Intravenous lidocaine infusion in a case of severe COVID-19 infection

A subset of patients with COVID-19 develops a severe inflammatory response that may lead to respiratory and multiorgan failure. Effective treatment strategies to mitigate or interrupt this self-destructive inflammatory process are limited. The local anesthetic lidocaine has anti-inflammatory properties in addition to its analgesic, antiarrhythmic, and sedating effects that may be beneficial in critically ill COVID-19 patients. We report the case of a patient with COVID-19 induced severe respiratory distress who was intubated and received supportive treatment including proning and neuromuscular blockade. He developed a strong inflammatory response that we treated with an intermittent lidocaine infusion resulting in subsequent resolution. This case occurred prior to emerging data from a large dexamethasone use trial that demonstrated a survival benefit from its use in hospitalized COVID-19 patients. At the time, lidocaine was the only anti-inflammatory medication our patient received.

Sharing Lessons Learned to Prevent Adverse Events in Anesthesiology Nationwide

OBJECTIVES

The Veterans Health Administration (VHA) lessons learned process for Anesthesia adverse events was developed to alert the field to the occurrences and prevention of actual adverse events. This article details this quality improvement project and perceived impact.

METHODS

As part of ongoing quality improvement, root cause analysis related to anesthesiology care are routinely reported to the VHA National Center for Patient Safety. Since May 2012, the National Anesthesia Service subject matter experts, in collaboration with National Center for Patient Safety, review actual adverse events in anesthesiology and detailed lessons learned are developed. A survey of anesthesiology chiefs to determine perceived usefulness and accessibility of the project was conducted in April 2018.

RESULTS

The distributed survey yielded a response rate of 69% (84/122). Most of those who have seen the lessons learned (85%, 71/84) found them valuable. Ninety percent of those aware of the lessons learned (64/71) shared them with staff and 75% (53/71) reported a changed or reinforced patient safety behavior in their facility. The lessons learned provided 72% (51/71) of chiefs with new knowledge about patient safety and 75% (53/71) gained new knowledge for preventing adverse events.

CONCLUSIONS

This nationwide VHA anesthesiology lessons learned project illustrates the tenets of a learning organization. implementing team and systems-based safeguards to mitigate risk of harm from inevitable human error. Sharing lessons learned provides opportunities for clinician peer-to-peer learning, communication, and proactive approaches to prevent future similar errors.

Fraction of expired oxygen: an additional safety approach to monitor oxygen delivery to the heart lung machine oxygenator

BACKGROUND

Monitoring oxygen delivery to the oxygenator of a heart lung machine (HLM) is typically accomplished with an O₂ analyzer connected to the gas inflow line. It is assumed when the FiO₂ is greater than 21% that oxygen is being delivered to the oxygenator. However, this assumption is imperfect because the connection of the inflow line to the oxygenator is downstream from the O₂ analyzer. FiO₂ monitoring will not alert the perfusionist if the inflow line is not actually connected to the oxygenator. Measuring the fraction of expired oxygen (FEO₂) is a more reliable way of monitoring O₂ delivery.

METHODS

An O₂ analyzer was placed on the scavenging line that is attached to the exhaust port of oxygenator (FEO₂).

RESULTS

Whenever the FiO₂ is greater than 21%, and the inflow line is properly connected, the FEO₂ exiting the oxygenator is greater than 21%. The FEO₂ falls to 21% when the inflow line is not functioning.

CONCLUSION

Monitoring the FEO₂ is a more reliable way to verify O₂ delivery to an oxygenator. An alarm can be set on the FEO₂ monitor to alert the perfusionist if the FEO₂ falls below a predetermined threshold so any issue with O₂ delivery will always be recognized.

Use of Helmet CPAP in COVID-19 - A practical review

Helmet CPAP (H-CPAP) has been recommended in many guidelines as a noninvasive respiratory support during COVID-19 pandemic in many countries around the world. It has the least amount of particle dispersion and air contamination among all noninvasive devices and may mitigate the ICU bed shortage during a COVID surge as well as a decreased need for intubation/mechanical ventilation. It can be attached to many oxygen delivery sources. The MaxVenturi setup is preferred as it allows for natural humidification, low noise burden, and easy transition to HFNC during breaks and it is the recommended transport set-up. The patients can safely be proned with the helmet. It can also be used to wean the patients from invasive mechanical ventilation. Our article reviews in depth the pathophysiology of COVID-19 ARDS, provides rationale of using H-CPAP, suggests a respiratory failure algorithm, guides through its setup and discusses the issues and concerns around using it.

Epiaortic Ultrasound for Assessment of Intraluminal Atheroma; Insights from the REGROUP Trial

OBJECTIVES

To assess the use of epiaortic ultrasound in contemporary cardiac surgery, as well as its impact on surgical cannulation strategy and cerebrovascular events.

DESIGN

Epiaortic ultrasound data was prospectively collected in the Randomized Endovein Graft Prospective (REGROUP) trial (VA Cooperative Studies Program #588, ClinicalTrials.gov, NCT01850082), which randomized 1,150 coronary artery bypass graft patients between 2014 and 2017 to endoscopic or open-vein graft harvest.

SETTING

Sixteen cardiac surgery programs within the Veterans Affairs Healthcare System with expertise at performing endoscopic vein-graft harvesting.

PARTICIPANTS

Veterans Affairs patients, greater than 18 years of age, undergoing elective or urgent coronary artery bypass grafting with cardiopulmonary bypass and cardioplegic arrest with at least one planned saphenous vein graft were eligible for enrollment.

INTERVENTIONS

Epiaortic ultrasound was performed by the surgeon using a high frequency (>7 MHz) ultrasound transducer. Two-dimensional images of the ascending aorta in multiple planes were acquired before aortic cannulation and cross-clamping.

MEASUREMENTS AND MAIN RESULTS

Epiaortic ultrasound was performed in 34.1% (269 of 790) of patients in REGROUP. Among these patients, simple intraluminal atheroma was observed in 21.9% (59 269), and complex intraluminal atheroma comprised 2.2% (6 of 269). The aortic cannulation or cross-clamp strategy was modified based on these findings in 7.1% of cases (19 of 269). There was no difference in stroke between patients who underwent epiaortic ultrasound and those who did not (1.9% v 1.2% p = 0.523).

CONCLUSIONS

Despite current guidelines recommending routine use of epiaortic ultrasound (IIa/B) to reduce the risk of stroke in cardiac surgery, in this contemporary trial, use remains infrequent, with significant site-to-site variability.

A Quick Reference Tool for Goal-Directed Perfusion in Cardiac Surgery

Traditionally, blood flow rates on cardiopulmonary bypass are based primarily on a formula that matches cardiac index to the patient's body surface area (BSA). However, Ranucci and associates in the Goal-Directed Perfusion Trial (GIFT) trial have shown that coupling the BSA with delivery of oxygen (DO₂), known as goal-directed perfusion (GDP), may be a safer approach to determine appropriate blood flows. The objective of this study was to create a GDP reference tool that would allow perfusionists to quickly determine the lowest acceptable blood flow needed to provide a patient of any BSA with a satisfactory DO₂ without the need for additional dedicated technology. We approached this problem by deriving a formula for flow (L/min), based on BSA, oxygen content of the blood, and a minimum DO₂ of 280 mL·min^-1m^-2. A quick reference GDP chart was created based on the derived formula, requiring only the patient's BSA and hemoglobin level to determine a safe minimum flow rate. The proposed tool allows any cardiac surgery center to adopt the GDP technique, even in the absence of instantaneous DO₂ monitoring equipment.

First Reported Use of Team Cognitive Workload for Root Cause Analysis in Cardiac Surgery

Cognitive workload data of members of the cardiac surgery team can be measured intraoperatively and stored for later analysis. We present a case of a near-miss (medication error) that underwent root cause analysis using workload data. Heart rate variability data, representing workload levels, were collected from the attending surgeon, attending anesthesiologist, and lead perfusionist using wireless heart rate monitors. An episode of cognitive overload of the anesthesiologist due to a distractor was associated with the preventable error. Additional studies are needed to better understand the role of psychophysiological data in enhancing surgical patient safety.

Enhanced Recovery After Surgery in Laparoscopic Surgery

BACKGROUND

As part of an effort to maximize value in the perioperative setting, a paradigm shift is underway in the way that patients are cared for preoperatively, on the day of surgery, and postoperatively-a setting collectively known as the perioperative care. Enhanced Recovery After Surgery (ERAS^®) is an evidence-based, patient-centered team approach to delivering high-quality perioperative care to surgical patients.

METHODS

This review focuses on anesthesiologists, with their unique purview of perioperative setting, who are important drivers of change in the delivery of valuable perioperative care. ERAS care pathways begin in the preoperative setting by both preparing the patient for the psychological stress of surgery and optimizing the patient's medical and physiologic status so the body is ready for the physical demands of surgery.

RESULTS

Minimization of perioperative fasting is important to maintain volume status-decreasing reliance on intravenous fluid administration, and to reduce protein catabolism around the time of surgery. Intraoperative management in ERAS pathways relies on goal-directed fluid therapy and opioid-sparing multimodal analgesia. Postoperatively, early feeding and ambulation, as well as discontinuation of extraneous lines and catheters facilitate patients' functional recovery.

CONCLUSION

The laparoscopic approach to surgery, when possible, compliments ERAS techniques by reducing abdominal wall trauma and the resultant milieu of inflammatory, neurohumoral, and pain responses. Anesthesiologists driving change in the perioperative setting, in collaboration with surgeons and other disciplines, can improve value in healthcare and provide optimal outcomes that matter most to patients and healthcare providers alike.

Use of the GlideScope®-Ranger for pre-hospital intubations by anaesthesia trained emergency physicians - an observational study

Background

Pre-hospital endotracheal intubation is more difficult than in the operating room (OR). Therefore, enhanced airway management devices such as video laryngoscopes may be helpful to improve the success rate of pre-hospital intubation. We describe the use of the Glidescope®-Ranger (GS-R) as an alternative airway tool used at the discretion of the emergency physician (EP) in charge.

Methods

During a 3.5 year period, the GS-R was available to be used either as the primary or backup tool for pre-hospital intubation by anaesthesia trained EP with limited expertise using angulated videolaryngoscopes.

Results

During this period 672 patients needed pre-hospital intubation of which the GS-R was used in 56 cases. The overall GS-R success rate was 66 % (range of 34–100 % among EP). The reasons for difficulties or failure included inexperience of the EP with the GS-R, impaired view due to secretion, vomitus, blood or the inability to see the screen in very bright environment due to sunlight.

Conclusion

Special expertise and substantial training is needed to successfully accomplish tracheal intubation with the GS-R in the pre-hospital setting. Providers inexperienced with DL as well as video-assisted intubation should not expect to be able to perform tracheal intubation easily just because a videolaryngoscope is available. Additionally, indirect laryngoscopy might be difficult or even impossible to achieve in the pre-hospital setting due to impeding circumstances such as blood, secretions or bright sun-light. Therefore, videolaryngoscopes, here the GS-R, should not be considered as the “Holy Grail” of endotracheal intubation, neither for the experts nor for inexperienced providers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12873-016-0069-2) contains supplementary material, which is available to authorized users.

Persistent Atrial Septum Defect Despite Placement of Two Amplatzer Septal Occluders

Herein, we are presenting a case of persistent interatrial septal defect diagnosed during coronary artery bypass grafting (CABG). Twice, attempts had been made to close this shunt using amplatzer septal occlude. However, percutaneous technique had failed in both occasions. The patient presented with chest pain 4 years after the second attempt and required urgent CABG. Persistent shunt was repaired during surgery.

A prospective, blinded evaluation of a video-assisted '4-stage approach' during undergraduate student practical skills training

BACKGROUND

The 4-stage approach (4-SA) is used as a didactic method for teaching practical skills in international courses on resuscitation and the structured care of trauma patients. The aim of this study was to evaluate objective and subjective learning success of a video-assisted 4-SA in teaching undergraduate medical students.

METHODS

The participants were medical students learning the principles of the acute treatment of trauma patients in their multidiscipline course on emergency and intensive care medicine. The participants were quasi- randomly divided into two groups. The 4-SA was used in both groups. In the control group, all four steps were presented by an instructor. In the study group, the first two steps were presented as a video. At the end of the course a 5-minute objective, structured clinical examination (OSCE) of a simulated trauma patient was conducted. The test results were divided into objective results obtained through a checklist with 9 dichotomous items and the assessment of the global performance rated subjectively by the examiner on a Likert scale from 1 to 6.

RESULTS

313 students were recruited; the results of 256 were suitable for analysis. The OSCE results were excellent in both groups and did not differ significantly (control group: median 9, interquantil range (IQR) 8-9, study group: median 9, IQR 8-9; p = 0.29). The global performance was rated significantly better for the study group (median 1, IQR 1-2 vs. median 2, IQR 1-3; p < 0.01). The relative knowledge increase, stated by the students in their evaluation after the course, was greater in the study group (85% vs. 80%).

CONCLUSION

It is possible to employ video assistance in the classical 4-SA with comparable objective test results in an OSCE. The global performance was significantly improved with use of video assistance.

Do the choices of airway affect the post-anesthetic occurrence of nausea after knee arthroplasty? A comparison between endotracheal tubes and laryngeal mask airways

OBJECTIVES

The primary goal of this study was to assess the impact of airway devices on the incidence of nausea after knee arthroplasty and their interaction with the use of nitrous oxide.

METHODS

Charts were reviewed for 499 patients after knee arthroplasty under general anesthesia. Demographic data, type of airway device, nitrous oxide, sevoflurane, desflurane, isoflurane, fentanyl, metoclopramide, ondansetron, dexamethasone, rocuronium and neostigmine were analyzed. Fisher's exact test was used to compare the categorical factors and t-test was used for continuous variables. Sinclair scores were used for post-operative nausea and vomiting (PONV) risk stratification. Multivariate logistic regression model was constructed to identify the factors contributing to the frequency of PONV.

RESULTS

PONV was documented in 10.3% of patients. Nitrous oxide was associated with a higher frequency of PONV than those received air mixture (12.5% vs. 8.7%, P < 0.01). Prior to risk stratification, the frequency of PONV was 17% in the endotracheal tube (ETT) vs. 6.7% in the laryngeal mask airway (LMA) group (P < 0.01). Sinclair score was 0.51 +/- 0.17 for the ETT group and 0.74 +/- 0.12 for the LMA group (P < 0.001). After risk stratification and matching, the incidence of PONV was 15.8% with the use of ETT compared with 7.9% for LMA (P < 0.05).

CONCLUSION

The frequency of PONV was almost twice with ETT as with LMA. Longer duration of anesthesia, neuromuscular blockade and non-standardized antiemetic regimen may have contributed to the increase PONV in ETT group. Prospective randomized studies are necessary to further explore whether and to which extend airway devices influence the incidence of PONV.

Respiratory perioperative management of patients with obstructive sleep apnea

Obstructive sleep apnea (OSA) has become a major public health problem in the United State and Europe. However, perioperative strategies regarding diagnostic options and management of untreated OSA remain inadequate. Preoperative screening and identification of patients with undiagnosed OSA may lead to early perioperative interventions that may alter cardiopulmonary events associated with surgery and anesthesia.(1) Hence, clinicians need to become familiar with the preoperative screening and diagnosis of OSA. Perioperative management of a patient with OSA should be modified and may include regional anesthesia and alternative analgesic techniques such as nonsteroidal anti-inflammatory drugs that may reduce the need for systemic opioids. Additionally, supplemental oxygen and continuous pulse oximetry monitoring should be utilized to maintain baseline oxygen saturation. Postoperatively patients should remain in a semi-upright position and positive pressure therapy should be used in patients with high-risk OSA.

Deep Hypothermic Circulatory Arrest and Bivalirudin Use in a Patient With Heparin-Induced Thrombocytopenia and Antiphospholipid Syndrome

BACKGROUND

Patients with heparin-induced thrombocytopenia II (HIT II) need an alternative nonheparin-based method of anticoagulation for cardiopulmonary bypass (CPB) to prevent thrombosis and thrombosis related complications.

METHODS

Bivalirudin was used during CPB and deep hypothermic circulatory arrest (DHCA) for resection of multiple right atrial masses in a patient with HIT II and antiphospholipid antibodies syndrome (APS). Anticoagulation was monitored with the activated clotting time (ACT) and a target ACT of 450 seconds or greater was maintained.

RESULTS

Surgical removal of multiple right atrial masses was successful and there was no evidence of thromboembolic events. Clot was noticed in the cardiotomy and venous reservoir after CPB was discontinued and the system flushed. The postoperative course was uneventful.

CONCLUSIONS

Anticoagulation was successfully managed with bivalirudin, a new short-acting, and direct thrombin inhibitor. Further studies are necessary to evaluate the safety of bivalirudin during DHCA.

Bioterrorism and children: unique concerns with infection control and vaccination

Treatment of child victims of a bioterrorism attack is complicated because they may be more vulnerable to the agents used and may suffer more complications from the treatment strategies. Isolation and other infection control measures can be psychologically harmful to young children and may require that they undergo sedation. Most of the recommended antibiotics and antiviral treatments for bioterror agents have not been approved for use in children, and children undergoing smallpox vaccination have a higher incidence of complications than adults. Pediatric anesthesiologists should expect to be part of the pediatric care team and must be careful to observe infection control procedures to limit the spread of disease caused by bioterror attack.