Anesthesia & Analgesia

Multicenter Evaluation of the Quantra QPlus System in Adult Patients Undergoing Major Surgical Procedures BACKGROUND: The management of perioperative bleeding and the optimization of the available therapies are subjects of significant clinical interest. Clinical guidelines recommend the use of whole blood viscoelastic testing devices to target the utilization of blood products during major surgical procedures. The Quantra QPlus System is a new cartridge-based viscoelastic testing device based on an innovative ultrasound technology. The aim of this study was to evaluate this new system in a surgical population. METHODS: Two hundred seventy-seven adult subjects were enrolled in a multicenter, prospective observational study consisting primarily of patients undergoing cardiac and major orthopedic surgeries. Samples were obtained at multiple time points for testing on the Quantra QPlus System, the rotational thromboelastometry (ROTEM) delta, and standard coagulation tests. Quantra measurements included Clot Time (CT), Heparinase Clot Time (CTH), Clot Time Ratio (CTR), Clot Stiffness (CS), Fibrinogen (FCS), and Platelet (PCS) Contributions to CS. Data analyses included assessment of the concordance of Quantra parameters with a series of clinical composite indexes formed on the basis of standard coagulation tests in 3 domains representing increased, decreased, and normal/subclinical coagulation function. Linear regression and receiver operator characteristic (ROC) analyses of Quantra parameters with corresponding parameters from ROTEM assays were also performed. RESULTS: The accuracy (overall percent agreement or ratio of true positives and true negatives over the entire population) between the Quantra and the composite indexes was between 72% and 98% depending on the specific parameter. Linear regression analysis indicated that the correlation between ROTEM delta and Quantra was very strong with r values ranging between 0.84 and 0.89. Results from ROC analysis demonstrated sensitivities and specificities in the 80%–90% range when QPlus parameters were used to discriminate ROTEM threshold values currently used in goal-directed treatment algorithms. CONCLUSIONS: This study demonstrated that the Quantra QPlus System is strongly correlated with a well-established viscoelastic testing device and its parameters effectively represent the results from multiple standard laboratory assays. The Quantra has been designed to operate at the point of care with the potential to provide rapid and comprehensive results to aid in the management of coagulopathic patients. Accepted for publication December 26, 2019. Funding: This study was funded by HemoSonics, LLC. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). The statistical analysis plan for this study was developed and approved before initiation of the study. Data analysis was performed by Precision For Medicine (PFM) Bethesda, MD. Clinical trial number and registry URL: This study was registered under Clinical Trial number: NCT03152461, https://clinicaltrials.gov/ct2/show/NCT03152461. Reprints will not be available from the authors. Address correspondence to Francesco Viola, PhD, HemoSonics, LLC, 323 Foster St, Suite 300, Durham, NC 27701. Address e-mail to fviola@hemosonics.com. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2020 International Anesthesia Research Society

Regional Anesthesia in Cardiac Surgery: An Overview of Fascial Plane Chest Wall Blocks Optimal analgesia is an integral part of enhanced recovery after surgery (ERAS) programs designed to improve patients’ perioperative experience and outcomes. Regional anesthetic techniques in a form of various fascial plane chest wall blocks are an important adjunct to the optimal postoperative analgesia in cardiac surgery. The most common application of fascial plane chest wall blocks has been for minimally invasive cardiac surgical procedures. An abundance of case reports has been described in the anesthesia literature and reports appear promising, yet higher-level safety and efficacy evidence is lacking. Those providing anesthesia for minimally invasive cardiac procedures should become familiar with fascial plane anatomy and block techniques to be able to provide enhanced postsurgical analgesia and facilitate faster functional recovery and earlier discharge. The purpose of this review is to provide an overview of contemporary fascial plane chest wall blocks used for analgesia in cardiothoracic surgery. Specifically, we focus on relevant anatomic considerations and technical descriptions including pectoralis I and II, serratus anterior, pectointercostal fascial, transverse thoracic muscle, and erector spine plane blocks. In addition, we provide a summary of reported local anesthetic doses used for these blocks and a current state of the literature investigating their efficacy, duration, and comparisons with standard practices. Finally, we hope to stimulate further research with a focus on delineating mechanisms of action of novel emerging blocks, appropriate dosing regimens, and subsequent analysis of their effect on patient outcomes. Accepted for publication December 30, 2019. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Marta Kelava, MD, Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195. Address e-mail to kelavam@ccf.org. © 2020 International Anesthesia Research Society

Ambulatory Anesthesia, An Issue of Anesthesiology Clinics, Volume 37, Number 2 No abstract available

Use of a Novel Electronic Maternal Surveillance System and the Maternal Early Warning Criteria to Detect Severe Postpartum Hemorrhage BACKGROUND: A leading cause of preventable maternal death is related to delayed response to clinical warning signs. Electronic surveillance systems may improve detection of maternal morbidity with automated notifications. This retrospective observational study evaluates the ability of an automated surveillance system and the Maternal Early Warning Criteria (MEWC) to detect severely morbid postpartum hemorrhage (sPPH) after delivery. METHODS: The electronic health records of adult obstetric patients of any gestational age delivering between April 1, 2017 and December 1, 2018 were queried to identify scheduled or unscheduled vaginal or cesarean deliveries. Deliveries complicated by sPPH were identified and defined by operative management of postpartum hemorrhage, transfusion of ≥4 units of packed red blood cells (pRBCs), ≥2 units of pRBCs and ≥2 units of fresh-frozen plasma, transfusion with >1 dose of furosemide, or transfer to the intensive care unit. The test characteristics of automated pages and the MEWC for identification of sPPH 24 hours after delivery were determined and compared using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) and their 95% confidence intervals (CIs). McNemar test was used to compare these estimates for both early warning systems. RESULTS: The average age at admission was 30.7 years (standard deviation [SD] = 5.1 years), mean gestational age 38 weeks 4 days, and cesarean delivery accounted for 30.0% of deliveries. Of 7853 deliveries, 120 (1.5%) were complicated by sPPH. The sensitivity of automated pages for sPPH within 24 hours of delivery was 60.8% (95% CI, 52.1–69.6), specificity 82.5% (95% CI, 81.7–83.4), PPV 5.1% (95% CI, 4.0–6.3), and NPV 99.3% (95% CI, 99.1–99.5). The test characteristics of the MEWC for sPPH were sensitivity 75.0% (95% CI, 67.3–82.7), specificity 66.3% (95% CI, 65.2–67.3), PPV 3.3% (95% CI, 2.7–4.0), and NPV 99.4% (95% CI, 99.2–99.6). There were 10 sPPH cases identified by automated pages, but not by the MEWC. Six of these cases were identified by a page for anemia, and 4 cases were the result of vital signs detected by the bedside monitor, but not recorded in the patient’s medical record by the bedside nurse. Therefore, the combined sensitivity of the 2 systems was 83.3% (95% CI, 75.4–89.5). CONCLUSIONS: The automated system identified 10 of 120 deliveries complicated by sPPH not identified by the MEWC. Using an automated alerting system in combination with a labor and delivery unit’s existing nursing-driven early warning system may improve detection of sPPH. Accepted for publication November 25, 2019 Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Thomas T. Klumpner, MD, 1H247 University Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109. Address e-mail to klumpner@med.umich.edu. © 2020 International Anesthesia Research Society

Differential Diagnosis of Cardiopulmonary Disease: A Handbook No abstract available

Biochemistry for Anesthesiologists and Intensivists No abstract available

Decline of Pediatric Ambulatory Surgery Cases Performed at Florida General Hospitals Between 2010 and 2018: An Historical Cohort Study BACKGROUND: In the province of Ontario, nonphysiologically complex surgical procedures have increased at 4 pediatric hospitals with a reciprocal decline among the other (general) hospitals performing pediatric surgery. Given the differences between the Canadian and US health systems, we studied whether a similar shift occurred in the state of Florida and examined the age dependence of the shift. METHODS: We used outpatient pediatric surgery data from all nonfederal hospitals, hospital-owned facilities, and independent ambulatory surgery centers in Florida, 2010–2018. Inferential analyses were performed comparing 2010–2011 with 2017–2018. Annual caseloads are reported as cases per workday by dividing by 250 workdays per year. RESULTS: Statewide, comparing 2010–2011 with 2017–2018, among children 1–17 years, pediatric hospitals’ caseload increased overall by 50.7 cases per workday, overall meaning collectively among all hospitals combined. The caseload at general hospitals and ambulatory surgery centers, combined, decreased by 97.7 cases per workday. The general hospitals performed 54.7 fewer cases per workday. Among the 112 general hospitals, the mean pairwise decline was −0.49 cases per workday (99% confidence interval, −0.87 to −0.10; P < .0001). The changes were due to multiple categories of procedures, not just a few. Comparing 2010–2011 with 2017–2018, among 3 age cohorts (1–5, 6–12, and 13–17 years), the pediatric hospitals, statewide, performed overall 16.2, 15.1, and 19.3 more cases per workday, respectively. The general hospitals and ambulatory surgery centers, combined, performed fewer cases per workday for each cohort: 49.4, 21.4, and 26.9, respectively. The general hospitals overall performed fewer cases per workday for each cohort: 27.3, 12.1, and 15.4, respectively. Among general hospitals, the mean pairwise difference in the declines between patients 1–5 years vs 6–17 years was 0.00 cases per workday (99% confidence interval, −0.13 to +0.14). CONCLUSIONS: The decline across all age groups was inconsistent with multiple general hospitals increasing their minimum age threshold for surgical patients because, otherwise, the younger patients would have accounted for a larger share of the decreases in caseload. Pediatric hospitals and their anesthesiologists have greater surgical growth than expected from population demographics. Many general hospitals can expect either needing fewer pediatric anesthesiologists or that their pediatric anesthesiologists, who also care for adults, will have smaller proportions of pediatric patients in their practices. Accepted for publication January 6, 2020. Funding: Departmental. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Franklin Dexter, MD, PhD, FASA, Division of Management Consulting, Department of Anesthesia, University of Iowa, 200 Hawkins Dr, 6-JCP, Iowa City, IA 52242. Address e-mail to franklin-dexter@uiowa.edu. © 2020 International Anesthesia Research Society

The Future of Anesthesia Education: Developing Frameworks for Perioperative Medicine and Population Health No abstract available

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention Postoperative delirium is a geriatric syndrome that manifests as changes in cognition, attention, and levels of consciousness after surgery. It occurs in up to 50% of patients after major surgery and is associated with adverse outcomes, including increased hospital length of stay, higher cost of care, higher rates of institutionalization after discharge, and higher rates of readmission. Furthermore, it is associated with functional decline and cognitive impairments after surgery. As the age and medical complexity of our surgical population increases, practitioners need the skills to identify and prevent delirium in this high-risk population. Because delirium is a common and consequential postoperative complication, there has been an abundance of recent research focused on delirium, conducted by clinicians from a variety of specialties. There have also been several reviews and recommendation statements; however, these have not been based on robust evidence. The Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together a team of multidisciplinary experts to formally survey and evaluate the literature on postoperative delirium prevention and provide evidence-based recommendations using an iterative Delphi process and Grading of Recommendations Assessment, Development and Evaluation (GRADE) Criteria for evaluating biomedical literature. Accepted for publication December 13, 2019. Funding: The Perioperative Quality Initiative-6 consensus conference was supported by unrestricted educational grants from the American Society for Enhanced Recovery and the Perioperative Quality Initiative, which have received grants from Baxter, Bev MD, Cadence, Cheetah Medical, Edwards, Heron Pharmaceutical, Mallinckrodt, Masimo, Medtronic, Merck, Trevena, and Pacira. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). A full list of contributors can be found at the end of the article. Reprints will not be available from the authors. Address correspondence to Timothy E. Miller, MB, ChB, FRCA, Department of Anesthesiology, Duke University Medical Center, DUMC 3094, Durham, NC 27710. Address e-mail to timothy.miller2@duke.edu. © 2020 International Anesthesia Research Society

Lipid Emulsion Restoration of Myocardial Contractions After Bupivacaine-Induced Asystole In Vitro: A Benefit of Long- and Medium-Chain Triglyceride Over Long-Chain Triglyceride BACKGROUND: The relative efficacies of a long- and medium-chain triglyceride (LCT/MCT) emulsion and an LCT emulsion for treatment of bupivacaine (BPV)-induced cardiac toxicity are poorly defined. METHODS: After inducing asystole by BPV, varied concentrations (1%–12%) of either LCT/MCT (Lipofundin; B. Braun, Melsungen, Germany) or LCT emulsion (Intralipid; Fresenius Kabi, Upsala, Sweden) were applied to observe the recovery of stimulated contractile responses and contractile forces in either a recirculating or washout condition for 60 minutes, using guinea pig papillary muscles. The recirculation condition was used to demonstrate BPV binding by lipid emulsion. The washout condition was used to determine whether the time-dependent recovery of contraction is due to their metabolic enhancement. Oxfenicine, an inhibitor of carnitine palmitoyltransferase I in heart mitochondria, was used to evaluate the effect of each lipid emulsion on mitochondrial metabolic inhibition by BPV. To examine the effect of the lipid emulsion alone on contractility, either lipid emulsion was examined. BPV concentrations in solution and myocardial tissues were measured. RESULTS: In the recirculating condition, LCT/MCT emulsions (2%–12%) restored regular stimulated contractile responses in all muscles. Eight percent and 12% LCT/MCT emulsions led to complete recovery of contractile forces after 30 minutes. Meanwhile, LCT emulsions (4%–12%) did not restore regular stimulated contractile responses in some muscles (6, 3, and 2 in 9 muscles each in 4%, 8%, and 12% emulsions, respectively). Partial recovery, approximately 60%, of contractile forces was observed with 8% and 12% LCT emulsions. In the washout experiments, after asystole, LCT/MCT emulsions (1%–12%) restored contractility to baseline levels earlier and greater than LCT emulsion. Partial recovery, approximately 60%, was observed with a high concentration of LCT emulsion (12%). In the oxfenicine-pretreated group, the contractile recovery was enhanced with LCT/MCT emulsion but showed no change with LCT emulsion. Contractile depression by 40% was observed with high concentrations of LCT emulsion alone (8% and 12%), whereas no depression or enhanced contraction was observed with LCT/MCT emulsion (1%–12%) alone. Both types of lipid emulsions (2%–12%) caused concentration-related reductions of tissue BPV levels; LCT/MCT emulsions reduced tissue BPV levels slightly greater than LCT emulsion in a recirculating condition. CONCLUSIONS: An LCT/MCT emulsion was more beneficial than an LCT emulsion in terms of local anesthetic-binding and metabolic enhancement for treating acute BPV toxicity. The metabolic benefit of MCT, combined with the local anesthetic-binding effect of LCT, in an LCT/MCT emulsion may improve contractile function better than an LCT emulsion in an isolated in vitro animal myocardium model. Accepted for publication December 6, 2019. Funding: This study was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF), funded by the Ministry of Education, Science and Technology (NRF-2012R1A1A2003861), Seoul, Korea. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Wyun Kon Park, MD, Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Korea 03722. Address e-mail to wkp7ark@yuhs.ac. © 2020 International Anesthesia Research Society