May 6-9, 2017 Washington, DC Review Course Lectures presented at the 2017 Annual Meeting and International Science Symposium of the International Anesthesia Research Society Washington, DC May 6-9, 2017 IARS 2017 REVIEW COURSE LECTURES Te material included in the publication has not undergone peer review or review by the Editorial Board of Anesthesia and Analgesia for this publication. Any of the material in this publication may have been transmitted by the author to IARS in various forms of electronic medium. IARS has used its best efforts to receive and format electronic submissions for this publication but has not reviewed each abstract for the purpose of textual error correction and is not liable in any way for any formatting, textual, or grammatical error or inaccuracy. ii ©2017 International Anesthesia Research Society. Unauthorized Use Prohibited IARS 2017 REVIEW COURSE LECTURES Table of Contents RCL-01 RCL-12 ECMO (Extracorporeal Membrane Oxygenation): Surgical Enhanced Recovery: Past, Implications For Anesthesiology and Critical Care .....5 Present and Future .................................43 Peter Von Homeyer, MD, FASE Tong J. (TJ) Gan, MD, MHS, FRCA RCL-02 RCL-13 SOCCA: Perioperative Ultrasound ....................7 TAVR : A Transformative Treatment for Patients Michael Haney, MD, PhD with Severe Aortic Stenosis: Past, Present and Future Directions...............................45 RCL-03 MaryBeth Brady, MD, FASE Blood Components and Blood Derivatives ...........10 Rani Hasan, MD, MHS Marisa B. Marques, MD RCL-16 RCL-04 Predicting and Managing “MODA”: SOAP: How to Decide if Neuraxial Anesthesia The Morbid Obesity Difficult Airway.................50 is Safe in the Face of Possible Naveen Eipe, MD Hematologic Contraindications .....................13 Lisa Lae Leffert, MD RCL-17 Organization Fear: The Silent Killer ..................54 RCL-05 Chet Wyman, MD Regional Anesthesia in Improving Outcomes ........15 Colin J. L. McCartney, MBChB, PhD, FRCA, FCARCSI, FRCPC RCL-18 What Every Anesthesiologist Should Know RCL-06 About Patient Safety ...............................56 U.S. Anesthesia Workforce and Group Practice Trends: Matthew B. Weinger, MD Data Sources and Research Questions ...............17 Thomas R. Miller, PhD, MBA RCL-19 Improve Sleep After Surgery: RCL-07 What Can We Do As Anesthesiologists? ..............59 Extubation of Patients Outside of the Dong-Xin Wang, MD, PhD Operating Room....................................21 Hannah Wunsch, MD, MSc RCL-20 State-of-the-Art Topics on RCL-08 Malignant Hyperthermia (MH) ......................62 Therapeutic Hypothermia and Neuroprotection .....25 Sheila Riazi, MSc, MD Ehab Farag, MD, FRCA RCL-21 RCL-09 Flying the Anesthesia Machine: Lessons for The Anesthesiologist’s Role in Preventing Anesthesiology from Aviation.......................64 Postoperative Infections ............................33 Steven J. Barker, PhD, MD Sebastian Schulz-Stübner RCL-22 RCL-10 Implementing Operating Room Management Health Economics 101: Improvement ......................................68 “Value” Rather Than Price Tags ......................36 Franklin Dexter, MD, PhD Janet Martin, MSc(HTA&M), PharmD, PhDEq RCL-23 RCL-11 Lies, Damn Lies and Anesthesia Myths...............71 Ultrasound Findings in Intraoperative John F. Butterworth, IV, MD Anesthetic Emergencies ............................38 Julia Sobol, MD MPH ©2017 International Anesthesia Research Society. Unauthorized Use Prohibited iii IARS 2017 REVIEW COURSE LECTURES iv ©2017 International Anesthesia Research Society. Unauthorized Use Prohibited RCL-01 ECMO (Extracorporeal Membrane Oxygenation): Implications for Anesthesia and Critical Care Peter Von Homeyer, MD, FASE Associate Professor, University of Washington, Seattle, Washington LEARNER OBJECTIVES from clotting. Given that much of the thrombotic circuit Afer participating in this activity, the learner will be able to: complications are due to platelet adhesion and aggregation, 1) Discuss principles and different modalities of ECMO; heparin is typically administered via IV infusion with a 2) Describe the indications and contraindications for goal aPTT of 60-80 seconds or an activated clotting time ECMO; (ACT) of 180-220 seconds. Again, given the improvements 3) Discuss common clinical problems and complication in ECMO technology over the years, these goals are much of ECMO; lower compared to historical systems that could only be safely 4) Describe ECMO outcomes and data; operated with an ACT greater 400 seconds. 5) Evaluate perioperative implications of ECMO. Critical for the application of either ECMO modality is the observation of aforementioned indications and also SYLLABUS contraindications such as a progressive and non-recoverable Extracorporeal membrane oxygen (ECMO) or extra- disease process in combination with a non-candidacy for corporeal life support (ECLS) has been used for many years organ transplantation or durable assist device. Other common to support patients with respiratory or combined cardiac contraindications are severe neurologic injury or intracerebral and respiratory failure. Initial success in the neonatal and bleeding, an unrepaired aortic dissection, and other absolute pediatric patient population was followed by disappointing contraindications to anticoagulation. It is quite important results of the first adult trials. Since the 1980s, ECMO to determine clear goals at the time of or immediately afer technology and management and generally critical care have initiation of ECMO, especially in the patient population changed dramatically. Although only one larger randomized requiring VA-ECMO for cardiac support. Once the decision controlled trial for adult ECMO exists, adult ECMO has now is made that this patient cannot be treated with other less become an accepted treatment option for both cardiac and invasive temporary support devices and requires ECMO, an respiratory support. exit strategy should be discussed. Potential treatment plans Respiratory failure patients are usually supported with include bridge-to-evaluation (needs to be readdressed within veno-venous ECMO (VV-ECMO), a modality that removes hours), bridge-to-recovery (most common strategy in patients blood from the inferior vena cava (IVC) (and sometimes the with respiratory failure on VV-ECMO), bridge to transplant superior vena cava (SVC)) and returns blood to the right atrium (poor outcomes for patients on VA-ECMO being bridged to and subsequently into the right ventricle. In rare cases, patients heart transplantation), and bridge-to-durable device (only with primary pulmonary pathology require veno-arterial available for heart failure patients). ECMO (VA-ECMO), such as in acute pulmonary embolism Tere are side effects, phenomena, and complications or other cases in which the pulmonary vascular resistance is that are typical for either VA- or VV-ECMO and then some elevated or right ventricular dysfunction is present. Common that are part of ECMO in general. Bleeding events are among indications for VV-ECMO include acute respiratory distress the most common general complications of ECMO and there syndrome (ARDS), primary graf dysfunction (PGD) afer is ofen a fine line between adequate anticoagulation and lung transplantation, and pneumonia. Cannulation strategies thromboembolic events. Limb ischemia or low-flow state is a are either bilateral femoral venous, femoral and jugular devastating complication of peripheral VA-ECMO, but can be venous, or double-lumen jugular cannulation. greatly reduced by standardization of cannulation procedures Patients with cardiac or combined cardio-respiratory including the insertion of a distal perfusion cannula. North- failure are generally supported with veno-arterial ECMO (VA- south syndrome describes a phenomenon of relative upper ECMO). In a parallel fashion, blood is removed from the venous body hypoxemia in the setting of peripheral VA-ECMO circulation and returned to the arterial circulation. Several and cardiac recovery, but ongoing pulmonary failure. With approaches exist, including central cannulation where venous improving native cardiac function, but poorly functioning blood is drained from the right atrium and returned into the lungs, de-oxygenated blood is ejected primarily into the ascending aorta (typically in the setting of post-cardiotomy coronary arteries and the cerebral branches of the aortic arch. heart failure) and various forms of peripheral cannulations, Adjustment of ventilator settings or change to VV-ECMO where most commonly blood is drained via a femoral vein and can usually remedy this problem. In contrast, ventricular returned via a femoral artery. Te most common indication distention occurs in the setting of cardiac failure with very for VA-ECMO is acute cardiogenic shock due to acute poor ventricular function or absence of native ejection. In myocardial infarction, fulminant myocarditis, an exacerbated this case, lack of contractility ultimately results in ventricular cardiomyopathy, or refractory ventricular arrhythmias. distention, stasis and possible thrombus formation, and Modern ECMO technology includes the use of closed pulmonary edema or even hemorrhage. Low-dose inotropic heparin-bonded circuits and centrifugal pumps. Tis has led therapy or mechanical venting of the lef ventricle can to a reduction in heparin requirements to keep these systems help avoid distention and a subsequent increase in wall ©2017 International Anesthesia Research Society. Unauthorized Use Prohibited 5 IARS 2017 REVIEW COURSE LECTURES tension