Understanding how the brain recovers from unconsciousness can inform neurobiological theories of consciousness and guide clinical investigation. To address this question, we conducted a multicenter study of 60 healthy humans, half of whom received general anesthesia for 3 hr and half of whom served as awake controls. We administered a battery of neurocognitive tests and recorded electroencephalography to assess cortical dynamics. We hypothesized that recovery of consciousness and cognition is an extended process, with differential recovery of cognitive functions that would commence with return of responsiveness and end with return of executive function, mediated by prefrontal cortex. We found that, just prior to the recovery of consciousness, frontal-parietal dynamics returned to baseline. Consistent with our hypothesis, cognitive reconstitution after anesthesia evolved over time. Contrary to our hypothesis, executive function returned first. Early engagement of prefrontal cortex in recovery of consciousness and cognition is consistent with global neuronal workspace theory.

Abstract This special article is the third in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia that is specifically dedicated to highlights in vascular anesthesiology. This review includes several updates in the perioperative optimization of vascular surgery patients. The first section provides an overview and updated outcomes for a novel endovascular procedure to treat carotid vascular disease. The second section summarizes recent long-term outcomes for endovascular abdominal aortic aneurysm repair recently released from the original landmark trials comparing endovascular and open repair. The third and final section is an update on acute kidney injury in vascular surgery. The themes selected for this special article are only a small sample of the advances in the specialty during 2019 but reflect important advances for patients with cardiovascular disease requiring vascular surgery.

BACKGROUND:This case highlights challenges in the assessment and management of the "difficult airway" patient in the SARS-CoV-2 (COVID-19) pandemic era. METHODS:A 60-year-old male with history of recent transoral robotic surgery resection, free flap reconstruction, and tracheostomy for p16+ squamous cell carcinoma presented with stridor and dyspnea 1 month after decannulation. Careful planning by a multidisciplinary team allowed for appropriate staffing and personal protective equipment, preparations for emergency airway management, evaluation via nasopharyngolaryngoscopy, and COVID testing. The patient was found to be COVID negative and underwent imaging which revealed new pulmonary nodules and a tracheal lesion. RESULTS:The patient was safely transorally intubated in the operating room. The tracheal lesion was removed endoscopically and tracheostomy was avoided. CONCLUSIONS:This case highlights the importance of careful and collaborative decision making for the management of head and neck cancer and other "difficult airway" patients during the COVID-19 epidemic.

BACKGROUND:The opioid crisis has reached epidemic proportions, yet risk of persistent opioid use following curative intent surgery for cancer and factors influencing this risk are not well understood. METHODS:We used electronic health record data from 3,901 adult patients who received a prescription for an opioid analgesic related to hysterectomy or large bowel surgery from January 1, 2013, through June 30, 2018. Patients with and without a cancer diagnosis were matched on the basis of demographic, clinical, and procedural variables and compared for persistent opioid use. RESULTS:Cancer diagnosis was associated with greater risk for persistent opioid use after hysterectomy [18.9% vs. 9.6%; adjusted OR (aOR), 2.26; 95% confidence interval (CI), 1.38-3.69; P = 0.001], but not after large bowel surgery (28.3% vs. 24.1%; aOR 1.25; 95% CI, 0.97-1.59; P = 0.09). In the cancer hysterectomy cohort, persistent opioid use was associated with cancer stage (increased rates among those with stage III cancer compared with stage I) and use of neoadjuvant or adjuvant chemotherapy; however, these factors were not associated with persistent opioid use in the large bowel cohort. CONCLUSIONS:Patients with cancer may have an increased risk of persistent opioid use following hysterectomy. IMPACT:Risks and benefits of opioid analgesia for surgical pain among patients with cancer undergoing hysterectomy should be carefully considered.

This special article is the second in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia that is specifically dedicated to highlights in vascular anesthesiology published in 2018. This review begins with 2 updates in preoperative medicine in the vascular surgery population, including recent publications regarding the management of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers and antiplatelet medications in the perioperative period. The next section focuses on complications related to thoracic endovascular aortic surgery, particularly as technology advances allow for endovascular repair of more complex anatomy. The final section focuses on quality in vascular surgery and evaluates recent publications that examine the safety and feasibility of fast-track endovascular aortic surgery. Even though this is only a sampling of the literature published in 2018 relevant to the cardiovascular anesthesiologist, these themes represent some of the topics most clinically relevant to the perioperative period.

THE ABILITY TO achieve lung isolation and a quiet surgical field is a crucial tenet of thoracic anesthesiology. The 2 techniques for lung isolation employed in modern thoracic surgery include placement of a double-lumen endotracheal tube (DLT) or a conventional single-lumen endotracheal tube with an endobronchial blocker (BB). Which technique is the best way to achieve lung isolation is a matter of ongoing debate, including in this Journal.1Neustein S.M. Pro: Bronchial blockers should be used routinely for providing one-lung ventilation.J Cardiothorac Vasc Anesth. 2015; 29: 234-236Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 2Brodsky J.B. Con: A bronchial blocker is not a substitute for a double-lumen endobronchial tube.J Cardiothorac Vasc Anesth. 2015; 29: 237-239Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 3Cohen E. Pro: The new bronchial blockers are preferable to double-lumen tubes for lung isolation.J Cardiothor Vasc Anesth. 2008; 22: 920-924Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 4Slinger P. Con: The new bronchial blockers are not preferable to double-lumen tubes for lung isolation.J Cardiothorac Vasc Anesth. 2008; 22: 925-929Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar In reality, each device has advantages and disadvantages, and it is incumbent upon the thoracic anesthesiologist to weigh the risks and benefits for each individual case. No shortage of randomized controlled trials have compared the efficacy and complication profiles of DLT versus BB for lung isolation. In this issue of the Journal of Cardiothoracic and Vascular Anesthesia, Templeton et al5Templeton T.W. Morris B.N. Goenaga-Diaz E.J. et al.A prospective comparison of intraluminal and extraluminal placement of the 9-French Arndt bronchial blocker in adult thoracic surgery patients.J Cardiothorac Vasc Anesth. 2017; 31: 1332-1337Abstract Full Text Full Text PDF Scopus (10) Google Scholar reported the first prospective, randomized controlled trial to compare 2 different techniques of BB placement. In this study, the authors recruited 41 patients who were randomized to either intraluminal or extraluminal placement of the Arndt BB for lung isolation. All intubations and BB placements were performed by the same 2 cardiothoracic anesthesia fellows who were trained on both techniques in the simulation laboratory prior to the study. The primary outcome variable was time to placement defined by insertion of a laryngoscope to correct positioning of the BB. Secondary outcomes included quality of isolation, number of device repositionings, and presence and severity of postoperative sore throat. The key findings of this study were that the median time to placement was more than twice as fast in the extraluminal group, with no difference in any of the secondary outcomes. Although statistically significant, are these results clinically significant? Median times to placement of extraluminal and intraluminal BBs were 162 seconds and 384 seconds, respectively. In the grand scheme of duration of surgery, it is unlikely that a difference of 3.5 minutes is of any real clinical importance in elective cases. Emergency cases, such as hemorrhage or trauma, truly may benefit from quicker isolation, although it is unclear if these times to lung isolation would be reproducible in emergent circumstances. Were one to prize efficiency above all else, it is worth noting that both techniques took longer than DLT placement by a similar cohort of cardiothoracic fellows in a study by Narayanaswamy et al.6Narayanaswamy M. McRae K. Slinger P. et al.Choosing a lung isolation device for thoracic surgery: A randomized trial of three bronchial blockers versus double-lumen tubes.Anesth Analg. 2009; 108: 1097-1101Crossref PubMed Scopus (138) Google Scholar A systematic review and meta-analysis of the current literature found that BB placement took longer than DLTs (mean difference of 51 seconds).7Clayton-Smith A. Bennett K. Alston R.P. et al.A comparison of the efficacy and adverse effects of double-lumen endobronchial tubes and bronchial blockers in thoracic surgery: A systematic review and meta-analysis of randomized controlled trials.J Cardiothorac Vasc Anesth. 2015; 29: 955-966Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar Perhaps the more clinically relevant finding of the current study was the similar quality of isolation with no increase in postoperative complications, although the study was not powered to detect differences in these outcomes. A strength of the Templeton et al5Templeton T.W. Morris B.N. Goenaga-Diaz E.J. et al.A prospective comparison of intraluminal and extraluminal placement of the 9-French Arndt bronchial blocker in adult thoracic surgery patients.J Cardiothorac Vasc Anesth. 2017; 31: 1332-1337Abstract Full Text Full Text PDF Scopus (10) Google Scholar study was that participating fellows were trained on both techniques in the simulation laboratory prior to commencement of the study. Successful lung isolation is an advanced skill requiring additional training for proper identification of airway anatomy and recognition of correct device placement. Each provider was required to place 20 BBs (10 times with each technique) to ensure familiarity and reduce operator variance. This requisite training is important, as unrecognized issues with device positioning are a major contributor to failure to achieve isolation. A previous study by Campos et al demonstrated an overall incidence of device malpositioning of nearly 40% when placed by inexperienced providers.8Campos J.H. Hallam E.A. Van Natta T. et al.Devices for lung isolation used by anesthesiologists with limited thoracic experience: Comparison of double-lumen endotracheal tube, Univent torque control blocker, and Arndt wire-guided endobronchial blocker.Anesthesiology. 2006; 104: 261-266Crossref PubMed Scopus (155) Google Scholar Simulation has proven an effective tool in thoracic anesthesia in this regard. Both interactive airway simulator training and computer-based training have been shown to be efficacious in training novice providers on lung isolation techniques.9Campos J.H. Hallam E.A. Ueda K. Training in placement of the left-sided double-lumen tube among non-thoracic anaesthesiologists: Intubation model simulator versus computer-based digital video disc, a randomised controlled trial.Euro J Anaesth. 2011; 28: 169-174Crossref PubMed Scopus (22) Google Scholar In a follow-up study from Campos et al, the isolation failure rate was decreased to 23% compared to historic controls after simulation training.9Campos J.H. Hallam E.A. Ueda K. Training in placement of the left-sided double-lumen tube among non-thoracic anaesthesiologists: Intubation model simulator versus computer-based digital video disc, a randomised controlled trial.Euro J Anaesth. 2011; 28: 169-174Crossref PubMed Scopus (22) Google Scholar Lung isolation is a skill that requires practice not only to learn but also to maintain. In one study, comparable rates of successful lung isolation were found between expert and novice providers following simulation training; however, proficiency of novice providers decreased quickly and significantly without practice.10Latif R.K. VanHorne E.M. Kandadai S.K. et al.Teaching basic lung isolation skills on human anatomy simulator: Attainment and retention of lung isolation skills.BMC Anesthesiol. 2016; 16: 7Crossref PubMed Scopus (8) Google Scholar Other studies have shown that skills decay when not maintained actively, even for those proficient in a procedure.11Naik V.N. Matsumoto E.D. Houston P.L. et al.Fiberoptic orotracheal intubation on anesthetized patients: Do manipulation skills learned on a simple model transfer into the operating room?.Anesthesiol. 2001; 95: 343-348Crossref PubMed Scopus (151) Google Scholar There were several limitations to the current study. The sample size was small, based on a sample size estimate using 50% power as the basis of the estimate. In addition to the nonstandard power calculation, a more clinically relevant metric, such as quality of isolation, would perhaps be a more meaningful primary outcome. The authors evaluated both left- and right-sided devices but did not report outcome metrics by side of isolation. This may be significant, as right-sided BBs notoriously are more difficult to position correctly and maintain. We hope Templeton and colleagues5Templeton T.W. Morris B.N. Goenaga-Diaz E.J. et al.A prospective comparison of intraluminal and extraluminal placement of the 9-French Arndt bronchial blocker in adult thoracic surgery patients.J Cardiothorac Vasc Anesth. 2017; 31: 1332-1337Abstract Full Text Full Text PDF Scopus (10) Google Scholar will follow up on this initial pilot study with a subsequent study, specifically evaluating the impact of the side on outcome measures. Finally, while the secondary outcome of quality of isolation admittedly is subjective, the authors’ grading of isolation on a scale of 1-to-3 (complete, adequate, and inadequate isolation) was a reasonable approach. It is not clear from the manuscript, however, if the surgical team was blinded to placement technique. As the outward appearance of an extraluminal versus an intraluminal blocker would be quite different to a trained surgeon’s eye, it is possible that bias could be introduced by a surgical team that was aware of the technique employed. A recent survey of anesthesiologists revealed an overwhelming preference for DLT, with nearly two-thirds of respondents reporting rarely using a BB.12Shelley B. Macfie A. Kinsella J. Anesthesia for thoracic surgery: A survey of UK practice.J Cardiothorac Vasc Anesth. 2001; 25: 1014-1017Abstract Full Text Full Text PDF Scopus (64) Google Scholar Are the results of this study likely to change current practice patterns? It is unlikely that a time savings measured in minutes will be compelling enough to make routine extraluminal BB placement the technique of choice. That being said, we agree with the authors that there are certain clinical scenarios in which extraluminal placement may be advantageous. Pediatric patients who require an endotracheal tube of less than 5-mm internal diameter may benefit from the extraluminal placement of the BB. Another obvious scenario would be an already intubated patient who requires both lung isolation but also high levels of ventilatory support. Such a patient may not tolerate either an airway exchange to a DLT or an increase in resistance that accompanies intraluminal placement. The authors did not report on ventilatory parameters in the current study nor did they include patients undergoing lung isolation who arrived intubated to the operating room. Patients with difficult airways and obese patients additionally were excluded from the study. These are 2 patient populations, however, who may derive the most benefit from BB use.13Campos J.H. Lung isolation techniques for patients with difficult airway.Curr Opin Anaesthesiol. 2010; 23: 12-17Crossref PubMed Scopus (85) Google Scholar, 14Campos J.H. Ueda K. Lung separation in the morbidly obese patient.Anesthesiol Research and Practice. 2012; 2012: 207598Crossref PubMed Scopus (7) Google Scholar We hope, in future studies, that the authors will expand upon this work to include ventilatory metrics and other patient populations. In summary, while extraluminal BB placement certainly is not a new practice, this study was the first to compare it directly to the more commonly described intraluminal technique. The fact that the 2 approaches had comparable quality of lung isolation, with no increased risk in incidence or severity of sore throat (a purported benefit to intraluminal placement), lends legitimacy to the extraluminal technique. The clinical scenario frequently will dictate which device (DLT versus BB) or which technique (intraluminal versus extraluminal) is most appropriate. As with most things, routine practice to remain facile is critical to success. This is particularly true in emergency situations in which speed of isolation may affect clinical outcomes. Advances in simulation mean that practice need not always occur in the operating room but also may occur in the laboratory. No matter how the skillset is maintained, the extraluminal approach to BB placement is a technique that should be a part of every cardiothoracic anesthesiologist’s armamentarium.

LOWER EXTREMITY peripheral artery disease (PAD) is a common manifestation of atherosclerotic cardiovascular disease, estimated to affect approximately 8.5 million Americans older than age 40 and more than 200 million people worldwide. 1 Mozaffarian D. Benjamin E.J. Go A.S. et al. Heart disease and stroke statistics-2016 update: A report from the American Heart Association. Circulation. 2016; 133: e38-e360 Crossref PubMed Scopus (2328) Google Scholar PAD portends a poor prognosis both because of its detrimental effect on physical functioning and its association with atherosclerotic cardiovascular disease in other regions, namely the coronary, cerebrovascular, and renovascular systems. 2 Mohler 3rd, E. Giri J. Management of peripheral arterial disease patients: Comparing the ACC/AHA and TASC-II guidelines. Curr Med Res Opin. 2008; 24: 2509-2522 Crossref PubMed Scopus (35) Google Scholar , 3 Bhatt D.L. Steg P.G. Ohman E.M. et al. International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA. 2006; 295: 180-189 Crossref PubMed Scopus (1348) Google Scholar , 4 Criqui M.H. Langer R.D. Fronek A. et al. Mortality over a period of 10 years in patients with peripheral arterial disease. New Engl J Med. 1992; 326: 381-386 Crossref PubMed Scopus (2209) Google Scholar In the Reduction of Atherothrombosis for Continued Health registry, a large international registry of more than 65,000 patients spanning more than 40 countries across 6 major regions (Latin America, North America, Europe, Asia, the Middle East, and Australia), approximately 1 in 6 patients with atherosclerotic cardiovascular disease had evidence of symptomatic polyvascular disease, including the majority of patients with PAD. 3 Bhatt D.L. Steg P.G. Ohman E.M. et al. International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA. 2006; 295: 180-189 Crossref PubMed Scopus (1348) Google Scholar A 2008 meta-analysis of nearly 50,000 patients demonstrated that men diagnosed with PAD had a 3-fold risk of all-cause death compared with men without PAD, with a similar risk in women. 5 Fowkes F.G. Murray G.D. Butcher I. et al. Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: A meta-analysis. JAMA. 2008; 300: 197-208 Crossref PubMed Scopus (1417) Google Scholar Vorapaxar Package Insert. http://www.merck.com/product/usa/pi_circulars/z/zontivity/zontivity_pi.pdf Accessed 22 May 2017

Objective: Metabolic acidosis after deep hypothermic circulatory arrest (DHCA) for thoracic aortic operations is commonly managed with sodium bicarbonate (NaHCO 3 ). The purpose of this study was to determine the relationships between total NaHCO 3 dose and the severity of metabolic acidosis, duration of mechanical ventilation, duration of vasoactive infusions, and Intensive Care Unit (ICU) or hospital length of stay (LOS). Methods: In a single center, retrospective study, 87 consecutive elective thoracic aortic operations utilizing DHCA, were studied. Linear regression analysis was used to test for the relationships between the total NaHCO 3 dose administered through postoperative day 2, clinical variables, arterial blood gas values, and short-term clinical outcomes. Results: Seventy-five patients (86%) received NaHCO 3 . Total NaHCO 3 dose averaged 136 ± 112 mEq (range: 0.0-535 mEq) per patient. Total NaHCO 3 dose correlated with minimum pH (r = 0.41, P < 0.0001), minimum serum bicarbonate (r = −0.40, P < 0.001), maximum serum lactate (r = 0.46, P = 0.007), duration of metabolic acidosis (r = 0.33, P = 0.002), and maximum serum sodium concentrations (r = 0.29, P = 0.007). Postoperative hypernatremia was present in 67% of patients and peaked at 12 h following DHCA. Eight percent of patients had a serum sodium ≥ 150 mEq/L. Total NaHCO 3 dose did not correlate with anion gap, serum chloride, not the duration of mechanical ventilator support, vasoactive infusions, ICU or hospital LOS. Conclusion: Routine administration of NaHCO 3 was common for the management of metabolic acidosis after DHCA. Total dose of NaHCO 3 was a function of the severity and duration of metabolic acidosis. NaHCO 3 administration contributed to postoperative hypernatremia that was often severe. The total NaHCO 3 dose administered was unrelated to short-term clinical outcomes.

Objective: To determine the severity, duration, and contributing factors for metabolic acidosis after deep hypothermic circulatory arrest (DHCA).Design: Retrospective observational study.Setting: University hospital.Patients: Eighty-seven consecutive patients undergoing elective thoracic aortic surgery with DHCA.Interventions: Regression analysis was used to test for relationships between the severity of metabolic acidosis and clinical and laboratory variables.Measurements and Main Results: Minimum pH averaged 7.27 +/- 0.06, with 76 (87%) having a pH <7.35; 55 (63%), a pH <7.30; and 7 (8%), a pH < 7.20. The mean duration of metabolic acidosis was 7.9 +/- 5.0 hours (range: 0.0 - 26.8), and time to minimum pH after DHCA was 4.3 +/- 2.0 hours (1.0 - 10.0 hours). Hyperchloremia contributed to metabolic acidosis in 89% of patients. The severity of metabolic acidosis correlated with maximum lactate (p < 0.0001) and hospital length of stay (LOS) (r = 0.22, p < 0.05), but not with DHCA time, DHCA temperature, duration of vasoactive infusions, or ICU LOS. Patient BMI was the sole preoperative predictor of the severity of postoperative metabolic acidosis.Limitations: This retrospective analysis involved short-term clinical outcomes related to pH severity and duration, which indirectly may have included the impact of sodium bicarbonate administration.Conclusions: Metabolic acidosis was common and severe after DHCA and was attributed to both lactic and hyperchloremic acidosis. DHCA duration and temperature had little impact on the severity of metabolic acidosis. The severity of metabolic acidosis was best predicted by the BMI and had minimal effects on short-term outcomes. Preventing hyperchloremic acidosis has the potential to decrease the severity of metabolic acidosis after DHCA. (C) 2015 Elsevier Inc. All rights reserved.

BACKGROUND:Carotid endarterectomy (CEA) is effective in reducing stroke risk in selected patient groups. The ideal anesthetic technique remains controversial in light of literature between general anesthesia (GA) and regional anesthesia (RA) for CEA.METHODS:We studied the NSQIP data from 2005 to 2012. There were 32,718 patients receiving general anesthesia (GA) and 5,384 patients receiving regional anesthesia, local anesthesia, or monitored anesthesia care (RA). The outcome measurements of 30 days postoperative complications were death, stroke, coma, unplanned intubation, on ventilator > 48 hours, cardiac arrest, and myocardial infarction. We next studied NY-SID data from 2007 to 2011. There were 13,913 patients receiving GA and 3,145 patients receiving RA. The outcome measurements by discharge time were death, stroke, paraplegia, new neurological disorder, aspiration, respiratory failure, pulmonary resuscitation procedure (include intubation), cardiac arrest, cardiac resuscitation procedure, myocardial infarction, and congestive heart failure. All analyses were risk adjusted with propensity score matching algorithm.RESULTS:There were significant differences in incidences of un-expected intubation (1.21% vs. 0.55%, P=0.001), and myocardial infarction (0.80% vs. 0.35%, P=0.039) between GA and RA respectively in NSQIP data. GA group had significant higher incidences of aspiration (0.61% vs. 0.19%, P=0.014), and pulmonary resuscitation procedure (including intubation) (1.02% vs. 0.54%, P=0.044) than RA group in NY-SID data.CONCLUSIONS:In comparison to GA, patients receiving RA had significant lower risks of postoperative unplanned intubation and/or pulmonary resuscitation procedure after carotid endarterectomy.

Elkassabany, Nabil; Ahmed, Moustafa; Malkowicz, S. Bruce; Heitjan, Daniel F.; Isserman, Joshua A.; Ochroch, E. Andrew Author Information

OBJECTIVE:To re-evaluate the effects of adding a statin before surgery on mortality at 30 days and at 1 year and on major morbidity at 0-30 days.DESIGN:A meta-analysis of parallel, randomized, controlled trials published in English.SETTING:A university-based electronic search.PARTICIPANTS:Adult patients undergoing any type of procedure.INTERVENTION:Adding a statin before a procedure compared to a placebo or no intervention.MEASUREMENTS AND MAIN RESULTS:A search for all randomized controlled trials (RCT) was done in PubMed, Embase, Ovid MEDLINE and the Cochrane Central Register of Controlled Trials in November 2012. The quality of each study was assessed with the Cochrane Collaboration Tools. An I-square ≥ 25% was chosen as the cut-off point for heterogeneity exploration. The search produced 29 trials. Statins reduced the 0-30 days' risk of myocardial infarction: risk ratio (RR) 0.48 (95%CI 0.38, 0.61); I-square 13.2%; p<0.001; number needed-to-treat 17 (14, 24). There were no statistical differences at 0-30 days for stroke RR 0.70 (0.25, 1.95), acute renal insufficiency RR 0.54 (0.26, 1.12) or reoperation RR 1.10 (0.51, 2.38). There was a trend for a reduced mortality at 1 year RR 0.26 (0.06, 1.02); I-square 0%; p = 0.053. The hospital length of stay was slightly decreased with atorvastatin: standardized mean difference (SMD) -0.27 (-0.39, -0.14), p<0.001; fluvastatin SMD -0.95 (-1.56, -0.34), p = 0.002; and rosuvastatin SMD -0.69 (-0.98, -0.40), p<0.001 but not with simvastatin SMD -0.04 (-0.41, 0.48).CONCLUSIONS:Adding a statin before a high risk cardiac procedure reduces the 0-30 days' risk of myocardial infarction.

We thank Dr. Kanchi Muralidhar for his interest in our work and his valuable comments. Dr. Muralidhar mentioned concerns on our meta-analysis.1Guay J. Ochroch E.A. Continuing antiplatelet therapy before cardiac surgery with cardiopulmonary bypass: A meta-analysis on the need for re-exploration and major outcomes.J Cardiothorac Vasc Anesth. 2014; 28: 90-97Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar First, he underlined the fact that some of the included studies were published years ago and wondered if our conclusions apply to current practice. Indeed, the included studies were published between 1982 and 2007, and the overall rate of re-exploration of those included studies was 4.3%. However, as clearly stipulated in our article, we calculated the number needed to treat based on the odds ratio and a basal rate of 2.4% as found in a recent publication.2Mehta R.H. Sheng S. O’Brien S.M. et al.Society of Thoracic Surgeons National Cardiac Surgery Database Investigators. Reoperation for bleeding in patients undergoing coronary artery bypass surgery: Incidence, risk factors, time trends, and outcomes.Circ Cardiovasc Qual Outcomes. 2009; 2: 583-590Crossref PubMed Scopus (154) Google Scholar We therefore think that our estimate should reflect current practice even if the studies included in our meta-analysis are older. Second, Dr. Muralidhar also mentioned that the regimen of antiplatelet drugs used in the included studies varied from 1 study to another. Once again, as clearly stipulated in our article, the I-square value on re-exploration, death at 30 days, and myocardial infarction was 0%, suggesting that the effect sizes for these 3 outcomes did not vary from 1 study to another more than what is expected from chance alone, and, therefore, that the risk was not influenced by the type of antiplatelet drug used or the number of antiplatelet drugs administered within the range of the drugs and doses used in the studies included in this analysis. Finally, Dr. Muralidhar is disappointed that we did not provide results on all the factors that can possibly influence bleeding in patients undergoing surgery with or without cardiopulmonary bypass or noncardiac surgery. Well, these objectives were not part of the main and secondary objectives of our study. We thank Dr. Kanchi Muralidhar for his interest in our work and his valuable comments. Dr. Muralidhar mentioned concerns on our meta-analysis.1Guay J. Ochroch E.A. Continuing antiplatelet therapy before cardiac surgery with cardiopulmonary bypass: A meta-analysis on the need for re-exploration and major outcomes.J Cardiothorac Vasc Anesth. 2014; 28: 90-97Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar First, he underlined the fact that some of the included studies were published years ago and wondered if our conclusions apply to current practice. Indeed, the included studies were published between 1982 and 2007, and the overall rate of re-exploration of those included studies was 4.3%. However, as clearly stipulated in our article, we calculated the number needed to treat based on the odds ratio and a basal rate of 2.4% as found in a recent publication.2Mehta R.H. Sheng S. O’Brien S.M. et al.Society of Thoracic Surgeons National Cardiac Surgery Database Investigators. Reoperation for bleeding in patients undergoing coronary artery bypass surgery: Incidence, risk factors, time trends, and outcomes.Circ Cardiovasc Qual Outcomes. 2009; 2: 583-590Crossref PubMed Scopus (154) Google Scholar We therefore think that our estimate should reflect current practice even if the studies included in our meta-analysis are older. Second, Dr. Muralidhar also mentioned that the regimen of antiplatelet drugs used in the included studies varied from 1 study to another. Once again, as clearly stipulated in our article, the I-square value on re-exploration, death at 30 days, and myocardial infarction was 0%, suggesting that the effect sizes for these 3 outcomes did not vary from 1 study to another more than what is expected from chance alone, and, therefore, that the risk was not influenced by the type of antiplatelet drug used or the number of antiplatelet drugs administered within the range of the drugs and doses used in the studies included in this analysis. Finally, Dr. Muralidhar is disappointed that we did not provide results on all the factors that can possibly influence bleeding in patients undergoing surgery with or without cardiopulmonary bypass or noncardiac surgery. Well, these objectives were not part of the main and secondary objectives of our study.

Study Objective: To evaluate the effect of steroid administration on myocardial infarction (MI), stroke, renal insufficiency, death, intensive care (ICU) length of stay (LOS) and hospital LOS of patients undergoing cardiopulmonary bypass (CPB).Design: Meta-analysis of parallel randomized controlled trials.Setting: University hospital.Meaurements: A search was conducted in PubMed, EMBASE, MEDLINE(R) and the Cochrane Central Register of Controlled Trials of studies on adults undergoing surgery with CPB who received steroid administration. Effect size (risk ratio or mean difference) for MI, stroke, renal insufficiency, death, ICU LOS, and hospital LOS were evaluated.Main Results: 48 RCTs published between 1977 and 2012 were retained for analysis. Steroids had no effect on the MI risk ratio (RR) 0.91(95% confidence interval [CI] 0.63, 1.32); death at 30 days RR 0.84 (0.59, 1.20); stroke RR 0.92 (0.60, 1.42) or renal insufficiency RR 0.83 (0.52, 1.32) Administration of steroids reduced ICU LOS (P = 0.00001; I-2 87.5%) and hospital LOS (P = 0.03; I-2 81.1%). Metaregressions showed that duration of steroid administration was correlated with the reduction in ICU LOS (P = 0.0004) and hospital LOS (P < 0.00001).Conclusions: Increasing the duration of steroid administration may reduce ICU and hospital LOS greater than increasing the dose. (c) 2014 Elsevier Inc. All rights reserved.

6. Bolsin S, Colson M, Conroy M: s-blockers and statins in noncardiac surgery. BMJ 334(7607):1283-1284, 2007 7. Bolsin SN, Colson M, Marsiglio A: Perioperative beta-blockade. BMJ 347:9, 2013 8. Dunkelgrun M, Boersma E, Schouten O, et al: Bisoprolol and fluvastatin for the reduction of perioperative cardiac mortality and myocardial infarction in intermediate-risk patients undergoing noncardiovascular surgery: A randomized controlled trial (DECREASE-IV). Ann Surg 249(6):921-926, doi:http://dx.doi.org/10.1097/SLA.0b013e 3181a77d00, 2009 9. Poldermans D, Boersma E, Bax JJ, et al: The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. N Engl J Med 341(24):1789-1794, 1999 10. Bouri S, Shun-Shin MJ, Cole GD, et al: Meta-analysis of secure randomised controlled trials of β-blockade to prevent perioperative death in non-cardiac surgery. Heart http://dx.doi.org/10.1136/heartjnl2013-304262, Jul 31, 2013

To determine major adverse outcomes, including the risk of mediastinal reexploration, death, stroke and myocardial infarction, associated with continuing antiplatelet therapy in patients undergoing surgery with cardiopulmonary bypass.A meta-analysis of parallel randomized, controlled trials published in English.A university-based electronic search.Patients undergoing surgery with cardiopulmonary bypass (CPB).Continuing antiplatelet therapy versus stopping antiplatelet therapy before the surgery.A search was conducted in PubMed, EMBASE, MEDLINE(R), and the Cochrane Central Register of Controlled Trials. Twelve studies were retained for analysis. Continuing antiplatelet drugs for CPB increases the rate of reexploration by a standardized mean difference (SMD) 0.22, 95% confidence interval (CI) 0.06, 0.39; I-square 0%; p value 0.01; classical fail-safe number 5. The number needed to harm (NNTH) is 87 (95% CI 390, 44). There was no statistical difference for death at 30 days and 1 year, myocardial infarction at 30 days, and stroke at 30 days. Continuing antiplatelet drugs increases blood loss, SMD 0.27 (95% CI 0.09, 0.45), I-square 73.1%; p = 0.003.Continuing antiplatelet therapy for patients undergoing surgery with CPB is associated with a low risk for reexploration.

Postoperative nausea and vomiting is a major cause of patient dissatisfaction towards surgery. For bariatric surgery, increased vomiting/retching is detrimental to surgical anastomosis. The present study evaluated the efficacy of aprepitant (neurokinin-1 inhibitor) as a prophylactic antiemetic in morbidly obese patients for laparoscopic bariatric surgery.

BACKGROUND Early extubation in select cardiac surgery patients reduces tracheal intubation times, intensive care unit length of stay, and hospital length of stay. While there is good evidence in the literature to support early extubation, there is very little published research that describes how to study and redesign processes of care to increase early extubation rates. OBJECTIVE To improve rates of early extubation by redesigning patient care processes using Lean principles to remove barriers to desired care and facilitate early extubation with guideline management. DESIGN Retrospective data analysis. SETTING Sixteen-bed intensive care unit in a mid-sized, academic community hospital. PATIENTS Four hundred four patients undergoing coronary artery bypass graft surgery, aortic valve replacement, or mitral valve replacement/repair. INTERVENTION The process of care for cardiac surgery patients, beginning with the immediate preoperative period and ending with extubation in the postoperative period, was analyzed using Lean methodologies. A value stream analysis was performed to identify waste in the process, and root causes for the largest sources of waste were identified. Hypothermia on admission to the intensive care unit, prolonged weaning using arterial blood gas results, hypertension management with pain medications and sedation medications, and delays in obtaining equipment were the primary reasons early extubation was delayed. Process redesign using Lean work design principles was implemented to eliminate these issues. MEASUREMENTS The rate of patients being extubated in fewer than 6 hours and length of intubation. RESULTS One hundred ninety-five pre-intervention subjects were compared with 171 post-intervention subjects. The pre- and post- groups did not differ in demographic predictors (Table 1). The intervention predicted extubation in<6 hours (pre-intervention 27% versus post-intervention 50%, p = 0.0001). Age, renal failure, and gender also predicted whether intubation occurred within 6 hours. The median length of intubation was lower post-intervention (pre-intervention 9.7 v post-intervention 6.1 hours, p = 0.0019) LIMITATIONS: The effect of this nonrandomized intervention could be due to other factors associated with a different care epoch. CONCLUSIONS The closely planned, coordinated, and integrated care paradigm dramatically increased the likelihood of extubation within 6 hours of arrival in the SICU.

OBJECTIVE:To evaluate the accuracy of Doppler-derived transmitral valve gradients immediately after mitral valve repair by comparing them with near simultaneously obtained direct catheter gradients.DESIGN:A prospective study.SETTING:A tertiary care medical center.PARTICIPANTS:Twenty elective adult surgical patients presenting for mitral valve repair surgery.METHODS:Mitral valve surgery proceeded in standard fashion except for the use of a smaller than usual left ventricular vent catheter (Medtronic DLP 10 French left heart vent catheter). After completion of the mitral valve repair and subsequent cardiac de-airing, the patient was weaned from cardiopulmonary bypass. Immediately after separation, the study period began. Near simultaneous transmitral Doppler gradients were obtained with directly measured catheter gradients via the vent catheter.RESULTS:While the mean peak gradient difference of 1.1 mmHg was small (p-value 0.18, 95% CI: -0.54 to 2.73 mmHg), the correlation between Doppler and catheter gradient measurements (Pearson correlation coefficient r = 0.54, p = 0.055) only approached statistical significance due to the large variance associated with the small sample size. In all patients with a peak gradient greater than 10 mmHg (4 of the 20 patients), overestimation of catheter gradients by Doppler occurred, with two showing a 62% to 73% discrepancy. In these two cases, there was also evidence for elevated left ventricular end-diastolic pressure (LVEDP) along with high transmitral blood flow velocities.CONCLUSION:Doppler-derived transmitral gradients provide a simple, safe, and reliable measure of the true physiologic transmitral valve gradient. At the same time, it is important to recognize that significant Doppler over-estimation of catheter gradients may occur in patients with elevated Doppler transmitral velocities. The causes of these overestimations are unknown. They may be related to technical recording errors. They may also be related to an inherent weakness in Doppler technology--its inability to account for any distal recovery of pressure, which in a select group of patients could be significant.