Introduction: Delirium is a common, distressing, and dangerous complication after cardiac surgery with cardiopulmonary bypass (CPB) with few modifiable risk factors. This study aims to determine the association between post-operative oxygen delivery (DO2i) and the risk of delirium and assess the critical threshold for DO2i associated with delirium risk after surgery. Methods: This study is a multi-site retrospective cohort study with 1690 patients undergoing elective cardiac surgery with CPB who had multiple cardiac output measurements with a pulmonary artery catheter and arterial blood gas analyses. Results: The cohort of 1690 patients analyzed included 185 patients diagnosed with delirium within 7 days of surgery (11%). Patients with delirium had a lower post-operative DO2i (mean difference of 26 ml/min/m(2), 95% CI 14 to 36, p < 0.0001) compared to the 1505 patients without delirium. In a multivariable analysis controlling for age, sex, race, heart failure, diabetes, obstructive sleep apnea, body mass index, CPB time, circulatory arrest time, aortic cross clamp time, carotid stenosis, and cognitive impairment the post-operative mean DO2i was not independently associated with delirium. Post-operative DO2i was inversely correlated with CPB time with a decrease of 0.27 ml/min/m(2) per minute of CPB exposure (p < 0.0001). The critical threshold of DO2i after cardiac surgery is lower with increased age and female sex. Conclusions: Post-operative DO2i over 7 days is not independently associated with the risk of delirium but significantly correlated with CPB time. Older patients may have a lower DO2i critical threshold for risk of delirium.

Objective: We sought to evaluate how implementing a thoracic Enhanced Recovery After Surgery (ERAS) protocol impacted surgical outcomes after elective anatomic lung resection. Summary Background Data: The effect of implementing the ERAS Society/European Society of Thoracic Surgery (ESTS) thoracic ERAS protocol on postoperative outcomes throughout an entire healthcare system has not yet been reported. Methods: This was a prospective cohort study within one healthcare system (1/2019-3/2023). A thoracic ERAS protocol was implemented on 5/1/2021 for elective anatomic lung resections, and postoperative outcomes were tracked using the electronic health record and Vizient data. The primary outcome was overall morbidity; secondary outcomes included individual complications, length of stay (LOS), opioid use, chest tube duration, and total cost. Patients were grouped into pre- and post-ERAS cohorts. Bivariable comparisons were performed using independent t-test, chi-square, or Fisher’s exact tests, and multivariable logistic regression was performed to control for confounders. Results: There were 1,007 patients in the cohort; 450 (44.7%) were in the post-ERAS group. Mean age was 66.2 years; most patients were female (65.1%), white (83.8%), had a BMI between 18.5-29.9 (69.7%), and were ASA class 3 (80.6%). Patients in the post-implementation group had lower risk-adjusted rates of any morbidity, any respiratory complication, pneumonia, surgical site infection, arrhythmias, infections, opioid usage, ICU use, and shorter postoperative LOS (all P <0.05). Conclusions: Postoperative outcomes were improved after implementation of an evidence-based thoracic ERAS protocol throughout the healthcare system. This study validates the ERAS Society/ESTS guidelines and demonstrates that simultaneous multihospital implementation can be feasible and effective.

Background: In 2012, the American Society of Anesthesiologists (ASA) published guidelines recommending against routine preoperative laboratory testing for low-risk patients to reduce unnecessary medical expenditures. The aim of this study was to assess the change in routine preoperative laboratory testing in low-risk versus higher-risk patients before and after release of these guidelines. Methods: The ACS-NSQIP database, 2005-2018, was separated into low-risk versus higher-risk patients based upon a previously published stratification. The guideline implementation date was defined as January 2013. Changes in preoperative laboratory testing over time were compared between low- and higher-risk patients. A difference-in-differences model was applied. The primary outcome included any laboratory test obtained <= 90 days prior to surgery. Results: Of 7,507,991 patients, 972,431 (13.0%) were defined as low-risk and 6,535,560 (87.0%) higher-risk. Use of any preoperative laboratory test declined in low-risk patients from 66.5% before to 59.6% after guidelines, a 6.9 percentage point reduction, versus 93.0%-91.9% in higher-risk patients, a 1.1 percentage point reduction (p < 0.0001, comparing percentage point reductions). After risk-adjustment, the adjusted odds ratio for having any preoperative laboratory test after versus before the guidelines was 0.77 (95% CI 0.76-0.78) in low-risk versus 0.93 (0.92-0.94) in higher-risk patients. In low-risk patients, lack of any preoperative testing was not associated with worse outcomes. Conclusions: While a majority of low-risk patients continue to receive preoperative laboratory testing not recommended by the ASA, there has been a decline after implementation of guidelines. Continued effort should be directed at the deimplementation of routine preoperative laboratory testing for low-risk patients.

Objective: Inadvertent perioperative hypothermia has been associated with poor surgical outcomes. The purpose of this study was to evaluate the incidence and associated postoperative complications of inadvertent perioperative hypothermia in patients undergoing robotic-assisted thoracic surgery lung resections. Methods: This was a single-center, retrospective cohort study evaluating all consecutive patients who underwent robotic-assisted thoracic surgery lung resection between January 1, 2021, and November 30, 2022. Temperatures were measured at 5 time points: preprocedure unit, anesthesia induction, 30 minutes postinduction, extubation, and recovery room arrival. Temperature changes were calculated at each interval. Adjusted and unadjusted comparison was performed between those who experienced varying levels of inadvertent perioperative hypothermia (Hypothermia I: <36 degrees C, Hypothermia II: <35.5 degrees C, and Hypothermia III: <35 degrees C) and those who did not. Results: A total of 313 patients were included, and 201 (64.2%) lobectomies, 50 (16.0%) segmentectomies, and 62 (19.8%) wedge resections were performed. Across all patients, 291 (93.0%) had a temperature less than 36 degrees C, 195 (62.3%) had a temperature less than 35.5 degrees C, and 100 (31.9%) had a temperature less than 35.0 degrees C. Patients experienced significant temperature change at all intervals (P < .001), with the greatest loss occurring during the preprocedure interval (between leaving preprocedure unit and anesthesia induction). On adjusted analysis, patients who experienced inadvertent perioperative hypothermia less than 35.5 degrees C were older (odds ratio, 1.03; 95% CI, 1.01-1.05), had lower body mass index (odds ratio, 0.95; 95% CI, 0.87-0.98), and had increasing operative time (odds ratio, 1.00; 95% CI, 1.00-1.01). Patients who experienced inadvertent perioperative hypothermia had higher risk-adjusted rates of overall morbidity and infectious postoperative complications. Conclusions: The majority of patients undergoing robotic-assisted thoracic surgery lung resections experience some degree of inadvertent perioperative hypothermia and have associated increased rates of 30-day morbidity. Structured and interval-specific interventions should be implemented to decrease rates of inadvertent perioperative hypothermia and subsequent complications.

Introduction: Compliance with thoracic Enhanced Recovery After Surgery (ERAS) protocols is critical to achieving their maximum benefits. We sought to examine utilization of quality review meetings as a method to improve protocol compliance through identification and resolution of barriers with compliance.Methods: A multidisciplinary committee implemented a thoracic ERAS protocol for anatomic lung resections across five hospitals within our health system. Compliance data at one institution were tracked for 4 mo after initiation of the ERAS protocol; a quality review meeting was held at one hospital, and two additional months of compliance data were recorded. Outcomes of interest were compliance changes to five protocol elements. Pathway elements deferred due to "mindful deviation" were excluded. Chi-square and Fisher's exact tests were used to compare compliance differences.Results: We included 81 patients: 53 patients before the quality review meeting and 28 after. There were 405 compliance opportunities; 68 (17%) were excluded for mindful deviation, leaving 337 (83%) for inclusion. Overall compliance improved from 53% before to 84% after the quality review meeting. Compliance to avoiding intraoperative urinary catheters, placing chest tubes to water seal in postanesthesia care unit, liberal chest tube removal, and postoperative multimodal pain regimen use improved after the quality review meeting (P values <0.05). Use of preoperative pain bundles was not significantly different (87% versus 96%, P = 0.25).Conclusions: Conducting a quality review meeting significantly improved ERAS protocol element use at our intervention healthcare region. This methodology should be considered at other institutions implementing surgical protocols.(c) 2023 Elsevier Inc. All rights reserved.

OBJECTIVE:To comprehensively assess relevant institutional variations in anesthesia and intensive care management during left ventricular assist device (LVAD) implantation. DESIGN:The authors used a prospective data analysis. SETTING:This was an online survey. PARTICIPANTS:Participants were from LVAD centers in Europe and the US. INTERVENTIONS:After investigating initial interest, 91 of 202 European and 93 of 195 US centers received a link to the survey targeting institutional organization and experience, perioperative hemodynamic monitoring, medical management, and postoperative intensive care aspects. MEASUREMENTS AND MAIN RESULTS:The survey was completed by 73 (36.1%) European and 60 (30.8%) US centers. Although most LVAD implantations were performed in university hospitals (>5 years of experience), significant differences were observed in the composition of the preoperative multidisciplinary team and provision of intraoperative care. No significant differences in monitoring or induction agents were observed. Propofol was used more often for maintenance in Europe (p < 0.001). The choice for inotropes changed significantly from preoperatively (more levosimendan in Europe) to intraoperatively (more use of epinephrine in both Europe and the US). The use of quantitative methods for defining right ventricular (RV) function was reported more often from European centers than from US centers (p < 0.05). Temporary mechanical circulatory support for the treatment of RV failure was more often used in Europe. Nitric oxide appeared to play a major role only intraoperatively. There were no significant differences in early postoperative complications reported from European versus US centers. CONCLUSIONS:Although the perioperative practice of care for patients undergoing LVAD implantation differs in several aspects between Europe and the US, there were no perceived differences in early postoperative complications.

Innovation has consistently been the hallmark of progress in the care of cardiac surgery and transplant patients— forward thinking in hopes of creating a better future. From the moment Ludwig Rehn sutured a myocardial laceration in 1896, or in 1954 when Joseph Murray performed the first successful solid organ transplant, there has been a clear eye towards the future and using innovative means of tackling the problems we see before us. The year 2022 was no exception, with a major advance made in xenotransplantation with a cardiac graft that functioned adequately for 7 weeks after implantation, as 1 example. Many such advancements are highlighted in this issue of Seminars in Cardiothoracic and Vascular Anesthesia, which compiles a series of review articles summarizing the notable research and innovations from this past year. The relevant publications have been divided into 5 separate categories for the reader, including critical care medicine, abdominal transplantation, congenital heart disease, cardiac anesthesia, and cardiac surgery. It was a busy year in critical care medicine and Alber et al have done a wonderful job summarizing the advancements made in the care of post-cardiac arrest patients, resuscitation, mechanical ventilation, septic shock, and nutritional support, as well as improving neurologic outcomes in the critically ill. The use of VA-ECMO as a means of rescue in the care of post-cardiac arrest patients has gained more attention this year, where there has been a focus towards temperature management and cytokine adsorption. Additionally, following the COVID-19 pandemic there was work done describing the neurocognitive outcomes of ECMO survivors. Building on prior work done evaluating the utility of targeted temperature management (TTM), the HYPO-ECMO group randomized patients with cardiac arrest or refractory cardiogenic shock that received ECLS to either moderate hypothermia (33-34°C) or normothermia (36-37°C) finding a non-statistically significant differences in the primary outcome of 30 day mortality though the composite outcome of death, or escalation to LVAD or heart transplant at 30 days favored the mild hypothermia group, and importantly there were no increased risks of adverse events in the mild hypothermia group. Post-cardiac arrest syndrome (PCAS) is a well-established inflammatory condition following ROSC that results in ischemia-reperfusion injury and the release of proinflammatory cytokines, such as interleukin-6 (IL-6). The CYTER Trial Group utilized a hemoadsorber in the ECMO circuit at the time of VA ECMO cannulation in the setting of ECPR, postulating that it maymitigate reperfusion injury at the time of cannulation. There was not a statistically significant fall in the IL-6 levels or any differences in a host of secondary outcomes, including mortality and SOFA score, though this single-center study was limited by a relatively small and heterogeneous population. Fernando et al added additional insight into neurocognitive outcomes for patients that spent time on ECMO (either VVor VA) in the province of Ontario. As postulated, the ECMO group had a higher incidence of mental health diagnoses, though secondary outcomes including substance misuse and self-harm did not differ. Moving on to updates in resuscitation, Cheskes et al evaluated novel techniques for defibrillation including double sequential external defibrillation (DSED; 2 shocks one second apart and in 2 different planes) and vector change (defibrillation pads moved to anterior posterior from anterior lateral positions). In this extension of their previous work, the authors concluded that DSED produced higher rates of survival to hospital discharge, suggesting that 2 shocks are truly better than one. Turning to ventilator management, the authors focus on the evolution of low tidal volume ventilation with respect to lung-diaphragm interaction and protection. With the original ARDS Network low tidal volume ventilation paper being 23 years old, De Vries and colleagues offered a new potential avenue to expand on these protective strategies to include respiratory muscles by considering a diaphragm protective

In its 1952 second annual report, the fledgling National Science Foundation framed the process of technological innovation as a “sequence [consisting] of basic research, applied research, and development... each of the successive stages [depending] upon the preceding.” Medical advancement has proven no exception to this, and the relationship between basic science, applied research, and clinical development underpins the modern framework of evidencebased medicine. As much as we may bias toward thinking of this sequence as linear, it is imperative that we also look at innovation critically and publish studies that detail what doesn’t work. This issue of Seminars in Cardiothoracic and Vascular Anesthesia (SCVA) is true to this ethos and encompasses the entirety of this arc. We present both positive and negative Original Research spanning basic science in thromboelastographic testing, applied research in arterial line ultrasound and video laryngoscopy training, as well as clinical development of lung isolation devices and opioid sparing cardiothoracic anesthetic techniques. Rounding this out is an excellent review of perioperative point of care ultrasound (POCUS) for hemodynamic assessment and 2 case reports describing ingenuity in the face of the unexpected. Finally, we present a retraction of a previously published study to correct the evidence-based medical record as well as reflect on the risks inherent in stepping away from the process of innovation framed by the National Science Foundation so many years ago. In the first Original Research article, Mathew et al report the results of the first pairwise meta-analysis of clinical outcomes for opioid-free anesthesia (OFA) vs opioid-based anesthesia (OBA) in patients undergoing cardiovascular and thoracic surgery. Including 919 patients across 8 studies, they found that OFA in cardiovascular surgery patients was associated with significantly reduced postoperative nausea and vomiting (PONV), inotrope need, and non-invasive ventilation while there was no observed difference in 24-hour pain scores, 48-hour morphine equivalent consumption, or length of hospital stay. Interestingly, these same trends were not observed in thoracic surgery patients, among whom there was no significant difference in any of the explored outcomes. In this first meta-analysis of OFA techniques specific to cardiothoracic surgical patients, the findings echo similar patterns of reduced PONV in the absence of increased pain scores across multiple surgical specialties. Taken together with literature demonstrating reductions in long-term opioid dependence and concurrent improvements in clinical outcomes and patient satisfaction with cardiac Enhanced Recovery After Surgery (ERAS), this study offers compelling support of OFA techniques within cardiothoracic-specific Enhanced Recovery After Surgery programs. While innovation is a constant driver of clinical care improvement and medical device development, not all novel techniques and technologies are universally superior. Our second Original Research article is a demonstration of this, evaluating the existing literature comparing the Rüsch EZ-BlockerTM to the more traditional left-sided double lumen tube (L-DLT) for lung isolation in thoracic surgery. In a systematic review and meta-analysis spanning 6 studies and 495 patients, Kumar and colleagues found that the L-DLT tube was faster to

In a healthcare sector that is constantly evolving, quality improvement has become one of the main areas of focus. Often tough to measure, the three pillars of quality improvement—structure, process, and outcome—provide the cornerstone on which advances in quality can be achieved. Length of stay (LOS) is one such often talked about outcome metric. It is desirable to have shorter lengths of stay since a longer LOS would generally indicate less efficient care and possibly higher complication rate and would in turn be less economical to the healthcare system. However, the relationship between the best possible care and LOS is seldom straightforward. This current issue of Seminars in Cardiothoracic and Vascular Anesthesia (SCVA) delves a bit into the strategies to predict and reduce hospital LOS. Two original research articles discuss predictive variables and therapeutic interventions to reduce hospital LOS, respectively. This is followed by two review articles to analyze the prevention and management of neurocognitive disorders after cardiac surgery and the management of perioperative diastolic dysfunction. A comprehensive review discusses biventricular repair from the perspective of the congenital cardiac anesthesiologist. The issue is rounded off by two interesting case reports that discuss challenging perioperative hemodynamic situations in thoracic surgery. In our firstOriginal Research article, Wang and colleagues analyzed the role of perioperative serum albumin and the albumin–bilirubin (ALBI) grade in predicting post-liver transplant LOS. In a single-institution study, they looked at 663 liver transplant recipients and concluded that a higher pre-operative serum albumin level was associated with a shorter hospital LOS. They also concluded that a lower ALBI grade, which is possibly a marker of greater hepatic synthetic activity, was associated with shorter hospital and intensive care unit (ICU) LOS in patients with a low Model for End Stage Liver Disease–sodium (MELD-Na) score. However, there was no difference in operative mortality across the ALBI grades. Higher MELD-Na scores are known to be associated with worse postoperative outcomes and would alert clinicians to the possibility of longer hospital and ICU LOS. The ability to risk stratify patients that are otherwise “low risk”with lowerMELD-Na scores based on ALBI grade makes this paper pertinent and may pave the way for future trials to investigate the role of ALBI in this subset of patients. Minimally invasive valve surgery has continued to evolve and can now be performed safely with shorter ICU and hospital LOS, while keeping the quality of the operation similar to that performed through a full sternotomy. Postoperative pain has been one of the barriers to a faster recovery and earlier discharge following minimally invasive valve surgery, and this may be because of extensive rib retraction and division of intercostal muscles associated with the surgical procedure. In the second Original Research article, Cheruku et al studied the outcomes of thoracic interfascial plane blocks after mini-thoracotomy for valve surgery. In a single center, single surgeon retrospective study, 400 consecutive patients who underwent minimally invasive mitral or aortic surgery, and were extubated within 2 hours of the procedure, were included. Forty-eight percent (193 patients) received an interfascial block, while 52% (207 patients) did not. They concluded that patients who received a thoracic interfascial block had a modest reduction in maximum visual analogue scale (VAS) pain score when compared to those who did not (mean VAS score 7.4 ± 2.5 vs 7.9 ± 2.2, P = .02). This did not translate to a significant reduction in opioid