Thomas E. Schulte

Liver Transplantation: Intraoperative Transesophageal Echocardiography Findings and Relationship to Major Postoperative Adverse Cardiac Events

OBJECTIVE The primary aim of the study was to describe the most common intraoperative transesophageal echocardiography (TEE) findings during the 3 separate phases of orthotopic liver transplantation (OLT). The secondary aim of the study was to determine if the abnormal TEE findings were associated with major postoperative adverse cardiac events (MACE) and thus may be amenable to future management strategies. DESIGN Data were collected retrospectively from the electronic medical record and institutional echocardiography database. SETTING Single university hospital. PARTICIPANTS A total of 100 patients undergoing OLT via total cavaplasty technique. INTERVENTIONS Intraoperative TEE was performed in all 3 phases of OLT. MEASUREMENT AND MAIN RESULTS TEE findings of 100 patients who had TEE during OLT during the dissection, anhepatic, and reperfusion phases of transplantation were recorded after blind review. Findings then were analyzed to see if those findings were predictive of postoperative MACE. Intraoperative TEE findings varied among the different phases of OLT. Common TEE findings at reperfusion were microemboli (n = 40, 40%), isolated right ventricular dysfunction (n = 22, 22%), and intracardiac thromboemboli (n = 20, 20%). CONCLUSIONS Intraoperative echocardiography findings during liver transplantation varied during each phase of transplantation. The presence of intracardiac thromboemboli or biventricular dysfunction on intraoperative echocardiography was predictive of short- and long-term major postoperative adverse cardiac events.

Trainee experience and success of urgent airway management.

BACKGROUND There are limited data regarding emergent, non-operating room, intubations performed by all levels of anesthesia residents. This study was a large retrospective review of all non-operating room emergent intubations performed at a single tertiary medical center. The study evaluated the rate of difficult intubations by level of resident training, compared success rates for direct versus video laryngoscopy and evaluated the rate and success of rescue video laryngoscopy following failed direct laryngoscopy. METHODS All emergent non-operating room intubations at a tertiary university medical center from July 1, 2009, to August 1, 2012, were reviewed and all study data were collected from the medical records. Intubations were classified as being initiated with either direct or video methods. The total number of attempts required and the rate of success were compared by resident year and intubation type. RESULTS Out of a total of 788 emergent intubations, 741 were performed by anesthesia residents. The higher level anesthesia residents (CA-2 and CA-3) had a statistically significant decrease in the number of attempts needed when compared to CA-1 residents. Rate of success did not vary by resident training year, but success rates were higher for cases initiated with video laryngoscopy. Among direct initiated cases, 8% failed initial direct laryngoscopy and were then successfully intubated with rescue video laryngoscopy. CONCLUSIONS During emergent, non-operating room intubations, senior level residents used fewer attempts at intubations with direct laryngoscopy. Successful intubation was improved by beginning residents when video laryngoscopy was utilized. Complications were not affected by the presence of the attending anesthesiologist.

Transesophageal Echocardiography Findings Associated with Transvenous Lead Extraction

December 2012 • Volume 115 • Number 6 From the *Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE. Accepted for publication May 7, 2012 Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www. anesthesiaanalgesia.org). Reprints will not be available from the authors. Address correspondence to Sasha K. Shillcutt, MD, Department of Anesthesiology, University of Nebraska Medical Center, 984455 Nebraska Medical Center, Omaha, NE 68198-4455, Address e-mail to sshillcu@unmc.edu Copyright

BrainLAB interference with pulse oximetry during stereotactic brain biopsy

To the Editor: A 64 year old woman with a right temporoparietooccipital lesion presented for frameless stereotactic brain biopsy. After an uneventful induction, the patients bed was turned 90 degrees. The patients pulse oximeter began to show an erratic pattern and oxygen saturation (SpO2) decreased from 100% to 82% 85%. Palpated radial pulse correlated with electrocardiographic rhythm and the pulse oximeter was switched to a different adhesive probe (the LNOP®, adult size was used throughout; Masimo Corp., Irvine, CA, USA), on the opposite hand, but this action failed to alleviate the problem. The pulse oximeter transducer used in the operating room (OR) was a GE Healthcare product (Waukesha, WI, USA). A portable Masimo pulse oximeter (Masimo Corp.) was tried on each sensor bilaterally, with a similar result. At this point, suspicion pointed toward the neuronavigation device in theORs as the source of the interference. The patients right hand was covered by a double-folded towel. This intervention produced a usable signal and significantly decreased the interference, but it did not eliminate it. On final draping of the patient, the waveform returned to normal and showed no signs of interference. No further disturbance of pulse oximeter measurement was noted for the remainder of the case. The process of neuronavigation interfered with pulse oximeter performance in a study simulating the clinical setting [1]. As noted, the interference does not necessarily result in the disruption of SpO2 recognition. This study used the BrainLAB VectorVision® system (BrainLAB AG, Munich, Germany), which showed resolution of the interference by covering the sensor with tinfoil. A case report involving the Stealth Station Treatment Guidance SystemTM (Medtronic, Minneapolis, MN, USA) was reported [2]. Covering the sensor with cloth decreased the interference, but did not eliminate it, much like our own experience. Resolution of the disturbancewas achieved in this incident by covering the sensor with the wrapper of a foillined isopropyl alcohol pad. BrainLAB neuronavigation uses a 880 nm infared light (personal correspondence with the manufacturer). Pulse oximetry relies on twowavelengths of light: 660 nm (red light, visible spectrum) is used to detect hemoglobin (Hb) level, while 910940 nm of light (infrared) detects the oxygenated Hb portion, or HbO2 [2,3]. The interference of pulse oximetry by neuronavigation devices in the OR occurs in this infrared zone [2]. Disruption of pulse oximetry by neuronavigation results in either a poor waveform, false values, or both. Suspicion of interference from the devices is key. A simple cloth barrier may help produce a usable signal and multiple layers will eliminate the interference; a thin metal barrier such as aluminum foil may be a better alternative. Infrared light has a tendency to bounce off of solid objects, so that a direct path from the system to the sensor is not required [2]; thus, barriers constructed to improve pulse oximeter readings may need to fully encompass the sensor.

Endotracheal tube cuff inflation failure

*Correspondence: Thomas E Schulte, Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE681984455, Nebraska, USA, Tel: 402-5594081; Fax: 402-559-7372; E-mail: teschult@unmc.edu Received Date: 04 Apr 2017 Accepted Date: 19 Jun 2017 Published Date: 27 Jun 2017 Citation: Schulte TE, Travnicek MA. Endotracheal Tube Cuff Inflation Failure. Ann Clin Anesth Res. 2017; 1(1): 1004. Copyright

Assessing electronic interruptions experienced by an anesthesiology clinical director

STUDY OBJECTIVE The purpose of this study was to assess the workflow interruptions on an anesthesiology clinical director (CD). By assessing the interruptions on the CD, we hypothesize that these frequent interruptions would prohibit the CD from medical direction of residents or certified nurse anesthetists in operating rooms. DESIGN Cellular phone data were obtained from Verizon Wireless statements over 10 months, August 2012 through May 2013. These data were from a single cellular phone carried by the anesthesia CD and subsequent overnight anesthesiologist 24 hours a day. The data obtained from the billing records included number of calls, date and time call occurred, number of minutes per call, and number of texts received. SETTING These calls occurred in the operating room. PATIENTS Not applicable. INTERVENTION Not applicable. MEASUREMENTS Phone calls, texts, and pager interruptions. MAIN RESULTS A total of 19,924 calls and 19,803 texts were received by the CD. The phone calls minutes for this period were 31,236 minutes. A total of 15,831 (80%) of the calls occurred during this period (0600-1800). A total of 24 489 minutes (78%) of the total minutes occurred during this time. CONCLUSION This study revealed that distracting events are frequent for an anesthesiology CD. The quantity of cellular phone interruptions, both calls and texts, by the anesthesiology CD was considered high. These calls occurred mainly during prime operating room time and utilization. As the CD is an integral part of the perioperative management team, they are expected to answer and return calls and texts promptly. Operating room efficiency and staff satisfaction decline if responses to these calls and texts are delayed. Although the nature of these distractions and interruptions can be viewed as having a positive or negative effect, many of these events are necessary to efficiently run the operating rooms.

Transesophageal echocardiography examination for percutaneous right ventricular assist device placement.

• Volume 118 • Number 1 www.anesthesia-analgesia.org 69 A 70-year-old man presented with ST elevation in leads II, III, and aVF with reciprocal depression in the anterior leads suggestive of inferior myocardial ischemia with right ventricular (RV) involvement. Emergent angiography revealed thrombus in the right coronary artery, and 2 bare metal stents were inserted. Despite treatment with infusions of heparin, abciximab, norepinephrine, and dopamine, he remained severely hypotensive and was brought to the operating room for percutaneous insertion of a right ventricular assist device (percRVAD). Written consent for publication of this report has been obtained. A right radial arterial line, left femoral central venous line, and transesophageal echocardiography (TEE) were used for intraoperative anesthetic management. The right internal jugular (IJ) vein was reserved for a percRVAD outflow cannula because this allows for easier placement of an initial pulmonary artery (PA) catheter. TEE examination revealed severe RV dilation, and the RV free wall was severely hypokinetic. To place the percRVAD outflow cannula, a sheath was placed through the right IJ vein, and an Arrow Swan-Ganz catheter (Arrow International, Reading, PA) was directed into the main PA. Catheter placement was confirmed using the midesophageal (ME) RV inflow–outflow and upper esophageal aortic short-axis (UE Ao SAX) views. A 0.035” Cook wire (Cook Critical Care, Bloomington, IN) was then placed through the PA catheter, the catheter was removed, and a Medtronic Bio-Medicus 17F short tip multiorifice cannula (Medtronic Inc., Minneapolis, MN) was directed into the main PA. The ME RV inflow–outflow and UE Ao SAX views were used to confirm the percRVAD outflow cannula placement distal to the pulmonic valve (PV) (Fig. 1). When the cannula was placed at the PV, color Doppler revealed mild pulmonary insufficiency (PI) (Video 1, see supplemental digital content 1, http://links. lww.com/AA/A677). This resolved with advancement of the cannula approximately 3 cm distal to the PV (Video 2, see supplemental digital content 2, http://links.lww.com/ AA/A678). The percRVAD inflow cannula was placed through the right femoral vein. A Medtronic 21F multistage venous cannula was placed over a Cook wire and the tip confirmed in the right atrium using the ME bicaval view. Both cannulas (Fig. 2) were connected to a Thoratec CentriMag pump (Thoratec Corporation, Pleasanton, CA), and 4 L/min of flow established. All inotropes were weaned over 48 hours, and the percRVAD was explanted on postoperative day 3. The patient was discharged to a skilled nursing facility on postoperative day 10.

Novel use of unstaffed operating room personnel - The swing shift CRNA

Operating room (OR) staff member wages are the single greatest cost of delivering surgical care [1]. When opening new operating rooms, it is necessary to maximize surgical case utilization of the ORs to pay for the staff wages. Operating room labor costs for full-time employees are a fixed cost [2]. The OR staffmust be available to run the operating room at full utilization. When ORs are not utilized, staff may perform other duties, however they are not being utilized to their full capacity. Nebraska Medicine opened two outpatient surgical centers recently; one in April 2016 and the other December 2016. The anesthesia services for these surgical centers were staffed with anesthesiologist supervision of certified registered nurse anesthetists (CRNAs). Occasionally, there were days in which an operating room had no scheduled surgical cases. During days where no cases were scheduled into the staffed operating room, the CRNA was given the option to work at the main campus ORs for first case starts or participate in a “Swing Shift.” The Swing Shift CRNA would come in at 1500 to the main campus ORs and work as needed until the ORs drew down and only oncall staff remained. The Swing Shift CRNA would relieve daytime CRNAs and decrease the amount of overtime pay to CRNAs (Table 1). The total number of daytime overtime hours paid for the entire year prior to the Swing Shift PM (SSPM) starting was 1160 h. After initiation of the SSPM shift, the daytime staff hours of overtime decreased to 998. Total surgical cases for the year prior to SSPM were 23,602. After initiating the SSPM, total surgical cases were 25,189. There are many benefits associated with the initiation of the SSPM CRNA. The SSPM shift adds greater predictability to the daytime CRNA shift, by enabling the daytime CRNA to be relieved at 1500 when the SSPM shift starts. The SSPM shift also increases job morale and satisfaction for the daytime CRNA, as one of the biggest dissatisfiers is job unpredictability. The daytime CRNA shift overtime decreased from 1160 h to only 998 h, which is a cost savings for the department. The cost savings from decrease in overtime pay was almost twenty five thousand dollars. By utilizing the SSPM CRNAs to help cover late (non-primetime) cases, we increased job satisfaction, decreased the number of daytime overtime hours paid, and increased OR capacity for late surgeries.

Heart Failure With Preserved Ejection Fraction: A Perioperative Review

HEART FAILURE (HF) with preserved ejection fraction (HFpEF) presents significant challenges for anesthesiologists. Nearly 50% of patients presenting with HF have HFpEF, defined as having clinical HF with a left ventricular ejection fraction (LVEF) 450% and abnormal left ventricular diastolic dysfunction (LVDD). Even though HFpEF is a strong predictor of negative postoperative outcomes, it often is difficult to diagnose and the management strategies are unclear. Although there have been specific articles published with regard to the echocardiography descriptors, diagnosis, and relationship of LVDD with HF, the authors believed it was timely to present a review article for clinicians on the subject of perioperative HFpEF. This article reviews what is known about the pathogenesis, diagnosis, management options, and implications of HFpEF in the perioperative arena.

Bulk oxygen tank vaporizer leak

analgesia. After completion of the two-hour surgery, the isoflurane was turned off and standard neuromuscular blockade reversal was administered. Recovery was inadequate and the patient remained sedated with poor jaw tone. The whole case was reassessed and all reversible causes such as hypothermia were excluded. The senior anesthetist observed an unusually strong smell of isoflurane in the operating room. On examining the vaporizer, the concentration dial was malfunctioning. The dial was free with a faulty lock; its movement could not be regulated and the set concentration did not corroborate with the concentration being delivered. Even on the “off” position, the vaporizer was delivering varying concentrations of isoflurane. The vaporizer was changed immediately and the patient recovered completely within 30 minutes. It is regular practice at our institution to check the anesthesia machine according to the ASA checklist, and this was done in this case. While performing the leak test, the vaporizer was checked with the concentration dial turned on by pressing the lever. On rechecking, it was found that even without pressing the lever, the concentration dial was still turned on. We did not have the ability for intraoperative monitoring of inhaled anesthetic. The vaporizer in question had been unused for some time and was mounted on the anesthesia workstation that day. This improper isoflurane delivery led to delayed recovery but it might have had more deleterious consequences in a high-risk patient. It is difficult to detect such a vaporizer fault by the usual recommended tests. We searched the literature for any other technique of pre-use checking of vaporizers. A “sniff test”, which is done by smelling the gas from the patient port with a 3 L/min flow of oxygen, was recommended. No smell indicates that a vaporizer is not leaking or turned on [3]. The vaporizers should be carefully inspected, checked for leaks and the movement off the dial fully evaluated before use.