Theresa A. Gelzinis

Comparison of Safety and Clinical and Radiographic Outcomes in Endovascular Acute Stroke Therapy for Proximal Middle Cerebral Artery Occlusion With Intubation and General Anesthesia Versus the Nonintubated State

Background and Purpose— There is considerable heterogeneity in practice patterns between sedation in the intubated state vs nonintubated state during endovascular acute stroke therapy. We sought to compare clinical and radiographic outcomes between these 2 sedation modalities. Methods— Consecutive patients with acute stroke due to middle cerebral artery–M1 segment occlusion treated with endovascular therapy between January 2006 and July 2009 were identified in our interventional acute stroke database. Level of sedation was determined as intubated (IS) vs nonintubated (NIS) state. Final infarct volumes on follow-up imaging and clinical outcomes at 3 to 6 months were obtained. Results— A total of 126 patients were included (73 [58%] NIS vs 53 [42%] IS). In IS patients, intensive care unit length of stay was longer (6.5 vs 3.2 days, P=0.0008). Intraprocedural complications were lower in NIS patients compared with IS patients (5/73 [6%] vs 8/53 [15%], respectively), but the difference was not significant (P=0.13). In univariate and multivariate analyses, NIS was significantly associated with in-hospital mortality (odds ratio=0.32, P=0.011), good clinical outcome (odds ratio=3.06, P=0.042), and final infarct volume (odds ratio=0.25, P=0.004). Conclusion— In endovascular acute stroke therapy, treatment of patients in NIS appears to be as safe as treatment in IS and may result in more favorable clinical and radiographic outcomes. Our preliminary observations derived from this retrospective study await confirmation from prospective trials.

New Insights Into Diastolic Dysfunction and Heart Failure With Preserved Ejection Fraction

As the population ages, the incidence of patients presenting for surgical procedures with diastolic dysfunction and heart failure with preserved ejection fraction will rise. This review will discuss the most current and relevant information on the pathophysiology, treatment, and perioperative management of these patients.

Non-Intubated General Anesthesia for Video-Assisted Thoracoscopic Surgery

The first reported thoracoscopic procedure was performed in 1865 by Francis Richards Cruise, using a binocular cystoscope on an 11-year-old patient with an empyema. Hans Jacobaeus advanced the technique and is considered the forefather of modern thoracoscopy. The first thoracoscopies were performed under local anesthesia with sedation. With the advent of improved double-lumen endobronchial tubes allowing for more reliable single-lung ventilation and the development of video-assisted minimally invasive techniques allowing for more extensive procedures to be performed, the majority of thoracoscopies were thought to require general anesthesia. Interest in non-intubated thoracoscopy was awakened when Mukaida et al used the technique on 4 high-risk patients who had good outcomes. The advantages of non-intubated thoracoscopy include the avoidance of general anesthesia and the adverse effects of tracheal intubation, mechanical ventilation, and muscle relaxants. The use of muscle relaxants can be associated with postoperative respiratory muscle weakness, hypoxia, hypercapnia, and upper respiratory obstruction, increasing the risk for aspiration. Other advantages of awake thoracoscopy under thoracic epidural anesthesia (TEA) or paravertebral blocks include improved respiratory function, attenuated stress response, and inflammation as measured by lower postoperative white blood cell counts, tumor necrosis factor-α, and C-reactive protein levels, improved analgesia, reduced chest drainage, early oral intake, early ambulation, and shortened recovery time. Reported drawbacks of non-intubated thoracoscopies include TEA-associated cough reflex, inadequate analgesia, panic attacks, respiratory movement of the lung and mediastinum, hypoxia, hypercapnia, and the conversion to general anesthesia. The cough reflex is due to a combination of surgical manipulation of the lung and bronchi and by increased airway hyper-reactivity as a result of TEA-induced sympathectomy and may interfere with hilar dissection and lymph node dissection. This reflex can be abolished using topical anesthesia placed directly onto the surface of the lung as well as intrathoracic vagal blockade.

The Year in Thoracic Anesthesia: Selected Highlights from 2016

THIS special article is the 4th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan; the associate editor-in-chief, Dr. Augoustides; and the editorial board for the opportunity to expand this series, the research highlights of the year that specifically pertain to the specialty of thoracic anesthesia. The major themes selected for 2019 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in this specialty for 2019 include updates in the preoperative assessment and optimization of patients undergoing lung resection and esophagectomy, updates in one lung ventilation (OLV) and protective ventilation during OLV, a review of recent meta-analyses comparing truncal blocks with paravertebral catheters and the introduction of a new truncal block, meta-analyses comparing nonintubated video-assisted thoracoscopic surgery (VATS) with those performed using endotracheal intubation, a review of the Society of Thoracic Surgeons (STS) recent composite score rating for pulmonary resection of lung cancer, and an update of the Enhanced Recovery After Surgery (ERAS) guidelines for both lung and esophageal surgery.

Anesthesia for Open Abdominal Aortic Aneurysm Repair

Abdominal aortic aneurysms (AAAs) are the 13th leading cause of death in the United States 1 and approximately 40,000 patients undergo elective AAA repair each year.2 With the population aging, this number is expected to increase. Although the use of endovascular AAA repair is becoming more common, open repair, first reported by Dubost et al. in 1951 remains the gold standard.2 This chapter will review the etiology, risk factors, diagnosis, pathophysiology, operative technique, perioperative management, and postoperative complications of patients undergoing open AAA repair.

An Update on Postoperative Analgesia Following Lung Transplantation

One challenging and controversial aspect of the perioperative management of patients undergoing lung transplantation is managing postoperative pain. Because the etiologies for transplantation, the patient populations, the surgical approaches, and the use of mechanical assistance either as extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass (CPB) are so diverse, it is difficult to standardize a regimen for treating postsurgical pain in these patients. The etiology of pain in this population is multifactorial and includes the type of incision, with the anterior submammary thoracosternotomy, also known as the clamshell incision, being the most painful, followed by the posterolateral thoracotomy incision, with the anterolateral thoracotomy incision being the least painful; the duration of surgery, leading to prolonged rib retraction and stretching of intercostal muscles; the manipulation of lungs and pleura; the insertion of largebore thoracostomy tubes; and patient factors. The patients who present for lung transplantation are generally debilitated, coupled by anxiety that may cause them to perceive pain differently. Many have been prescribed long-term preoperative analgesics or sedatives, which can increase their tolerance to postoperative analgesics. Craven et al. discovered that up to 21% of candidates awaiting lung transplantation developed a psychiatric disorder, and Scott et al. found that anxiety was a significant predictor of postoperative pain. Providing adequate pain control is essential because inadequate postoperative analgesia prevents deep breathing and graft expansion, combined with an inadequate cough response and impaired mucociliary function due to airway denervation, which can result in the retention of pulmonary secretions, atelectasis, and airway closure, eventually resulting in hypoxemia, pneumonia, graft failure, and prolonged mechanical ventilation. In addition to pulmonary complications, incomplete postoperative analgesia is associated with hemodynamic, immunologic, metabolic, and hemostatic alterations, as well as the activation of the autonomic and stress response systems, which may result in the development of myocardial ischemia or arrhythmias, increased pulmonary vascular resistance, and

Preoperative risk factors for unexpected postoperative intensive care unit admission: A retrospective case analysis

INTRODUCTION The purpose of this retrospective case-control study was to investigate preoperative risk factors for unexpected postoperative intensive care unit (ICU) admissions in patients undergoing non-emergent surgical procedures in a tertiary medical centre. METHODS A medical record review of adult patients undergoing elective non-cardiac and non-transplant major surgical procedures during the period of January 2011 through December 2015 in the operating rooms of a large university hospital was carried out. The primary outcome assessed was unexpected ICU admission, with mortality as a secondary outcome. Demographic data, length of hospital and ICU stay and preoperative comorbidities were also obtained as exposure variables. Propensity score matching was then employed to yield a study and control group. RESULTS The group of patients who met inclusion criteria in the study and the control group that did not require ICU admission were obtained, each containing 1191 patients after propensity matching. Patients with acute and/or chronic kidney injury (odds ratio (OR) 2.20 [1.75-2.76]), valvular heart disease (OR: 1.94 [1.33-2.85]), peripheral vascular disease (PVD) (OR: 1.41 [1.02-1.94]) and congestive heart failure (CHF) (OR: 1.80 [1.31-2.46]) were all associated with increased unexpected ICU admission. History of cerebrovascular accident (CVA) (OR: 3.03 [1.31-7.01]) and acute and/or chronic kidney injury (OR: 1.62 [1.12-2.35]) were associated with increased mortality in all patients; CVA was also associated with increased mortality (OR: 3.15 [1.21-8.20]) specifically in the ICU population. CONCLUSIONS CHF, acute/chronic kidney injury, PVD and valve disease were significantly associated with increased unexpected ICU admission; patients with CVA suffered increased mortality when admitted to the ICU.

The Hemodynamic Hole

This case discusses multiple cumulative pharmacodynamic interactions between general and neuraxial anesthetics, angiotensin converting enzyme inhibitors and angiotensin receptor blockers, resulting in significant intraoperative hypotension.

Systolic heart failure and anesthetic considerations.

Heart failure (HF) is the fastest growing cardiac diagnosis in North America in patients over 65 years and is the only cardiovascular disease that is increasing in incidence, prevalence, and mortality. HF is defined as a clinical syndrome in which the cardiac output cannot meet the metabolic demands of the body or requires elevated filling pressures to meet this demand, resulting in end-organ damage. HF can be because of isolated left ventricular (LV) systolic or diastolic dysfunction, or, more commonly, a combination of both. This review will focus on the perioperative management of patients with LV systolic dysfunction for both cardiac and noncardiac surgery.