Cardiac Arrest in the OR

Cardiac Arrest in the Operating Room:  Resuscitation and Management for the Anesthesiologist Part 1

Moitra, Vivek K.; Einav, Sharon; Thies, Karl-Christian; Nunnally, Mark E.; Gabrielli, Andrea; Maccioli, Gerald A.; Weinberg, Guy; Banerjee, Arna; Ruetzler, Kurt; Dobson, Gregory; McEvoy, Matthew D.; O’Connor, Michael F.

Anesthesia & Analgesia126(3):876-888, March 2018.


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Cardiac anesthesiologists and LVAD patients: Pro vs Cons

There’s been a big debate re: who should care for LVAD patients… a general anesthesiologist or a cardiac anesthesiologist?  See below for pros and cons of each.  Ultimately, I think all anesthesiologists should be comfortable caring for these patients as we’ll see more and more LVAD patients undergoing procedures.

Troubleshooting the Left Ventricular Assist Device.  Emergency Medicine. 2016 February;48(2):58-63.

RTEmagicC_em048020061_t1.jpg
From Emergency Medicine, Feb 2016.
LVAD Parameter Abnormalities:
  • High power, low-pulsatility index and fluctuating pump speed: Consider pump thrombosis or hypotension, vasodilation, initial response to exercise.
  • High power with high pulsatility index: Consider fluid overload, normal physiological response to increased demand; myocardial recovery.
  • Low power, low pulsatility index, and unchanging speed: Consider hypertension or inflow/outflow obstruction, LV failure, dysrhythmia.
  • Low power with normal or high pulsatility index: Consider suction event.

Pro: Cardiothoracic Anesthesiologists Should Provide Anesthetic Care for Patients With Ventricular Assist Devices Undergoing Noncardiac Surgery. JCVA, February 2017. Volume 31, Issue 1, Pages 378–381

Con: Cardiothoracic Anesthesiologists Are Not Necessary for the Management of Patients With Ventricular Assist Devices Undergoing Noncardiac Surgery. JCVA, February 2017. Volume 31, Issue 1, Pages 382–387.


VAD-2
From LifeInTheFastLane.com

Ventricular assist devices and non-cardiac surgery.  BMC Anesthesiology201515:185

  • Goals of care for LVAD patients undergoing non-cardiac surgery should be directed at maintaining forward flow and adequate perfusion. Three main factors that affect LVAD flow are preload, RV function, and afterload.
  • The right ventricle is the primary means of LVAD filling; therefore, maintaining RV function is imperative.
  • Marked increases in systemic vascular resistance should be avoided.
  • Generally, decreases in pump flow should first be treated with a fluid challenge. Hypovolemia should be avoided and intraoperative losses should be replaced aggressively. Second line treatment should include inotropic support for the right ventricle.
  • Low-dose vasopressin (<2.4 U/h) may be the vasopressor of choice due to its minimal effect on pulmonary vascular resistance.
  • Standard Advanced Cardiovascular Life Support Guidelines should be followed; however, external chest compressions should be avoided during cardiac arrest.
  • Steep Trendelenburg may increase venous return, risking RV strain. Peritoneal insufflation for laparoscopic surgery also increases afterload and has detrimental effects on preload.  Insufflation should utilize minimum pressures and be increased in a gradual, step-wise fashion.
  • TEE can be extremely valuable in diagnosing the cause of obstruction.

Perioperative management of patients with left ventricular assist devices undergoing noncardiac surgery. Annals of cardiac anaesthesia 2016. Vol 19, Issue 4: 676-686.

LVAD: What Should I report? Feb 2017 ASE conference. **ECHO**

  • Higher the RPMs (pump speed)
    • More LV compression, smaller LV size
    • Less functional MR
    • More AI, less AV opening
    • Less LVED diameter
  • De Novo Aortic Regurgitation Post LVAD
    • Proposed mechanisms
      • Aortic valve remains closed during systole
      • Commissural fusion of the aortic valve from disuse
      • Subsequent degeneration of valve
      • Turbulent blood backflow from small outflow cannula onto a closed valve
      • Persistent elevation of aortic root pressure –> aortic root dilation and valve incompetence
    • Treatment
      • Lower LVAD speed (but that may worsen mitral regurgitation)
      • Aortic valve surgery or percutaneous intervention
      • Heart transplant
  • RV Fractional Area Change (RV FAC)
    • RVFAC is a rough measure of RV systolic function (4 chamber view)
    • RVFAC = (RVEDA – RVESA) / RVEDA
    • Normal RVFAC = 35 – 63%

Ventricular Assist Device (VAD). LifeInTheFastLane.com. .

Care of the LVAD patient PPT. Summit 2014.

  • Pulsatility Index:
    • —normally decrease as pump speed is increased

LVAD: Understanding equipment and Alarms. Duke Heart Center PPT.

LVAD Management in the ICU. Crit Care Med 2014; 42:158–168. 

Screen Shot 2018-11-26 at 11.20.26 AM
From Left Ventricular Assist Device Management in the ICU Pratt, Alexandra K. MD1; Shah, Nimesh S. MD1; Boyce, Steven W. MD2 Critical Care Medicine: January 2014 – Volume 42 – Issue 1 – p 158–168 doi: 10.1097/01.ccm.0000435675.91305.76 Concise Definitive Review
Screen Shot 2018-11-26 at 11.20.47 AM
Left Ventricular Assist Device Management in the ICU Pratt, Alexandra K. MD1; Shah, Nimesh S. MD1; Boyce, Steven W. MD2 Critical Care Medicine: January 2014 – Volume 42 – Issue 1 – p 158–168 doi: 10.1097/01.ccm.0000435675.91305.76 Concise Definitive Review

 

Anesthesia for Left Ventricular Assist Device Insertion: A Case Series and Review. Ochsner J. 2011 Spring; 11(1): 70–77.

Medical Management of Patients With Continuous-Flow Left Ventricular Assist Devices. Curr Treat Options Cardiovasc Med. 2014 Feb; 16(2): 283.

 


My blog posts:

HeartWare vs. HeartMate LVAD

Ventricular Assist Devices: Impella

Neuraxial anesthesia and External Cephalic Version

ACOG: If Your Baby is Breech

What is an external cephalic version?

External-Cephalic-Version
From Pregmed.org

Wikipedia: external cephalic version


Randomized trial of anaesthetic interventions in external cephalic version for breech presentation. British Journal of Anaesthesia 114 (6): 944–50 (2015)

  • Conclusions: Spinal Anesthesia (SA: hyperbaric bupivacaine 9mg + fentanyl 15mcg) increased the success rate and reduced pain for both primary and re-attempts of External Cephalic Version (ECV), whereas IV Anesthesia (IVA) using remifentanil infusion (0.1mcg/kg/min) only reduced the pain. There was no significant increase in the incidence of fetal bradycardia or emergency CS, with ECV performed under anaesthetic interventions. Relaxation of the abdominal muscles from SA appears to underlie the improved outcomes for ECV.
  • Editor’s key points: There is no consensus on best anaesthetic technique for external cephalic version (ECV).  In this study, success at ECV was higher using spinal anaesthesia compared with remifentanil infusion or no intervention.  Pain was also reduced in the remifentanil group but success at ECV was no different to the no intervention group.  The effect of spinal anaesthesia in ECV may relate to relaxation of the abdominal musculature.

Neuraxial blockade for external cephalic version: Cost analysis. J Obstet Gynaecol Res. 2015 Jul; 41(7): 1023–1031.

  • Neuraxial blockade is associated with minimal hospital and insurer cost changes in the setting of external cephalic version, while reducing the cesarean delivery rate.

External cephalic version with or without spinal anesthesia: a cost-effectiveness analysis.  American Journal of Obstetrics and Gynecology, January 2016Volume 214, Issue 1, Supplement, Pages S206–S207.  

  • It is both effective and cost-effective to utilize spinal anesthesia to perform ECV in term, nulliparous women with breech fetuses. Translation of this potentially impactful approach into broad obstetric practice should be undertaken.

Effect of Regional Anesthesia on the Success Rate of External Cephalic Version: A Systematic Review and Meta-Analysis. Obstet Gynecol. 2011 Nov; 118(5): 1137–1144.

  • Six RCTs met criteria for study inclusion. Regional anesthesia was associated with a higher external cephalic version success rate compared to intravenous or no analgesia (59.7% vs. 37.6%; pooled RR 1.58, 95% confidence interval [CI] 1.29-1.93). This significant association persisted when the data was stratified by type of regional anesthesia (spinal vs. epidural). The number needed to treat with regional anesthesia to achieve one additional successful ECV was 5. There was no evidence of statistical heterogeneity (p=0.32, I2=14.9%) or publication bias (Harbord test p=0.78). There was no statistically significant difference in the risk of cesarean delivery comparing regional anesthesia to intravenous or no analgesia (48.4% vs. 59.3%; pooled RR 0.80, 95% CI 0.55-1.17). Adverse events were rare and not significantly different between the two groups.

Does Regional Anesthesia for External Cephalic Version Increase the Risk of Emergent Cesarean Delivery? Obstetrics & Gynecology: May 2016

  • Neuraxial Anesthesia (NA) for External Cephalic Version (ECV) increased the risk of emergent cesarean delivery (CD) without impacting ECV success. These findings differ from previous randomized controlled trials (RCTs). The increased risk and decreased success of our ECVs compared to ECVs performed in the context of RCTs could be explained by patient selection, variation in operator experience or technique, or variation in anesthetic management.  Future studies should further evaluate the risk of NA for ECV in true practice scenarios outside of RCTs.

Clinical outcomes after external cephalic version with spinal anesthesia after failure of a first attempt without anesthesia.  International Journal of Obstetrics & Gynecology. Volume139, Issue3. December 2017: 324-328.

  • Repeat ECV with spinal anesthesia after a failed first attempt without spinal anesthesia increased vertex presentation at birth and decreased the rate of cesarean delivery.

Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial. Anesthesiology 10 2017, Vol.127, 625-632.

  • Results: A total of 240 subjects were enrolled, and 239 received the intervention. External cephalic version was successful in 123 (51.5%) of 239 patients. Compared with bupivacaine 2.5 mg, the odds (99% CI) for a successful version were 1.0 (0.4 to 2.6), 1.0 (0.4 to 2.7), and 0.9 (0.4 to 2.4) for bupivacaine 5.0, 7.5, and 10.0 mg, respectively (P = 0.99). There were no differences in the cesarean delivery rate (P = 0.76) or indication for cesarean delivery (P = 0.82). Time to discharge was increased 60 min (16 to 116 min) with bupivacaine 7.5 mg or higher as compared with 2.5 mg (P = 0.004).
  • Conclusions: A dose of intrathecal bupivacaine greater than 2.5 mg does not lead to an additional increase in external cephalic procedural success or a reduction in cesarean delivery.