1
|
Lenn D, Le DT, Scheiber CJ, Smeltz AM. The Perfect Med Bag is One that Doesn't Fall Off a Cliff: A Combat Mass Casualty Case. Mil Med 2024; 189:e948-e953. [PMID: 37975228 DOI: 10.1093/milmed/usad444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/19/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023] Open
Abstract
Military trauma provides a unique pattern of injuries due to the high velocity, high kinetic energy ammunition utilized, and the high prevalence of blast injury. To further complicate this, military trauma often occurs in austere environments with limited logistical support. Therefore, military medical providers are forced to learn nonstandard techniques and when necessary, practice a level of improvisation not commonly seen in other medical fields. The case presented in this manuscript is a prime example of these challenges. At the onset of fighting both the medic's rucksack, carrying with it the primary source of medical gear and the precious supply of cold-stored blood products are lost. The scenario was further complicated by rough mountainous terrain and a prolonged evacuation time. The medical provider was forced to utilize nonstandard devices such as an improvised junctional tourniquet which used a rock to focus the devices pressure. They also adapted their basic understanding of surgical procedures to conduct a vascular cutdown procedure for wound exposure and effectively pack an otherwise non-compressible wound to a major artery. Despite a significant loss of equipment, the medic and their team were able to successfully care for a number of patients in this mass casualty scenario.
Collapse
Affiliation(s)
- David Lenn
- SCPO (USN), 2d Marine Raider Battalion, Marine Forces Special Operations Command (MARSOC), Camp Lejeune, NC 28547, USA
| | - Daniel T Le
- ENS (USNR), University of North Carolina School of Medicine, Bondurant Hall, CB #9500, Chapel Hill, NC 27599, USA
| | - Christopher J Scheiber
- Department of Anesthesiology, N2198, CB7010, The University of North Carolina at Chapel Hill, UNC Hospitals, Chapel Hill, NC 27599-7010, USA
| | - Alan M Smeltz
- Cardiothoracic Division, Department of Anesthesiology, N2198, CB7010, The University of North Carolina at Chapel Hill, UNC Hospitals, Chapel Hill, NC 27599-7010, USA
| |
Collapse
|
2
|
Smeltz AM, Wicker AB, Belliston-Fowkes DJ, Tran LN, Smith EJ, An X, Lin BI, Teeter EG. Relationship Between Computed Tomography-Derived Left Bronchial Diameter and Double- Lumen Endotracheal Tube Size Selection. J Cardiothorac Vasc Anesth 2024; 38:1286-1287. [PMID: 38458827 DOI: 10.1053/j.jvca.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/08/2024] [Accepted: 02/12/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Alan M Smeltz
- University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Ashley B Wicker
- University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Linh N Tran
- University of North Carolina School of Medicine, Chapel Hill, NC
| | - Emmaline J Smith
- University of North Carolina School of Medicine, Chapel Hill, NC
| | - Xinming An
- University of North Carolina School of Medicine, Chapel Hill, NC
| | - Bridget I Lin
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC
| | - Emily G Teeter
- University of North Carolina School of Medicine, Chapel Hill, NC
| |
Collapse
|
3
|
Serrano RA, Smeltz AM. The Promise of Artificial Intelligence-Assisted Point-of-Care Ultrasonography in Perioperative Care. J Cardiothorac Vasc Anesth 2024; 38:1244-1250. [PMID: 38402063 DOI: 10.1053/j.jvca.2024.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/29/2024] [Indexed: 02/26/2024]
Abstract
The role of point-of-care ultrasonography in the perioperative setting has expanded rapidly over recent years. Revolutionizing this technology further is integrating artificial intelligence to assist clinicians in optimizing images, identifying anomalies, performing automated measurements and calculations, and facilitating diagnoses. Artificial intelligence can increase point-of-care ultrasonography efficiency and accuracy, making it an even more valuable point-of-care tool. Given this topic's importance and ever-changing landscape, this review discusses the latest trends to serve as an introduction and update in this area.
Collapse
Affiliation(s)
| | - Alan M Smeltz
- University of North Carolina School of Medicine, Chapel Hill, NC
| |
Collapse
|
4
|
Smeltz AM, Patel DS, Williams JH. The influence of needleless connectors and inserted catheters on flow rates through vascular introducer sheaths. Anaesth Intensive Care 2024; 52:180-183. [PMID: 38649298 DOI: 10.1177/0310057x241226715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
SummaryA vascular introducer sheath is often used for rapid volume replacement. However, common manipulations such as the addition of needleless connectors to infusion ports and the insertion of catheters or other devices through the introducer sheath may impede flow. In this study we utilised a rapid infuser to deliver room-temperature normal saline through two introducer sheath configurations with and without the addition of needleless connectors and the placement of catheters through the introducer sheaths. The maximal flow rate delivered by the rapid infuser was 1000 mL/min, which was observed with both introducer sheath sizes tested without additional resistive elements. However, with the addition of a needleless connector, flow rates through the introducer sheaths were substantially lower (64 (standard deviation (SD) 6) mL/min and 61 (SD 7) mL/min for the 8.5 Fr and 9 Fr introducers, respectively). Flow rates were also reduced when catheters were placed within the sheaths (298 (SD 9) mL/min with the 7 Fr catheter and 74 (SD 9) mL/min with the 8 Fr catheter placed in an 8.5 Fr sheath; 649 (SD 6) mL/min with the 7 Fr catheter and 356 (SD 14) mL/min with the 8 Fr catheter placed in the 9 Fr sheath). These findings indicated that both needleless connectors and the placement of catheters through vascular introducer sheaths substantially reduced potential flow rates. Even 'large' vascular introducer sheaths capable of delivering high flow rates could be rendered minimally effective for rapid fluid administration when used in this way. Clinicians should consider these impediments to flow when rapid fluid administration is required, and obtain alternative vascular access if necessary.
Collapse
Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Dillon S Patel
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - James H Williams
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
5
|
Scheiber CJ, Teeter EG, Smeltz AM. An Intracardiac Shunt in a Patient Undergoing Left Ventricular Assist Device Implantation. J Cardiothorac Vasc Anesth 2024; 38:1260-1264. [PMID: 38246824 DOI: 10.1053/j.jvca.2023.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Christopher J Scheiber
- University of North Carolina at Chapel Hill, Department of Anesthesiology, Chapel Hill, NC
| | - Emily G Teeter
- University of North Carolina at Chapel Hill, Department of Anesthesiology, Chapel Hill, NC
| | - Alan M Smeltz
- University of North Carolina at Chapel Hill, Department of Anesthesiology, Chapel Hill, NC.
| |
Collapse
|
6
|
Smeltz AM. Not Even a Whisper: On Losing One's Voice. Anesth Analg 2024:00000539-990000000-00786. [PMID: 38451869 DOI: 10.1213/ane.0000000000006818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Affiliation(s)
- Alan M Smeltz
- From the Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|
7
|
Bhatia M, Scheiber CJ, Arora S, Gustafson C, Funk I, Grosshuesch C, Simmers C, Li Q, Liu Y, Smeltz AM. Should All Patients With Pulmonary Hypertension Undergoing Non-Cardiac Surgery Be Managed by Cardiothoracic Fellowship-Trained Anesthesiologists? Semin Cardiothorac Vasc Anesth 2023; 27:305-312. [PMID: 37724522 PMCID: PMC10676614 DOI: 10.1177/10892532231203128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
OBJECTIVES To identify differences in practice patterns and outcomes related to the induction of general anesthesia for patients with pulmonary hypertension (PH) performed by anesthesiologists who have completed a cardiothoracic fellowship (CTA group) vs those who have not (non-CTA group). DESIGN Retrospective study with propensity score matching. SETTING Operating room. PARTICIPANTS All adult patients with PH undergoing general anesthesia requiring intubation at a single academic center over 5 years. INTERVENTIONS Patient baseline characteristics, peri-induction management variables, post-induction mean arterial pressure (MAP), and other outcomes were compared between CTA and non-CTA groups. METHODS AND MAIN RESULTS Following propensity scoring matching, 402 patients were included in the final model, 100 in the CTA group and 302 in the non-CTA group. Also following matching, only cases of mild to moderate PH without right ventricular dysfunction remained in the analysis. Matched groups were overall statistically similar with respect to baseline characteristics; however, there was a greater incidence of higher ASA class (P = .025) and cardiology and thoracic procedures (P < .001) being managed by the CTA group. No statistical differences were identified in practice patterns or outcomes related to the induction of anesthesia between groups, except for longer hospital length of stay in the CTA group (P = .008). CONCLUSIONS These results provide early evidence to suggest the induction of general anesthesia of patients with non-severe PH disease can be comparably managed by either anesthesiologists with or without a cardiothoracic fellowship. However, these findings should be confirmed in a prospective study.
Collapse
Affiliation(s)
- Meena Bhatia
- Department of Anesthesiology, School of Medicine, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Christopher J. Scheiber
- Department of Anesthesiology, School of Medicine, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Simrat Arora
- Department of Anesthesiology, School of Medicine, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Chelsea Gustafson
- Department of Anesthesiology, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Ian Funk
- Department of Anesthesiology, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Craig Grosshuesch
- Department of Anesthesiology, School of Medicine, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Carter Simmers
- Department of Anesthesiology, School of Medicine, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Quefeng Li
- Department of Biostatistics, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Yutong Liu
- Department of Biostatistics, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Alan M. Smeltz
- Department of Anesthesiology, School of Medicine, University of North Carolina Hospitals, Chapel Hill, NC, USA
| |
Collapse
|
8
|
Smeltz AM, Farber MA, Parodi FE, An X, Kirsch RJ, Hipp JS, Kumar PA, Arora H. Comparison of Landmark-Guided Versus Fluoroscopy-Guided Cerebrospinal Fluid Drain-Related Complications After Aortic Repairs. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00358-0. [PMID: 37328307 DOI: 10.1053/j.jvca.2023.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/23/2023] [Accepted: 05/30/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE Cerebrospinal fluid drains (CSFDs) are efficacious in preventing spinal cord injury after thoracic or thoracoabdominal aortic repair with extensive coverage. Increasingly, fluoroscopy is used to guide placement instead of the traditional landmark-based approach, but it is unknown which approach is associated with fewer complications. DESIGN A retrospective cohort study. SETTING In the operating room. PARTICIPANTS Patients having undergone thoracic or thoracoabdominal aortic repair with a CSFD over a 7-year period at a single center. INTERVENTIONS No intervention. MEASUREMENTS AND MAIN RESULTS Groups were reviewed and statistically compared with respect to baseline characteristics, ease of CSFD placement, and major and minor complications directly related to placement. A total of 150 CSFDs were placed with landmark guidance as opposed to 95 with fluoroscopy guidance. Compared to the landmark group, patients with fluoroscopy-guided CSFDs were older (p < 0.008), had lower American Society of Anesthesiologists physical status scores (p = 0.008), required fewer CSFD placement attempts (p = 0.011), had the CSFD in place for longer duration (p < 0.001), and had a similar incidence of CSFD-related complications (p > 0.999). Composites of both major (4.5% of cases) and minor CSFD-related complications (6.1% of cases), the primary outcomes of the study, occurred with similar incidences between the 2 groups (p > 0.999 for both comparisons) after adjusting potential confounders. CONCLUSIONS In patients undergoing thoracic or thoracoabdominal aortic repairs, there were no significant differences in the risk of major and minor CSFD-related complications between fluoroscopic guidance and the landmark approach. Although the authors' institution is a high-volume center for this type of procedure, the study was limited by a small sample size. Hence, regardless of the technique used for the placement of CSFD, the risks related to the placement should be balanced carefully against the potential benefits resulting from spinal cord injury prevention. Fluoroscopy-aided insertion of CSFD requires fewer attempts and, hence, may be better tolerated by patients.
Collapse
Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Mark A Farber
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - F Ezequiel Parodi
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Xinming An
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Rachel J Kirsch
- Department of Anesthesiology, University of California, San Francisco, CA
| | - John S Hipp
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| | - Harendra Arora
- Outcomes Research Consortium, Cleveland, OH; Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS
| |
Collapse
|
9
|
Smeltz AM, Commander CW, Arora H. Pro: Fluoroscopic Guidance Should Be Routinely Used to Place Cerebrospinal Fluid Drains for Patients Undergoing Aortic Surgery. J Cardiothorac Vasc Anesth 2023; 37:179-182. [PMID: 36273944 DOI: 10.1053/j.jvca.2022.09.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/24/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Clayton W Commander
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Harendra Arora
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| |
Collapse
|
10
|
Bhatia M, Smeltz AM, Desai CS, Arora H, Kumar PA. Treatment of type B lactic acidosis with N-acetylcysteine and levocarnitine. Anaesth Intensive Care 2023; 51:75-78. [PMID: 36373414 DOI: 10.1177/0310057x221105300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Meena Bhatia
- Department of Anesthesiology, University of North Carolina, Chapel Hill, USA
| | - Alan M Smeltz
- Department of Anesthesiology, University of North Carolina, Chapel Hill, USA
| | - Chirag S Desai
- Department of Surgery, University of North Carolina, Chapel Hill, USA
| | - Harendra Arora
- Department of Anesthesiology, University of North Carolina, Chapel Hill, USA.,Outcomes Research Consortium, Cleveland, USA
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina, Chapel Hill, USA.,Outcomes Research Consortium, Cleveland, USA
| |
Collapse
|
11
|
Arora H, Encarnacion JA, Li Q, Liu Y, Kumar PA, Smeltz AM. Hypothermia and Prolonged Time From Procedure End to Extubation After Endovascular Thoracic Aortic Surgery. J Cardiothorac Vasc Anesth 2022; 36:4320-4326. [PMID: 36216686 DOI: 10.1053/j.jvca.2022.09.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/23/2022] [Accepted: 09/06/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Perioperative hypothermia (core temperature <36°C) occurs in 50%-to-80% of patients recovering from thoracic aortic surgery, though its effects have not been described fully in this context. The authors, therefore, sought to characterize the incidence of perioperative hypothermia and its association with time from procedure end to extubation in endovascular aortic surgical patients. DESIGN A retrospective cohort study. SETTING At a single academic tertiary center. PARTICIPANTS Patients recovering from thoracic aortic surgery with lumbar drains. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS A total of 196 patients were included in this study, 55 of whom were hypothermic with temperatures <35.0°C at the end of surgery. Though the unadjusted time to extubation was not statistically different in the hypothermic group (median 8 minutes, IQR 5-13.5 minutes) compared to the normothermic group (median 7 minutes, IQR 4-12 minutes; p = 0.062), multivariate predictors of increased time from procedure end to extubation included hypothermia (p = 0.011), age (p = 0.009), diabetes (p = 0.015), history of carotid disease (p = 0.040), and crystalloid volume (p = 0.019). CONCLUSIONS Hypothermia in patients recovering from endovascular aortic surgery was associated with prolonged time from procedure end to extubation. Because of the retrospective observational nature of the authors' analysis, it was not possible to determine the extent to which prolonged mechanical ventilation was influenced by low temperature.
Collapse
Affiliation(s)
- Harendra Arora
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| | - John A Encarnacion
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Quefeng Li
- Department of Biostatistics, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC
| | - Yutong Liu
- Department of Biostatistics, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| | - Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| |
Collapse
|
12
|
Smeltz AM, Merlo A, Ikonomidis JS, Vavalle JP, Kolarczyk LM. Paravalvular Leak Immediately Following Repeat Mitral Valve Replacement: Considerations for Repair in a High-Risk Patient. J Cardiothorac Vasc Anesth 2022; 36:3945-3954. [DOI: 10.1053/j.jvca.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 11/11/2022]
|
13
|
Smeltz AM, Coleman P, Mondal S. TEMPORARY REMOVAL: Pro – Acute normovolemic hemodilution (ANH) should be used in infective endocarditis (IE) patients coming for primary or redo cardiac surgery. J Cardiothorac Vasc Anesth 2022; 36:2811-2814. [DOI: 10.1053/j.jvca.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/10/2022] [Indexed: 01/28/2023]
|
14
|
Gray L, Chen F, Teeter EG, Kolarczyk LM, Smeltz AM. Evaluation of the Simpson’s Method to Determine Left Ventricular Ejection Fraction Using the Transgastric Two-Chamber View. Semin Cardiothorac Vasc Anesth 2022; 26:195-199. [DOI: 10.1177/10892532211073240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Left ventricular chamber size and functional assessment by transesophageal echocardiography can be difficult if visualization is poor in the mid-esophageal views. However, the accuracy of using the Simpson’s method in the transgastric 2-chamber (TG2C) as an alternative approach has not been assessed. Methods The Simpson’s method was performed by 2 independent reviewers using midesophageal 2-chamber (ME2C) and TG2C views. Echocardiographic images were retrieved retrospectively for 49 adult cardiac surgical patients. Results Two-way random effects intraclass correlation coefficients demonstrated no significant interobserver variability. Linear mixed effects models showed no significant differences in ME2C and TG2C measurements with regard to EDV (P=.4407), ESV (P=.5113), or EF (P=.0610). Compared to the ME2C view, the TG2C view had better image quality of the LV walls (image quality score median [interquartile range]: 2.00 [.00] vs 1.00 [1.00]; P<.0001), but worse image quality of the mitral annulus (1.00 [1.00] vs 2.00 [.00]; P<.0001) and LV apex (.00 [1.00] vs 2.00 [1.00]; P<.0001). Conclusions This study suggests the Simpson’s method can be applied to the TG2C view as an alternative to the standard midesophageal method to estimate chamber volumes and EF.
Collapse
Affiliation(s)
- Logan Gray
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Fei Chen
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Emily G. Teeter
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lavinia M. Kolarczyk
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alan M. Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
15
|
Doan V, Liu Y, Teeter EG, Smeltz AM, Vavalle JP, Kumar PA, Kolarczyk LM. Propofol Versus Remifentanil Sedation for Transcatheter Aortic Valve Replacement: A Single Academic Center Experience. J Cardiothorac Vasc Anesth 2022; 36:103-108. [PMID: 34074554 PMCID: PMC8563487 DOI: 10.1053/j.jvca.2021.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/23/2021] [Accepted: 04/24/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Comparison of remifentanil versus propofol for sedation during transcatheter aortic valve replacement (TAVR) procedures to analyze the risk of sedation-related hypoxemia and hypotension. Secondary outcomes included the rate of conversion to general anesthesia, procedure length, rate of intensive care unit (ICU) admission, ICU and hospital lengths of stay, and 30-day mortality. DESIGN Retrospective cohort study. SETTING A single tertiary teaching hospital. PARTICIPANTS Two hundred fifty-nine patients who had propofol or remifentanil sedation for TAVR between March 2017 and March 2020. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS There were 130 patients (50.2%) in the propofol cohort and 129 patients (49.8%) in the remifentanil cohort. The primary outcomes were oxygen saturation nadir values and vasopressor infusion use. Remifentanil was associated with a lower oxygen saturation nadir, as compared to propofol (91.3% v . 95.4%, p < 0.001). Risk factors associated with hypoxemia (defined as <92%) were body mass index (p = 0.0004), obstructive sleep apnea (p = 0.004), and remifentanil maintenance (p < 0.001). Vasopressor infusion use was significantly higher with propofol (64.9% v . 8.5%, p < 0.001). Propofol maintenance and angiotensin-converting enzyme inhibitor/angiotensin II receptor-blocker use were the only variables identified as risk factors for vasopressor use (p < 0.001 and p = 0.009). CONCLUSIONS For patients undergoing TAVR with conscious sedation, remifentanil was associated with more hypoxemia while propofol was associated with a higher rate of vasopressor use.
Collapse
Affiliation(s)
- Vivian Doan
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC 27599
| | - Yutong Liu
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599
| | - Emily G. Teeter
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC 27599
| | - Alan M. Smeltz
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC 27599
| | - John P. Vavalle
- Division of Cardiology, Department of Medicine, University of North Carolina Hospitals, Chapel Hill, NC 27599
| | - Priya A. Kumar
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC 27599,Outcomes Research Consortium, Cleveland, OH 44103
| | - Lavinia M. Kolarczyk
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC 27599
| |
Collapse
|
16
|
Smeltz AM, Arora H. Pro: Metabolic Acidosis SHOULD be Corrected With Sodium Bicarbonate in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2021; 36:616-618. [PMID: 34774405 DOI: 10.1053/j.jvca.2021.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/16/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Harendra Arora
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| |
Collapse
|
17
|
Grosshuesch C, Hrvatin C, Johnson L, Kolarczyk LM, Smeltz AM. Dollars for Diagnosis: A Single-Institutional Analysis of Billing for Intraoperative Transesophageal Echocardiography Examinations. J Cardiothorac Vasc Anesth 2021; 36:1658-1661. [PMID: 34654634 DOI: 10.1053/j.jvca.2021.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/14/2021] [Accepted: 09/22/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The authors sought to identify correctable reasons for the failed completion of required billing elements necessary for the reimbursement of services for intraoperative transesophageal echocardiography (TEE). DESIGN This was a retrospective study. SETTING This study was completed at a single institution and large academic center. PARTICIPANTS The patient population included all adult patients who underwent cardiac surgery at a single academic center over one year. INTERVENTIONS This retrospective review of TEE documentation and billing data was performed for the all adults undergoing cardiac surgery over the course of one year. METHODS AND MAIN RESULTS Documentation characteristics were compared between examinations that were reimbursed and those that were not. Out of 504 TEE examinations, 30% were not reimbursed. For these examinations, there was a lower compliance in the completion of minimum billing requirements, compared with those that were reimbursed; designation as "diagnostic" (29% v 93%, respectively, p < 0.0001), procedure note (70% v 99%, p < 0.0001), and procedure order (67% v 98%, p = 0.0002). The total estimated annual loss in revenue was $36,000. CONCLUSIONS Understanding documentation requirements for TEE is an overlooked but important part of anesthesiology practice that may lead to substantial cost savings. Completion of a procedure note, procedure order, and documentation of an examination as "diagnostic" was associated with successful billing.
Collapse
Affiliation(s)
- Craig Grosshuesch
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC
| | - Cory Hrvatin
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC
| | - Lisa Johnson
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC
| | - Lavinia M Kolarczyk
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC
| | - Alan M Smeltz
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC.
| |
Collapse
|
18
|
Abstract
Persistent postoperative pain (PPP) after cardiac surgery is a significant complication that negatively affects patient quality of life and increases health care system burden. However, there are no standards or guidelines to inform how to mitigate these effects. Therefore, in this review, we will discuss strategies to prevent and manage PPP after cardiac surgery. Adequate perioperative analgesia may prove instrumental in the prevention of PPP. Although opioids have historically been the primary analgesic approach to cardiac surgery, an opioid-sparing strategy may prove advantageous in reducing side effects, avoiding secondary hyperalgesia, and decreasing risk of PPP. Implementing a multimodal analgesic plan using alternative medications and regional anesthetic techniques may offer superior efficacy while reducing adverse effects.
Collapse
Affiliation(s)
| | | | - Alan M Smeltz
- University of North Carolina at Chapel Hill, NC, USA
| |
Collapse
|
19
|
Smeltz AM, Kumar PA. Pro: General Anesthesia Is Superior to Regional Anesthesia for Patients with Pulmonary Hypertension Undergoing Noncardiac Surgery. J Cardiothorac Vasc Anesth 2021; 35:1884-1887. [PMID: 33516605 DOI: 10.1053/j.jvca.2020.12.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 12/30/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| |
Collapse
|
20
|
Smeltz AM, Kumar PA, Arora H. Anesthesia for Combined Heart and Liver Transplantation. J Cardiothorac Vasc Anesth 2020; 35:3350-3361. [PMID: 33384228 DOI: 10.1053/j.jvca.2020.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/26/2020] [Accepted: 12/03/2020] [Indexed: 01/23/2023]
Abstract
A heart or liver transplantation procedure performed in isolation itself presents multiple challenges for the perioperative team. Accordingly, combining both transplants yields a vastly more complicated surgery, with many unique multisystem and multidisciplinary considerations. Although combined heart and liver transplantations are being performed with increasing frequency, nationwide experience is relatively limited at most institutions. The aim of this review is to discuss the perioperative challenges presented to the anesthesiology teams and provide evidence-based guidance for the management of these daunting procedures.
Collapse
Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| | - Harendra Arora
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| |
Collapse
|
21
|
Smeltz AM, Kumar PA. An Unusual Left Ventricular Outflow Tract Obstruction, or Just Another Artifact? J Cardiothorac Vasc Anesth 2020; 35:1541-1543. [PMID: 33139161 DOI: 10.1053/j.jvca.2020.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/03/2020] [Accepted: 10/09/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| |
Collapse
|
22
|
Doan V, Kolarczyk L, Smeltz AM. A Mysterious Right Atrial Jet. J Cardiothorac Vasc Anesth 2020; 34:2841-2843. [PMID: 32624432 DOI: 10.1053/j.jvca.2020.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Vivian Doan
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC.
| | - Lavinia Kolarczyk
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC
| | - Alan M Smeltz
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC
| |
Collapse
|
23
|
Spencer C, Khatri N, Smeltz AM. Determinants of Discrepancy in the Left Ventricular Systolic Function Evaluation Between Preoperative and Intraoperative Evaluations. Semin Cardiothorac Vasc Anesth 2020; 24:321-327. [PMID: 32605429 DOI: 10.1177/1089253220936784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Unexpectedly decreased left ventricular global systolic function can be difficult to manage, even for patients undergoing elective cardiac surgery, and should prompt a multidisciplinary discussion. Therefore, in this review, we discuss the evidence describing key perioperative variables expected to influence left ventricular systolic function to facilitate this discussion.
Collapse
Affiliation(s)
- Chad Spencer
- University of North Carolina at Chapel Hill, NC, USA
| | - Nasir Khatri
- University of North Carolina at Chapel Hill, NC, USA
| | - Alan M Smeltz
- University of North Carolina at Chapel Hill, NC, USA
| |
Collapse
|
24
|
Smeltz AM, Bhatia M, Arora H, Long J, Kumar PA. Anesthesia for Resection and Reconstruction of the Trachea and Carina. J Cardiothorac Vasc Anesth 2020; 34:1902-1913. [DOI: 10.1053/j.jvca.2019.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/11/2019] [Accepted: 10/02/2019] [Indexed: 12/17/2022]
|
25
|
Smeltz AM, Arora H, Kumar PA. Con: The New United Network for Organ Sharing Heart Allocation System Is Not a Positive Change in Listing Patients for Transplantation. J Cardiothorac Vasc Anesth 2020; 34:1968-1971. [DOI: 10.1053/j.jvca.2020.02.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 02/24/2020] [Indexed: 01/06/2023]
|
26
|
Smeltz AM, Kumar PA. Con: Qualitative Left Ventricular Ejection Fraction Is Not Sufficient for Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:335-338. [PMID: 32620495 DOI: 10.1053/j.jvca.2020.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/03/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| |
Collapse
|
27
|
Smeltz AM, Kumar PA. Functional Tricuspid Regurgitation or Rare Congenital Condition? J Cardiothorac Vasc Anesth 2019; 34:837-839. [PMID: 31761654 DOI: 10.1053/j.jvca.2019.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/16/2019] [Accepted: 10/20/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| |
Collapse
|
28
|
Smeltz AM, Kolarczyk LM, Isaak RS. Update on Perioperative Pulmonary Embolism Management: A Decision Support Tool to Aid in Diagnosis and Treatment. Adv Anesth 2018; 35:213-228. [PMID: 29103574 DOI: 10.1016/j.aan.2017.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pulmonary embolism (PE) affects up to 1 in every 1000 people per year, one-third of whom do not survive. Moreover, perioperative presentation of PE is 5 times more likely than at other times and poses a unique set of challenges for both diagnosis and treatment. This article discusses several important aspects regarding the prevention, diagnosis, and management of perioperative PE, incorporating information from the most recent practice guidelines, emerging literature on medical therapy, and interventional therapies. It proposes a clinical decision support tool that organizes the salient aspects of perioperative PE management to serve as an aid in practice.
Collapse
Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill School of Medicine, N2198 UNC Hospitals, CB 7010, Chapel Hill, NC 27599, USA
| | - Lavinia M Kolarczyk
- Department of Anesthesiology, University of North Carolina at Chapel Hill School of Medicine, N2198 UNC Hospitals, CB 7010, Chapel Hill, NC 27599, USA
| | - Robert S Isaak
- Department of Anesthesiology, University of North Carolina at Chapel Hill School of Medicine, N2198 UNC Hospitals, CB 7010, Chapel Hill, NC 27599, USA.
| |
Collapse
|
29
|
Karhausen JA, Qi W, Smeltz AM, Li YJ, Shah SH, Kraus WE, Mathew JP, Podgoreanu MV, Kertai MD. Genome-Wide Association Study Links Receptor Tyrosine Kinase Inhibitor Sprouty 2 to Thrombocytopenia after Coronary Artery Bypass Surgery. Thromb Haemost 2018; 118:1572-1585. [PMID: 30103242 DOI: 10.1055/s-0038-1667199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Thrombocytopenia after cardiac surgery independently predicts stroke, acute kidney injury and death. To understand the underlying risks and mechanisms, we analysed genetic variations associated with thrombocytopenia in patients undergoing coronary artery bypass grafting (CABG) surgery. MATERIALS AND METHODS Study subjects underwent isolated on-pump CABG surgery at Duke University Medical Center. Post-operative thrombocytopenia was defined as platelet count < 100 × 109/L. Using a logistic regression model adjusted for clinical risk factors, we performed a genome-wide association study in a discovery cohort (n = 860) and validated significant findings in a replication cohort (n = 296). Protein expression was assessed in isolated platelets by immunoblot. RESULTS A total of 63 single-nucleotide polymorphisms met a priori discovery thresholds for replication, but only 1 (rs9574547) in the intergenic region upstream of sprouty 2 (SPRY2) met nominal significance in the replication cohort. The minor allele of rs9574547 was associated with a lower risk for thrombocytopenia (discovery cohort, odds ratio, 0.45, 95% confidence interval, 0.30-0.67, p = 9.76 × 10-5) with the overall association confirmed by meta-analysis (meta-p = 7.88 × 10-6). Immunoblotting demonstrated expression of SPRY2 and its dynamic regulation during platelet activation. Treatment with a functional SPRY2 peptide blunted platelet extracellular signal-regulated kinase (ERK) phosphorylation after agonist stimulation. CONCLUSION We identified the association of a genetic polymorphism in the intergenic region of SPRY2 with a decreased incidence of thrombocytopenia after CABG surgery. Because SPRY2-an endogenous receptor tyrosine kinase inhibitor-is present in platelets and modulates essential signalling pathways, these findings support a role for SPRY2 as a novel modulator of platelet responses after cardiac surgery.
Collapse
Affiliation(s)
- Jörn A Karhausen
- Department of Anesthesiology, Duke Perioperative Genomics Program, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - Wenjing Qi
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - Alan M Smeltz
- Department of Anesthesiology, Duke Perioperative Genomics Program, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Duke University, Durham, North Carolina, United States.,Molecular Physiology Institute, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - Svati H Shah
- Molecular Physiology Institute, Duke University Medical Center, Duke University, Durham, North Carolina, United States.,Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - William E Kraus
- Molecular Physiology Institute, Duke University Medical Center, Duke University, Durham, North Carolina, United States.,Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - Joseph P Mathew
- Department of Anesthesiology, Duke Perioperative Genomics Program, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - Mihai V Podgoreanu
- Department of Anesthesiology, Duke Perioperative Genomics Program, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - Miklos D Kertai
- Department of Anesthesiology, Duke Perioperative Genomics Program, Duke University Medical Center, Duke University, Durham, North Carolina, United States.,Department of Anesthesiology, Vanderbilt University Medical Center, Vanderbilt University, Nashville, Tennessee, United States
| | | |
Collapse
|
30
|
Smeltz AM, Cooter M, Rao S, Karhausen JA, Stafford-Smith M, Fontes ML, Kertai MD. Elevated Pulse Pressure, Intraoperative Hemodynamic Perturbations, and Acute Kidney Injury After Coronary Artery Bypass Grafting Surgery. J Cardiothorac Vasc Anesth 2018; 32:1214-1224. [DOI: 10.1053/j.jvca.2017.08.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Indexed: 12/21/2022]
|
31
|
Karhausen JA, Smeltz AM, Akushevich I, Cooter M, Podgoreanu MV, Stafford-Smith M, Martinelli SM, Fontes ML, Kertai MD. Platelet Counts and Postoperative Stroke After Coronary Artery Bypass Grafting Surgery. Anesth Analg 2017. [PMID: 28632537 DOI: 10.1213/ane.0000000000002187] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Declining platelet counts may reveal platelet activation and aggregation in a postoperative prothrombotic state. Therefore, we hypothesized that nadir platelet counts after on-pump coronary artery bypass grafting (CABG) surgery are associated with stroke. METHODS We evaluated 6130 adult CABG surgery patients. Postoperative platelet counts were evaluated as continuous and categorical (mild versus moderate to severe) predictors of stroke. Extended Cox proportional hazard regression analysis with a time-varying covariate for daily minimum postoperative platelet count assessed the association of day-to-day variations in postoperative platelet count with time to stroke. Competing risks proportional hazard regression models examined associations between day-to-day variations in postoperative platelet counts with timing of stroke (early: 0-1 days; delayed: ≥2 days). RESULTS Median (interquartile range) postoperative nadir platelet counts were 123.0 (98.0-155.0) × 10/L. The incidences of postoperative stroke were 1.09%, 1.50%, and 3.02% for platelet counts >150 × 10/L, 100 to 150 × 10/L, and <100 × 10/L, respectively. The risk for stroke increased by 12% on a given postoperative day for every 30 × 10/L decrease in platelet counts (adjusted hazard ratio [HR], 1.12; 95% confidence interval [CI], 1.01-1.24; P= .0255). On a given day, patients with moderate to severe thrombocytopenia were almost twice as likely to develop stroke (adjusted HR, 1.89; 95% CI, 1.13-3.16; P= .0155) as patients with nadir platelet counts >150 × 10/L. Importantly, such thrombocytopenia, defined as a time-varying covariate, was significantly associated with delayed (≥2 days after surgery; adjusted HR, 2.83; 95% CI, 1.48-5.41; P= .0017) but not early postoperative stroke. CONCLUSIONS Our findings suggest an independent association between moderate to severe postoperative thrombocytopenia and postoperative stroke, and timing of stroke after CABG surgery.
Collapse
Affiliation(s)
- Jörn A Karhausen
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Alan M Smeltz
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina,Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
| | - Igor Akushevich
- Center for Population Health and Aging, Duke University Medical Center, Durham, North Carolina
| | - Mary Cooter
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Mihai V Podgoreanu
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Mark Stafford-Smith
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Susan M Martinelli
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
| | - Manuel L Fontes
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Miklos D Kertai
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
32
|
Padma S, Smeltz AM, Banks PM, Iannitti DA, McKillop IH. Altered aquaporin 9 expression and localization in human hepatocellular carcinoma. HPB (Oxford) 2009; 11:66-74. [PMID: 19590626 PMCID: PMC2697857 DOI: 10.1111/j.1477-2574.2008.00014.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2008] [Accepted: 08/06/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND In addition to the biochemical components secreted in bile, aquaporin (AQP) water channels exist in hepatocyte membranes to form conduits for water movement between the sinusoid and the bile canaliculus. The aim of the current study was to analyse AQP 9 expression and localization in human hepatocellular carcinoma (HCC) and non-tumourigenic liver (NTL) tissue from patients undergoing hepatic resection. METHODS Archived tissue from 17 patients was sectioned and analysis performed using an antibody raised against AQP 9. Slides were blind-scored to determine AQP 9 distribution within HCC and NTL tissue. RESULTS Aquaporin 9 was predominantly expressed in the membranes of hepatocytes and demonstrated zonal distribution relative to hepatic sinusoid structure in normal liver. In HCC arising in the absence of cirrhosis AQP 9 remained membrane-localized with zonal distribution in the majority of NTL. By contrast, AQP 9 expression was significantly decreased in the HCC mass vs. pair-matched NTL. In HCC in the presence of cirrhosis, NTL was characterized by extensive AQP 9 staining in the membrane in the absence of zonal distribution and AQP 9 staining in NTL was significantly greater than that observed in the tumour mass. CONCLUSIONS These data demonstrate that human HCC is characterized by altered AQP 9 expression and AQP 9 localization in the NTL mass is dependent on underlying liver pathology. Given the central role of AQPs in normal liver function and the potential role of AQPs during transformation and progression, these data may prove valuable in future diagnostic and/or therapeutic strategies.
Collapse
Affiliation(s)
- Srikanth Padma
- Departments of General Surgery Carolinas Medical CenterCharlotte, NC, USA
| | - Alan M Smeltz
- Department of Biology, University of North Carolina at CharlotteCharlotte, NC, USA
| | - Peter M Banks
- Pathology, Carolinas Medical CenterCharlotte, NC, USA
| | - David A Iannitti
- Departments of General Surgery Carolinas Medical CenterCharlotte, NC, USA
| | - Iain H McKillop
- Departments of General Surgery Carolinas Medical CenterCharlotte, NC, USA
| |
Collapse
|