Comparison of clinical outcomes with the utilization of monitored anesthesia care vs. general anesthesia in patients undergoing transcatheter aortic valve replacement. Kiramijyan Sarkis,Ben-Dor Itsik,Koifman Edward,Didier Romain,Magalhaes Marco A,Escarcega Ricardo O,Negi Smita I,Baker Nevin C,Gai Jiaxiang,Torguson Rebecca,Okubagzi Petros,Asch Federico M,Wang Zuyue,Gaglia Michael A,Satler Lowell F,Pichard Augusto D,Waksman Ron Cardiovascular revascularization medicine : including molecular interventions BACKGROUND:There is no clear consensus in regard to the optimal anesthesia utilization during transcatheter aortic valve replacement (TAVR). The aim was to compare outcomes of transfemoral (TF) TAVR under monitored anesthesia care (MAC) vs. general anesthesia (GA) and evaluate the rates and causes of intra-procedural MAC failure. METHODS:All consecutive patients who underwent TF TAVR from April 2007 through March 2015 were retrospectively analyzed and dichotomized into two groups: TAVR under MAC vs. GA. The main endpoints of the study included 30-day and 1-year mortality, the rates and reasons for failure of MAC, in-hospital clinical safety outcomes, and post-procedural hospital and intensive care unit length-of-stays. RESULTS:A total of 533 patients (51% male, mean-age 83years) underwent TF TAVR under MAC (n=467) or GA (n=66). Fifty-six patients (12%) in the MAC group required conversion to GA. The MAC group had significantly shorter post-procedural hospital (6.0 vs. 7.9, p=0.023) and numerically shorter ICU (2.4 vs. 2.8, p=0.355) mean length-of-stays in days. The clinical safety outcomes were similar in both groups. Kaplan-Meier unadjusted cumulative in-hospital and 30-day mortality rates were higher in the GA group but similar in both groups at 1-year. CONCLUSIONS:TF TAVR under MAC is feasible and safe, results in shorter hospital stays, can be performed in the majority of cases, and should be utilized as the default strategy. Trans-esophageal echocardiography utilization during TAVR with MAC is safe and feasible. The most common cause for conversion of MAC to GA is cardiac instability and hypotension. The complete heart team should be available at all times in case the need arises for a rapid conversion to GA. 10.1016/j.carrev.2016.02.003

Feasibility and indicator outcomes using computerized clinical decision support in pediatric traumatic brain injury anesthesia care. Colletti Ashley A,Kiatchai Taniga,Lyons Vivian H,Nair Bala G,Grant Rosemary M,Vavilala Monica S Paediatric anaesthesia BACKGROUND:Traumatic brain injury anesthesia care is complex. The use of clinical decision support to improve pediatric trauma care has not been examined. AIMS:The aim of this study was to examine feasibility, reliability, and key performance indicators for traumatic brain injury anesthesia care using clinical decision support. METHODS:Clinical decision support was activated for patients under 19 years undergoing craniotomy for suspected traumatic brain injury. Anesthesia providers were prompted to adhere to process measures via on-screen alerts and notified in real time of abnormal monitor data or laboratory results (unwanted key performance indicator events). Process measures pertained to arterial line placement and blood gas draws, neuromuscular blockade, hypotension, anemia, coagulopathy, hyperglycemia, and intracranial hypertension. Unwanted key performance indicators were: hypotension, hypoxia, hypocarbia, hypercarbia, hypothermia, hyperthermia, anesthetic agent overdose; hypoxemia, coagulopathy, anemia, and hyperglycemia. Anesthesia records, vital signs, and alert logs were reviewed for 39 anesthetic cases (19 without clinical decision support and 20 with clinical decision support). RESULTS:Data from 35 patients aged 11 months to 17 years and 77% males were examined. Clinical decision support reliably identified 39/46 eligible anesthetic cases, with 85% sensitivity and 100% specificity, and was highly sensitive, detecting 89% of monitor key performance indicator events and 100% of reported lab key performance indicator events. There were no false positive alerts. Median event duration was lower in the "with clinical decision support" group for 4/7 key performance indicators. Second insult duration was lower for duration of hypocarbia (by 44%), hypotension (29%), hypothermia (12%), and hyperthermia (15%). CONCLUSION:Use of clinical decision support in pediatric traumatic brain injury anesthesia care is feasible, reliable, and may have the potential to improve key performance indicator outcomes. This observational study suggests the possibility of clinical decision support as a strategy to reduce second insults and improve traumatic brain injury guideline adherence during pediatric anesthesia care. 10.1111/pan.13580