Sujatha P Bhandary

Endogenous Opioids in Wound-Site Neutrophils of Sternotomy Patients

Background Postoperative pain management is a critical aspect of patient care. The inflammatory state of the post-sternotomy surgical wound sensitizes nerve endings, causing pain. Unrelieved or improperly managed pain compromises wound healing. Peripheral opioid receptors play a major role in analgesia, particularly under inflammatory conditions where both opioid receptor expression and efficacy are increased. Leukocytic opioid peptides include β-endorphin (END), met-enkephalin (ENK), and dynorphin-A (DYN), with END and ENK being predominant. Methodology/Principal Findings This work represents the first study of inflammatory cells collected from post-sternotomy wounds of patients undergoing cardiac surgery including coronary artery bypass grafting (CABG). Wound fluid (WF) and cells were collected from sternal wounds using a JP Blake drain at 24, 48, and 72 hours post sternum closure. Anti-CD15 staining and flow cytometry revealed that polymorphonuclear neutrophils (PMN) are the predominant cells present in wound fluid collected post-surgery. Compared to peripheral blood (PB) derived PMN, significant increases in CD177+/CD66b+ PMN were observed suggesting activation of wound-site PMN. Such activation was associated with higher levels of opioid peptide expression in PMN derived from WF. Indeed, increased level of opioid peptides in sternal wound environment was noted 72 h post-surgery. We demonstrate that WF contains factors that can significantly induce POMC transcription in human PMNs. IL-10 and IL-4 were abundant in WF and both cytokines significantly induced POMC gene expression suggesting that WF factors such as IL-10 and IL-4 contribute towards increased opioid peptide expression in wound-site PMN. Conclusions/Significance This approach provided a unique opportunity to study the cross-talk between inflammation and opioid peptides in PMN at a sternotomy wound-site. Wound-site PMN exhibited induction of END and ENK. In addition, sternal wound fluid significantly induced END expression in PMN. Taken together, these data constitute first clinical evidence that human wound-site PMNs are direct contributors of opioids at the sternal wound-site.

Extracorporeal life support for refractory ventricular tachycardia

Extracorporeal life support (ECLS) is a very effective bridging therapy in patients with refractory ventricular tachycardia (VT) associated with cardiogenic shock. A moribund patient in extremis, is not amenable to optimization by standard ACC/AHA guidelines. New approaches and novel salvage techniques are necessary to improve outcomes in patients with refractory clinical settings such as malignant ventricular arrhythmias, cardiac arrest, cardiogenic shock and/or pulmonary failure until further management options are explored. Data base searches were done using key words such as ECLS, VT, cardiac arrest, VT ablation, venoarterial extra-corporeal membrane oxygenation (VA-ECMO). The use of ECLS has been described in a few case reports to facilitate VT ablation for incessant VT refractory to medical therapy. For patients with, out-of- hospital ventricular fibrillation (VF) and VT, Minnesota Resuscitation Consortium has implemented emergent advanced perfusion and reperfusion strategy, followed by coronary angiography and primary coronary intervention to improve outcome. The major indications for ECLS are cardiogenic shock related to acute myocardial infarction, myocarditis, post embolic acute cor pulmonale, drug intoxication and post cardiac arrest syndrome with the threat of multi-organ failure. ECLS permits the use of negative inotropic antiarrhythmic drug therapy, facilitates the weaning of catecholamine administration, thereby ending the vicious cycle of catecholamine driven electric storm. ECLS provides hemodynamic support during ablation procedure, while mapping and induction of VT is undertaken. ECLS provides early access to cardiac catheterization laboratory in patients with cardiac arrest due to shockable rhythm. The current evidence from literature, supports the use of ECLS to ensure adequate vital organ perfusion in patients with refractory VT. ECLS is a safe, feasible and effective therapeutic option when conventional therapies are insufficient to support cardiopulmonary function. A highly driven multidisciplinary team approach is essential to accomplish this task.

Establishing an instrumented training environment for simulation-based training of health care providers: An initial proof of concept

Objective: Several decades of armed conflict at a time of incredible advances in medicine have led to an acknowledgment of the importance of cognitive workload and environmental stress in both war and the health care sector. Recent advances in portable neurophysiological monitoring technologies allow for the continuous real-time measurement and acquisition of key neurophysiological signals that can be leveraged to provide high-resolution temporal data indicative of rapid changes in functional state, (i.e., cognitive workload, stress, and fatigue). Here, we present recent coordinated proof of concept pilot project between private industry, the health sciences, and the USA government where a paper-based self-reporting of workload National Aeronautics and Space Administration Task Load Index Scale (NASA TLX) was successfully converted to a real-time objective measure through an automated cognitive load assessment for medical staff training and evaluation (ACLAMATE). Methods: These real-time objective measures were derived exclusively through the processing and modeling of neurophysiological data. This endeavor involved health care education and training with real-time feedback during high fidelity simulations through the use of this artificial modeling and measurement approach supported by Aptima Corporations FuSE2, SPOTLITE, and PM Engine technologies. Results: Self-reported NASA TLX workload indicators were converted to measurable outputs through the development of a machine learning-based modeling approach. Workload measurements generated by this modeling approach were represented as a NASA TLX anchored scale of 0–100 and were displayed on a computer screen numerically and visually as individual outputs and as a consolidated team output. Conclusions: Cognitive workloads for individuals and teams can be modeled through use of feed forward back-propagating neural networks thereby allowing healthcare systems to measure performance, stress, and cognitive workload in order to enhance patient safety, staff education, and overall quality of patient care. The following core competencies are addressed in this article: Medical Knowledge, Interpersonal Skills, Patient Care, and Professionalism.

Putting the pieces together: The role of multidisciplinary simulation in medical education

Simulation is becoming an increasingly important tool in medical education. Specifically, multidisciplinary team-based simulation exercises are being used to promote teamwork and communication among various members of care teams. Similar to its use in the aviation industry, this type of team building simulation has shown promising results in improving teamwork and improving patient safety outcomes. Several key players in the health-care setting, including hospitals and malpractice insurance providers, have recognized these benefits and are promoting the use of multidisciplinary simulation for staff training. Despite several barriers to implementation, the use of multidisciplinary simulation will be an important part of a new emerging model of medical education. The following core competencies are addressed in this article: Patient care, Interpersonal and communication skills, Systems-based practice.

Anesthetic Management of the Resection of a Kommerell’s Diverticulum

CASE REPORTA 66-year-old woman (159 centimeter, 59 kilogram) presented tothe authors’ institution with a history of difficulty swallowing, chestpressure, and heartburn of increasing severity. She was diagnosed witha KD by magnetic resonance imaging (MRI), which demonstrated anaberrant left SC artery with a right-sided aortic arch. The left commoncarotid artery arose as the first branch from the distal ascending aortafollowed by the right common carotid, right vertebral, and rightsubclavian artery. The left subclavian artery originated as the lastbranch with a 2.3-cm aneurysmal dilation of its proximal segmentconsistent with KD. The aberrant artery had a retroesophageal courseresulting in moderate compression of the esophagus and mild com-pression of the trachea as seen in the MRI (Fig 1). There was noevidence of dissection, rupture, or leak. Her past medical history wassignificant for hypertension, hyperlipidemia, hiatal hernia, gastroeso-phageal reflux disease, hypothyroidism, and obstructive sleep apnea.Her medications consisted of ramipril, levothyroxine, and hydrochlor-othiazide. Physical examination was unremarkable and laboratoryresults were within normal limits. Preoperative transthoracic echocar-diogram revealed normal biventricular function without significantvalvular abnormalities. The patient was scheduled for resection of theKD and repair of the aorta.After applying ASA monitors, the patient was premedicated with2 mg of intravenous midazolam. A right radial arterial catheter wasplaced to monitor arch pressures. Blood pressure was equal in bothupper extremities. A pulse oximeter probe was placed on the left handin order to monitor limb perfusion indirectly. A rapid-sequenceinduction was performed using propofol, fentanyl, and succinylcholinefollowed by intubation with a 7.5-mm endotracheal tube. This wasfollowed by a fiberoptic examination of the airway that revealed mildcompression of the right main bronchus with a normal-appearingtrachea and left main bronchus. Subsequently, the single-lumenendotracheal tube was changed to a 37Fr left-sided double-lumen tubeassisted by video laryngoscope and a 14Fr soft-tipped airwayexchanger. A double-lumen tube was guided into position underfiberoptic guidance and positioned without difficulty. Anesthesia wasmaintained with isoflurane in oxygen, and the patient tolerated single-lung ventilation. A left femoral arterial catheter was placed to monitordistal perfusion as needed. A pulmonary artery catheter was insertedthrough a 9Fr multi-lumen introducer. In view of her normal cardiacstudies and symptomatic esophageal compression, which had worsenedsince her esophagoscopy, a transesophageal echocardiography probewas not placed. Right femoral vessels were exposed before chestincision to facilitate peripheral cannulation. A right thoracotomyapproach was used to dissect the distal arch and descending aorta.The ascending aorta was cannulated, and the cardiopulmonary systemwas bypassed with venous drainage through a multi-orificed catheteradvanced to the right atrium from the right femoral vein (Fig 2). Thedecision not to perform distal perfusion was made by the team in viewof the short segment required to be replaced without interfering withintercostal circulation and also satisfactory preoperative distal organfunction. Cardiopulmonary bypass (CPB) with mild hypothermia,temperature in the range of 32-34oC, was implemented because thediseased arch had a potential for disruption. CPB also facilitatedmediastinal dissection by maintaining systemic perfusion duringexternal cardiac compression.The distal arch and descending aorta were repaired with interpositionof a hemashield graft without sacrificing any intercostal arteries after theKD was ligated and then over-sewn. The aberrant left subclavian arterywith the attached ligamentum arteriosum was dissected, thus, decom-pressing the esophagus. Aortic unclamping did not result in significanthypotension and could be controlled with a low-dose vasopressor onCPB. Total CPB time was 65 minutes with an aortic clamp time of 47minutes. Separation from the cardiopulmonary bypass was uneventful.At the end of the procedure, the double-lumen endotracheal tube wasswitched to a single-lumen tube. The patient was transferred to theintensive care unit and extubated on postoperative day 1. Postoperativeanalgesia was achieved with intermittent boluses of a narcotic. Post-operative neurologic assessment was normal.DISCUSSION

NASA Task Load Index Scale to Evaluate the Cognitive Workload during Cardiac Anesthesia Based Simulation Scenarios

Simulation-based education is an important tool for anesthesiology educators given the work hour restrictions and limited exposure of anesthesiology residents to high acuity cardiac cases. Cognitive load is key to learning, performance, and resilience. When working with new and complicated information in an environment prone to changes and distractions, working memory has a limited capacity, duration, and is diminished by excessive cognitive workload. When this capacity is surpassed, learning and performance are impaired. Wecreated cardiac anesthesia-based high fidelity simulation scenarios to determine how to bestmeasure cognitive load by administering the NASA Task Load Index(NASA-TLX). We recreated a cardiac operating room by mimicking a complex learning environment that places high demand on the novice learners. Fourteen anesthesiology residents participated in this study for determination of cognitive load using NASA-TLX. This scale measures effort, frustration, performance, mental demand, physical demand, and temporal demand. The residents perceived mental demand as the most challenging, with a mean of 15.21 ± 1.86; followed by effort, demand with a mean of 14.32±2.49. We determined that using the NASA-TLX Scale to measure and report cognitive load provides an opportunity to effectively evaluate cognitive distress during the acquisition of new skills and enhance physician resilience.

Massive intracardiac thrombosis during coronary artery bypass grafting surgery

Thrombosis is a potential life-threatening complication in patients undergoing cardiac surgery. Various clinical and heritable conditions, like cancer, trauma, immobilization, the presence of factor V Leiden or prothrombin 20210A, deficiency of or resistance to the inhibitor proteins C, S, or antithrombin, elevated levels of coagulation proteins, antiphospholipid antibody syndrome, pregnancy, and the use of exogenous hormones, may contribute to catastrophic thrombosis. Massive thrombi with cerebrovascular and cardiovascular events develop in patients with polycythemia vera (PV). However, thrombus formation in the cardiac chambers is extremely rare. We report a case of massive intracardiac thrombosis in a patient undergoing coronary artery bypass grafting.

Hypercapnia during endoscopic saphenectomy complicating CABG

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