RESUMEN
Intraprocedural transesophageal echocardiography imaging is an integral part of percutaneous structural heart disease (SHD) interventions. The rapid growth in the number, scope, and complexity of SHD interventions has outpaced the efforts to develop training and proficiency standards in periprocedural imaging. At the Beth Israel Deaconess Medical Center in Boston, Massachusetts, the authors have developed a 6-month duration fellowship in interventional echocardiography for SHD to address this issue. The purpose of this fellowship is to train cardiac anesthesiologists to address the unique challenges of interventional echocardiography. In this paper, the authors describe the rationale for and specific features of this training program. Their fellowship curriculum follows a multimodal integrative approach to training in SHD imaging, which includes simulation sessions, online modules, deliberate practice in the clinical setting, and interdisciplinary team-based training. In the next several years, there will be an increased need for echocardiographers who are proficient in intraprocedural SHD imaging. In this article, the authors describe their experience with a competency-based curriculum for subspecialty anesthesia training in SHD imaging.
Asunto(s)
Anestesia , Cardiopatías , Internado y Residencia , Adulto , Curriculum , Ecocardiografía Transesofágica , Cardiopatías/diagnóstico por imagen , HumanosRESUMEN
OBJECTIVE: To describe the current nationwide perspectives and practice regarding intraoperative oxygen titration in cardiac surgery. DESIGN: Prospective, observational survey. SETTING: Hospitals across the United States. PARTICIPANTS: Cardiovascular anesthesiologists and perfusionists. INTERVENTIONS: Expert- and consensus-derived electronic surveys were sent to perfusionists and cardiac anesthesiologists to evaluate the current intraoperative practices around oxygen administration. Providers were asked about individual intraoperative oxygen titration practices used at different stages of cardiac surgical procedures. Anonymous responses were collected in the Research Electronic Data Capture (REDCap). MEASUREMENTS AND MAIN RESULTS: A total of 3,335 providers were invited to participate, of whom 554 (317 anesthesiologists and 237 perfusionists) were included in the final analysis (17% response rate). During cardiopulmonary bypass (CPB), perfusionists reported a median (interquartile range [IQR]) target range from 150 (110-220)-to-325 mmHg (250-400), while anesthesiologists reported a significantly lower target range from 90 (70-150)-to-250 mmHg (158-400) (p values <0.0001 and 0.02, respectively). This difference was most pronounced at lower partial pressure of arterial oxygen (PaO2) ranges. The median PaO2 considered "too low" by perfusionists was 100 mmHg (IQR 80-125), whereas it was 60 mmHg (IQR 60-75) for anesthesiologists, who reported for both off and on bypass. The median PaO2 considered "too high" was 375 mmHg (IQR 300-400) for perfusionists and 300 mmHg (IQR 200-400) for anesthesiologists. Anesthesiologists, therefore, reported more comfort with significantly lower PaO2 values (p < 0.0001), and considered a higher PaO2 value less desirable compared with perfusionists (p < 0.0001). CONCLUSIONS: This survey demonstrated there was wide variation in oxygen administration practices between perfusionists and anesthesiologists. Hyperoxygenation was more common while on CPB.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Cirugía Torácica , Procedimientos Quirúrgicos Cardíacos/métodos , Puente Cardiopulmonar/métodos , Humanos , Oxígeno , Estudios ProspectivosRESUMEN
PURPOSE: Limited data are available on venovenous extracorporeal membrane oxygenation (ECMO) in patients with severe hypoxemic respiratory failure from coronavirus disease 2019 (COVID-19). METHODS: We examined the clinical features and outcomes of 190 patients treated with ECMO within 14 days of ICU admission, using data from a multicenter cohort study of 5122 critically ill adults with COVID-19 admitted to 68 hospitals across the United States. To estimate the effect of ECMO on mortality, we emulated a target trial of ECMO receipt versus no ECMO receipt within 7 days of ICU admission among mechanically ventilated patients with severe hypoxemia (PaO2/FiO2 < 100). Patients were followed until hospital discharge, death, or a minimum of 60 days. We adjusted for confounding using a multivariable Cox model. RESULTS: Among the 190 patients treated with ECMO, the median age was 49 years (IQR 41-58), 137 (72.1%) were men, and the median PaO2/FiO2 prior to ECMO initiation was 72 (IQR 61-90). At 60 days, 63 patients (33.2%) had died, 94 (49.5%) were discharged, and 33 (17.4%) remained hospitalized. Among the 1297 patients eligible for the target trial emulation, 45 of the 130 (34.6%) who received ECMO died, and 553 of the 1167 (47.4%) who did not receive ECMO died. In the primary analysis, patients who received ECMO had lower mortality than those who did not (HR 0.55; 95% CI 0.41-0.74). Results were similar in a secondary analysis limited to patients with PaO2/FiO2 < 80 (HR 0.55; 95% CI 0.40-0.77). CONCLUSION: In select patients with severe respiratory failure from COVID-19, ECMO may reduce mortality.
Asunto(s)
COVID-19/terapia , Oxigenación por Membrana Extracorpórea , Síndrome de Dificultad Respiratoria/terapia , Adulto , COVID-19/complicaciones , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Síndrome de Dificultad Respiratoria/virología , Resultado del TratamientoRESUMEN
The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented stresses on modern medical systems, overwhelming the resource infrastructure in numerous countries while presenting a unique series of pathophysiologic clinical findings. Thrombotic coagulopathy is common in critically ill patients suffering from COVID-19, with associated high rates of respiratory failure requiring prolonged periods of mechanical ventilation. Here, we report a case series of five patients suffering from profound, medically refractory COVID-19-associated respiratory failure who were treated with fibrinolytic therapy using tissue plasminogen activator (tPA; alteplase). All five patients appeared to have an improved respiratory status following tPA administration: one patient had an initial marked improvement that partially regressed after several hours, one patient had transient improvements that were not sustained, and three patients had sustained clinical improvements following tPA administration. LEVEL OF EVIDENCE: Therapeutic, Level V.
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Betacoronavirus , Infecciones por Coronavirus/complicaciones , Enfermedad Crítica/terapia , Neumonía Viral/complicaciones , Respiración Artificial/métodos , Insuficiencia Respiratoria/terapia , Terapia Trombolítica/métodos , Activador de Tejido Plasminógeno/uso terapéutico , Adulto , Anciano , COVID-19 , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/terapia , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/epidemiología , Neumonía Viral/terapia , Insuficiencia Respiratoria/etiología , SARS-CoV-2Asunto(s)
Calcinosis/diagnóstico por imagen , Cardiomiopatías/diagnóstico por imagen , Ecocardiografía Transesofágica/métodos , Implantación de Prótesis de Válvulas Cardíacas , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Anciano , Humanos , Cuidados Intraoperatorios/métodos , MasculinoRESUMEN
The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.
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Anestesia/normas , Anestésicos/uso terapéutico , Cuidados Intraoperatorios/normas , Intubación Intratraqueal/normas , Pulmón/fisiopatología , Respiración Artificial/normas , Respiración , Apnea Obstructiva del Sueño/terapia , Analgésicos Opioides/uso terapéutico , Anestesia/efectos adversos , Anestesia/métodos , Anestesiología , Anestésicos/efectos adversos , Consenso , Medicina Basada en la Evidencia/normas , Humanos , Cuidados Intraoperatorios/efectos adversos , Cuidados Intraoperatorios/métodos , Intubación Intratraqueal/efectos adversos , Intubación Intratraqueal/métodos , Pulmón/efectos de los fármacos , Complicaciones Posoperatorias/epidemiología , Prevalencia , Respiración/efectos de los fármacos , Respiración Artificial/efectos adversos , Respiración Artificial/métodos , Medición de Riesgo , Factores de Riesgo , Apnea Obstructiva del Sueño/diagnóstico , Apnea Obstructiva del Sueño/epidemiología , Apnea Obstructiva del Sueño/fisiopatología , Resultado del TratamientoRESUMEN
Vascular dysfunction is an important pathophysiologic manifestation of sickle cell disease (SCD), a condition that increases risk of pulmonary hypertension and stroke. We hypothesized that infrared (IR) imaging would detect changes in cutaneous bloodflow reflective of vascular function. We performed IR imaging and conventional strain gauge plethysmography in twenty-five adults with SCD at baseline and during intra-arterial infusions of an endothelium-dependent vasodilator acetylcholine (ACh), an endothelium-independent vasodilator sodium nitroprusside (SNP), and a NOS inhibitor L-NMMA. Skin temperature measured by IR imaging increased in a dose-dependent manner to graded infusions of ACh (+1.1°C, p<0.0001) and SNP (+0.9°C, p<0.0001), and correlated with dose-dependent increases in forearm blood flow (ACh: +19.9 mL/min/100 mL, p<0.0001; r(s)=0.57, p=0.003; SNP: +8.6 mL/min/100 mL, p<0.0001; r=0.70, p=0.0002). Although IR measurement of skin temperature accurately reflected agonist-induced increases in blood flow, it was less sensitive to decreases in blood flow caused by NOS inhibition. Baseline forearm skin temperature measured by IR imaging correlated significantly with baseline forearm blood flow (31.8±0.2°C, 6.0±0.4 mL/min/100 mL; r=0.58, p=0.003), and appeared to represent a novel biomarker of vascular function. It predicted a blunted blood flow response to SNP (r=-0.61, p=0.002), and was independently associated with a marker of pulmonary artery pressure, as well as hemoglobin level, diastolic blood pressure, homocysteine, and cholesterol (R(2)=0.84, p<0.0001 for the model). IR imaging of agonist-stimulated cutaneous blood flow represents a less cumbersome alternative to plethysmography methodology. Measurement of baseline skin temperature by IR imaging may be a useful new marker of vascular risk in adults with SCD.
Asunto(s)
Anemia de Células Falciformes/sangre , Anemia de Células Falciformes/patología , Óxido Nítrico/metabolismo , Espectrofotometría Infrarroja/métodos , Acetilcolina/metabolismo , Adulto , Velocidad del Flujo Sanguíneo , Relación Dosis-Respuesta a Droga , Ecocardiografía/métodos , Endotelio Vascular/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Óxido Nítrico Sintasa/metabolismo , Análisis de Regresión , Riesgo , Temperatura Cutánea , omega-N-Metilarginina/farmacologíaAsunto(s)
Anemia de Células Falciformes/metabolismo , Arginina/farmacología , Hemoglobinas/metabolismo , Donantes de Óxido Nítrico/farmacología , Óxido Nítrico/metabolismo , Vasodilatadores/farmacología , Anemia de Células Falciformes/tratamiento farmacológico , Anemia de Células Falciformes/fisiopatología , Animales , Modelos Animales de Enfermedad , Hemodinámica/efectos de los fármacos , Hemólisis/efectos de los fármacos , Humanos , Microcirculación/efectos de los fármacos , Microcirculación/metabolismo , Óxido Nítrico Sintasa/metabolismo , Estrés Oxidativo/efectos de los fármacos , Tirosina/análogos & derivados , Tirosina/metabolismo , Vasodilatadores/metabolismoRESUMEN
Amdoxovir [(-)-beta-D-2,6-diaminopurine dioxolane, DAPD], the prodrug of dioxolane guanosine (DXG), is currently in Phase I/II clinical development for the treatment of HIV-1 infection. In this study, we examined the phosphorylation pathway of DXG using 15 purified enzymes from human (8), animal (6), and yeast (1) sources, including deoxyguanosine kinase (dGK), deoxycytidine kinase (dCK), high Km 5'-nucleotidase (5'-NT), guanylate (GMP) kinase, nucleoside monophosphate (NMP) kinase, adenylate (AMP) kinase, nucleoside diphosphate (NDP) kinase, 3-phosphoglycerate (3-PG) kinase, creatine kinase, and pyruvate kinase. In addition, the metabolism of 14C-labeled DXG was studied in CEM cells. DXG was not phosphorylated by human dCK, and was a poor substrate for human dGK with a high Km (7 mM). Human 5'-NT phosphorylated DXG with relatively high efficiency (4.2% of deoxyguanosine). DXG-MP was a substrate for porcine brain GMP kinase with a substrate specificity that was 1% of dGMP. DXG-DP was phosphorylated by all of the enzymes tested, including NDP kinase, 3-PG kinase, creatine kinase, and pyruvate kinase. The BB-isoform of human creatine kinase showed the highest relative substrate specificity (47% of dGDP) for DXG-DP. In CEM cells incubated with 5 microM DXG for 24 h, 0.015 pmole/10(6) cells (approximately 7.5 nM) of DXG-TP was detected as the primary metabolite. Our study demonstrated that 5'-nucleotidase, GMP kinase, creatine kinase, and NDP kinase could be responsible for the activation of DXG in vivo.