Cardiothoracic operating room blood gas workflow performance improvement initiative

OBJECTIVES

To evaluate the current workflow of blood gas ordering and testing in a cardiothoracic operating room to identify opportunities to streamline the process, using performance improvement methodologies.

METHODS

Issues with specimen relabeling were identified that lead to delayed results and potential patient safety concerns. Blood gas specimen relabeling was evaluated for operating room cases from August 2018 to December 2022. An OpTime Epic Sidebar button for arterial blood gas and venous blood gas orders was created in January 2019 to streamline the ordering process so that laboratory barcode labels were then printed in the operating room and attached to the specimen, eliminating the need for relabeling by the technologists.

RESULTS

This Epic Sidebar intervention led to a drastic improvement of appropriate labeling, which has been sustained. From March 2019 to January 2023, with our new workflow, over 95% of blood gas specimens arrived barcode labeled compared to less than 1% in the preintervention era.

CONCLUSIONS

A multidisciplinary team with key stakeholders is important to address complex care issues. Performance improvement methodology is critical to develop interventions that hardwire the process. This intervention led to a sustained reduction in secondary relabeling of patient samples and improved timeliness of reporting of blood gas results.

Methemoglobin as a marker of acute anemic stress in cardiac surgery

Biological evidence supports plasma methemoglobin as a biomarker for anemia-induced tissue hypoxia. In this translational planned substudy of the multinational randomized controlled transfusion thresholds in cardiac surgery (TRICS-III) trial, which included adults undergoing cardiac surgery requiring cardiopulmonary bypass with a moderate-to-high risk of death, we investigated the relationship between perioperative hemoglobin concentration (Hb) and methemoglobin; and evaluated its association with postoperative outcomes. The primary endpoint was a composite of death, myocardial infarction, stroke, and severe acute kidney injury at 28 days. We observe weak non-linear associations between decreasing Hb and increasing methemoglobin, which were strongest in magnitude at the post-surgical time point. Increased levels of post-surgical methemoglobin were associated with a trend toward an elevated risk for stroke and exploratory neurological outcomes. Our generalizable study demonstrates post-surgical methemoglobin may be a marker of anemia-induced organ injury/dysfunction, and may have utility for guiding personalized approaches to anemia management. Clinicaltrials.gov registration NCT02042898.

A Comparison of Inflammatory Responses Between Robotically Enhanced Coronary Artery Bypass Grafting and Conventional Coronary Artery Bypass Grafting: Implications for Hybrid Revascularization

OBJECTIVE

The inflammatory response elicited by robotically enhanced coronary artery bypass grafting (r-CABG) has not been well described. When r-CABG is performed as part of hybrid coronary revascularization, the inflammatory milieu and the timing of percutaneous coronary intervention may affect the stent patency negatively in the short and long term. The goal of this study was to describe the extent and time course of cytokine release after r-CABG compared with conventional CABG (c-CABG) and to elucidate the optimal timing for r-CABG in the setting of hybrid coronary revascularization for a future study.

DESIGN

Prospective, observational study.

SETTING

Tertiary-care center in a university hospital.

PARTICIPANTS

The study comprised patients scheduled to undergo r-CABG or c-CABG from October 2012 to November 2014.

INTERVENTIONS

Cytokine levels of interleukin (IL)-6, IL-8, IL-10; tumor necrosis factor-α; and C-reactive protein (CRP) were measured at the following time points: preprocedure; at the end of the procedure; and at 4, 8, 12, 24, and 48 hours after the procedure.

MEASUREMENTS AND MAIN RESULTS

Twenty-eight patients undergoing r-CABG and 10 patients undergoing c-CABG were enrolled. The levels of cytokines after r-CABG and c-CABG were compared using the mixed-effect linear regression model for longitudinal data. Cytokine release in the r-CABG group was comparatively less for IL-6, IL-10, tumor necrosis factor, and CRP levels. They all trended toward the baseline by the 48th hour in both groups, except CRP levels, which reached their peak at 48 hours in both groups.

CONCLUSIONS

The inflammatory response to r-CABG was blunted compared with that of c-CABG. The high CRP levels on the second postoperative day after r-CABG were a cause for concern in regard to percutaneous coronary intervention performed at that time period, but additional studies are necessary.

HeartWare Ventricular Assist Device Placement in a Patient With Corrected Dextro-Transposition of Great Arteries: A Case Report and Its Clinical Challenges

Given the improved survival in patients with corrected dextro-transposition of great arteries (D-TGA), it has evolved into an adult congenital heart defect. It is important to understand the management and complications observed in this population that eventually progresses to systemic ventricular failure requiring cardiac transplantation. Our case focuses on the rapid right ventricle (RV) deterioration of a patient with corrected D-TGA following a surgical procedure requiring systemic support. With such patients awaiting heart transplantation, there are limited assist devices available for RV support and no right ventricular assist device is approved for destination therapy yet. Current indications for implantation of the HeartWare ventricular assist device (HVAD) are limited by the Food and Drug Administration (FDA) to the left ventricle support as a bridge to transplantation. However, its use in the United States for right-sided support has rarely been described for adult congenital defects. In this case, a HeartWare assist device was used to provide systemic support as a bridge to cardiac transplant. The size and implantation design of the HVAD makes it a promising option for patients with this challenging patient population and RV failure as a late complication.

Intraoperative epicardial ultrasound probe for visualization of embedded coronary arteries: a novel approach

The identification of coronary anatomy at the time of cardiac revascularization can be problematic. Preoperative studies (ie, coronary angiography) can aid in the mapping of the coronary anatomy. However, there remain a select few patients with intramyocardial coronaries that provide challenges for surgical dissection during revascularization. Probing the visible portion of the coronary artery, intraoperative cine angiography, thermal angiography, and epicardial Doppler probes have been used to identify the coronary anatomy intraoperatively. Aggressive surgical maneuvers can result in damage and increased time on cardiopulmonary bypass. Previous studies have used epicardial echocardiography on patients undergoing off-pump coronary artery bypass grafting. We report 2 cases in patients undergoing cardiac revascularization on cardiopulmonary bypass where the use of a high-frequency epicardial ultrasound probe facilitated the identification of the embedded coronary arteries. We describe a technique of using antegrade and retrograde cardioplegia administration sequentially to locate the coronary arteries. Easy availability and familiar technology make the epicardial Doppler probe an attractive tool for the identification of embedded coronary arteries.

A case of difficulty predicting neurological deficit during thoracoabdominal aortic surgery

Perioperative spinal cord injury associated with thoracoabdominal aorta (TAAA) surgery is a devastating complication. With variable results, the intraoperative use of neurophysiologic monitoring has been employed for the diagnosis and prevention of spinal cord ischemia. We present a case report of a patient undergoing TAAA surgery with the use of evoked potential monitoring. Intraoperatively, both sensory and motor evoked potentials were utilized and consequently the patient experienced changes in monitoring consistent with a new neurologic deficit. However, postoperatively these changes in evoked potentials never manifested in neurologic injury. We examine the utility of neurophysiologic monitoring as it pertains to TAAA surgery.

Left Ventricular Assist Devices: An Evolving State of the Art

Heart failure is a disease of increasing prevalence around the world. The treatment options for patients suffering from this ailment range from pharmacologic to surgical. Heart failure, however, continues to harbor a dismal prognosis despite conventional treatments. The high mortality rate among this patient population has spawned interest in alternative therapies. Mechanical circulatory support has emerged as a treatment option for patients with refractory heart failure. Over the past years a number of studies have highlighted the effectiveness of left ventricular assist devices (LVAD’s) in improving patient’s outcomes. The technologies that support these devices have evolved and provide new opportunities to manage patients suffering from this debilitating disease. Heart transplantation continues to generate the most reproducible survival benefit to patients with advanced heart failure, but is limited by a lack of donors. It is therefore the goal of mechanical assist therapy to improve patient survival and quality of life in heart failure in light of the limitations of heart transplantation. In this article we examine the evolving utility of LVAD’s in the treatment of heart failure.