Cardiac – Sleepy Time

22ff02 — From Anesthesiology: April 2016

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References

Cerebral oximetry. BJA Education, Volume 16, Issue 12, December 2016, Pages 417–421.

Cerebral oximetry in cardiac anesthesia. J Thorac Dis. 2014 Mar; 6(Suppl 1): S60–S69.

Cerebral oximetry and its role in adult cardiac, non-cardiac surgery and resuscitation from cardiac arrest. Anaesthesia, Volume72, IssueS1 Special Issue: Monitoring in the peri‐operative period; January 2017, Pages 48-57.

Prothrombin Complex Concentrate

PCC – StatPearls, Dec 2022.

PCC – Hosp Pharm. 2013 Dec; 48(11): 951–957.

PCC Dosing – Medscape

K Centra dosing calculator

Use of PCC – 2014? PCC Dosing – year?

Comparison of 4-Factor Prothrombin Complex Concentrate With Frozen Plasma for Management of Hemorrhage During and After Cardiac Surgery A Randomized Pilot Trial. JAMA Netw Open. 2021;4(4):e213936.

A European consensus statement on the use of four-factor prothrombin complex concentrate for cardiac and non-cardiac surgical patients. Anaesthesia, 76: 381-392. https://doi.org/10.1111/anae.15181

In the massively bleeding patient with coagulopathy, our group recommends the administration of an initial bolus of 25 IU.kg^-1. This applies for: the acute reversal of vitamin K antagonist therapy; haemostatic resuscitation, particularly in trauma; and the reversal of direct oral anticoagulants when no specific antidote is available.
In patients with a high risk for thromboembolic complications, e.g. cardiac surgery, the administration of an initial half-dose bolus (12.5 IU.kg^-1) should be considered.
A second bolus may be indicated if coagulopathy and microvascular bleeding persists and other reasons for bleeding are largely ruled out. Tissue-factor-activated, factor VII-dependent and heparin insensitive point-of-care tests may be used for peri-operative monitoring and guiding of prothrombin complex concentrate therapy.

Four-factor prothrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: a phase 3b, open-label, non-inferiority, randomised trial. The Lancet, Volume 385, Issue 9982, 2015, Pages 2077-2087,ISSN 0140-6736,https://doi.org/10.1016/S0140-6736(14)61685-8.

From Four-factor prothrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: a phase 3b, open-label, non-inferiority, randomised trial. The Lancet, Volume 385, Issue 9982, 2015, Pages 2077-2087,ISSN 0140-6736,https://doi.org/10.1016/S0140-6736(14)61685-8.

In summary:
For the endpoint of rapid INR reduction, the results from our trial are consistent with previously published (mainly observational) data and demonstrate that 4F-PCC is non-inferior and superior to plasma for rapid INR reduction in patients on VKA therapy.
Furthermore, we noted that 4F-PCC could be given more rapidly than plasma, which is in agreement with previously published (retrospectively collected) data.²⁴
For the endpoint of clinical efficacy, we found no other adequately powered trial examining reversal of VKA therapy in patients needing urgent surgical procedures, and this trial therefore offers new insights into their treatment. We noted that 4F-PCC was superior to plasma for haemostatic efficacy.
Although our study was not powered to assess safety, we did not detect any between-treatment differences for the occurrence of thromboembolic events or deaths, a finding in agreement with the existing scientific literature.11, 17, 25, 26 Additionally, although these data guide clinicians on how best to achieve urgent VKA reversal, the scientific literature concerning which patients should be urgently reversed before surgical or invasive interventions continues to evolve; for example, findings from a recent trial showed the safety of pacemaker placement without interruption of anticoagulation.²⁹

Efficacy and safety of a four-factor prothrombin complex concentrate (4F-PCC) in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation, 128 (2013), pp. 1234-1243.

From Efficacy and safety of a four-factor prothrombin complex concentrate (4F-PCC) in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation, 128 (2013), pp. 1234-1243.

Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest, 133 (2008), pp. 160S-198S

Among the key recommendations in this article are the following:
For dosing of VKAs, we recommend the initiation of oral anticoagulation therapy, with doses between 5 mg and 10 mg for the first 1 or 2 days for most individuals, with subsequent dosing based on the international normalized ratio (INR) response (Grade 1B); we suggest against pharmacogenetic-based dosing until randomized data indicate that it is beneficial (Grade 2C); and in elderly and other patient subgroups who are debilitated or malnourished, we recommend a starting dose of ≤ 5 mg (Grade 1C). The article also includes several specific recommendations for the management of patients with nontherapeutic INRs, with INRs above the therapeutic range, and with bleeding whether the INR is therapeutic or elevated.
For the use of vitamin K to reverse a mildly elevated INR, we recommend oral rather than subcutaneous administration (Grade 1A).
For patients with life-threatening bleeding or intracranial hemorrhage, we recommend the use of prothrombin complex concentrates or recombinant factor VIIa to immediately reverse the INR (Grade 1C).
For most patients who have a lupus inhibitor, we recommend a therapeutic target INR of 2.5 (range, 2.0 to 3.0) [Grade 1A].
We recommend that physicians who manage oral anticoagulation therapy do so in a systematic and coordinated fashion, incorporating patient education, systematic INR testing, tracking, follow-up, and good patient communication of results and dose adjustments [Grade 1B].
In patients who are suitably selected and trained, patient self-testing or patient self-management of dosing are effective alternative treatment models that result in improved quality of anticoagulation management, with greater time in the therapeutic range and fewer adverse events. Patient self-monitoring or self-management, however, is a choice made by patients and physicians that depends on many factors. We suggest that such therapeutic management be implemented where suitable (Grade 2B).

Guideline-concordant administration of prothrombin complex concentrate and vitamin K is associated with decreased mortality in patients with severe bleeding under vitamin K antagonist treatment (EPAHK study). Critical Care volume 18, Article number: R81 (2014).

In patients on VKA therapy presenting with severe hemorrhage, international guidelines recommend, as soon as the diagnosis is confirmed, the administration of PCC (≥20 UI/kg) and vitamin K (≥5 mg) to normalize coagulation (post-reversal INR ≤1.5).
A guideline-concordant administration dose of PCC and vitamin K administrated in the first eight hours was associated with a two-fold decrease in seven-day mortality overall and with a three-fold decrease in the ICH subgroup
The guideline-concordant reversal was performed in 38% of the patients within eight hours after admission
Whereas pre-reversal INR is not absolutely necessary, post-reversal INR is essential to evaluate treatment efficacy
The post-reversal INR target must be performed systematically and immediately after PCC administration

Pulmonary Hypertension

The case: Patient came in for laparoscopic colectomy. She had a history of severe COPD, newly diagnosed adenocarcinoma of colon, anemia (Hb 9), newly diagnosed ANCA vasculitis, h/o mitral stenosis s/p robotic mitral valve replacement, pulmonary HTN, severe TR, systemic HTN, normal EF. Patient had recent exacerbations of CHF with BNP in 1200s. Recent (within the last 3 months) history of coding on induction requiring chest compressions during robotic MVR (50mg propofol). On a steroid taper.

BPs 180-200s/90-110s; PAPs 40-60s/20-40s. 50kg.

Plan: aline, swan, R2, slow induction

Induction: fentanyl 50mcg, propofol 20mg, lidocaine 100mg, etomidate 10mg, roc 50mg. Gtt: epinephrine @ 0.02mcg/kg/min, norepinephrine @ 0.04mcg/kg/min. Milrinone arrived to OR after induction. Able to titrate off epinephrine to Milrinone 0.3mcg/kg/min even with insufflation of abdomen. Did not need to decrease insufflation pressures as hemodynamics were relatively stable.

Extubated safely at the end of the case. Received 100mcg fentanyl, 20mg ketamine, Exparel TAP block, pre-op PO Tylenol 1000mg for pain control. She’s doing well and pleased with her anesthetic management.

From Mayo Clinic: Pulmonary Hypertension

What is Pulmonary Hypertension?

Medscape: Perioperative Pulmonary Hypertension

Cardiovascular and Ventilatory Consequences of Laparoscopic Surgery. Circulation; Vol 135, no. 7. Feb 2017.

The Physiologic Effects of Pneumoperitoneum in the Morbidly Obese. Ann Surg. 2005 Feb; 241(2): 219–226.

Impairment of Cardiac Performance by Laparoscopy in Patients Receiving Positive End-Expiratory Pressure. Arch Surg. 1999;134(1):76-80.

The effect of pulmonary hypertension on inpatient outcomes of laparoscopic procedures. Updates Surg. 2018 Dec; 70(4):521-528.

Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement. BJA; Volume 126, Issue 4, April 2021, Pages 774-790. PDF

From Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement. BJA; Volume 126, Issue 4, April 2021, Pages 774-790.

Laparoscopic Cholecystectomy with Pulmonary Hypertension: Anaesthetic Challenges – A Case Report. Indian Journal of Anaesthesia 52(2):p 217-220, Mar–Apr 2008.

Anesthesia for a Patient with Severe Pulmonary Hypertension Undergoing Laparoscopic Cholecystectomy: A Case Report. Zhou et al., J Pulm Respir Med 2017, 7:2

Heparin and Hypotension

Healthy appearing patient with afib s/p ablation and returning for repeat ablation for recurrent afib. Anesthesia induced normally and patient VSS. 3 minutes after a request of a heparin bolus, patient dropped their SBP into the upper 40s, lower 50s. Patient recovered well after small bolus of epinephrine. ICE used to rule out pericardial effusion as well as confirm normal LVEF and RVEF.

The hemodynamic effects of heparin and their relation to ionized calcium levels. J THoRAc CARDIOVASC SURG 91:303-306, 1986.

Histamine blockade and cardiovascular changes following heparin administration during cardiac surgery. J Cardiothorac Anesth . 1990 Dec;4(6):711-4.

Heparin-Mediated Hypotension Associated with Cardiac Surgery. Anesthesia & Analgesia: September 2000 – Volume 91 – Issue 3 – p 766-767.

Preoperative Heparin Therapy Causes Immune-Mediated Hypotension Upon Heparin Administration for Cardiac Surgery. Journal of Cardiothoracic and Vascular Anesthesia. Volume 24, Issue 1, February 2010, Pages 69-72.

Prediction of heparin induced hypotension during cardiothoracic surgery: A retrospective observational study. Anaesth pain & intensiv care 2019;23(2):145-150.

Angiotensin Receptor Blocker (ARB) Reversal

From Angiotensin Axis Blocking Drugs In the Perioperative Period. Anesthesiology News, Feb 2016

What does an angiotensin receptor blocker (ARB) do?

Angiotensin II receptor blockers (ARBs) represent a newer class of effective and well tolerated antihypertensive agents ¹. Several clinical studies have indicated the beneficial effects of ARBs in hypertensive patients such as reduction of left ventricular hypertrophy, decrease in ventricular arrhythmias, and improved diastolic function ¹. Inhibitors of the renin-angiotensin system (RAS), either angiotensin converting enzyme (ACE) inhibitors or ARBs, mediate vasodilation and consequently decrease blood-pressure by different mechanisms ¹. ARBs specifically inhibit angiotensin II from binding to its receptor, the Angiotensin-1 (AT ₁) receptor on vascular smooth muscle cells. This blockade results in increased angiotensin II and normal bradykinin plasma levels. ARBs were developed to overcome several deficiencies of ACE inhibitors, which, by comparison, lead to decreased angiotensin II, but increased bradykinin levels. Hence, the key advantage of ARBs over ACE inhibitors is their lack of adverse effects related to bradykinin potentiation. ARBs have been shown to reduce morbidity and mortality associated with hypertension, and therefore, it is not surprising that an increasing number of patients scheduled for surgery are chronically treated with ARBs ². However, RAS blockade increases the risk of severe hypotension during and after anesthetic induction. ACE-inhibitors are well known for inducing severe circulatory side effects during anesthesia, which led to the general recommendation to withhold the drug on the day of surgery ³.
Refractory hypotension during general anesthesia despite preoperative discontinuation of an angiotensin receptor blocker. F1000Research 2013, 2:12.

Comparison of Angiotensin‐Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Management Strategies Before Cardiac Surgery: A Pilot Randomized Controlled Registry Trial. Journal of the American Heart Association. 2018;7:e009917.

Consequences of continuing renin angiotensin aldosterone system antagonists in the preoperative period: a systematic review and meta-analysis. BMC Anesthesiol. 2018 Feb 26;18(1):26.

How do I reverse an ARB in an emergency?

Chronic AT ₁ blockade also reduces the vasoconstrictor response to α ₁ receptors activated by norepinephrine, which explains why ARB-induced hypotension can be so resistant to phenylephrine, ephedrine and norepinephrine ^{2, 8} Clinical studies have shown significant vasoconstrictor effects of vasopressin and increased cardiac filling during echocardiographic measurements ².
Vasopressin or its synthetic analogues can restore the sympathetic response and may be useful pressors in cases of refractory hypotension during anaphylaxis ⁹ and septic shock ¹⁰ as well as in patients on RAS inhibitors, although norepinephrine has been reported to have a more favorable effect on splanchnic perfusion and oxygen delivery ¹¹.
Refractory hypotension during general anesthesia despite preoperative discontinuation of an angiotensin receptor blocker. F1000Research 2013, 2:12.

Angiotensin Axis Blocking Drugs In the Perioperative Period. Anesthesiology News, Feb 2016.

When conventional therapies such as: decreasing the anesthetic agent, volume expansion, phenylephrine, ephedrine, norepinephrine, and epinephrine are not effective, exogenous vasopressin may improve hypotension. To date, at least 5 clinical trials have demonstrated that patients on chronic ACEI/ARB undergoing general anesthesia, respond to exogenous vasopressin derivatives with an increase in blood pressure and fewer hypotensive episodes.^6,7 Typically, a 0.5-1 unit bolus of AVP is administered to achieve a rise in mean arterial pressure.⁴ The subsequent recommended infusion dose is 0.03U/min for AVP and 1-2 mcg/kg/h for terlipressin. Caution should be used as V1 agonists have been associated with the following deleterious effects: reduction in cardiac output and systemic oxygen delivery, decreased platelet count, increased serum aminotransferases and bilirubin, hyponatremia, increased pulmonary vascular resistance, decrease in renal blood flow, increase in renal oxygen consumption, and splanchnic vasoconstriction.
Studies involving cardiac surgical patients suggest that MB treatment for patients with VS may reduce morbidity and mortality.⁵ It has also been suggested that the early use (preoperative use in patients at risk for VS) of MB in patients undergoing coronary artery bypass grafting may reduce the incidence of VS.5,9A bolus dose of 1-2mg/kg over 10-20 minutes followed by an infusion of 0.25mg/kg/hr for 48-72 hours is typically utilized in clinical practice and trials (with a maximum dose of 7 mg/kg).¹⁰ Side effects include cardiac arrhythmias (transient), coronary vasoconstriction, increased pulmonary vascular resistance, decreased cardiac output, and decreased renal and mesenteric blood flow.¹ Both pulse and cerebral oximeter readings may not be reliable during MB administration due to wavelength interference.^11,12 The use of MB is absolutely contraindicated in patients with severe renal impairment because it is primarily eliminated by the kidney.¹³ It may also cause methemoglobinemia and hemolysis.¹³ At high doses, neurotoxicity may occur secondary to the generation of oxygen free radicals. Neurologic dysfunction may be more severe in patients receiving serotoninergic agents such as: tramadol, ethanol, antidepressants, dopamine agonists and linezolid. Recommended doses for VS ranging from 1-3 mg/kg do not typically cause neurologic dysfunction.¹⁴ However, recent reports suggest that MB in doses even ≤ 1mg/kg in patients taking serotonin reuptake inhibitors (SSRIs) may lead to serotonin toxicity due to its monoamine oxidase (MAO) inhibitor property.¹⁵

Vasoplegic Syndrome and Renin-Angiotensin System Antagonists. APSF Newsletter, Circulation 94,429 • Volume 27, No. 1 • Summer-Spring 2012 .

Vasopressin for persistent hypotension due to amlodipine and olmesartan overdose: A case report. Ann Med Surg (Lond). 2021 May; 65: 102292.

Vasoplegic syndrome following cardiothoracic surgery—review of pathophysiology and update of treatment options. Crit Care. 2020; 24: 36.

Refractory hypotension during general anesthesia despite preoperative discontinuation of an angiotensin receptor blocker. F1000Research 2013, 2:12.

Terlipressin for refractory hypotension following angiotensin-II receptor antagonist overdose. Anaesthesia, 2006,61, pages 402–414.

Angiotensin II for the Treatment of Vasodilatory Shock. N Engl J Med. 2017 Aug 3;377(5):419-430.

Vasopressin: physiology and clinical use in patients with vasodilatory shock: a review. Neth J Med. 2005 Jan;63(1):4-13.

Treatment of intraoperative refractory hypotension with terlipressin in patients chronically treated with an antagonist of the renin-angiotensin system. Anesth Analg. 1999 May;88(5):980-4.

Role of vasopressinergic V1 receptor agonists in the treatment of perioperative catecholamine-refractory arterial hypotension. Best Pract Res Clin Anaesthesiol. 2008 Jun;22(2):369-81.

Predicting response to methylene blue for refractory vasoplegia following cardiac surgery. Pharmacotherapy Conference: 2013 American College of Clinical Pharmacy Annual Meeting. October 2013.

Exparel

Liposomal bupivacaine (Exparel) is a longer acting form of traditional bupivacaine that delivers the drug by means of a multivesicular liposomal system.

Exparel FDA drug sheet

Max Dose: 266 mg or 4mg/kg (6yo-17yo). Interscalene NB max dose (adults) =133mg

Exparel dosing company info: Pocket Dosing Guide , Billing Guide

Liposomal bupivacaine: a review of a new bupivacaine formulation. J Pain Res. 2012; 5: 257–264.

Emerging roles of liposomal bupivacaine in anesthesia practice. J Anaesthesiol Clin Pharmacol. 2017 Apr-Jun; 33(2): 151–156.

Liposomal bupivacaine peripheral nerve block for the management of postoperative pain. Cochrane Database Syst Rev. 2016 Aug 25;2016(8):CD011476.

Liposomal bupivacaine infiltration at the surgical site for the management of postoperative pain. Cochrane Database Syst Rev. 2017 Feb; 2017(2): CD011419.

Novel Local Anesthetics in Clinical Practice: Pharmacologic Considerations and Potential Roles for the Future. Anesth Pain Med. 2022 Feb; 12(1): e123112.

Cardiac/Thoracic

The role of liposomal bupivacaine in thoracic surgery. J Thorac Dis. 2019 May; 11(Suppl 9): S1163–S1168.

Intercostal nerve blockade for thoracic surgery with liposomal bupivacaine: the devil is in the details. J Thorac Dis. 2019 May; 11(Suppl 9): S1202–S1205.

VATs: Dilute liposomal bupivacaine (266 mg, 20 cc) mixed with 20 cc injectable saline. We use two syringes to save time (refill syringe between injections).
For planned thoracotomy, we add 60 cc injectable saline for wider injection.
The efficacy of this strategy requires attention to specific details, such as timing and technique of injection, dilution with saline, and injection of multiple interspaces (typically interspaces 3–10 when technically possible).
Inject EXPAREL slowly and deeply (generally 1-2 mL per injection) into soft tissues using a moving needle technique (ie, inject while withdrawing the needle)
Infiltrate above and below the fascia and into the subcutaneous tissue
Aspirate frequently to minimize the risk of intravascular injection
Use a 25-gauge or larger-bore needle to maintain the structural integrity of the liposomal particles
Inject frequently in small areas (1-1.5 cm apart) to ensure overlapping analgesic coverage

Liposomal Bupivacaine Versus Bupivacaine for Intercostal Nerve Blocks in Thoracic Surgery: A Retrospective Analysis. Pain Physician. 2020 Jun;23(3):E251-E258.

Intercostal Blocks with Liposomal Bupivacaine in Thoracic Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth. 2021 May;35(5):1404-1409.

Is liposomal bupivacaine superior to standard bupivacaine for pain control following minimally invasive thoracic surgery? Interactive CardioVascular and Thoracic Surgery, Volume 31, Issue 2, August 2020, Pages 199–203, https://doi.org/10.1093/icvts/ivaa083

Paravertebral Nerve Block With Liposomal Bupivacaine for Pain Control Following Video-Assisted Thoracoscopic Surgery and Thoracotomy. J Surg Res. 2020 Feb;246:19-25.

Rib fractures case report: ESP block

Evaluation of an Enhanced Recovery After Surgery Protocol Including Parasternal Intercostal Nerve Block in Cardiac Surgery Requiring Sternotomy. Am Surg. 2021 Dec;87(10):1561-1564.

Ultrasound-guided Modified Parasternal Intercostal Nerve Block: Role of Preemptive Analgesic Adjunct for Mitigating Poststernotomy Pain. Anesth Essays Res. 2020 Apr-Jun; 14(2): 300–304.

Comparison of preincisional and postincisional parasternal intercostal block on postoperative pain in cardiac surgery. J Card Surg. 2020 Jul;35(7):1525-1530.

Ultrasound-guided parasternal intercostal nerve block for postoperative analgesia in mediastinal mass resection by median sternotomy: a randomized, double-blind, placebo-controlled trial. BMC Anesthesiol. 2021; 21: 98.

Pain Relief Following Sternotomy in Conventional Cardiac Surgery: A Review of Non Neuraxial Regional Nerve Blocks. Ann Card Anaesth. 2020 Apr-Jun; 23(2): 200–208.

A Novel Use of Liposomal Bupivacaine in Erector Spinae Plane Block for Pediatric Congenital Cardiac Surgery. Case Rep Anesthesiol. 2021; 2021: 5521136.

Breast/Gen Surg

Evaluating the Efficacy of Two Regional Pain Management Modalities in Autologous Breast Reconstruction. Plast Reconstr Surg Glob Open. 2022 Jan 19;10(1):e4010.

Perioperative Blocks for Decreasing Postoperative Narcotics in Breast Reconstruction. Anesth Pain Med. 2020 Oct; 10(5): e105686.

Opioid-sparing Strategies in Alloplastic Breast Reconstruction: A Systematic Review. Plast Reconstr Surg Glob Open. 2021 Nov 16;9(11):e3932.

Comparison of the efficacy of erector spinae plane block performed with different concentrations of bupivacaine on postoperative analgesia after mastectomy surgery: ramdomized, prospective, double blinded trial. BMC Anesthesiol. 2019; 19: 31.

Efficacy of liposomal bupivacaine versus bupivacaine in port site injections on postoperative pain within enhanced recovery after bariatric surgery program: a randomized clinical trial. Surg Obes Relat Dis. 2019 Sep;15(9):1554-1562.

The use of extended release bupivacaine with transversus abdominis plane and subcostal anterior quadratus lumborum catheters: A retrospective analysis of a novel technique. J Anaesthesiol Clin Pharmacol. 2020 Jan-Mar; 36(1): 110–114.

Ortho

Pain Control and Functional Milestones in Total Knee Arthroplasty: Liposomal Bupivacaine versus Femoral Nerve Block. Clin Orthop Relat Res. 2017 Jan;475(1):110-117.

OB

Transversus Abdominis Plane Block With Liposomal Bupivacaine for Pain After Cesarean Delivery in a Multicenter, Randomized, Double-Blind, Controlled Trial. Anesth Analg. 2020 Dec; 131(6): 1830–1839.

Fascia Iliaca blocks for TAVR under conscious sedation

Editorial: The use of Fascia iliaca Block with Minimal Conscious Sedation in Transcatheter Aortic Valve Replacement: Advances in TAVR Anesthesia. Cardiovasc Revasc Med. 2020 May;21(5):602-603. doi: 10.1016/j.carrev.2020.03.017.

Local Anesthesia-Conscious Sedation: The Contemporary Gold Standard for Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv. 2018 Mar 26;11(6):579-580. doi: 10.1016/j.jcin.2018.01.238.

Transfemoral Transcatheter Aortic Valve Replacement Using Fascia Iliaca Block as an Alternative Approach to Conscious Sedation as Compared to General Anesthesia. Cardiovasc Revasc Med. 2020 May;21(5):594-601. doi: 10.1016/j.carrev.2019.08.080. Epub 2019 Sep 7.

**NYSORA U/S guided Fascia Iliaca nerve block**

TCT-808 Transfemoral Transcatheter Aortic Valve Replacement Using Fascia Iliaca Block as an Alternative Approach to Conscious Sedation as Compare to General Anesthesia: Findings From a Single Center. J Am Coll Cardiol. 2019 Oct, 74 (13_Supplement) B792

Handoffs in Medicine

Patient safety is crucial for the delivery of effective, high-quality healthcare¹ and is defined by the World Alliance for Patient Safety of WHO as ‘the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum’. The practice and delivery of healthcare is argued to be fundamentally and critically dependent on effective and efficient communication. Depending on physicians’ needs and responsibilities, handoff content will vary, requiring customization by individual physician groups; there is no “one size fits all” content.