Wendy L. Gross

Clinical Assessment and Management of Patients With Implanted Cardioverter-Defibrillators Presenting to Nonelectrophysiologists

All physicians increasingly will encounter patients who have implanted cardioverter-defibrillators (ICDs) for protection from ventricular arrhythmias. This advisory provides a concise summary relevant to the assessment and management of patients with ICDs, including those who present to primary care or emergency department physicians with symptoms suggesting arrhythmia or ICD malfunction and those who require cardiac or surgical procedures.

Offsite anesthesiology in the cardiac catheterization lab.

Purpose of review The cardiac catheterization lab has concerns for both patient care and for safety. As the cardiac catheterization lab continues to evolve, the demand for anesthesia services will certainly increase. The role of the anesthesiologist in the cardiac catheterization lab must be defined in this changing environment. Recent findings Procedures in the cardiac catheterization lab are more complex, take longer, and involve higher acuity patients. Many of these cases require general anesthesia rather than sedation, and require management of unstable hemodynamics. Knowledge of echocardiography and fluoroscopy is beneficial. Anesthesiologists should be active in developing sedation and practice management guidelines. Radiation exposure and safety is an important concern. Summary The anesthesiologist is becoming an integral part of the cardiac catheterization lab team, and an important element in maintaining a high level of patient care with minimal complications in the evolving modern day cardiac catheterization lab.

Impact of general anesthesia on initiation and stability of VT during catheter ablation

BACKGROUND Radiofrequency ablation of ventricular tachycardia (VT) may be performed with general anesthesia (GA) or conscious sedation; however, comparative data are limited. OBJECTIVE The purpose of the study was to assess the effects of GA on VT inducibility and stability. METHODS A retrospective comparison of 226 patients undergoing radiofrequency ablation for scar-related VT under GA or intravenous conscious sedation was performed. Data were then prospectively collected in 73 patients undergoing noninvasive programmed stimulation (NIPS) while awake, followed by GA and invasive programmed stimulation for VT induction. RESULTS In the retrospective study, groups did not differ in VT inducibility, complications, or abolition of clinical VT. Intravenous hemodynamic support was used more often in the GA group. In the prospective group, 12 patients (16%) were noninducible with NIPS. Of the 61 patients with inducible VT with NIPS, 5 (8%) were noninducible with GA, 25 (41%) were inducible with more aggressive simulation, and 31 (51%) were inducible with the same or less aggressive stimulation. Of the 56 patients who were inducible with NIPS and under GA, 28 (50%) had the same induced VTs and 28 (50%) had different induced VTs. In 23 of 56 patients, the clinical VT morphology was known. The clinical VT was reproduced with NIPS in 17 of 23 patients (74%) and under GA in 13 of 23 patients (59%). Under GA, nonclinical VTs were more often induced in patients with a lower ejection fraction and nonischemic cardiomyopathy. CONCLUSION GA does not prevent inducible VT in the majority of patients. GA is associated with an increased use of hemodynamic support, but this did not adversely affect VT stability or procedure outcomes.

Analysis of Adverse Events Associated With Adult Moderate Procedural Sedation Outside the Operating Room

Introduction Moderate sedation outside the operating room is performed for a variety of medical and surgical procedures. It involves the administration of different drug combinations by nonanesthesia professionals. Few data exist on risk stratification and patient outcomes in the adult population. Current literature suggests that sedation can be associated with significant adverse outcomes. Objectives The aims of this study were to evaluate the nature of adverse events associated with moderate sedation and to examine their relation to patient characteristics and outcomes. Methods In this retrospective review, 52 cases with moderate sedation safety incidents were identified out of approximately 143,000 cases during an 8-year period at a tertiary care medical center. We describe types of adverse events and the severity of associated harm. We used bivariate and multivariate analyses to examine the links between event types and both patient and procedure characteristics. Results The most common adverse event and unplanned intervention were oversedation leading to apnea (57.7% of cases) and the use of reversal agents (55.8%), respectively. Oversedation, hypoxemia, reversal agent use, and prolonged bag-mask ventilation were most common in cardiology (84.6%, 53.9%, 84.6%, and 38.5% of cases, respectively) and gastroenterology (87.5%, 75%, 87.5%, and 50%) suites. Miscommunication was reported most frequently in the emergency department (83.3%) and on the inpatient floor (69.2%). Higher body mass index was associated with increased rates of hypoxemia and intubation but lower rates of hypotension. Advanced age boosted the rates of oversedation, hypoxemia, and reversal agent use. Women were more likely than men to experience oversedation, hypotension, prolonged bag-mask ventilation, and reversal agent use. Patient harm was associated with age, body mass index, comorbidities, female sex, and procedures in the gastroenterology suite. Conclusions Providers should take into account patient characteristics and procedure types when assessing the risks of harmful sedation-related complications.

Anesthesia Outside the Operating Room

The text also covers surgical procedures and anesthetic considerations by procedure location, such as radiology, infertility clinics, field and military environments, and pediatric settings, among many others Select guidelines from the American Society of Anesthesiologists (ASA) are provided as well. Edited by the senior faculty from Harvard Medical School and with contributions from other academic institutions, Anesthesia Outside of the Operating Room provides a unique and convenient compendium of expertise and experience.

Repairing interatrial septal defects from the operating room to the cardiac catheterization laboratory: 2d or not 2D?

Uncorrected congenital interatrial septal defect can be found in nearly a third of all adults and are associated with significant morbidity, including pulmonary hypertension, right-heart failure, atrial arrhythmias, and paradoxical embolic stroke. With advancing technology, percutaneous closure of atrial septal defects has become a viable alternative to open surgical repair. In this review, the authors provide 3 examples in which 3-dimensional interventional transesophageal echocardiogram effectively provided more precise visualization of the dynamic surface and geometry of the atrial septum and related structures than 2-dimensional TEE, permitting accurate sizing and repair of the defects.

Use of Real-Time 3D Transesophageal Echocardiography in Percutaneous Intervention of a Flush-Occluded Pulmonary Vein

A 52-year-old man presented with progressive dyspnea on exertion and hemoptysis following unsuccessful cardioversion and radiofrequency ablation for paroxysmal atrial fibrillation 5 months earlier. He underwent magnetic resonance angiography and CT angiography to assess pulmonary venous anatomy and to rule out pulmonary embolism. Imaging demonstrated an occluded left-lower pulmonary vein (Figure A). Figure. A, An MRI image showing both arterial and venous phases of filling. A paucity of pulmonary vasculature is seen in the area normally supplied by the left-lower pulmonary vein (white arrow), suggesting occlusion. B, Real-time 3D TEE of the left pulmonary venous system (rotated image) revealing the origin of the occluded left-lower pulmonary vein (top orifice) in relation to the patent left-upper pulmonary vein (bottom orifice). C, Angiographic image revealing wire passage through an …

Anesthesiology and Competitive Strategy

Whether we like it or not, medicine is big business. The argument is sometimes made that standard management strategies from the business world do not apply to medicine because the economics and practice of medicine are unique--driven by science and rapid rates of change. But an exploding knowledge base, light-speed technological development, and ever-changing reimbursement schemes are not exclusive to medicine and health care. Some fundamental principles of finance, business management, and strategic development have evolved to deal with problems of rapid change. These principles do apply to modern medicine. The business side of anesthesia practice is off-putting to many clinicians. However, knowledge of the market forces at play can help enhance patient care, improve service, expand opportunities, and extend the perimeter of the discipline. The mission and current market position of anesthesiology practice are considered here.

The challenges of implementing electronic health records for anesthesia use outside the operating room.

Purpose of review The nonoperating room environment presents a number of distinct challenges for anesthesiologists in the implementation of electronic health records (EHRs). These include documentation compliance, billing, and room design. Recent findings EHRs offer multiple opportunities for improved continuity of care, expedited preoperative evaluation, and seamless transitions between anesthesia and nonanesthesia providers. Additionally, data gathered through adoption of EHRs provide the promise of future analysis and research, allowing for data-driven improvements in quality of care and value optimization. Institutions adopting a new EHR in areas where anesthesia is provided outside of the operating room should plan wisely to address these matters. Summary The needs of anesthesiology practice should be carefully incorporated into future EHR builds as demands for anesthesia care outside of the operating room expand.

TEE and Interventional Cardiology.

DouglasC.Shook,MD As the scope and complexity of percutaneous interventions for structural heart disease broadens, the need for precise, real-time adjunctive imaging becomes more acute. While fluoroscopy has served traditionally as the imaging technique for interventional cardiology procedures, it entails significant radiation exposure and requires the use of intravenous contrast for optimal visualization of soft tissue structures. It can be temporally and spatially imprecise in cases involving placement or removal of intracardiac devices and repairs of paravalvular leaks or other structural defects. Transesophageal echocardiography (TEE), performed during interventional cardiology procedures (Interventional TEE) defines and creates a new indication for the modality. Interventional TEE is used to guide and assess the progress and outcome of interventions in a real-time, continuous, and stepwise fashion. In this context the interventional echocardiographer becomes a co-proceduralist, providing clear, time-efficient, step-by-step guidance for interventional cardiologists navigating the complexities of cardiac anatomy with catheters, balloons, and devices. It is critical that during intra-procedural imaging, the interventionalist and echocardiographer maintain constant communication regarding anatomic structure and function as well as the actual progress of the procedure. Interventional TEE examinations are performed to guide placement and assess positioning of devices for a variety of procedures including septal occlusion, paravalvular leak repair, and valve replacement and repair. This establishes a new role for echocardiographers, who may routinely have performed cardiac assessments preand post-intervention, but are not necessarily familiar with guiding procedures while they are in progress. The difference in acuity and timing, not just the venue change, makes important new demands of the echocardiographer, whether he/she is a cardiologist, cardiac anesthesiologist, or sonographer. A comprehensive interventional TEE examination begins with both a structural and functional definition of the primary defect and consideration of any associated pathology in the context of the proposed procedural plan. Effective communication among team members is critical. The unique value of interventional two-dimensional (2D) and three-dimensional (3D) TEE can be neutralized by confusion regarding either the complexities of image acquisition or the goals of the procedure itself. It is helpful for the interventional echocardiographer to be familiar with all of the imaging modalities used in the interventional suite. Fluoroscopic and echocardiographic images can augment each other, particularly when unusual clinical presentations or anatomy obtain. Each display should be visible to, understood, and discussed by all teammembers, particularly when seemingly contradictory interpretations arise. A complete interventional TEE exam includes both 2D and Doppler imaging complemented by 3D and real-time 3D (RT3D) datasets.