Journal-related Activities and Other Special Activities at the 2018 American Society of Anesthesiologists Meeting
2018; Lippincott Williams & Wilkins; Volume: 129; Issue: 4 Linguagem: Inglês
10.1097/aln.0000000000002404
ISSN1528-1175
AutoresMichael J. Avram, J. David Clark, Andrew Davidson, Evan D. Kharasch, Sachin Kheterpal, Jerrold H. Levy,
Tópico(s)Non-Invasive Vital Sign Monitoring
ResumoSunday, October 14, 2018, 8:15 am to 11:15 amMoscone Center South, Room 305The 2018 Journal Symposium titled “Point-of-care Ultrasound in Perioperative, Critical Care, and Pain Medicine” addresses the latest science on point-of-care ultrasound used to guide diagnosis, treatment, and management of patients across the perioperative, critical care, and pain medicine spectrum. It will feature the following moderators and speakers.J. David Clark, M.D., Ph.D., Editor, Anesthesiology, Stanford University, Palo Alto, California; Sachin Kheterpal, M.D., M.B.A., Editor, Anesthesiology, University of Michigan, Ann Arbor, Michigan; Jerrold H. Levy, M.D., F.A.H.A., F.C.C.M., Executive Editor, Anesthesiology, Duke University, Durham, North Carolina.Mahdav Swaminathan, M.D., M.B.B.S., Department of Anesthesiology, Duke University, Durham, North Carolina Marcos Silva Restrepo, M.D., M.Sc., F.R.C.P.C., Department of Anesthesia, University of Toronto, Toronto, Ontario, CanadaA stroll through the operating rooms, intensive care units, or clinics of a modern health system demonstrate that we are in the midst of a revolution in the use of point-of-care ultrasound. Just a decade or two ago, large, unwieldy point-of-care ultrasound machines were relegated to high-acuity operating rooms. Now, point-of-care ultrasound is used to guide diagnosis, treatment, and management of patients across the perioperative, critical care, and pain medicine spectrum. As devices have shrunk from large carts to handheld smartphones, they have permeated all phases of care and levels of training; first-year residents comfortably use ultrasound for routine vascular cannulation, and it has replaced invasive hemodynamic monitoring in many high-risk procedures. However, many questions remain regarding the use of point-of-care ultrasound by the anesthesiologist. What diagnostic and management dilemmas could be informed or eliminated by the use of point-of-care ultrasound? Where does convincing, reliable evidence demonstrate the underutilization of point-of-care ultrasound as a standard of care? How much of current point-of-care ultrasound use is evidence based, versus technology fad? How has point-of-care ultrasound changed clinical outcomes? What can the history of point-of-care ultrasound teach us about its future applications? What are the next novel frontiers for the use of point-of-care ultrasound by anesthesiologists? The 2018 Journal Symposium will showcase current concepts and current research in the field. Two experts will introduce these topics with 20-min presentations and 10-min discussions.These lectures will be followed by oral presentations of eight abstracts, summarized below, that were selected for their relevance to the symposium topic. The full text for each abstract can be found at the American Society of Anesthesiologists (ASA) abstract Web site.“Validation of Ultrasonography to Visualize Successful Insertion of Nasogastric Tubes in Pediatric Patients” by Edward Choi, M.D., Andrew Walker, Ph.D., Michael Korostensky, Adam O. Spencer, M.D., Department of Anesthesiology, University of Calgary, Calgary, Alberta, Canada. Enteral access in the form of nasogastric tube placement is essential in the care of many hospitalized pediatric patients. Although radiographic confirmation is the “gold standard,” it does not provide real-time information during insertion. This study aims to determine the feasibility of real-time ultrasound use for nasogastric tube insertion in the pediatric population. Thirty pediatric patients requiring nasogastric tube placement were enrolled and stratified into three age groups (between 0 and 2 yr, 2 and 6 yr, and older than 6 yr). Participants were placed supine with their head facing upward to facilitate tube placement. Upon nasogastric tube insertion, ultrasound images were acquired to visualize tube progression through the esophagus and gastric antrum with high-frequency linear probe or low-frequency curvilinear probe. After placement, standard institutional guidelines for final confirmation of nasogastric tube position were followed. To date, 27 patients have been enrolled. The nasogastric tube placement was successfully placed in the stomach in 26 of 27 patients on the basis of standard confirmatory testing. Of the 26 successful placements, the nasogastric tube placement was visualized in the esophagus by ultrasound in all 26 patients. A successful ultrasound view showing nasogastric tube placement in the stomach was limited to 16 of 26 patients. Our study shows that visualization of the nasogastric tube placement through the esophagus is successful regardless of age. Our data suggest that nasogastric tube placement confirmation may be more challenging when scanning with a probe in the epigastric region.“Evaluation of Success in Spinal Block Placement between Using Palpation of Landmark versus Pocket-Size, Handheld Ultrasound Method in Cesarean Delivery Anesthesia” by Joshua Pan, M.D., Jasveen Kaur Chadha, M.B., B.S., Vernon H. Ross, M.D., Lynne Harris, B.S.N., Peter H. Pan, M.D., Jessica L. Booth, M.D., Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, North Carolina. Administration of spinal block is commonly achieved by palpating surface landmarks. A newly developed pocket-size ultrasound (Accuro; Rivanna, USA) provides real-time pattern recognition for spinal bony structures and three-dimensional overlay for recognition of the midline spinous process and intervertebral space. We hypothesize this novel device may reduce time and attempts to successfully place spinal block versus conventional palpation in obese patients. Sixty patients with body mass index greater than 30 kg/m2 having spinal block for cesarean section were planned for consent and randomized into group Palpation or Ultrasound. In group Ultrasound, the needle insertion site was identified and marked by ultrasound and was used by a separate experienced provider to perform spinal block without palpating landmarks. For group Palpation, the usual palpation was used to identify the needle insertion site. The primary outcome was time from spinal needle insertion to cerebrospinal fluid (CSF) return. Forty-five of the 60 planned participants have been enrolled. Median scanning time was 34 s for group Ultrasound versus 32 s for group Palpation. Our primary outcome, time from spinal needle insertion to CSF return, was shorter with Ultrasound (median 41 s) than Palpation (118 s). We also observed a higher success rate (71% vs. 29%) of single-needle pass to obtain CSF, and a lower median number of needle passes (1 vs. 2) and redirections (1 vs. 3) to success. Our preliminary results suggest that the ultrasound device shortened time for successful placement of spinal block in obese patients (body mass index greater than 30 kg/m2).“Incidence of Interstitial Alveolar Syndrome on Lung Sonography in Preeclamptic Women with Severe Features: A Prospective Observational Study” by Kajal Jain, M.D., Seshagiri babu Yagini, M.B., B.S., Rashmi Bagga, M.D., Nidhi Bhatia, M.D., Ajay Bahl, M.D., Departments of Anesthesia and Intensive Care, Obstetrics and Gynecology, and Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Acute pulmonary edema is a serious manifestation in women presenting with severe preeclampsia. Bedside lung ultrasound was shown to identify lung interstitial edema even before severe deterioration of arterial oxygenation. The aim of this prospective observational study was to assess the ability of bedside lung ultrasound to detect interstitial alveolar syndrome in preeclamptic women with severe features. Seventy preeclamptic women with severe features reporting with critically high blood pressure readings were studied. In all enrolled patients, baseline bedside lung ultrasound and two-dimensional echocardiography were performed on admission (T0), immediately after delivery (T1), and then within 24 h after delivery (T2). The recent history included details of blood pressure readings over the preceding week and reasons for admission to labor room. Sixty-four percent of women showed significant B lines, and 47% showed diastolic dysfunction on echo at admission. The incidence of B lines before delivery was 66%, but it was 59% after delivery. The median values of admission blood pressure were 173 ± 21 mmHg systolic and 108 ± 11 mmHg diastolic. B lines correlated with rapidity of rise in blood pressure (Pearson correlation; P = 0.07). Significantly more patients with the presence of B lines on lung sonography complained of breathlessness (P = 0.007) and had facial puffiness (P = 0.001). Perinatal outcomes were comparable in those with and without B lines. Bedside lung ultrasound identifies at-risk preeclamptic parturients with severe features for development of pulmonary edema.“Perioperative Point-of-care Ultrasound Training: A Survey of Anesthesiology Programs in the United States” by Alexandra H. Reynolds, M.D., Hong Wang, M.D., Daniel C. Sizemore, M.D., Department of Anesthesiology, West Virginia University, Morgantown, West Virginia. The current status of nontransesophageal echocardiography and regional block point-of-care ultrasound training in anesthesiology residency programs is unknown. A 22-question online survey was sent to U.S. Accreditation Council for Graduate Medical Education Programs. The survey questions gauged current levels of training and exposure to ultrasound training in several areas, including regional blocks, transesophageal echocardiography (TEE), and point-of-care ultrasound. Survey questions also gauged the extent to which point-of-care ultrasound teaching occurred in institutional curriculums or at regional or national meetings. There were 130 survey responses from U.S. Accreditation Council for Graduate Medical Education anesthesiology residency programs. Forty-nine percent of responses were from residents and 51% of responses were from faculty. Almost all (96%) residents were in programs of more than 20 residents. Respondents exhibited a high level of ultrasound-guided regional block training, with 96% reporting having a rotation in residency. The extent of TEE training is also universally high, with 90% of respondents having received training. In contrast, only 36% of survey respondents had received non-TEE point-of-care ultrasound training, with even fewer (20%) having a point-of-care ultrasound rotation in residency. However, of the 20% that had a point-of-care ultrasound rotation, most had 4 weeks or more (87%). Less than half of all respondents (43.9%) had attended a point-of-care ultrasound workshop. Only a little more than one third (36%) of U.S. respondents received explicit point-of-care ultrasound training, and even fewer (20%) received specific point-of-care ultrasound rotations during their anesthesia residencies.“Intraoperative Point-of-care Ultrasound for Identification of Endotracheal Tube Position in the Pediatric Population” by Davinder S. Ramsingh, M.D., Elizabeth A. Ghazal, M.D., Darren H. Goltiao, M.D., Justin Pugh, B.S., Philip Ross, M.D., Linda J. Mason, M.D., Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, California. Studies have shown that 18 to 19% of all pediatric intubations result in inappropriate endotracheal tube (ETT) placement, and up to 11% of malpositioned ETTs are not recognized. The usefulness of point-of-care ultrasound to establish accurate position has yet to be determined in pediatrics. Informed consent was provided for patients younger than 10 yr requiring cuffed ETTs for cardiac catherization procedures involving chest fluoroscopy. Patients underwent induction and standard verification of ETT positioning. Then, with an ultrasound linear probe placed in a midline longitudinal tracheal view, the ETT cuff position was identified by assessment of tracheal motion during palpation of the pilot balloon. Measurements of cuff relative to sternal notch, cricoid cartilage, and thyroid cartilage were obtained. Chest fluoroscopy was reviewed to assess ETT in relationship to the carina. Primary comparison was correlation assessment between the ultrasound measurements and the fluoroscopy measurements. Time to perform the point-of-care ultrasound exam was recorded. Preliminary results (n = 32) show an age range of 2 months to 8 yr. Current results indicate 100% detection or visualization of the ETT cuff with the point-of-care ultrasound exam. Average time to perform the exam was 163 s (SD = 67 s). A strong correlation (R = −0.87) was demonstrated between the ultrasound measurements and the fluoroscopy measurements (P < .001) after accounting for the patients’ heights. Preliminary data suggest that airway point-of-care ultrasound appears to be a fast and effective method to identify the position of the endotracheal tube relative to important landmarks.“Empty Gut: Evaluation and Measurement of Preoperative Total Emptying with Gastric Ultrasound Technique” by George Williams II, M.D., Muaz Aijazi, M.D., Nadia Hernandez, M.D., Xu Zhang, Ph.D., Albert K. Xiao, B.S., Daniel A. Contreras, M.D., Navneet K. Grewal, M.D., Velvet M. Patterson, M.D., Robert C. Wegner, M.D., Departments of Anesthesiology and Biostatistics/Epidemiology/Research Design Component, University of Texas Health Science Center at Houston, Houston, Texas. The study assessed the utility of point-of-care gastric ultrasound in guiding nutritional paradigms for the critically ill patient. Using a point-of-care ultrasound technique, we measured the cross-sectional area of the gastric antrum in adult trauma patients scheduled to undergo surgery in a Level I Trauma Center. Images were taken when the patient was supine because of the prevalence of injuries. Ultrasound images were reviewed by an intensivist and were qualitatively classified as “empty” or “not empty.” A Wilcoxon rank sum test was used to compare cross-sectional area of “empty” versus “not empty” stomachs. A total of 104 separate images from 76 patients were analyzed. Seven percent of scans were taken of patients with postpyloric feeding tubes; 41% of scans were of patients with gastric tubes, and finally 45% of scans were of patients on a regular diet. Eighty-five scans (82%) were taken of patients non per os (NPO) since midnight, and 55 (33%) were of stomachs determined to be “empty.” Antral cross-sectional area in patients qualitatively determined to have empty versus not empty stomach was significantly different (“empty” cross-sectional area = 4.56 cm2, “not empty” cross-sectional area = 7.43 cm2; P < 0.001). NPO status was not associated with qualitative assessment of stomach contents (P = 0.12). No correlation was seen between the number of hours a patient was NPO and their antral cross-sectional area (r = −0.096; P = 0.38). NPO status and the number of hours a trauma patient remained NPO had no correlation with the size of their gastric antrum.“Ultrasound for Proximal Humeral Intraosseous Vascular Access: A Novel Approach” by Gausan Ratna Bajracharya, M.D., Sergio Bustamante, M.D., Asha Singh, M.D., Shravan Cheruku, M.D., Steve M. Leung, M.D., Guangmei Mao, Ph.D., Negmeldeen F. Mamoun, M.D., Departments of Outcomes Research and Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, Ohio; Department of Anesthesiology, Duke University, Durham, North Carolina. Intraosseous access is a viable option in situations where venous access is otherwise difficult or impossible; inability to identify anatomical landmarks is an absolute contraindication. Success rates with proximal humeral intraosseous access range from 60 to 91%, likely because of difficult landmark identification by palpation. We hypothesized that point-of-care ultrasonography can successfully identify proximal humeral intraosseous landmarks across human participants of varying body habitus. Thirty participants were separated into three groups: normal weight, obesity, and morbid obesity. Our primary outcome was to identify six anatomical landmarks: the humeral shaft, the surgical neck of the humerus, the lesser tubercle, the greater tubercle, the intertubercular sulcus, and the target site in the greater tubercle for needle insertion on both upper extremities of each patient. Time taken to identify each landmark and depth from the surface were recorded and analyzed. The overall success rate of identifying all six landmarks was 0.87 (0.78, 0.95), with no significant difference among various body mass index groups. Overall time to identify all landmarks was 31 s (27, 38). Overall depth for individual landmark varies from 1.25 ± 0.51 to 2.00 ± 0.84 cm. Ultrasound is reliable and quick in identifying proximal humeral intraosseous landmarks with reasonable accuracy across various body mass index groups.“Impact Assessment on the Training and Implementation of a Perioperative Point-of-care Ultrasound Service: A Quality Improvement Initiative” by Davinder S. Ramsingh, M.D., Alec C. Runyon, M.D., Dustin H. Wailes, M.D., Jaron Yang, Student, Mark Ringer, Student, Gina F. Brown, M.D., Justin Pugh, Student, Matthew Alschuler, Student, Jason W. Gatling, M.D., Robert D. Martin, M.D., Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, California. A comprehensive perioperative point-of-care ultrasound curriculum was successfully implemented at a single academic center in 2015. Ten attending and 20 resident physicians at another academic center were trained with this curriculum after 9 months of weekly sessions using an online platform. Beginning in December of 2016, a perioperative point-of-care ultrasound service was launched as a quality improvement initiative. Of 428 perioperative point-of-care ultrasound examinations performed, nearly half (49%) were performed intraoperatively and a third (33%) were performed preoperatively. Most (54%) triggers for the exams were significant past medical history while 19% were for questionable non per os status. Cardiac exams were the most commonly performed (45%) followed by pulmonary (24%) and abdominal (15%). Although a preliminary review found that only 18% of patients who received a perioperative point-of-care ultrasound exam intraoperatively had abnormal physical exam findings, exam findings altered patient care management at a rate of 44% due to new diagnosis (35%), verification of current diagnosis (32%), and confirmation of normal findings (32%).Sunday, October 14, 2018, 3:45 pm to 4:45 pmEvan D. Kharasch, M.D., Ph.D., Editor-in-Chief, Anesthesiology, Duke University, Durham, North Carolina.Anesthesiology is sponsoring its third Major Trials session at the 2018 Annual Meeting of the ASA. The session will provide a high-profile, large-audience forum for initial presentation of major randomized clinical trial results. It is designed for substantial trials, usually randomized and blinded, with a clinically important primary outcome.Neurodevelopmental Outcome at 2 Years of Age after General Anaesthesia and Awake-regional Anaesthesia in Infancy (GAS): An International Multicentre, Randomised Controlled Trial. Mary Ellen McCann, M.D., M.P.H., Harvard Medical School, Boston Children’s Hospital, Boston, MassachusettsMeasurement of Exercise Tolerance before Surgery (METS) Study: An International Multicentre Prospective Cohort Study of Cardiopulmonary Exercise Testing prior to Major Noncardiac Surgery. Brian H. Cuthbertson, M.B.Ch.B., Sunnybrook Health Sciences Centre, Toronto, OntarioPreoperative Epoetin-α with Intravenous or Oral Iron for Major Orthopedic Surgery: A Randomized Controlled Trial. Xavier Capdevila, Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, CHU Montpellier, University of Montpellier, Montpellier, FranceTriple Low Alerts do not Reduce Mortality: A Real-time Randomized Trial. Daniel I. Sessler, M.D., Editor, Anesthesiology, Cleveland Clinic, Cleveland, OhioAnesthesiology will sponsor two Best Abstract sessions this year, one in basic science and another in clinical science. These abstracts were chosen by a panel of editors who examined the highest-scoring abstracts from the ASA subcommittees, choosing those with important scientific and clinical application and novelty. Subsequently, a combination of these editors and appointees from the ASA chose one abstract in each category to receive the Best Abstract award for basic and clinical sciences at the meeting in San Francisco, California. The following are summaries of the excellent abstracts that will be presented.Saturday, October 13, 2018, 1:15 pm to 3:15 pmMoscone Center, North, Room 20Michael J. Avram, Ph.D., Assistant Editor-in-Chief, A nesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Andrew Davidson, M.B.B.S., M.D., F.A.N.Z.C.A., Editor, Anesthesiology, The Royal Children’s Hospital and the Murdoch Children’s Research Institute, Parkville, Victoria, Australia; Jerrold H. Levy, M.D., F.A.H.A., F.C.C.M., Executive Editor, Anesthesiology, Duke University, Durham, North Carolina.“Preliminary Results from the Society of Anesthesia and Sleep Medicine (SASM) OSA Registry” by Karen Posner, Ph.D., Norman Bolden, M.D., Frances F. Chung, M.B., B.S., Karen B. Domino, M.D., M.P.H., Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; Metro Health, Solon, Ohio; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada. Among 75 case reports for obstructive sleep apnea–related death or near-miss events occurring within 30 days of surgery, most patients were middle aged, ASA physical status III, and obese, had inpatient elective procedures with general anesthesia, and were receiving opioids at the time of the event. Death or severe brain damage occurred in 47 (63%) cases. Death or severe brain damage associated with obstructive sleep apnea was more common when events occurred on the hospital ward or at home. Rescue without significant patient injury was more common in the postanesthesia care unit, intensive care unit, or step-down unit, environments with more intensive monitoring and nursing observation.“Nociception Level–guided Analgesia: Influence on Opioid Consumption and Hypotensive Events during Propofol/Remifentanil Anesthesia” by Albert Dahan, M.D., Ph.D., Fleur S. Meijer, M.D., Suzanne Broens, M.D., Monique van Velzen, Ph.D., Christian Martini, M.D., Ph.D., Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands. The nociception level index is a multiparameter measure of nociception that ranges from 0 to 100. The effect of the nociception level index–guided analgesia on opioid dose and hemodynamic stability was tested in 80 patients scheduled for elective major surgery under total intravenous anesthesia, randomized to receive standard of care or nociception level index–guided analgesia. Intraoperative remifentanil consumption was less in the nociception level index–guided group (mean, 0.08 μg · kg−1 · min−1) than it was in the group receiving standard care (0.12 μg · kg−1 · min−1). Hypotensive events (mean arterial pressure < 55 Hg) occurred more frequently in the standard care group (n = 11) than it did in the nociception level index–guided group (n = 2).“A Cluster-randomized Crossover Trial of Multimodal Narcotic-sparing and Conventional Pain Regimens after Discharge from Hip Replacement: Are Opiates Even Necessary?” by Andrew N. Fleischman, M.D., Majd Tarabichi, M.D., Gabriel Makar, B.S., Carol Foltz, Ph.D., William J. Hozack, M.D., Matthew S. Austin, M.D., Antonia F. Chen, M.D., Department of Anesthesiology and the Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania. In a cluster-randomized, crossover trial, 235 patients undergoing total hip replacement were assigned to receive either a multimodal pain regimen with a minimal opiate supply after discharge, a conventional multimodal regimen, or a traditional opiate regimen without multimodal therapy. The multimodal pain regimen consisted of standing dose of 1,000 mg acetaminophen every 8 h, 200 mg gabapentin every 12 h, and 15 mg meloxicam every morning. Daily pain and daily opiate use and duration of use were significantly lower in both multimodal groups. The multimodal pain regimen with a minimal opiate supply after discharge group also had significantly lower daily opiate use than the conventional multimodal regimen group and fewer opiate-related symptoms than the traditional opiate group.“Patient Factors Associated with Opioid Consumption in the 30 Days following Major Surgery” by Daniel B. Larach, M.D., M.S., Michael J. Sahara, B.A., Sawsan As-Sanie, M.D., M.P.H., Stephanie E. Moser, Ph.D., Andrew G. Urquhart, M.D., Jules Lin, M.D., Joseph A. Wakeford, B.S., Daniel J. Clauw, M.D., Jennifer F. Waljee, M.D., M.S., M.P.H., Chad M. Brummett, M.D., Departments of Anesthesiology, Obstetrics and Gynecology, Orthopaedic Surgery, and Surgery, University of Michigan, Ann Arbor, Michigan.A single-center, prospective, observational cohort study was conducted to determine preoperative patient characteristics independently associated with home opioid use during the first 30 days after surgery in patients not taking opioids before hysterectomy, thoracic surgery, or total knee or hip arthroplasty. The median total oral morphine equivalents prescribed after surgery in 688 patients was 600 mg (interquartile range, 450 mg), while median opioid consumption was 187.5 mg (interquartile range, 475 mg). In the 628 patients for whom phenotypic predictor data were available, older age, college graduate status, and increased functional status were significantly associated with decreased opioid consumption, while higher anxiety scores were significantly associated with increased opioid consumption.“Development of a Novel Self-administered Cognitive Function Assessment for Preoperative Evaluation” by Kenneth C. Cummings, M.D., M.S., Kamal Maheshwari, M.D., M.P.H., Elizabeth Jansen, M.P.H., Anson Rosenfeldt, D.P.T., Tanujit Dey, Ph.D., Linda Skolaris, B.S.N., Jay Alberts, Ph.D., Department of Anesthesiology and Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio. The feasibility of using a mobile application to evaluate cognitive function in a preoperative screening clinic with a self-administered assessment model was evaluated in more than 1,100 patients aged 65 yr or older presenting to the preanesthesia consultation and evaluation clinic between November 2017 and February 2018. All patients completed two self-administered neurocognitive assessments: a processing speed test and Trail Making Test parts A and B on an internally developed iPad application. Patients performed, on average, 1.1 and 1.5 SD worse than their healthy peers on Trail Making Test parts A and B, respectively. Performance on the processing speed test was 0.95 SD worse for patients compared to healthy peers.“The Impact of Frailty on Delirium and Cognitive Change after Cardiac Surgery” by Andrew Laflam, B.S., Mitsunori Nakano, M.D., Brian P. Bush, M.D., Charles W. Hogue, M.D., Charles H. Brown, M.D., Tufts University School of Medicine, Boston, Massachusetts; Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois. The hypothesis that increased frailty would increase both the risk of delirium and the risk of a decline in a composite measure of cognition was tested in patients more than 65 yr old undergoing elective cardiac surgery. Frailty was evaluated at baseline with a validated binary scoring method of five age-related domains. Delirium was assessed with methodologies including the Confusion Assessment Method. The overall incidence of delirium was 42% (56 of 133); the incidence of delirium was higher in prefrail (48%) and frail (48%) patients than it was in nonfrail patients (13%). The cognitive data available from 83 patients revealed that frail patients were at increased risk of cognitive decline at 30 days, but at 1 yr cognitive change was similar by frailty status.“A Comparison of Right Ventricular Function between Patients with and without Pulmonary Hypertension due to Left-sided Heart Failure: Assessment by Right Ventricular Pressure Volume Curve” by Eiki Kanemaru, M.D., Kenji Yoshitani, M.D., Shinya Kato, M.D., Yoshihiko Ohnishi, M.D., Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Japan. Right ventricular energetics were evaluated intraoperatively by analysis of right ventricular pressure volume curves with use of three-dimensional transesophageal echocardiography and hemodynamic data obtained with a pulmonary artery catheter in 33 patients undergoing cardiac surgeries for left-sided heart diseases, 10 of whom had pulmonary hypertension due to left-sided heart failure. Although cardiac index was similar in patients with and without pulmonary hypertension, stroke work index and right ventricular minute work index were significantly higher and right ventricular-arterial coupling, which specifically refers to the right ventricle’s ability to increase its contractility in response to the increased afterload, were significantly lower in patients with pulmonary hypertension. The pressure volume curves were significantly different between patients with and without pulmonary hypertension.“Remote Ischemic Preconditioning Increases Serum Extracellular Vesicles in Coronary Artery Bypass Graft Patients and Is Cardioprotective” by Ulrich Frey, M.D., Marina Klaassen, M.D., Crista Ochsenfarth, B.Sc., Matthias Thielmann, M.D., Heinz Jakob, M.D., Eva Kottenberg, M.D., Petra Kleinbongard, Ph.D., Gerd Heusch, M.D., Bernd Giebel, Ph.D., Jürgen Peters, M.D., Department of Anesthesiology and Intensive Care, University Hospital Bochum, Herne, Germany; Departments of Anesthesiology and Pathophysiology, University Hospi
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