Höfer, R

Introduction and importance: Reports are limited on video-assisted thoracoscopic surgery for lung malignancy of patients with situs inversus totalis (SIT). Patients with SIT have significant anatomic differences with implications that are important for surgery, anesthesia, and nursing to understand in order to provide care for this patient population. Case presentation: A 64-year-old man with SIT and lung adenocarcinoma needed flexible bronchoscopy and wedge resection of a 9×8 mm adenocarcinoma in the right upper lobe and underwent video-assisted thoracoscopic surgery. Clinical discussion: Preoperative planning, including collaboration with the surgical team, allowed safe monitoring, induction of anesthesia, and airway isolation in this patient allowing them to have successful resection of their pulmonary malignancy. Postoperative care was enhanced by detailed communication and understanding of the patient’s anatomy and implications of this condition for post anesthesia care unit nursing care. Conclusion: Patients with rare clinical conditions and backgrounds may require surgical and anesthetic intervention. The authors describe important anesthetic considerations of preoperative evaluation, airway management, cardiac monitoring, and vascular access that should be noted and taken into account for patients with SIT. Proper preparation, planning, and communication allow for patients with SIT to safely undergo surgical procedures.

BACKGROUND: Kidney transplant is the most common transplant operation performed in the United States. Although various approaches to pain management have been described, the optimal analgesic strategy remains undefined. Specifically, the role of intrathecal opioids in this patient population has not been comprehensively evaluated. METHODS: Using a retrospective cohort design, data from kidney transplant operations at a single tertiary care medical center between August 1, 2017, and July 31, 2022, were extracted. Inverse probability of treatment weighting (IPTW) was used to assess differences in clinical outcomes based on the presence or absence of intrathecal opioid administration before surgical incision. The primary outcome was total opioid exposure expressed in milligram morphine equivalents (MME) in the first 72 hours postoperatively, with secondary outcomes including total MME (intraoperative plus postoperative MME, postoperative pain scores, and the presence of postoperative nausea/vomiting [PONV], pruritus, or adverse events). RESULTS: A total of 1014 kidney transplants in 1012 unique patients were included, with 411 (41%) receiving intrathecal opioids preoperatively. Hydromorphone was the intrathecal opioid used in all cases with median dose of 100 µg (interquartile range [IQR], 100, 100; range 50–200). Subjects receiving intrathecal opioids had significantly lower postoperative opioid requirements at 72 hours (30 [0–68] vs 64 [22, 120] MME), with ratio of geometric means in the IPTW analysis (ratio of geometric means 0.34, 95% confidence interval [CI], 0.26–0.43; P < .001). Similar findings were observed for total opioids (45 [30–75] vs 75 [60–90] MME; ratio of geometric means 0.58, 95% CI, 0.54–0.63; P < .001). Maximum reported pain scores in the intrathecal group were lower at 24 hours (4 [2–7] vs 7 [5, 8]; OR, 0.28; 95% CI, 0.21–0.37 for experiencing a higher pain score with intrathecal opioids, P < .001) and 72 hours (6 [4–7] vs 7 [5–8]; OR, 0.41; 95% CI, 0.31–0.54; P < .001). Patients receiving intrathecal opioids were more likely to experience PONV (225 of 411 [55%] vs 232 of 603 [38%]; OR, 2.16; 95% CI, 1.63–2.86; P < .001). CONCLUSIONS: Intrathecal opioid administration was associated with improved pain outcomes in patients undergoing kidney transplantation, including lower opioid requirements and pain scores through 72 hours. However, this was accompanied by an increased risk of PONV.

Case: A 76-year-old woman with multiple myeloma and osteoporosis presented with right hip pain and an impending atypical femoral fracture in the setting of chronic bisphosphonate use. After preoperative medical optimization, she was scheduled for prophylactic intramedullary nail fixation. Intraoperatively, the patient experienced episodes of severe bradycardia and asystole associated with intramedullary reaming, which ceased after distal venting of the femur. No additional intraoperative or postoperative complications were encountered, and the patient recovered uneventfully. Conclusion: Femoral canal venting may be an appropriate intervention for similar transient dysrhythmias caused by intramedullary reaming.

Surgical innovation and multidisciplinary management have allowed children born with univentricular physiology congenital heart disease to survive into adulthood. An estimated global population of 70 000 patients have undergone the Fontan procedure and are alive today, most of whom are <25 years of age. Several unexpected consequences of the Fontan circulation include Fontan-associated liver disease. Surveillance biopsies have demonstrated that virtually 100% of these patients develop clinically silent fibrosis by adolescence. As they mature, there are increasing reports of combined heart-liver transplantation resulting from advanced liver disease, including bridging fibrosis, cirrhosis, and hepatocellular carcinoma, in this population. In the absence of a transplantation option, these young patients face a poor quality of life and overall survival. Acknowledging that there are no consensus guidelines for diagnosing and monitoring Fontan-associated liver disease or when to consider heart transplantation versus combined heart-liver transplantation in these patients, a multidisciplinary working group reviewed the literature surrounding Fontan-associated liver disease, with a specific focus on considerations for transplantation.

Background. Anesthetic management of orthotopic liver transplantation (OLT) can be challenging. Management involves responding to sudden hemodynamic shifts, addressing instability, and performing ongoing volume assessment. To best prepare for these perturbations, various monitors are used intraoperatively. We sought to explore the impact of transesophageal echocardiography (TEE) and pulmonary artery catheter (PAC) use on outcomes of patients undergoing OLT. Methods. We retrospectively reviewed records of patients who underwent OLT at a single institution and included all who were monitored intraoperatively with TEE alone, PAC alone, or both methods concurrently (TEE + PAC). We determined whether these groups had differences in length of hospitalization (primary outcome), 30-day mortality rate, and other outcomes. Results. Three hundred eighteen liver transplant operations were included in the study. Patients in the TEE + PAC group had the shortest median length of hospitalization (TEE + PAC, 8.6 days; TEE, 10.3; PAC, 9.1; P = 0.04). The TEE + PAC group also had the lowest 30-day mortality rate (TEE + PAC, n = 1 [1.3%]; TEE, n = 5 [12.8%]; PAC, n = 7 [3.5%]; P = 0.009). However, the TEE + PAC group also had the highest rate of a new postoperative need for dialysis (TEE + PAC, n = 8 [10.3%]; TEE, n = 2 [5.1%]; PAC, n = 1 [0.5%]; P < 0.001). Conclusions. Compared with either TEE alone or PAC alone, intraoperative monitoring with TEE + PAC during OLT was associated with the shortest length of hospitalization and lowest 30-day mortality rate. Transplant anesthesiologists should be aware of the potential benefit on patient mortality and hospital length of stay with concurrent intraoperative TEE + PAC monitoring and the increased need for new postoperative dialysis.

BACKGROUND: The use of cognitive aids, such as emergency manuals (EMs), improves team performance on critical steps during crisis events. In our large academic anesthesia practice, we sought to broadly implement an EM and subsequently evaluate team member performance on critical steps. METHODS: We observed the phases of implementing an EM at a large academic anesthesia practice from 2013 to 2016, including the formation of the EM implementation team, identification of preferred EM characteristics, consideration of institution-specific factors, selection of the preferred EM, recognition of logistical barriers, and staff education. Utilization of the EM was tested in a regular clinical environment with all available resources using a standardized verbal simulation of 3 crisis events both preimplementation and 6 months postimplementation. Individual members of the anesthesia team were asked to verbalize interventions for specific crisis events over 60 seconds. RESULTS: We introduced a customized version of the Stanford Emergency Manual on January 26, 2015. Fifty-nine total participants (equal proportion of anesthesiology attending physicians, resident physicians, certified registered nurse anesthetists, and student registered nurse anesthetist staff) were surveyed in the preimplementation phase and 60 in the 6-month postimplementation phase. In the postimplementation phase, a minority (41.7%) utilized the EM for the verbal-simulated crisis events. Those who used the EM performed better than those who did not (median 21.0 critical steps out of a possible 30 total steps [70.0%], interquartile range 19–25 vs 18.0 critical steps verbalized [60.0%], interquartile range 16–20; P < .001). Among all subjects, the median number of critical steps verbalized was 16 (53.3%) preimplementation and 19.5 critical steps (65.0%) postimplementation. CONCLUSIONS: Implementation of an EM in a large academic anesthesia practice is not without challenges. While full integration of the EM was not achieved 6 months after implementation, verbalization of critical steps on 3 simulated crisis events improved when the EM was utilized.

SummaryA 51‐year‐old male was admitted to the intensive care unit following a cardiac arrest during which he received chest compressions and suffered rib fractures. The patient's condition subsequently improved and tracheal extubation was eventually planned. However, he was unable to tolerate spontaneous breathing trials due to pain from his rib fractures. Systemic analgesia provided either insufficient pain control or over‐sedation. Neuraxial techniques were contraindicated as he was receiving systemic anticoagulation and antiplatelet medications. Intercostal nerve blocks with liposomal bupivacaine were performed under ultrasound guidance without complications. Approximately six hours after the injections, the patients trachea was successfully extubated with no further need for respiratory support through to discharge. In appropriately selected patients, intercostal nerve blocks with liposomal bupivacaine can adequately treat pain from rib fractures and improve respiratory mechanics.

BACKGROUNDPatients with polycythemia vera (PV) have historically been considered to be at high risk for perioperative hemorrhagic and thromboembolic complications. However, no recent studies have compared these outcomes between treated PV patients and patients without PV undergoing similar procedures.STUDY DESIGN AND METHODSPatients with PV who underwent surgery with anesthesia from June 1, 2006, to May 31, 2011, were randomly matched (sex, age, type of surgical procedure, surgical year) at a ratio of 1:4 with control patients without PV. Conditional logistic regression analysis adjusting for surgical duration, preoperative hemoglobin, platelet count, and cardiovascular disease was used to assess the association between PV and blood product transfusions, thromboembolism, and other major cardiovascular and pulmonary complications.RESULTSFifty‐six PV patients who underwent 79 surgeries were matched with 312 controls. During hospitalization, 35 (44.3%) and 82 (25.9%) PV and control patients, respectively, were transfused with blood products. PV patients were at increased risk for transfusion intraoperatively (odds ratio [OR], 4.35; 95% confidence interval [CI], 1.79‐10.57; p = 0.001) and during hospitalization (OR, 4.35; 95% CI, 1.84‐10.31; p < 0.001). The likelihood of thromboembolic complications and/or other major complications did not differ between the two study groups (thromboembolic—OR 1.53, 95% CI 0.39‐6.02, p = 0.540; other major complications—OR 2.15, 95% CI 0.93‐4.96, p = 0.073).CONCLUSIONSMedically managed PV patients had an increased likelihood of receiving blood products perioperatively. Given the low number of observed thromboembolic events, we cannot make definitive conclusions regarding the association between PV and thromboembolism.