedback containing negative/constructive feedback and pertaining to professionalism/communication. As secondary analyses, we explored these outcomes at the individual institutions. METHODS: In this prospective cohort study (October 2013 to July 2014), we implemented a video-based educational program on feedback at 4 institutions. Feedback records from 3 months before to 3 months after the intervention were rated for quality (0–5), utility (0–5), and whether they had negative/constructive feedback and/or were related to professionalism/communication. Feedback records during the preintervention, intervention, and postintervention periods were compared using the Kruskal-Wallis and &khgr;2 tests. Data are reported as median (interquartile range) or proportion/percentage. RESULTS: A total of 1926 feedback records were rated. The institutions overall did not have a significant difference in feedback quantity (preintervention: 855/3046 [28.1%]; postintervention: 896/3327 [26.9%]; odds ratio: 1.06; 95% confidence interval, 0.95–1.18; P = .31), feedback quality (preintervention: 2 [1–4]; intervention: 2 [1–4]; postintervention: 2 [1–4]; P = .90), feedback utility (preintervention: 1 [1–3]; intervention: 2 [1–3]; postintervention: 1 [1–2]; P = .61), or percentage of feedback records containing negative/constructive feedback (preintervention: 27%; intervention: 32%; postintervention: 25%; P = .12) or related to professionalism/communication (preintervention: 23%; intervention: 33%; postintervention: 24%; P = .03). Institution 1 had a significant difference in feedback quality (preintervention: 2 [1–3]; intervention: 3 [2–4]; postintervention: 3 [2–4]; P = .001) and utility (preintervention: 1 [1–3]; intervention: 2 [1–3]; postintervention: 2 [1–4]; P = .008). Institution 3 had a significant difference in the percentage of feedback records containing negative/constructive feedback (preintervention: 16%; intervention: 28%; postintervention: 17%; P = .02). Institution 2 had a significant difference in the percentage of feedback records related to professionalism/communication (preintervention: 26%; intervention: 57%; postintervention: 31%; P < .001). CONCLUSIONS: We detected no overall changes but did detect different changes at each institution despite the identical intervention. The intervention may be more effective with new faculty and/or smaller discussion sessions. Future steps include refining the rating system, exploring ways to sustain changes, and investigating other factors contributing to feedback quality and utility.

Robotic Mammary Artery Harvest and Anastomotic Device Allows Minimally Invasive Mitral Valve Repair and Coronary Bypass

Abstract  We report the case of a 60‐year‐old man requiring combined mitral valve repair and coronary artery bypass grafting. A unique minimally invasive approach was used combining robotic internal mammary artery harvesting, partial lower sternotomy, and single vessel coronary artery bypass grafting using an automated distal coronary artery anastomotic device. Issues in approaching the commonly encountered patient with mitral valve disease and coronary artery disease using minimally invasive techniques are discussed.