Faculty Bibliography

Anesthetic considerations are integral to the success of facial transplantation (FT), yet limited evidence exists to guide quality improvement. This study presents an institutional anesthesia protocol, defines reported anesthetic considerations, and provides a comprehensive update to inform future directions of the field.

Purpose: Intra-aortic balloon pumps (IABPs) can be used to provide hemodynamic support in patients with end-stage heart failure. IABPs are commonly inserted via the femoral artery, which can limit patients' mobility. The Ramsey Protocol, developed by a critical care Physical Therapist (PT), allows patients with femoral IABPs to safely transfer out of bed to a standing position using a tilt table. Our institution adapted this protocol to create a clinical practice guideline for ambulating patients with femoral IABPs.
Method(s): Our team's guideline included key components of the Ramsey Protocol, such as assessment of the patient's pre-morbid function, strength, and medical stability, as well as monitoring of IABP augmentation, IABP waveforms pre- and post-mobilization, and tilt table follow during ambulation. Appropriate candidates were patients with stable hemodynamics who were ambulatory prior to IABP placement, demonstrated against gravity muscle strength, and followed multi-step instructions.
Result(s): From April 1, 2019 to August 31, 2019, 9 patients (mean age 57 +/- 15 years) underwent IABP insertion via either right or left femoral artery, as a bridge to transplant, and were mobilized following our protocol for a total of 27 ambulation sessions (Table). There were no adverse events associated with ambulation, defined as changes in IABP augmentation, waveform, and positioning, or bleeding requiring transfusion. The mean time from IABP to ambulation was 2 +/- 2 days. All patients were successfully transplanted with mean time of IABP support of 6 +/- 3 days and all were alive at 30 days post-transplant. There were no complications during IABP support (i.e. limb ischemia, hemorrhage, stroke, device dislodgement or failure, end-organ dysfunction, or balloon rupture).
Conclusion(s): Early mobilization in select patients with femoral IABPs can be performed safely and successfully, avoiding the deleterious effects of bedrest that have been historically seen in this patient population.
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Inotropes are an integral component of the early stabilization of the patient presenting with cardiogenic shock. Despite years of clinical experience with the 2 most commonly used inotropes, dobutamine and milrinone, there remains limited data comparing outcomes between the two. We conducted a retrospective review to compare the effectiveness and safety of milrinone or dobutamine for the initial management of cardiogenic shock. Adult patients with cardiogenic shock regardless of etiology who received initial inotrope therapy with either milrinone (n = 50) or dobutamine (n = 50) and did not receive mechanical circulatory support were included. The primary end point was the time to resolution of cardiogenic shock. Changes in hemodynamic parameters from baseline and adverse events were also assessed. Resolution of shock was achieved in similar numbers in both the groups (milrinone 76% vs dobutamine 70%, P = .50). The median time to resolution of shock was 24 hours in both groups ( P = .75). There were no differences in hemodynamic changes during inotrope therapy, although dobutamine trended toward a greater increase in cardiac index. Arrhythmias were more common in patients treated with dobutamine than milrinone, respectively (62.9% vs 32.8%, P < .01), whereas hypotension occurred to a similar extent in both groups (milrinone 49.2% vs dobutamine 40.3%, P = .32). The use of concomitant vasoactive medications, dosage required, and duration of therapy did not differ between groups. There was no difference in the overall rate of discontinuation due to adverse event; however, milrinone was more commonly discontinued due to hypotension (13.1% vs 0%, P < .01) and dobutamine was more commonly discontinued due to arrhythmia (0% vs 11.3%, P < .01). Milrinone and dobutamine demonstrated similar effectiveness and safety profiles but with differences in adverse events. The choice of milrinone or dobutamine as initial inotrope therapy for cardiogenic shock may depend more on tolerability of adverse events.

BACKGROUND: Massive transfusion practices have undergone several recent developments. We sought to examine institutional practices guiding hemostatic resuscitation in the setting of massive hemorrhage. STUDY DESIGN AND METHODS: A 37-question online survey was sent to American Association for the Surgery of Trauma members. RESULTS: A total of 191 surgeons from 125 institutions completed the survey. Level I and II centers composed 70 and 18% of responding sites, respectively. A total of 123 institutions have a massive transfusion protocol (MTP); 54% report having an MTP for less than 5 years. The number of coolers and units of red blood cells, plasma, and platelets are highly variable. Tranexamic acid is part of the MTP at 64% of centers; 26% continue to use recombinant activated Factor VII. MTP activation occurs more than five times per month at 32% of centers. MTPs are utilized for nontrauma patients in 82% of institutions. Point-of-care prothrombin time, international normalized ratio, and partial thromboplastin time testing is utilized in 37% of institutions. Only 9% routinely utilize thromboelastography or rotational thromboelastometry (TEG/ROTEM) within their MTP. Just 7% use a validated scoring system to guide MTP activation. The incorporation of TEG/ROTEM into the MTP is associated with the use of a scoring system in regression analysis (p = 0.024). CONCLUSION: Most institutions regularly activate recently implemented MTPs for trauma and nontrauma indications; however, few use validated scoring systems for MTP activation. MTP content is highly variable. Few institutions use TEG, while most have incorporated tranexamic acid into their protocol. The lack of consistent practices underscores the need for outcome-based studies to guide transfusion practices.

Background: Missed vascular injuries in lower extremity trauma may lead to a preventable lower extremity amputation. CT angiography (CTA) is an accurate and expedient, but costly and potentially harmful, test for vascular injury in lower extremity trauma. Specific physical examination findings and injury patterns may be predictive of detection of a vascular injury by CTA and could guide CTA use in lower extremity trauma. Methods: This was a retrospective review of consecutive trauma patients at an academic level 1 trauma center who underwent CTA of a lower extremity from January 2006 through December 2012. The positive predictive values of injury pattern and physical examination signs for CTA detection of a vascular injury and vascular intervention, adherence to published guidelines for CTA use, and CTA-related adverse events were assessed. Results: Diagnostic CTA studies demonstrated a vascular injury in 55.6%. A vascular intervention followed in 13.9%, while 5.6% of studies led to a contrast-related adverse event. The positive predictive value of a CTA affecting treatment was significantly higher in the presence of high-risk injuries and hard examination findings than in the presence of low-risk injuries and soft examination findings (84.6%,95%CI [54.6-98.1%] vs. 16.7%, 95% CI [3.6-41.1%]). Palpable pulses and ankle brachial index (ABI) &gt; 0.9 led to observational management without complications, regardless of CTA findings or other signs of vascular injury. Conclusions: The utility of CTA is improved by assessing the pretest positive predictive value of vascular injury from injury pattern and physical examination. The Eastern Association for the Surgery of Trauma guidelines may miss some vascular injuries in patients with high-risk injuries and normal ABI. CTA is not indicated in lower extremity trauma when physical examination and injury pattern do not suggest a vascular injury.

Given the meteoric rise in physician assistants and nurse practitioners in critical care units across the United States, identifying successful paradigms with which to train these clinicians is critical to help meet current and future demands. We describe an apprenticeship model of training that is deployable in any ICU including curriculum, didactic and procedural training, as well as 3- and 6-month benchmarks that embraces dedicated intensivist mentorship.