Methangkool E, Howard-Quijano K, Scovotti JC, Mazor E, Grogan TR, Kratzert WB, Mahajan A. Regional Left Ventricular Myocardial Dysfunction After Cardiac Surgery Characterized by 3-Dimensional Strain. Anesthesia & Analgesia. doi: 10.1213/ANE.0000000000003785. Epub ahead of print March 20, 2019.
Postoperative changes in myocardial function are heterogeneous in nature, depending on the surgical procedure, and these changes may have long-term impacts on outcome. Therefore, 3D regional strain may be used to identify patients at risk for worsened postoperative outcomes, allowing early inventions to mitigate risk.
Methangkool E, Howard-Quijano K, Mahajan A. Cardiac Dysrhythmias: Understanding Mechanisms, Drug Treatments, and Novel Therapies. Advances in Anesthesia, December 2018, Vol 36(1):181-199. Epub September 27, 2018.
This review article describes the mechanisms for cardiac arrhythmia generation and delineates different types of dysrhythmias that can occur under anesthesia. Potential medical and interventional therapies for these arrhythmias are also discussed.
Vaillancourt M, Chia P, Sarji S, Nguyen J, Hoftman M, Ruffenach G, Eghbali M, Mahajan A, Umar S. Autonomic nervous system involvement in pulmonary arterial hypertension. Respiratory Research, 18:201, https://doi.org/10.1186/s12931-017-0679-6, online publication Dec. 4, 2017.
Pulmonary arterial hypertension (PAH) is associated with increased sympathetic nervous system (SNS) activation, decreased heart rate variability, and presence of cardiac arrhythmias. Reduction of neurohormonal activation could be an effective therapeutic strategy. Direct methods such as cervical ganglion block, pulmonary artery denervation (PADN), and renal denervation have been employed to attenuate SNS activation in PAH. The authors summarize the multiple aspects of autonomic nervous system involvement in PAH, and discuss different strategies used to target the autonomic nervous system for treatment.
Fischer M, Salehi A, Sopher MJ, Vorobiof G, Shemin RJ. Ruptured Papillary Muscles after Chordae Preserving Bioprosthetic Mitral Valve Replacement. Accepted for publication in Annals of Thoracic Surgery, 2017.
Detection of masses shortly after valve surgery is rare; accurately assessing and making a differential diagnosis plays a crucial role in determining an appropriate surgical approach.
Green JB, Hart B, Cornett EM, Kaye AD, Salehi A, Fox CJ. Pulmonary Vasodilators and Anesthesia Considerations. Anesthesiology Clinics, June, 2017, Vol 35 221-232
Pulmonary hypertension is a complex disease process; understanding the characteristics and clinical implications of pulmonary vasodilators is of utmost importance in anesthesia practice.
General Anesthesiology & Perioperative Medicine
Gabel E, Shin J, Hofer I, Grogan T, Ziv K, Hong J, Dhillon A, Moore J, Mahajan A, Cannesson M. Digital Quality Improvement Approach Reduces the Need for Rescue Antiemetics in High-Risk Patients: A Comparative Effectiveness Study Using Interrupted Time Series and Propensity Score Matching Analysis. Anesthesia & Analgesia December 2018. Doi: 10.1213/ANE 0000000000003828. Epub ahead of print. https://www.ncbi.nlm.nih.gov/pubmed/30585897
Postoperative Nausea and Vomiting (PONV) affects 30% of all surgical patients and can lead to patient dissatisfaction, prolonged recovery times, and unanticipated hospital admissions. We hypothesized that an electronic medical record-based clinical decision support (CDS) approach that incorporates a new PONV pathway, education initiative, and personalized feedback reporting system can decrease the incidence of PONV. The study showed a decrease in incidence of PONV after implementation of the CDS.
Lee LK, Woodfin MY, Vadi MG, Grogan TR, Ross PJ, Applegate RL 2nd, Iravani M. A comparison of postoperative outcomes with PDA ligation in the OR versus the NICU: a retrospective cohort study on the risks of transport. BMC Anesthesiology December 2018. doi: 10.1186/s12871-018-0658-6. https://www.ncbi.nlm.nih.gov/pubmed/30579349
This study aimed to determine whether PDA ligations in the NICU corresponded to higher risk of surgical site infection or mortality and if transport was associated with worsened perioperative outcomes. The study found no increased risk. There was an increased incidence of hemodynamic instability in the RO group on transport back to the NICU. Larger multicenter studies following long-term outcomes are needed to evaluate the safety of performing all PDA ligations in the NICU.
Lee LK, Bernardo MKL, Grogan TR, Elashoff DA, Ren WHP. Perioperative Respiratory Adverse Event Risk Assessment in Children with Upper Respiratory Tract Infection: Validation of the COLDS Score. Pediatric Anesthesiology October 2018. doi: 10.1111/pan.13491.https://www.ncbi.nlm.nih.gov/pubmed/30281195
The decision to proceed with anesthesia and surgery has been controversial in pediatric patients with an upper respiratory tract infection. The COLDS score was proposed by Lee and August as a potential risk stratification scheme. The aim of the study was to evaluate the utility of the COLDS score in predicting perioperative respiratory adverse events and optimize its predictive abililty. The COLDS score has the potential to be a valuable risk assessment tool for prediction of perioperative respiratory adverse events and appears to have a better predictive value in certain subpopulations.
Lee LK, Burns RA, Dhamraits RS, Carter HF, Vadi MG, Grogan TR, Elashoff DA, Applegate RL 2nd, Iravani M. Retropsective Cohort Study on the Optimal Timing of Orogastric Tube/Nasogastric Tube Insertion in Infants with Pyloric Stenosis. Anesthisia and Analgesia September 2018. doi: 10.1213/ANE.0000000003805 https://www.ncbi.nlm.nih.gov/pubmed/30234537
Hypertrophic pyloric stenosis in infants can cause a buildup of gastric contents. Orogastric tubes (OGTs) or nasogastric tubes (NGTs) are often placed in patients with pyloric stenosis before surgical management to prevent aspiration. However, exacerbation of gastric losses may lead to electrolyte abnormalities that can delay surgery, and placement has been associated with increased risk of postoperative emesis. In this multicenter retrospective cohort study, data were extracted from the medical records of 481 patients who underwent pyloromyotomy for infantile hypertrophic pyloric stenosis from March 2013 to June 2016. The study concluded that OGT/NGT placement on admission for pyloric stenosis is associated with a longer time to electrolyte correction in infants with abnormal laboratory values on presentation and, subsequently, a longer time until they are ready for surgery.
Hatib F, Jian Z, Buddi S, Lee C, Settels J, Sibert K, Rinehart J, Cannesson M. Machine-learning Algorithm to Predict Hypotension Based on High-fidelity Arterial Pressure Waveform Analysis. Anesthesiology 2018; 129:663-74. Epub June 2018. doi: 10.1097/ALN.0000000000002300 http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2685008
With appropriate algorithms, computers can learn to detect patterns and associations in large data sets. The authors' goal was to apply machine learning to arterial pressure waveforms and create an algorithm to predict hypotension. The algorithm detects early alteration in waveforms that can herald the weakening of cardiovascular compensatory mechanisms affecting preload, afterload, and contractility.
The purpose of this chapter is to provide an evidence-based understanding of the pharmacokinetics and pharmacodynamics of sugammadex. Sugammadex is a c-cyclodextrin that rapidely reverses the effect of aminosteroid nondepolarizing neuromuscular blocking agents (NMBAs) rocuronium and vecuronium by forming an inactive 1:1 complex. Sugammandex has been shown to be an effective agent in reversing the effects of NMBAs with an acceptable safety and efficacy profile.
Vacas S, Takashige Y, Cannesson M. Intraoperative Noninvasive Cardiovascular and Brain Monitoring in the Elderly.
The purpose of this work is to provide a brief review of noninvasive cardiovascular and brain monitoring tools that could potentially decrease neurological complications in the perioperative period. Aging population is one of the most salient and ever-expanding issues affecting healthcare for the foreseeable future. Defining and implementing optimal perioperative care for this aging population is of increasing importance. During surgery, preserving brain perfusion is probably one of the most important parts of hemodynamic management and can be appropriately achieved by using several available cardiovascular and neurologic monitoring tools.
Mahajan A,Islam S, Schwartz M, Cannesson M.A hospital is not just a factory, but a complex adaptive system – Implications for perioperative care.Anesthesia & Analgesia:July 2017 – Vol 125, p 333-341.
The authors make the case that a hospital is not essentially a factory, and that engineering and manufacturing-derived redesign approaches will work only for noncomplex, low-variance, high-volume surgical episodes. Complex surgery and high-variance cases should be viewed as “complex adaptive systems”, which tend to self-organize and may resist or adapt unpredictably to attempts at control. Both approaches may be appropriate within the same hospital, and should be viewed as complementary rather than competitive.
Patients presenting with a history of foregut, midgut NETs or carcinoid syndrome can experience life-threatening carcinoid crises during anesthesia or surgery. Clinicians should understand the pharmacology of octreotide and appreciate the use of continuous infusions of high dose octreotide, which can minimize the incidence of intraoperative carcinoid crises. We recommend administration of a prophylactic 500 mcg bolus of octreotide intravenously and begin a continuous infusion of 500 mcg/hr for all NET patients during surgery, regardless of the location of their primary tumor or functional status. Advantages of octreotide include low cost of an infusion and excellent safety profile.
Jahr JS, Bergese SD, Sheth KR, Bernthal NM, Ho HS, Apfel CC. Current perspective on the use of opioids in perioperative practice: a multidisciplinary clinical appraisal. In Press, Pain Medicine, 2017.
With the current opioid epidemic and clinicians eager to find newer ways to treat acute pain, a multidisciplinary clinical appraisal surveyed 70,000 American Medical Association anesthesiologists, surgeons and orthopedists, to determine their preferred multimodal analgesia, and a panel also evaluated available modes of analgesia. The consensus was that multimodal analgesia, utilizing local anesthesia whenever possible, and non-opiate alternatives as analgesics, are the preferred methods of treatment.
Bernthal NM, Sheth KR, Bergese SD, Ho HS, Stoicea N, Apfel CC,Jahr JS. Non-steroidal anti-inflammatory drugs (NSAIDs) for pain management in joint surgery: an evidence-based literature review, national survey of physicians, and appraisal of the current clinical and scientific evidence. Accepted with revisions, just resubmitted, Journal of the American Orthopedic Society (JAAOS), 2017.
While growing evidence demonstrates the benefits of non-steroidal anti-inflammatory drugs (NSAIDS) for postoperative pain management, there is ongoing debate regarding NSAID use in orthopedic surgery. There is convincing evidence that NSAIDS administered locally in the joint provide pain management benefits following orthopeic procedures, yet questions remain about how to most effectively deliver NSAIDs to the joint, and improve availability and duration of effect.
V, Tieman D, Park E, Salehi A. Alpha-2 Agonists. Anesthesiology Clinics June 2017, Vol 35 233-245
Alpha-2 agonists have sedative, anxiolytic, analgesic and sympatholytic properties which allow for a wide variety of applications in anestheisology practice.
Agopian VG, Harlander-Locke MP, Markovic D, Dumronggittigule W, Xia V, Kaldas FM, Zarrinpar A, Yersiz H, Farmer DG, Hiatt JR, Busuttil RW. Evaluation of Early Allograft Function Using the Liver Graft Assessment Following Transplantation Risk Score Model. Jama Surg. 2018; 153:436-444. doi: 10.1001/jamasurg.2017.5040.https://www.ncbi.nlm.nih.gov/pubmed/29261831
The L-GrAFT risk score allows a highly accurate, individualized risk estimation of 3-month graft failure following LT that is more accurate than existing EAD and MEAF scores. Multicenter validation may allow for the adoption of L-GrAFT as a tool for evaluating the need for a retransplant, for establishing standardized grading of early allograft function across transplant centers, and as a highly accurate clinical end point in translational studies aiming to mitigate ischemia or reperfusion injury by modulating donor quality and recipient factors.
Fu H, Sun K, Li J, Gong W, Agopian V, Yan M, Busuttil RW, Steadman RH, Xia VW. Preoperative beta blockade and severe intraoperative bradycardia in liver transplantation. Clin Transplant. 2018 Oct 12:e13422. doi: 10.1111/ctr.13422. https://www.ncbi.nlm.nih.gov/pubmed/30312516
Preoperative NSBB was associated with severe intraoperative bradycardia in LT. In patients who receive preoperative NSBB, severe intraoperative bradycardia should be closely monitored in LT. Further studies assessing safety of preoperative NSBB and intraoperative bradycardia in LT are warranted.
Ershoff BD, Gordin JS, Vorobiof G, Elashoff D, Steadman RH, Scovotti JC, Wray CL. Improving the Prediction of Mortality in the High Model for End-Stage Liver Disease Score Liver Transplant Recipient: A Role for the Left Atrial Volume Index. Transplant Proc. 2018 Jun;(50)5:1407-1412. doi: 10.1016/j.transproceed.2018.03.017. PMID: 29880363
Left atrial volume index (LAVI) is an echocardiographic measurement used in assessing diastolic dysfunction, and is associated with mortality in many populations. In this retrospective cohort study including 254 patients, we investigated whether LAVI is an independent predictor of post-liver transplantation mortality using multivariable Cox regression. We further show that the inclusion of LAVI in multivariable model led to a statistically significant improvement in the ability to predict post-liver transplantation mortality. The incorporation of LAVI inb multivariable risk moels may be useful in the selection of transplant recipients with high MELD scores, and may be helpful in decreasing the probability of futile transplantation.
Potential organs for transplant need to maintain their viability during a series of insults, including the original disease, physiologic derangements during the dying process, ischemia, and reperfusion. Proper donor management before, during, and after procurement has potential to increase the number and qualityof organs from donors. Anesthesiologists need to understand the phsiologic derangements associated with brain death and the updated donor management during the periprocurement period.
Agopian VG, Busuttil RW, Hong F, Min Y, Steadman RH, Wang Y, Xia VW. Venovenous Bypass Is Associated with a Lower Incidence of Acute Kidney Injury After Liver Transplantation in Patients with Compromised Pretransplant Renal Function. Anesthesia & Analgesia. 2017 Nov;125(5):1463-1470. doi: 10.1213/ANE.0000000000002311. https://www.ncbi.nlm.nih.gov/pubmed/28742776
The aim of this large retroactive study was to determine if VVB was associated with a lower incidence of posttransplant acute kidney injury (AKI). We demonstrated that utilization of intraoperative VVB was associated with a significantly lower incidence of posttransplant AKI in patients with compromised pretransplant renal function.
A wide range of cardiovascular disorders may affect the LT patient. However, cardiac conditions that are most common in LT candidates include coronary artery disease (CAD), cirrhotic cardiomyopathy (CCM), and structural heart disease. In this review, these conditions are explored in the context of the perioperative cardiac evaluation of LT candidates.
Lunsford KE, Bodzin AS, Markovic D, Zarrinpar A, Kaldas FM, Gritsch HA, Xia V, Farmer DG, Danovitch GM, Hiatt JR, Busuttil RW, Agopian VG. Avoiding Futility in Simultaneous Liver-kidney Transplantation: Analysis of 331 Consecutive Patients Listed for Dual Organ Replacement. Ann Surg. 2017 May;265(5):1016-1024. doi: 10.1097/SLA.0000000000001801. PMID:27232249. https://www.ncbi.nlm.nih.gov/pubmed/27232249
We sought to evaluate outcomes and predictors of renal allograft futility (RAF-patient death or need for renal replacement therapy at 3 months) after simultaneous liver-kidney transplantation (SLKT). A retrospective single-center multivariate regression analysis was performed for adult patients undergoing SLKT. With 20% short-term loss of transplanted kidneys after SLKT, our data strongly suggest that renal transplantation should be deferred in liver recipients at high risk for RAF. Consideration for a kidney allocation variance to allow for delayed renal transplantation after liver transplantation may prevent loss of scarce renal allografts.
Huang S, Apinyachon W, Agopian VG, Wray CL, Busuttil RW, Steadman RH, Xia VW. Myocardial injury in patients with hemodynamic derangements during and/or after liver transplantation. Clin Transplant. 2016 Dec;30(12):1552-1557. doi: 10.1111/ctr.12855. Epub 2016 Oct 14. PMID:27653509 https://www.ncbi.nlm.nih.gov/pubmed/27653509
Myocardial injury, defined as an elevation of cardiac troponin (cTn) resulting from ischemia, is associated with substantial mortality in surgical patients, and its incidence, risk factors, and impact on patients undergoing liver transplantation (LT) are poorly understood. In this study, adult patients who experienced perioperative hemodynamic derangements and had cTn measurements within 30 days after LT were studied. We concluded that post-LT myocardial injury in this high-risk population was common and associated with mortality. Our findings may be used in pretransplant stratification. Further studies to investigate this postoperative cardiac complication in all LT patients are warranted.
Wang A, An X, Xia VW. Female Gender of the Recipient Is Independently Associated With Prolonged Ventilation Time and Hospital Stay After Liver Transplantation. Transplant Proc. 2016 Jan-Feb;48(1):120-2. doi: 10.1016/j.transproceed.2016.01.004. PMID:26915855. https://www.ncbi.nlm.nih.gov/pubmed/26915855
The aims of this study were to investigate the relationship between female gender and ventilation time and hospital stay after OLT. Female gender of the recipient is associated with significantly longer ventilation time and hospital stay after OLT and the management should be tailored to the unique characteristics and susceptibility to postoperative complications in female patients.
Zhao W, Ge X, Sun K, Agopian VG, Wang Y, Yan M, Busuttil RW, Steadman RH, Xia VW. Acute respiratory distress syndrome after orthotopic liver transplantation. J Crit Care. 2016 Feb;31(1):163-7. doi: 10.1016/j.jcrc.2015.09.028. Epub 2015 Oct 5. PMID:26601754. https://www.ncbi.nlm.nih.gov/pubmed/26601754
The aims of this study were to identify the incidence, preoperative and intraoperative risk factors, and impact of ARDS on outcomes in patients after orthotopic liver transplantation (OLT). Acute respiratory distress syndrome occurred at a rate of 4.1% following OLT in adult patients and was associated with preoperative encephalopathy, requirement of intubation, and total bilirubin and intraoperative large boluses of pressors. Acute respiratory distress syndrome was associated with increased mortality, longer ventilation time, and hospital stay.
Jun H, Vacas S, et al. Dexmedetomidine prevents cognitive decline by enhancing resolution of High Mobility Group Box 1 protein-induced inflammation through a vagomimetic action in mice. Anesthesiology5 2018, Vol.128, 921-931. doi:10.1097/ALN.0000000000002038
Inflammation initiated by damage-associated molecular patterns has been implicated for the cognitive decline associated with surgical trauma and serious illness. We determined whether resolution of inflammation mediates dexmedetomidine-induced reduction of damage-associated molecular pattern-induced cognitive decline. Conclusion: Dexmedetomidine resolves inflammation through vagomimetic (neural) and humoral pathways, thereby preventing damage-associated molecular pattern-induced cognitive decline.
Craniotomy is a relatively common surgical procedure with a high incidence of postoperative pain. Development of standardized pain management and enhanced recovery after surgery (ERAS) protocols are necessary and crucial to optimize outcomes and patient satisfaction and reduce health care costs. Strategies to ameliorate craniotomy pain demand interventions during all phases of patient care: preoperative, intraoperative, and postoperative interventions. Opioids remain the mainstay for pain relief, but patient-controlled analgesia, NSAIDs, standardization of pain management, bio/behavioral interventions, modification of head dressings as well as patient-centric management are useful opportunities that potentially improve patient care.
Blumenthal E, Rao R, Murphy A, Gornbein J, Hong R, Mariarty JM, Kahn DA, Janzen C. Pilot Study of Intra-Aortic Balloon Occlusion to Limit Morbidity in Patients with Adherent Placentation Undergoing Cesarean Hysterectomy. American Journal of Perinatology Reports, Vol. 8, No. 2, pp. e57-63. doi: 10.1055/s-0038-1641736
We study whether using an intra-aortic balloon (IAB) during cesarean hysterectomy decreases delivery morbidity in 35 patients with suspected morbidly adherent placentation. We did not detect statistically significant differences in overal surgical complications, bladder complications, ICU admissions, surgical duration ot blood transfusions. However, larger studies may be warranted given the potential for extreme morbidity in these cases.
Kamdar N, Hoftman N, Rahman S, Cannesson, M. Opioid-Free Analgesia in the Era of Enhanced Recovery After Surgery and the Surgical Home: Implications for Postoperative Outcomes and Population Health. Anesthesia & Analgesia, Vol. 125, No. 4, pp. 1089-91.
Aggressive opioid-based postoperative pain control has been demonized as a major contributor to the national opioid addiction epidemic and its associated morbidity, ultimately leading to many preventable deaths. We must actively work to curtail the detrimental path from acute surgical pain to chronic pain syndromes that may culminate in opioid addiction.
Sniderman, M.Epidural Injections Contraindicated for Lumbar Radiculopathy in May-Thurner Syndrome: A Case Report. A&A Case Reports: Post Author Corrections: July 10, 2017doi: 10.1213/XAA.0000000000000597
Lumbar radiculopathy is one of the most common reasons patients see a pain doctor. Unfortunately, when IVC obstruction is causing the symptoms, routine epidural injections will not help.
Jonathan S. Jahr, MD Sergio D. Bergese, MD Ketan R. Sheth, MD, FACS Nicholas M. Bernthal, MD Hung S. Ho, MD, FACS Nicoleta Stoicea, MD, PhD Christian C. Apfel, MD, PhD, MBA. Current Perspective on the Use of Opioids in Perioperative Medicine: An Evidence-Based Literature Review, National Survey of 70,000 Physicians, and Multidisciplinary Clinical Appraisal. Pain Medicine, pnx191, https://doi.org/10.1093/pm/pnx191. Published: 16 August 2017
Opioids remain a key component of multimodal perioperative analgesia, and strategic opioid use based on clinical considerations and patient-specific needs represents an opportunity to support improved postoperative outcomes and satisfaction. Future studies should focus on identifying optimal procedure-specific and patient-centered approaches to multimodal perioperative analgesia.
The authors analyzed the tension between the need to develop efficient, reproducible protocols for healthcare, and the equally compelling need to use the tools of genetics and genomics to provide patients with individualized “precision” health care. They suggest that as point-of-care (POC) testing is becoming better and faster, soon patients may undergo targeted genetic testing during preoperative visits, enabling precise selection of medications for intraoperative and postoperative management depending on the findings.
Hoftman N, Eikermann E, Shin J, Buckley J, Navab K, Abtin F, Grogan T, Cannesson M, Mahajan A. Utilizing Forced Vital Capacity to Predict Low Lung Compliance and Select Intraoperative Tidal Volume During Thoracic Surgery.Anesthesia & Analgesia:Published online ahead of print, 2017 March 8.
Tidal volume selection during mechanical ventilation utilizes dogmatic formulas that only consider a patient's predicted body weight (PBW). In this study, the authors investigate whether forced vital capacity (FVC) correlates better to total lung capacity than PBW, predicts low pulmonary compliance, and provides an alternative method for tidal volume selection. FVC is more strongly correlated to total lung capacity than to PBW, and a cutoff of about 3.5 L can be utilized to predict low pulmonary compliance.
Buckley JC, Brown AP, Shin JS, Rogers KM, Hoftman NN. A Comparison of the Haider Tube-Guard(R) Endotracheal Tube Holder Versus Adhesive Tape to Determine if This Novel Device Can Reduce Endotracheal Tube Movement and Prevent Unplanned Extubation. Anesthesia & Analgesia: 2016 May; 122(5): 1439-43. doi: 10.1213/ANE.0000000000001222. https://www.ncbi.nlm.nih.gov/pubmed/26983051
This clinical trial compared the standard tape method for securing endotracheal tubes during surgery to the Haider Tube Guard, a novel device designed to secure an endotracheal tube. With each patient acting has their own control, the ETT was secured with tape and a 15N force applied. A bronchoscope was then used to measure ETT movement within the airway, and the experiment was then repeated, this time with the Haider TubeGuard securing the ETT. Study results demonstrated that the Haider TubeGuard was superior at securing the ETT compared to all standard tapes, reducing both mean motion as well as potential extubation.