Peter M. Schulman

Should More Patients Continue Aspirin Therapy Perioperatively?: Clinical Impact of Aspirin Withdrawal Syndrome

Objective:To provide an evidence-based focused review of aspirin use in the perioperative period along with an in-depth discussion of the considerations and risks associated with its preoperative withdrawal. Background:For patients with established cardiovascular disease, taking aspirin is considered a critical therapy. The cessation of aspirin can cause a platelet rebound phenomenon and prothrombotic state leading to major adverse cardiovascular events. Despite the risks of aspirin withdrawal, which are exacerbated during the perioperative period, standard practice has been to stop aspirin before elective surgery for fear of excessive bleeding. Mounting evidence suggests that this practice should be abandoned. Methods:We performed a PubMed and Medline literature search using the keywords aspirin, withdrawal, and perioperative. We manually reviewed relevant citations for inclusion. Results/Conclusions:Clinicians should employ a patient-specific strategy for perioperative aspirin management that weighs the risks of stopping aspirin with those associated with its continuation. Most patients, especially those taking aspirin for secondary cardiovascular prevention, should have their aspirin continued throughout the perioperative period. When aspirin is held preoperatively, the aspirin withdrawal syndrome may significantly increase the risk of a major thromboembolic complication. For many operative procedures, the risk of perioperative bleeding while continuing aspirin is minimal, as compared with the concomitant thromboembolic risks associated with aspirin withdrawal. Those cases where aspirin should be stopped include patients undergoing intracranial, middle ear, posterior eye, intramedullary spine, and possibly transurethral prostatectomy surgery.

Patients with Pacemaker or Implantable Cardioverter- Defibrillator

The preparation of patients with a cardiac implantable electronic device (CIED) for the perioperative period necessitates familiarity with recommendations from the American Society of Anesthesiologists and Heart Rhythm Society. Even clinicians who are not CIED experts should understand the indications for implantation, as well as the basic functions, operations, and limitations of these devices. Before any scheduled procedure, proper CIED function should be verified and a specific CIED prescription obtained. Acquiring the requisite knowledge base and developing the systems to competently manage the CIED patient ensures safe and efficient perioperative care.

Use caution when applying magnets to pacemakers or defibrillators for surgery

The application of a magnet to a pacemaker (intended to cause asynchronous pacing) or implanted cardioverter defibrillator (intended to prevent shocks) during surgery without a clear understanding of actual magnet function(s) or precautions can have unexpected, untoward, or harmful consequences. In this report, we present 3 cases in which inadequate assessment of cardiac implanted electronic device (CIED) function, coupled with magnet application, contributed to or resulted in inappropriate antitachycardia pacing or shocks, CIED damage, or patient injury. Although these cases might be rare, they reinforce the need for a timely, detailed preoperative review of CIED function and programming as recommended by the American Society of Anesthesiologists and the Heart Rhythm Society.

Perioperative aspirin management after POISE-2: some answers, but questions remain.

Aspirin constitutes important uninterrupted lifelong therapy for many patients with cardiovascular (CV) disease or significant (CV) risk factors. However, whether aspirin should be continued or withheld in patients undergoing noncardiac surgery is a common clinical conundrum that balances the potential of aspirin for decreasing thrombotic risk with its possibility for increasing perioperative blood loss. In this focused review, we describe the role of aspirin in treating and preventing cardiovascular disease, summarize the most important literature on the perioperative use of aspirin (including the recently published PeriOperative ISchemic Evaluation [POISE]-2 trial), and offer current recommendations for managing aspirin during the perioperative period. POISE-2 suggests that aspirin administration during the perioperative period does not change the risk of a cardiovascular event and may result in increased bleeding. However, these findings are tempered by a number of methodological issues related to the study. On the basis of currently available literature, including POISE-2, aspirin should not be administered to patients undergoing surgery unless there is a definitive guideline-based primary or secondary prevention indication. Aside from closed-space procedures, intramedullary spine surgery, or possibly prostate surgery, moderate-risk patients taking lifelong aspirin for a guideline-based primary or secondary indication may warrant continuation of their aspirin throughout the perioperative period.

Therapeutic Hypothermia After Perioperative Cardiac Arrest in Cardiac Surgical Patients

BACKGROUND: Therapeutic hypothermia (TH) has been established as an effective treatment for preserving neurological function after out of hospital cardiac arrest (CA). Use of TH has been limited in cardiac surgery patients in particular because of concern about adverse effects such as hemorrhage and dysrhythmia. Little published data describe efficacy or safety of TH in cardiac surgical patients who suffer unintentional CA. However, the benefits of TH are such as may suggest clinical equipoise, even in this high risk patient population. OBJECTIVE: To report a series of three patients in our institutions cardiac surgery intensive care unit who suffered unintentional CA within 48 hours of cardiac surgery and were treated with TH. METHODS: After institutional review board approval, study patients were identified by diagnosis of undesired intraoperative CA or arrest on ICU days 1-2, as well as having documented TH. The institutions electronic medical record and the Society of Thoracic Surgeons database were retrospectively reviewed for demographic information, comorbid diagnoses, surgical procedure, and outcomes including hemorrhage, re-warming dysrhythmias, infection, in-hospital mortality, and neurologic outcome were assessed. TH was initiated and monitored using active cooling pads according to written institutional protocol. RESULTS: Four patients received TH after perioperative arrest. One patient was inadequately cooled and had massive surgical bleeding, and was therefore excluded from this review. The remaining three patients had a predicted mortality of 14.6% (±13.3) based on Euroscore calculation, and were cooled for 17.6±4.0 hours after CA. Coagulopathy, hypovolemia, severe electrolyte abnormalities, and re-warming dysrhythmias were not identified in any patient. 2 patients were discharged home and 1 was discharged to a long-term care facility. CONCLUSION: Herein we report the safe and successful use of TH after unintentional perioperative CA in 3 cardiac surgery patients. These data suggest that further investigation of this therapy may be warranted given the potential benefit and apparent safety in a small series.

Creating an Anesthesiologist-run Pacemaker and Defibrillator Service: Closing the Perioperative Care Gap for These Patients.

Anesthesiology, V 123 • No 5 990 November 2015 H istorically, anesthesiologists have relied on a combination of three strategies for the perioperative management of pacemakers (PMs) or implanted cardioverterdefibrillators (icD)— consulting a cardiologist, calling a “device rep,” and/or applying a magnet. However, none of these strategies provides ideal care for these patients. The first two options involve personnel who often are not immediately available and/or are unfamiliar with perioperative issues. all three options invite generic care not truly tailored to the patient, the procedure, or both. as one possible solution, rooke et al.1 created an “anesthesiology Device service (aDs)” for the perioperative management of these cardiovascular implanted electronic devices (ciEDs) at the University of Washington. Five anesthesiologists learned to interrogate and program these devices to provide customized, optimized care for ciED patients undergoing surgery. This training was conducted by electrophysiologists and device company representatives; it consisted of required reading, 20 h of didactic sessions, and a minimum of 30 proctored ciED interrogations. in addition, the lead member of the aDs became a testamur of the international Board of Heart rhythm Examiners (iBHrE) in cardiac rhythm Device Therapy. in this issue of anEstHEsiology, rooke et al. offer insight into the planning and execution of this service, as well as report quality performance data comparing their aDs to patients managed by a typical academic electrophysiology/ cardiology service (EPcs) over the first 4 yr of the aDs. During this time, the aDs managed more than twice as many ciED patients than managed by the EPcs (548 vs. 250, respectively). The aDs resulted in a modest reduction in operative delays without appearing to compromise patient safety. on several occasions, the aDs successfully provided immediate intraoperative assistance for ciED malfunction or pseudomalfunction. The most serious error by the aDs was failure to suspend tachyarrhythmia detection preoperatively on one occasion. another four errors were made by the aDs in restoring postoperative ciED function owing to ciED and programmer idiosyncrasies, but these errors were all promptly recognized and corrected. no apparent harm resulted from any of these errors, and the errors committed by the aDs appeared to decrease with experience. By comparison, the most common error made by the EPcs was failure to follow published perioperative management recommendations from the Heart rhythm society (Hrs); unnecessarily programming ciEDs to pace asynchronously, which has the potential to induce malignant arrhythmias.2 Perhaps, the programming errors made by the EPcs imply less familiarity with perioperative advisories or best perioperative practices than members of the aDs. The impetus to create this service arose primarily from perceived case delays involving ciED patients. indeed, some institutions discourage scheduling these patients as a first case owing to the difficulty of obtaining timely preoperative assistance.3 cardiologists have competing Creating an Anesthesiologist-run Pacemaker and Defibrillator Service

R-on-T and cardiac arrest from dual-chamber pacing without an atrial lead.

Introduction R-on-T phenomena occur when any electrical stimulus is delivered to the ventricle during a vulnerable period of repolarization. Although R-on-T can precipitate arrhythmias, actual reports of R-on-T initiating polymorphic ventricular tachycardia (VT) or ventricular fibrillation are surprisingly rare Herein, we present 2 cases of dual-chamber acing without an atrial lead resulting in R-on-T and cardiac rrest. These cases serve to caution users of dual-chamber, emporary external pacemakers (PMs), which have been rogrammed inappropriately to the DDD mode without a unctioning atrial lead.

The Thrombotic and Arrhythmogenic Risks of Perioperative NSAIDs

From the *Department of Anesthesiology, University of New Mexico, Albuquerque, NM; †Department of Internal Medicine, Raymond G. Murphy VA Medical Center, Albuquerque, NM; and ‡Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR. Address reprint requests to Neal Stuart Gerstein, MD, Department of Anesthesiology, MSC 10 6000, 2211 Lomas Blvd N.E. University of New Mexico, Albuquerque, NM 87120. E-mail: ngerstein@gmail.com

External Defibrillator Damage Associated With Attempted Synchronized Dual-Dose Cardioversion

The simultaneous use of 2 external defibrillators to administer either dual or sequential cardioversion or defibrillation for refractory cardiac arrhythmias is increasing in both the out-of-hospital and inhospital settings. Using 2 defibrillators to administer higher energy levels than can be achieved with a single defibrillator is considered off-label and is currently not part of published advanced cardiac life support guidelines. We report the first case in which the use of dual-dose cardioversion was associated with external defibrillator damage. Because defibrillator damage, especially if undetected, jeopardizes patient safety and off-label medical product use may void the manufacturers warranty, this case should urge users to proceed with caution when contemplating this technique.

Process Improvement Initiative for the Perioperative Management of Patients With a Cardiovascular Implantable Electronic Device

BACKGROUND: Economic, personnel, and procedural challenges often complicate and interfere with efficient and safe perioperative care of patients with cardiovascular implantable electronic devices (CIEDs). In the context of a process improvement initiative, we created and implemented a comprehensive anesthesiologist-run perioperative CIED service to respond to all routine requests for perioperative CIED consultations at a large academic medical center. This study was designed to determine whether this new care model was associated with improved operating room efficiency, reduced institutional cost, and adequate patient safety. METHODS: We included patients with a CIED and a concurrent cohort of patients with the same eligibility criteria but without a CIED who underwent first-case-of-the-day surgery during the periods between February 1, 2008, and August 17, 2010 (preintervention) and between March 4, 2012, and August 1, 2014 (postintervention). The primary end point was delay in first-case-of-the day start time. We used multiple linear regression to compare delays in start times during the preintervention and postintervention periods and to adjust for potential confounders. A patient safety database was queried for CIED-related complications. Cost analysis was based on labor minutes saved and was calculated using nationally published administrative estimates. RESULTS: A total of 18,148 first-case surgical procedures were performed in 15,100 patients (preintervention period—7293 patients and postintervention period—7807 patients). Of those, 151 (2.1%) patients had a CIED in the preintervention period, and 146 (1.9%) had a CIED in the postintervention period. After adjustment for imbalances in baseline characteristics (age, American Society of Anesthesiologists physical status, and surgical specialty), the difference in mean first-case start delay between the postintervention and preintervention periods in the cohort of patients with a CIED was −16.7 minutes (95% confidence interval [CI], −26.1 to −7.2). The difference in mean delay between the postintervention and preintervention periods in the cohort without a CIED was −4.7 minutes (95% CI, −5.4 to −3.9). There were 3 CIED-related adverse events during the preintervention period and none during the postintervention period. Based on reduction in first-case start delay, the intervention was associated with cost savings (estimated institutional savings