Coexisting Cardiac and Hematologic Disorders.

Patients with concomitant cardiac and hematologic disorders presenting for noncardiac surgery are challenging. Anemic patients with cardiac disease should be approached in a methodical fashion. Transfusion triggers and target should be based on underlying symptomatology. The approach to anticoagulation management in patients with artificial heart valves, cardiac devices, or severe heart failure in the operative setting must encompass a complete understanding of the rationale of a patient\u27s therapy as well as calculate the risk of changing this regimen. This article focuses common disorders and discusses strategies to optimize care in patients with coexisting cardiac and hematologic disease

Preventing Isolated Perioperative Reintubation: Who is at highest risk?

Objectives: 1. We aim to characterize IPR nationally through a retrospective review of the National Surgical Quality Improvement Program participant user file (NSQIP PUF). 2.Identify risk factors for IPR including analysis of procedure type and preoperative characteristics.https://jdc.jefferson.edu/patientsafetyposters/1041/thumbnail.jp

How I perform totally endoscopic robotic mitral valve repair.

A sixty-two-year-old male presented with significant symptoms related to severe mitral regurgitation with posterior leaflet flail and prolapse on transesophageal echocardiogram (TEE). Preoperative computed tomography (CT) angiography showed normal caliber thoracoabdominal aorta and patent access vessels. The patient underwent totally endoscopic robotic mitral valve repair (rMVr) with left atrial CryoMAZE procedure

Effect of lipid-lowering medications in patients with coronary artery bypass grafting surgery outcomes

Background: Increased life expectancy and improved medical technology allow increasing numbers of elderly patients to undergo cardiac surgery. Elderly patients may be at greater risk of postoperative morbidity and mortality. Complications can lead to worsened quality of life, shortened life expectancy and higher healthcare costs. Reducing perioperative complications, especially severe adverse events, is key to improving outcomes in patients undergoing cardiac surgery. The objective of this study is to determine whether perioperative lipid-lowering medication use is associated with a reduced risk of complications and mortality after coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). Methods: After IRB approval, we reviewed charts of 9,518 patients who underwent cardiac surgery with CPB at three medical centers between July 2001 and June 2015. The relationship between perioperative lipid-lowering treatment and postoperative outcome was investigated. 3,988 patients who underwent CABG met inclusion criteria and were analyzed. Patients were divided into lipid-lowering or non-lipid-lowering treatment groups. Results: A total of 3,988 patients were included in the final analysis. Compared to the patients without lipid-lowering medications, the patients with lipid-lowering medications had lower postoperative neurologic complications and overall mortality (P \u3c 0.05). Propensity weighted risk-adjustment showed that lipid-lowering medication reduced in-hospital total complications (odds ratio (OR) = 0.856; 95% CI 0.781-0.938; P \u3c 0.001); all neurologic complications (OR = 0.572; 95% CI 0.441-0.739; P \u3c 0.001) including stroke (OR = 0.481; 95% CI 0.349-0.654; P \u3c 0.001); in-hospital mortality (OR = 0.616; 95% CI 0.432-0.869; P = 0.006; P \u3c 0.001); and overall mortality (OR = 0.723; 95% CI 0.634-0.824; P \u3c 0.001). In addition, the results indicated postoperative lipid-lowering medication use was associated with improved long-term survival in this patient population. Conclusions: Perioperative lipid-lowering medication use was associated with significantly reduced postoperative adverse events and improved overall outcome in elderly patients undergoing CABG surgery with CPB

Robotically Assisted Mitral Valve Repair—Port-Only Totally Endoscopic Approach

Robotic mitral valve repair (MVR) is an emerging option to treat degenerative valve disease. Compared to open thoracotomy, robotic mitral valve surgery has been shown to afford decreased postoperative length of stay with comparable rates of mortality and morbidity. Among the variety of techniques for robotic MVR, the totally endoscopic approach remains the least invasive method to date. In this report, we describe our technique for totally endoscopic robotically-assisted MVR. In particular, we seek to highlight the use of several unique techniques in MVR. Percutaneous cannulation with use of the endoballoon is employed for cardiopulmonary bypass (CPB), thus avoiding traditional aortic cross-clamping. Moreover, intercostal nerve cryoanesthesia is performed from T3–T9 to reduce post-operative pain and aid in reducing opioid management. Barbed, nonabsorbable sutures are used throughout the procedure (for left atrial appendage closure, mitral valve annuloplasty band placement, left atrial closure, pericardial re-approximation), eliminating the need for knot-tying at several steps. We also detail the installation of two sets of neochords for mitral regurgitation and the fastening of the mitral annuloplasty band. Finally, we would like to highlight the small size of each port used in the case (eight millimeters maximum diameter). Taken together, these features of the robotic platform make it notable for its minimally invasive approach to MVR

Effects of diabetes mellitus and chronic kidney disease on major outcomes in patients undergoing cardiac surgery

Introduction: • Diabetes mellitus (DM) is the leading cause of chronic kidney disease (CKD). CKD typically manifests in late stages of DM. • DM and CKD are prevalent in patients with cardiovascular disease. • The impact of concurrent DM and CKD on major adverse cardiocerebral events (MACE) in patients undergoing cardiac surgery remains unclear.1,2 Objective: To determine the effect of DM and CKD on major outcomes in patients undergoing cardiac surgery.https://jdc.jefferson.edu/anposters/1001/thumbnail.jp

Effects of preoperative aspirin on major outcomes in graded high-risk patients undergoing cardiac surgery

Introduction: Among patients with cardiovascular disease, nearly 70% take preventive aspirin.1 The benefits of aspirin are greater as a patient’s risk of cardiovascular events increases; patients with a lower risk of cardiovascular events derive less of a benefit from aspirin.2 The effect of aspirin in surgical patients has not yet been investigated, in particular if there is an optimal effect based on operative risk when undergoing cardiac surgery. Objective: To determine the effects of preoperative aspirin on major outcomes after cardiac surgery in patients with low, medium, and high predicted operative mortality as determined by the EuroSCORE risk model.https://jdc.jefferson.edu/anposters/1002/thumbnail.jp

Intranasal Medication Administration Using a Squeeze Bottle Atomizer Results in Overdosing if Deployed in Supine Patients

BACKGROUND: Vasoconstrictors and local anesthetics are commonly administered using a squeeze bottle atomizer to the nasal mucosa to reduce edema, limit bleeding, and provide analgesia. Despite widespread use, there are few clinical guidelines that address technical details related to safe administration. The purpose of this study was to quantify, via simulation, the amount of liquid delivered to the nasal mucosa when patients are in the supine and upright positions and administration parameters that would reliably provide the desired amount of medication per spray. METHODS: A convenience sample of 10 anesthesia residents was studied. Providers were instructed to use a 25-mL dip and tube nasal squeeze bottle to administer the test solution (sterile water) to a mannequin in the upright (90 degrees elevation) and supine (0 degrees elevation) position. After mannequin testing, additional testing was completed with the spray bottles at 0 degrees, 15 degrees, 30 degrees, 45 degrees, and 90 degrees to determine the relationship between the angles of administration and the amount of liquid dispensed. RESULTS: The mean volume delivered per spray was substantially greater when administered in the supine position (0.56 +/- 0.22 mL) compared with the upright position (0.041 +/- 0.02 mL, difference = 0.52 mL, 95% confidence interval [CI], 0.37-0.67 mL, P < .001). Converting the administered volume to the dose of phenylephrine that would be administered using our standard 0.25% solution, an estimated additional 1300 mcg is delivered per spray in the supine position compared with the upright position (95% CI, 925-1675 mcg, P < .001). Administration with a delivery angle of = 30 degrees resulted in significantly more volume than when the bottle was oriented at a 90 degrees angle. The volume dispensed at 45 degrees was not different from the volume delivered at 90 degrees (0.032 +/- 0.006 mL vs 0.030 +/- 0.005 mL, P = .34). CONCLUSIONS: We found a 14-fold increase in the volume (ie, dose) delivered per spray when a nasal squeeze bottle was used with a mannequin in the supine position compared with the upright position. Given the reported toxicity from the use of intranasal medication and the inadvertent overdosing that occurs when squeeze bottle atomizers are used in clinical practice, our data suggest that all intranasal drugs should be administered with a precise, metered-dose device. If a metered-dose device is unavailable, the medication should be delivered at an angle of = 45 degrees; however, we recommend administering the drug with the patient in the sitting position and the bottle at 90 degrees because only a small change in angle below 45 degrees will result in a substantial increase in medication delivered

Innovative Use of Biotrace Tempo Pacemaker Lead Following Cardiac Surgery

The Tempo® Temporary Pacing Lead is a temporary, transvenous, active fixation pacemaker lead used exclusively in structural heart and electrophysiology procedures since regulatory approval in 2016. We utilized the Tempo lead for four patients undergoing redo-robotic cardiac surgery in which surgical epicardial leads could not be placed. No failure-to-pace events were encountered and patients were able to participate in various levels of physical activity without limitation

The Effect of Aspirin on Bleeding and Transfusion in Contemporary Cardiac Surgery.

Despite evidence that preoperative aspirin improves outcomes in cardiac surgery, recommendations for aspirin use are inconsistent due to aspirin's anti-platelet effect and concern for bleeding. The purpose of this study was to investigate preoperative aspirin use and its effect on bleeding and transfusion in cardiac surgery.This retrospective study involved consecutive patients (n=1571) who underwent CABG, valve, or combined CABG and valve surgery at a single center between March 2007 and July 2012. Of all patients, 728 met the inclusion criteria and were divided into two groups: those using (n=603) or not using (n=125) aspirin within 5 days of surgery. Data were collected on chest tube drainage, re-operation for bleeding, and transfusion of red blood cells (RBCs), fresh frozen plasma (FFP), and platelets.No significant difference was observed between the two groups in chest tube drainage or re-operation for bleeding. An increase in patients transfused with RBCs was observed in the aspirin group (61.9 vs 51.2%, adjusted OR 1.77, p=0.027); however, among those transfused RBCs, no significant difference in mean units transfused or massive transfusion was observed. No significant difference was seen in transfusion requirement of FFP or platelets.In patients undergoing CABG, valve, or combined CABG/valve surgery, preoperative aspirin, within 5 days of surgery, was associated with an increased probability of receiving an RBC transfusion. Preoperative aspirin was not associated with an increase in chest tube drainage, re-operation for bleeding complications, or transfusion of FFP or platelets