Citations

Study Design. Literature review and institutional analysis. Objective. This review examines the potential advantages of awake spinal surgery under neuroaxial anesthesia in minimizing positioning-related complications compared with traditional general anesthesia. Summary of Background Data. Spinal surgeries performed in the prone position under general anesthesia are associated with perioperative complications, such as ocular injury and vision loss, nerve damage, and pressure ulcers. Materials and Methods. A comprehensive literature search was conducted for articles published from 1986 to 2023 focusing on awake spinal surgery and positioning-related complications. In addition, insights from the Mayo Clinic team were incorporated to assess the potential benefits of awake spine surgery. Results. The review identified several positioning-related complications associated with prone positioning during spine surgery, including perioperative visual loss, neuropathies, pressure ulcers, and intra-abdominal hypertension leading to systemic cardiovascular effects and potential organ dysfunction. Advances at the Mayo Clinic have enabled the use of awake spinal surgery under neuroaxial anesthesia for complex procedures such as robotic transforaminal lumbar interbody fusion. The use of awake lumbar spine surgery has demonstrated advantages, including reduced positioning-related complications, immediate patient feedback to avoid harmful maneuvers, shorter operating room times, and improved hemodynamic stability. Conclusions. Awake lumbar spine surgery offers notable advantages in reducing positioning-related complications and presents a promising alternative to general anesthesia.

Background We aimed to identify patients with subphenotypes of postacute coronary syndrome (ACS) using repeated measurements of high‐sensitivity cardiac troponin T, N‐terminal pro‐B‐type natriuretic peptide, high‐sensitivity C‐reactive protein, and growth differentiation factor 15 in the year after the index admission, and to investigate their association with long‐term mortality risk. Methods and Results BIOMArCS (BIOMarker Study to Identify the Acute Risk of a Coronary Syndrome) was an observational study of patients with ACS, who underwent high‐frequency blood sampling for 1 year. Biomarkers were measured in a median of 16 repeated samples per individual. Cluster analysis was performed to identify biomarker‐based subphenotypes in 723 patients without a repeat ACS in the first year. Patients with a repeat ACS (N=36) were considered a separate cluster. Differences in all‐cause death were evaluated using accelerated failure time models (median follow‐up, 9.1 years; 141 deaths). Three biomarker‐based clusters were identified: cluster 1 showed low and stable biomarker concentrations, cluster 2 had elevated concentrations that subsequently decreased, and cluster 3 showed persistently elevated concentrations. The temporal biomarker patterns of patients in cluster 3 were similar to those with a repeat ACS during the first year. Clusters 1 and 2 had a similar and favorable long‐term mortality risk. Cluster 3 had the highest mortality risk. The adjusted survival time ratio was 0.64 (95% CI, 0.44–0.93; P =0.018) compared with cluster 1, and 0.71 (95% CI, 0.39–1.32; P =0.281) compared with patients with a repeat ACS. Conclusions Patients with subphenotypes of post‐ACS with different all‐cause mortality risks during long‐term follow‐up can be identified on the basis of repeatedly measured cardiovascular biomarkers. Patients with persistently elevated biomarkers have the worst outcomes, regardless of whether they experienced a repeat ACS in the first year.

Abstract Aims Evidence regarding the role of serial measurements of biomarkers for risk assessment in post-acute coronary syndrome (ACS) patients is limited. The aim was to explore the prognostic value of four, serially measured biomarkers in a large, real-world cohort of post-ACS patients. Methods and results BIOMArCS is a prospective, multi-centre, observational study in 844 post-ACS patients in whom 12 218 blood samples (median 17 per patient) were obtained during 1-year follow-up. The longitudinal patterns of high-sensitivity cardiac troponin T (hs-cTnT), N-terminal-pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein (hs-CRP), and growth differentiation factor 15 (GDF-15) were analysed in relation to the primary endpoint (PE) of cardiovascular mortality and recurrent ACS using multivariable joint models. Median age was 63 years, 78% were men and the PE was reached by 45 patients. The average biomarker levels were systematically higher in PE compared with PE-free patients. After adjustment for 6-month post-discharge Global Registry of Acute Coronary Events score, 1 standard deviation increase in log[hs-cTnT] was associated with a 61% increased risk of the PE [hazard ratio (HR) 1.61, 95% confidence interval (CI) 1.02–2.44, P = 0.045], while for log[GDF-15] this was 81% (HR 1.81, 95% CI 1.28–2.70, P = 0.001). These associations remained significant after multivariable adjustment, while NT-proBNP and hs-CRP were not. Furthermore, GDF-15 level showed an increasing trend prior to the PE (Structured Graphical Abstract). Conclusion Longitudinally measured hs-cTnT and GDF-15 concentrations provide prognostic value in the risk assessment of clinically stabilized patients post-ACS. Clinical Trial Registration The Netherlands Trial Register. Currently available at URL https://trialsearch.who.int/; Unique Identifiers: NTR1698 and NTR1106.

The goal of this project was to improve preoperative medication instructions. After baseline data were collected prospectively through standardised patient surveys, preoperative care providers were educated to convey clear, appropriate preoperative medication instructions. After the education period, patient surveys were again completed to assess improvement. Hospital-wide education effectively increased the percentage of medications with written, colour-coded, and medically appropriate instructions. Patients found the instructions clearer and easier to follow.

Background Paraplegia is a devastating complication for patients undergoing repair of thoracoabdominal aortic aneurysms. A monitor to detect spinal cord ischemia is necessary if anesthesiologists are to intervene to protect the spinal cord during aortic aneurysm clamping. Methods The medical records of 60 patients who underwent thoracoabdominal aortic aneurysm repair with regional lumbar epidural cooling with evoked potential monitoring were reviewed. The authors analyzed latency and amplitude of motor evoked potentials, somatosensory evoked potentials, and H reflexes before cooling and clamping, after cooling and before clamping, during clamping, and after release of aortic cross clamp. Results Twenty minutes after the aortic cross clamp was placed, motor evoked potentials had 88% sensitivity and 65% specificity in predicting spinal cord ischemia. The negative predictive value of motor evoked potentials at 20 min after aortic cross clamping was 96%. Conclusions Rapid loss of motor evoked potentials or H reflexes after application of the aortic cross clamp identifies a subgroup of patients who are at high risk of developing spinal cord ischemia and in whom aggressive anesthetic and surgical interventions may be justified.

Paraplegia is a major complication associated with repair of thoracoabdominal aortic aneurysms (TAAA). A number of therapies have been tried over the years, none of which has been successful. Recently, regional lumbar epidural cooling has been tried in an attempt to prolong the safe ischemic time during aortic cross- clamping. In approximately 90 patients in whom the authors have tried this technique, there was no de crease in the incidence of paraplegia in patients with type II TAAAs. This is perhaps not unanticipated be cause the paraplegia is related to a number of factors including the duration of the aortic cross-clamping, the adequacy of collateral circulation, embolization during the procedure, and perhaps thrombosis in situ. Given the multimodal cause of paraplegia, perhaps it is naive to think that a single therapy would be of benefit. Additional studies are necessary to explore the mecha nisms and to prove efficacy or lack of benefit of any techniques designed to decrease the incidence of paraplegia in patients undergoing TAAA repair.

The postoperative care of a patient who receives an intra-abdominal organ transplant is in some ways simi lar to that of any major intra-abdominal procedure. However, certain features unique to organ transplanta tion, such as the variable functional status of the newly transplanted graft, complications that are specific to the organ transplanted, and the side effects from immuno suppressive drugs, suggest that transplantation inten sive care is a distinct subspecialty in critical care medicine. Today, the majority of patients receiving an intra-abdominal transplant will have a relatively uncom plicated postoperative course. However, preoperative disposition, intraoperative misadventure, or immediate postoperative difficulty will require the availability of an intensivist experienced in transplantation. The future of intra-abdominal transplantation will be highly depen dent on progress in immunotherapy. Newer, more spe cific immunomodulators with fewer nonimmune toxici ties should result in improved organ receptance, less graft dysfunction, and improved patient survival.