Purpose Pulmonary hypertension (PH) is a common cause of postoperative mortality in cardiac surgery that is commonly treated with conventional inhaled therapies, specifically nitric oxide and prostacyclin. Alternative therapies include inhaled milrinone and levosimendan, which are receiving more research interest and are increasing in clinical use as they may cut costs while allowing for easier administration. We sought to conduct a scoping review to appraise the evidence base for the use of these two novel inhaled vasodilators as an intervention for PH in cardiac surgery.SourceWe searched Embase and MEDLINE for relevant articles from 1947 to 2022.Principal findingsWe identified 17 studies including 969 patients. The included studies show that inhaled milrinone and levosimendan are selective pulmonary vasodilators with potential benefits ranging from ease of weaning from cardiopulmonary bypass to reduction in ventricular dysfunction. Nevertheless, high-quality data are limited, and study design and comparators are extremely heterogeneous, limiting the potential validity and generalizability of findings.ConclusionThe findings of this scoping review suggest that milrinone and levosimendan may be effective alternatives to current inhaled therapies for cardiac dysfunction in the setting of PH. Nevertheless, randomized trials have focused on specific agents and consistent outcome measures are needed to better validate the early-stage promise of these agents.Study registrationOpen Science Framework (https://osf.io/z3k6f/); first posted 21 July 2022.

In this retrospective cohort study we sought to evaluate the association between the etiology and timing of rapid response team (RRT) activations in postoperative patients at a tertiary care hospital in the southeastern United States. From 2010 to 2016, there were 2,390 adult surgical inpatients with RRT activations within seven days of surgery. Using multivariable linear regression, we modeled the correlation between etiology of RRT and timing of the RRT call, as measured from the conclusion of the surgical procedure. We found that respiratory triggers were associated with an increase in time after surgical procedure to RRT of 10.6 h compared to activations due to general concern (95% CI 3.9 - 17.3) (p = 0.002). These findings may have an impact on monitoring of postoperative patients, as well as focusing interventions to better respond to clinically deteriorating patients.

RHEOLYTIC thrombectomy (AngioJet; Boston Scientific, Marlborough, MA) is an emerging endovascular therapy for arterial and venous thrombosis.1Leung D.A. Blitz L.R. Nelson T. et al.Rheolytic pharmacomechanical thrombectomy for the management of acute limb ischemia: Results from the PEARL registry.J Endovasc Ther. 2015; 22: 546-557Crossref PubMed Scopus (53) Google Scholar,2Garcia M.J. Lookstein R. Malhotra R. et al.Endovascular management of deep vein thrombosis with rheolytic thrombectomy: Final report of the prospective multicenter PEARL (Peripheral Use of AngioJet Rheolytic Thrombectomy with a Variety of Catheter Lengths) registry.J Vasc Interv Radiol. 2015; 26: 777-785Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar It has been studied best in extremity vessel procedures, including deep venous thrombosis (DVT).2Garcia M.J. Lookstein R. Malhotra R. et al.Endovascular management of deep vein thrombosis with rheolytic thrombectomy: Final report of the prospective multicenter PEARL (Peripheral Use of AngioJet Rheolytic Thrombectomy with a Variety of Catheter Lengths) registry.J Vasc Interv Radiol. 2015; 26: 777-785Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 3Dumantepe M. Uyar I.. The effect of Angiojet rheolytic thrombectomy in the endovascular treatment of lower extremity deep venous thrombosis.Phlebology. 2018; 33: 388-396Crossref PubMed Scopus (17) Google Scholar, 4Song X.J. Liu Z.L. Zeng R. et al.The efficacy and safety of AngioJet rheolytic thrombectomy in the treatment of subacute deep venous thrombosis in lower extremity.Ann Vasc Surg. 2019; 58: 295-301Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 5Dopheide J.F. Sebastian T. Engelberger R.P. et al.Early clinical outcomes of a novel rheolytic directional thrombectomy technique for patients with iliofemoral deep vein thrombosis.Eur J Vasc Med. 2018; 47: 56-62Google Scholar Previous studies have focused on bleeding complications; hemodynamic complications have been documented but not quantified further.2Garcia M.J. Lookstein R. Malhotra R. et al.Endovascular management of deep vein thrombosis with rheolytic thrombectomy: Final report of the prospective multicenter PEARL (Peripheral Use of AngioJet Rheolytic Thrombectomy with a Variety of Catheter Lengths) registry.J Vasc Interv Radiol. 2015; 26: 777-785Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar,6Boston Scientific. AngioJet™ thrombectomy systems safety information: Safety statement for peripheral use. Available at:https://www.bostonscientific.com/content/gwc/en-US/products/thrombectomy-systems/angiojet-thrombectomy-system/angiojet-systems-safety-information.html. Accessed August 9, 2020.Google Scholar,7Jeyabalan G. Saba S. Baril D.T. et al.Bradyarrhythmias during rheolytic pharmacomechanical thrombectomy for deep vein thrombosis.J Endovasc Ther. 2010; 17: 416-422Crossref PubMed Scopus (14) Google Scholar We noticed frequent severe hypertension during these procedures and sought to estimate its incidence and describe associated patient and case characteristics given the current gap in the literature. With institutional review board approval, we retrospectively reviewed a database maintained by our institution's interventional radiology department to identify all rheolytic thrombectomy procedures for lower extremity DVT procedures performed from 2014 to 2018 with anesthesiology services. We assessed the incidence of severe intraoperative hypertension (systolic blood pressure >190 mmHg) and clinically significant increases in blood pressure (>20% increase in mean arterial pressure [MAP], relative to the median MAP recorded by the anesthesiologist before the start of the procedure). Our Anesthesia Information Management System (AIMS; CompuRecord, Philips Medical Systems, Andover, MA) automatically records blood pressure every 15 seconds from an arterial catheter and every reading from a noninvasive blood pressure monitor. Two authors (SL, LQ) manually reviewed all cases in which either blood pressure threshold was exceeded to exclude spurious readings from artifact. From the AIMS, we gathered data on age, sex, American Society of Anesthesiologists physical status score, body mass index, anesthetic technique, patient position, use of an arterial catheter, and administration of intraoperative vasodilators. We reviewed our institution's electronic health record (Epic Systems Corporation, Verona, WI) to ascertain the presence of preoperative hypertension and other significant comorbidities. We identified 35 patients who underwent rheolytic thrombectomy for lower extremity DVT with anesthesiology services. Severe hypertension was seen in 13 (37.14% [95% confidence interval 21.99%-55.05%]). Overall, 30 patients (85.71% [68.96%-94.62%]) experienced MAP increases >20% from their baseline. A substantial proportion of cases were performed with the patient under general anesthesia (42.86%), and arterial catheters were used in fewer than half the patients (22.86%). Of the patients who experienced severe hypertension, 76.92% required treatment with intravenous vasodilators, compared with 45.45% of those who did not (p = 0.1431). General anesthesia was used in a similar percentage of patients who did and did not experience severe intraoperative hypertension (46.15% and 40.91%, respectively; p = 1.00). We do not suggest a mechanism for these hemodynamic derangements. The onset of hypertension was typically after the initiation of the thrombectomy itself and not the initial vessel puncture. Thrombectomy may be more stimulating than was anticipated, leading to a light plane of anesthesia and hypertension. However, the proportion of cases performed with the patient under general anesthesia versus monitored anesthesia care was similar among patients who did and did not experience severe hypertension. A case series of symptomatic bradycardia during thrombectomy of peripheral veins explored but rejected the possibility of vasoactive mediators being released by hemolyzed blood cells or pressure oscillations causing dysfunctional activation of right-sided heart stretch receptors.7Jeyabalan G. Saba S. Baril D.T. et al.Bradyarrhythmias during rheolytic pharmacomechanical thrombectomy for deep vein thrombosis.J Endovasc Ther. 2010; 17: 416-422Crossref PubMed Scopus (14) Google Scholar Those potential mechanisms would not explain the sudden hypertension seen in our study. Regardless of the mechanism, rheolytic thrombectomy of lower extremity DVT is frequently marked by severe intraoperative hypertension; anesthesiologists should ensure close communication with the procedural team and exhibit heightened vigilance for this complication. None.

BACKGROUND:Reimbursement for anesthesia services has been shifting from a fee-for-service model to a value-based model that ties payment to quality metrics. The Centers for Medicare & Medicaid Service's (CMS) value-based payment program includes a quality measure for perioperative temperature management (Measure #424, Perioperative Temperature Management). Compliance may impose new challenges in clinical practice, data collection, and reporting. We investigated the impact of an electronic decision-support tool on adherence to this emerging standard. METHODS:In this retrospective observational study, perioperative temperature data were collected from cases eligible for reporting this measure to CMS from a single academic medical center before and after the implementation of an electronic decision-support tool that prompted temperature measurement and maintenance of normothermia. Proportions of measure compliance were assessed using segmented regression analysis. Proportions of intraoperative temperature measurement were also assessed, and multivariable logistic regression was performed to assess the association between patient and surgical factors and measure compliance. RESULTS:A total of 24,755 cases eligible for reporting in 2017 were assessed, and 25,274 cases from 2016 were included as an extended baseline. Segmented time-series regression did not show a significant baseline trend in measure compliance. Introduction of the alerts was associated with an increase in overall compliance from 84.4% (95% confidence interval [CI], 83.6%-85.2%) to 92.4% (91.4%-93.4%), and an increase in intraoperative compliance from 26.8% (25.8%-27.8%) to 71.0% (69.6%-72.4%). The association between the alerts and overall compliance was also present on multivariable analysis. CONCLUSIONS:Implementation of an intraoperative decision-support tool was associated with statistically significant improvement in the maintenance of normothermia in cases eligible for reporting to CMS. This led to improved compliance with Measure #424 and suggests that electronic alerts can help practices improve their performance and payment bonus eligibility.

Background: Cardiopulmonary resuscitation (CPR) requires effective chest compressions and ventilations to circulate and oxygenate blood. It has been established that a 2-handed mask seal is superior when providing bag-valve-mask (BVM) ventilations. However a 1-handed technique remains the standard with which health care providers are trained to perform 2-rescuer CPR. Objectives: We sought to determine if a modified 2-rescuer CPR technique that incorporates a 2-handed mask seal during ventilations can be accomplished without compromising chest compression quality during a simulated cardiac arrest. Methods: Medical student volunteers were divided into an "intervention'' arm, with 1 rescuer creating a 2-handed mask seal and the second rescuer performing chest compressions followed by that second rescuer squeezing the BVM bag to deliver ventilations during compression pauses, and a "control'' arm, in which standard 2-rescuer CPR was performed. Both arms received a brief CPR refresher following a standard script. The 2 rescuer teams then performed 2 rounds of CPR on a manikin while being video recorded. Data were collected from real-time evaluation and post hoc video analysis. Results: Forty-seven pairs of students enrolled in the study. There were no statistically significant differences between the intervention and control arms for median (interquartile range [IQR]) compression fraction (72% [69.5-75.7%] vs. 73.2% [69.1-76.1%]; p = 1.0), median time to complete 2 rounds of CPR (207.8 s [198.5-222.9 s] vs. 214.7 s [201.3-219.5 s]; p = 0.625), median hands-off time (49.8 s [46.2-63.0 s] vs. 55.4 s [50.4-65.2 s]; p = 0.278), or median time for 30 compressions (15.2 s [14.3-15.9 s] vs. 15.4 s [14.6-16.3 s]; p = 0.452). Conclusion: Two-rescuer CPR incorporating a 2-handed face mask seal can be performed effectively without impacting chest compression quality during simulated cardiac arrest. (C) 2019 Elsevier Inc. All rights reserved.

BACKGROUND:Vascular manifestations including pulmonary artery aneurysms and venous thrombosis are seen in up to 14% of patients with Behcet's disease. We report a patient who had recurrent deep vein thrombosis (DVT) as the presenting symptom of Behcet's Disease. METHODS:A 19-year-old male who presented with acute iliofemoral DVT, confirmed by intravascular ultrasound (IVUS) and venogram. May-Thurner syndrome was also observed. Repeated catheter-based pharmacomechanical thrombolysis, thrombectomy, and subsequent iliac vein stenting were performed. The patient was then discharged on rivaroxaban and aspirin. RESULTS:Five months later, the patient experienced left calf pain. In the interim, he had been diagnosed with Behcet's disease by a rheumatologist who was consulted due to oral ulcers and skin lesions and accordingly started on prednisone, colchicine, and azathioprine. At this time, IVUS and venogram revealed thrombotic occlusion of the previously placed stent. Tissue plasminogen activator was infused into the stent, and pharmacomechanical thrombectomy restored flow through the left iliac veins. Follow-up laboratory workup revealed that subtherapeutic azathioprine dosing, and after appropriate adjustment, the patient has been asymptomatic for 12 months. CONCLUSIONS:Acute refractory DVT is a possible presenting symptom of Behcet's disease, which may be complicated by May-Thurner syndrome. Such patients should receive therapeutic immunosuppression in addition to anticoagulation.

Background In free flap head and neck reconstructions, hemodynamic management is complicated by the deleterious effects of excessive crystalloid administration. Patients may undergo periods of hypotension or excess fluid administration. The purpose of this study was to present our examination of the hypotheses that intraoperative hypotension and blood pressure lability are associated with increased fluid administration and flap failure. Methods We reviewed the records of 445 patients undergoing head and neck surgery involving free tissue transfer. We used multivariate logistic regression to examine the relationship between hemodynamic variables and flap loss (primary outcome) and other complications. Results On multivariate analysis, intraoperative hypotension and large-volume fluid administration were associated with flap loss. Neither blood pressure lability nor vasopressor administration was significantly associated to our primary outcome. Conclusions Intraoperative hypotension is associated to flap failure in head and neck free tissue transfer surgeries, as is large-volume fluid administration.

RATIONALE:Video-assisted thoracoscopic surgery (VATS) and open lobectomy are both standard of care for the treatment of early-stage non-small cell lung cancer (NSCLC) because of equivalent long-term survival. OBJECTIVES:To evaluate whether the improved perioperative outcomes associated with VATS lobectomy are explained by surgeon characteristics, including case volume and specialty training. METHODS:We analyzed the Surveillance, Epidemiology, and End Results-Medicare-linked registry to identify stage I-II NSCLC in patients above 65 years of age. We used a propensity score model to adjust for differences in patient characteristics undergoing VATS versus open lobectomy. Perioperative complications, extended length of stay, and perioperative mortality among patients were compared after adjustment for surgeon's volume and specialty using linear mixed models. We compared survival using a Cox model with robust standard errors. RESULTS:We identified 9,508 patients in the registry who underwent lobectomy for early-stage NSCLC. VATS lobectomies were more commonly performed by high-volume surgeons (P < 0.001) and thoracic surgeons (P = 0.01). VATS lobectomy was associated with decreased adjusted odds of cardiovascular complications (odds ratio [OR] = 0.65; 95% confidence interval [CI] = 0.47-0.90), thromboembolic complications (OR = 0.47; 95% CI = 0.38-0.58), extrapulmonary infections (OR = 0.75; 95% CI = 0.61-0.94), extended length of stay (OR = 0.47; 95% CI = 0.40-0.56), and perioperative mortality (OR = 0.33; 95% CI = 0.23-0.48) even after controlling for differences in surgeon volume and specialty. Long-term survival was equivalent for VATS and open lobectomy (hazard ratio = 0.95; 95% CI = 0.85-1.08) after controlling for patient and tumor characteristics, surgeon volume, and specialization. CONCLUSIONS:VATS lobectomy for NSCLC is associated with better postoperative outcomes, but similar long-term survival, compared with open lobectomy among older adults, even after controlling for surgeon experience.

BACKGROUND Visceral pleural invasion (VPI) may impact non-small cell lung cancer (NSCLC) survival. However, previous studies are mixed as to whether VPI is an independent prognostic factor in early-stage cancers and whether its effect is size dependent. In the current American Joint Committee on Cancer (AJCC) staging system, VPI leads to upstaging of cancers < 3 cm but not of those 3 to 7 cm in size. METHODS Using the Surveillance, Epidemiology, and End Results (SEER) registry, we identified 16,315 patients with stage I-II NSCLC treated with lobectomy. We used the Kaplan-Meier method and Cox regression to assess the association of VPI with lung cancer-specific (primary outcome) and overall survival. Based on these results, we created a revised VPI staging classification. RESULTS Overall, 3,389 patients (21%) had VPI. Kaplan-Meier analysis stratified by tumor size showed worse cancer-specific survival in patients with VPI (P < .0001). VPI was independently associated with decreased lung cancer-specific survival (hazard ratio, 1.38; 95% CI, 1.29-1.47) after controlling for tumor size and other confounders; this effect was not size dependent. In our revised classification, tumors < 7 cm with VPI were upstaged to the next T category. CONCLUSIONS VPI is a prevalent finding associated with worse prognosis in early-stage lung cancer, even among patients with tumors > 3 cm, a factor not captured in the current staging system. Patients with VPI may be considered candidates for more aggressive treatment.