Cardiothoracic Operating Room Research Articles

Medical Student Role in the Cardiothoracic Operating Room: A Needs Assessment to Optimize Engagement

BackgroundFocused preparation for the cardiothoracic operating room (CTOR) may optimize intraoperative engagement and medical student interest, but such resources are lacking. We sought to characterize student educational needs in the CTOR to guide resource development. MethodsA web-based survey targeting cardiothoracic surgeons, trainees, and operating room staff was distributed to identify areas for student improvement in the CTOR. Concepts investigated explored common student mistakes and expectations for knowledge and participation in the CTOR. Descriptive analyses were performed on multiple-choice polls and open-ended responses. ResultsPolls received a mean of 317 responses (range, 222-504) and 20 open-ended comments. The most frequently cited student mistake was failure to understand their role in the CTOR (164 [32.5%]), followed by inappropriate chatting (141 [28.0%]) and breaking sterility (132 [26.2%]). Poll respondents valued students’ understanding of how to be helpful in the CTOR (101 [45.5%]) in addition to knowing what can or cannot be touched (47 [21.2%]) and basics of cardiopulmonary bypass (43 [19.4%]). Respondents indicated that students should assume active roles (84 [36.7%]), ask questions (66 [29%]), and help with minor tasks (41 [17.9%]). Respondents reported that students benefited most when they understood patient-specific clinicopathologic factors and basic operative steps. ConclusionsWe identified several areas for student improvement in the CTOR. Development of educational resources addressing these issues may enhance interest and augment recruitment of students to cardiothoracic surgery.

Cardiothoracic operating room blood gas workflow performance improvement initiative.

To evaluate the current workflow of blood gas ordering and testing in a cardiothoracic operating room to identify opportunities to streamline the process, using performance improvement methodologies. Issues with specimen relabeling were identified that lead to delayed results and potential patient safety concerns. Blood gas specimen relabeling was evaluated for operating room cases from August 2018 to December 2022. An OpTime Epic Sidebar button for arterial blood gas and venous blood gas orders was created in January 2019 to streamline the ordering process so that laboratory barcode labels were then printed in the operating room and attached to the specimen, eliminating the need for relabeling by the technologists. This Epic Sidebar intervention led to a drastic improvement of appropriate labeling, which has been sustained. From March 2019 to January 2023, with our new workflow, over 95% of blood gas specimens arrived barcode labeled compared to less than 1% in the preintervention era. A multidisciplinary team with key stakeholders is important to address complex care issues. Performance improvement methodology is critical to develop interventions that hardwire the process. This intervention led to a sustained reduction in secondary relabeling of patient samples and improved timeliness of reporting of blood gas results.

A Call for Diversity: Women, Professional Development, and Work Experience in Cardiothoracic Anesthesiology

DESPITE THE ACHIEVEMENT of parity in medical school matriculation decades ago, 1 Association of American Medical Colleges. AAMC chart 5: Graduates of US medical schools by sex, academic years 1980-1981 through 2018-2019. Available at: https://www.aamc.org/media/9631/download?attachment. Accessed December 10, 2020. Google Scholar female physicians across specialties continue to face barriers in their professional development. Women in cardiothoracic anesthesiology (CTA) are a growing and increasingly vocal minority in a medical subspecialty that has been dominated by men throughout history. Approximately 36% of United States medical school faculty anesthesiologists are women, 2 Association of American Medical Colleges. AAMC table 13: US medical school faculty by gender, rank, and department, 2019. Available at: https://www.aamc.org/media/8441/download?attachment. Accessed September 27, 2022. Google Scholar and women account for 29% of cardiothoracic anesthesiologists. 3 Capdeville M. If all the world's a stage, then where's our microphone?. J Cardiothor Vasc Anes. 2020; 34: 1810-1814 Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar These latter women face unique challenges in the often-stressful and dynamic environment of the cardiothoracic operating room. These challenges have led to the formation of organizations whose mission is to provide support and guidance in the professional lives of female cardiac anesthesiologists.

Comparison Among Ultrasound-Guided Thoracic Paravertebral Block, Erector Spinae Plane Block and Serratus Anterior Plane Block for Analgesia in Thoracotomy for Lung Surgery

To compare the analgesic efficacy and safety of preoperative, single-shot ultrasound-guided thoracic paravertebral block (TPVB), erector spinae plane block (ESB), and serratus anterior plane block (SAPB) in thoracotomy pain. A prospective, randomized study. The cardiothoracic operating room and intensive care unit of a tertiary-care hospital in India. Ninety adult patients scheduled to undergo posterolateral thoracotomy for lung surgery under general anesthesia were recruited and randomized into 3 equal groups. Preoperatively, the patients received ultrasound-guided, single-shot nerve blocks within their respective groups, as follows: Erector spinae plane block in the ESB group, Thoracic paravertebral block in the TPVB group, and Serratus anterior plane block in the SAPB group. The primary outcome measure, the visual analog scale (VAS) score, was recorded postoperatively in the intensive care unit at 0, 3, 6, 12, and 24 hours. The secondary outcome measures were the time to first rescue analgesic, total rescue opioid dose used, patient satisfaction at 24 hours, success of one-time attempt, and occurrence of adverse events. Data were statistically analyzed and a significant difference was found in the VAS score at all time points, the time to rescue analgesic and total opioid dosage, and patient satisfaction level (p < 0.05) among the groups with only 1 incidence of hypotension in the TPVB group. From post hoc analysis, ESB was found to have better analgesic efficacy compared with TPVB and SAPB. Serratus anterior plane block was found to be least efficacious and shortest acting among the three. The nerve blocks in decreasing order of analgesic efficacy in relieving post-thoracotomy pain would be ESB, TPVB, and SAPB.

The utilization of caudal hydromorphone for fast-tracking in congenital cardiac surgery in a tertiary-care Children's hospital: An audit

Study objectiveOur study sought to audit our institutional practice of routine single-shot caudal epidural hydromorphone injection in children undergoing congenital cardiothoracic surgery to assess perioperative pain control and evaluate for any caudal complications. DesignRetrospective observational study of all patients that received a caudal hydromorphone injection as part of the anesthetic for their cardiac surgical operation between January 2017 and July 2019. SettingPediatric Cardiothoracic Operating Room (OR), Cardiac Intensive Care Unit. PatientsOne hundred and twenty-seven patients that received caudal hydromorphone as part of their anesthetic for a cardiac surgical operation. InterventionsCaudal epidural injection performed immediately following induction of anesthesia utilizing only hydromorphone. MeasurementsThe primary outcome was well-controlled pain, defined as a score of <4/10 on rFLACC or verbal pain scoring. Secondary outcome measures included in-OR extubation, pain service duration (from first assessment to “sign-off”), complications related to the caudal block, intensive care unit (ICU) length of stay (LOS), and Hospital LOS. Main resultsOne hundred and nine patients were included in the final analysis. Pain was “well-controlled” on average in 96.3% of patients (105/109). Average pain in the 24-h post-block period was 1.67 (SD = 2.37), with median pain score of 0 [0–3]. Peak pain score remained <4/10 for the entire 24-h post-block period in 22% of patients. 77.1% of caudal hydromorphone patients were extubated in the operating room. The median time to heparinization post-block was 108 min, beyond the ASRA recommendation of 60 min for neuraxial procedures. There were two caudal-related complications: one subcutaneous injection, and one instance of a time to heparinization of less than 60 min (56 min). Neither caudal complication led to patient harm. ConclusionCaudal hydromorphone injection can safely contribute to achieving “well-controlled” pain in the pediatric cardiac surgical population when used as a component of a perioperative pain control plan.

Successful pregnancy with centrifugal flow left ventricular assist device: A case report and review of the literature

Successful deliveries from patients supported by axial flow left ventricular devices have been previously reported. We present the first case of a successful pregnancy and birth in a patient with a centrifugal-flow left ventricular assist device. A 24-year-old female with methamphetamine-induced cardiomyopathy and end-stage congestive heart failure supported by a HeartWare™ ventricular assist device (Medtronic) presented two years after device implantation with an unplanned pregnancy at 11-weeks of gestation. Following a multidisciplinary evaluation by experts in advanced heart failure, maternal fetal medicine, cardiothoracic surgery, anesthesia, ethics, psychiatry, and palliative care, an advanced plan of care was established. An elective induction of labor was scheduled for the 34th week of gestation. Given poor labor progression despite maximal induction efforts, the patient was transferred to a cardiothoracic operating room where she delivered a healthy baby boy via Cesarean section under close hemodynamic monitoring by advanced heart failure and cardiothoracic surgery teams.

Building a Collaborative Culture: Focus on Psychological Safety and Error Reporting

At a Midwestern academic medical center, we introduced a structured teamwork training program to cardiothoracic operating room members with a goal of greater than or equal to 90% reporting positive psychological safety after the program. We conducted teamwork training over 3 months. We distributed confidential questionnaires before the training, and then at 6 months and 12 months after the training. The primary outcome was the percentage of respondents reporting good or excellent psychological safety. Surveys were also distributed at the end of each case. Secondary outcomes were medical errors reported. Comparisons between percentages were evaluated with chi-square test. We examined the turnover of nurses and surgical technologists. Positive psychological safety was reported by 57 of 73 (78.1%) at baseline and by 60 of 68 (88.2%) at 12 months (difference= 10.1%; 95% confidence interval, -2.4% to 23.4%; P= .122). On the daily survey, 93.9% (n= 2786 of 2987) of operating room team members strongly agreed with the statement "I felt comfortable speaking up with questions and concerns" during the last quarter of the study. Reported medical errors decreased from 7.44% (n= 78 of 1048) in the first 6 months of the study to 4.65% (n= 55 of 1184) in the second 6 months (difference= 2.79%; 95% confidence interval, 0.8% to 4.8%; P= .005). In 2015, 19 nurses of a pool of 40 (47.5%) left, followed by 7 (17.5%) in 2016 and 10 (25%) in2017. Overall, the results of this study suggest that structured teamwork training in the cardiothoracic operating room environment has the potential to improve teamwork, psychological safety, and communication, and potentially also patient outcomes.

Care of a Complex Cardiac Patient With a Left Ventricular Assist Device

A 24-year-old, gravida 7 para 2040 woman presented at 12-weeks gestation. Her medical history included nonischemic cardiomyopathy, systolic heart failure, posttraumatic stress disorder, polysubstance drug abuse, iron-deficiency anemia, gestational thrombocytopenia, generalized anxiety disorder, attention deficit/hyperactivity disorder, chronic pain, and migraines. The patient was taking enoxaparin sodium irregularly. She was scheduled to arrive for heparin infusion before her induction. Birth was scheduled to occur at 34 weeks, 5 days because there was concern for the potential of maternal and fetal morbidity earlier or later in pregnancy. Another concern was the availability of the teams during the holiday season. Plans were made with the cardiac teams, including the left ventricular assist device (LVAD) team to set up a birth plan for the patient. The obstetric team scheduled an induction date but planned for the unexpected. This included reaching out to the emergency medical services teams because the patient was noncompliant and there was concern her LVAD could clot off and she would go into cardiac arrest. The patient was not in labor on her arrival. She was scheduled for induction of labor at 34 weeks, 5 days. After 8 hours of no cervical change, despite artificial rupture of membranes, oxytocin injection, and adequate labor, the patient underwent a cesarean in the cardiothoracic operating room. She received postpartum care in the cardiothoracic intensive care unit and was discharged 11-days postoperative after receiving antibiotics for multifocal pneumonia. The patient successfully gave birth, and her healthy baby was discharged on day of life 13. Patients with complicated cardiac disease can be effectively managed with a team approach.

Comparative assessment of left ventricular function after coronary artery bypass grafting and percutaneous coronary intervention to LAD by speckle tracking echocardiography study

Background: Speckle-tracking echocardiography (STE) is a noninvasive imaging technique that analyzes global and regional myocardial function. Aims: This study aims to compare the assessment of the left ventricular (LV) function after percutaneous coronary intervention (PCI). Settings and Design: One hundred patients presented to the catheterization laboratory and cardiothoracic operating room in Benha University Hospital and Kasr Al–Ainy University Hospital for PCI and coronary artery bypass grafting (CABG) to left anterior descending artery (LAD). Patients and Methods: This study enrolled 100 patients. They were divided into two groups: Group I: 50 patients with PCI to LAD and Group II: 50 patients with CABG to LAD. Echocardiography (conventional echocardiography and two-dimensional STE) was performed for all patients 24 h before and 1 month after the procedures. Statistical Analysis Used: Data management and statistical analysis were done using SPSS version 25. Results: There were significant increases in global circumferential strain (GCS) after CABG surgery with mean value of −17.8 before the procedure and −23.8 after it while there were no significant increases in global longitudinal strain (GLS) after the same procedure with mean value of −17.5 before the procedure and −18.1 after it. There were significant increases in GLS with mean value of −17.0 before PCI and −21.2 after it, and there were significant increases in GCS with mean value of −17.1 before PCI and −25.4 after it with improvement in myocardial function after this procedure. GLS and GCS were significantly higher in patients with PCI than patients with CABG with P

A Comparison of Global Longitudinal, Circumferential, and Radial Strain to Predict Outcomes After Cardiac Surgery

Myocardial strain measured by speckle-tracking echocardiography detects subtle regional and global left ventricular dysfunction. Myocardial strain is measured in the longitudinal, circumferential, and radial dimensions; however, it is unclear which dimension of strain is the best predictor of postoperative outcomes. A secondary analysis of prospectively collected data from a clinical trial (NCT01187329). The cardiothoracic surgical operating rooms of an academic tertiary-care center. Cardiothoracic surgery patients with aortic stenosis having aortic valve replacement (AVR) with or without coronary artery bypass grafting enrolled in a clinical trial. Myocardial deformation analysis from standardized investigative transesophageal echocardiographic examinations performed after induction of anesthesia. The authors compared the ability of intraoperative global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) strain to predict adverse postoperative outcomes, including prolonged hospitalization and the need for pharmacologic hemodynamic support after cardiac surgery. The association of GLS, GCS, and GRS with prolonged hospitalization (>7 days) and the need for pharmacologic hemodynamic support, with epinephrine or norepinephrine after cardiopulmonary bypass, were assessed using separate multivariable logistic regression models with adjustment for multiple comparisons. Of 100 patients, 86 had acceptable measurements for GLS analysis, 73 for GCS, and 72 for GRS. Worse GLS was associated with prolonged hospitalization [odds ratio [OR] (98.3% confidence interval [CI]) of 1.21 (1.01-1.46) per-unit worsening in strain (p = 0.01, significance criterion <0.0167)] and the need for inotropic support with epinephrine [OR (99.2% CI) of 1.81 (1.10-2.97) per-unit worsening in strain (p = 0.002, significance criterion <0.0083)], but not norepinephrine. GCS and GRS were not associated with adverse outcomes. GLS, but not GCS or GRS, predicts prolonged hospitalization and the requirement for inotropic support with epinephrine after AVR.

Comparison between Upper Mini Sternotomy and Full Sternotomy in Aortic Valve Replacement

Background: aortic valve disease is common and its prevalence increases with age. For people over the age of 75 years, the prevalence of aortic stenosis (AS) is 5%. More than one in eight people over the age of 75 have moderate or severe valve disease. Aim of the Work: the aim of this study was to compare the short term results of aortic valve replacement through upper mini sternotomy and full sternotomy. Patients and Methods: This study was a prospective randomized controlled clinical trial. The study was conducted at Suez Canal University Hospital in the cardiothoracic operating rooms and inward after approval of Research and Ethics Committees. The study included 50 patients having aortic valve disease presented to Suez Canal University Hospital, cardiothoracic outpatient clinic for isolated aortic valve replacement. Results: The mean age of patients in Full Sternotomy in Aortic Valve Replacement (FSAVR) group was 33.48 ± 17.74 while it was 32.03 ± 15.29 in Mini Sternotomy in Aortic Valve Replacement (MSAVR) group which showed insignificance difference (p > 0.05). (20- 29y) was the most frequent age group in both study groups (28% in FSAVR group and 32% in MSAVR group). No significance different found (p > 0.05) according to gender in both group. Male gender was the most frequent in both group (56% in FSAVR group and 64% in MSAVR group). Conclusion: Mini Sternotomy (MS) can be considered as excellent option with favorable outcomes that should be considered part of the routine practice of cardiac surgeons in the modern era

Comparison between Upper Mini Sternotomy and Full Sternotomy in Aortic Valve Replacement

Background: aortic valve disease is common and its prevalence increases with age. For people over the age of 75 years, the prevalence of aortic stenosis (AS) is 5%. More than one in eight people over the age of 75 have moderate or severe valve disease. Aim of the Work: the aim of this study was to compare the short term results of aortic valve replacement through upper mini sternotomy and full sternotomy. Patients and Methods: This study was a prospective randomized controlled clinical trial. The study was conducted at Suez Canal University Hospital in the cardiothoracic operating rooms and inward after approval of Research and Ethics Committees. The study included 50 patients having aortic valve disease presented to Suez Canal University Hospital, cardiothoracic outpatient clinic for isolated aortic valve replacement. Results: The mean age of patients in Full Sternotomy in Aortic Valve Replacement (FSAVR) group was 33.48 ± 17.74 while it was 32.03 ± 15.29 in Mini Sternotomy in Aortic Valve Replacement (MSAVR) group which showed insignificance difference (p > 0.05). (20- 29y) was the most frequent age group in both study groups (28% in FSAVR group and 32% in MSAVR group). No significance different found (p > 0.05) according to gender in both group. Male gender was the most frequent in both group (56% in FSAVR group and 64% in MSAVR group). Conclusion: Mini Sternotomy (MS) can be considered as excellent option with favorable outcomes that should be considered part of the routine practice of cardiac surgeons in the modern era

Correlation of 2-Dimensional and 3-Dimensional Echocardiographic Analysis to Surgical Measurements of the Tricuspid Valve Annular Diameter

This study sought to determine if 3-dimensional (3D) echocardiography would more closely correspond to direct surgical measurements of the maximal tricuspid valve (TV) annular diameter than 2-dimensional (2D) measurements. Prospective study. The cardiothoracic operating rooms (ORs) at Mount Sinai Medical Center in New York, NY. Fifty-nine patients over 18years of age underwent elective mitral valve surgery for severe mitral regurgitation from 2014 to 2015. None. Two-dimensional and 3D data sets and surgical TV annular dimensions were measured. Bland-Altman analysis was conducted and absolute differences were compared using paired t tests and the McNemar test. The observed mean difference between the 2D measurements by transgastric right ventricular diastolic view and the surgical measurements was 0.21cm (standard deviation [SD] = 0.36 cm); the mean difference between the 3D measurements and surgical measures was -0.03cm (SD = 0.19 cm). The McNemar test showed that the rate of highly successful measurements, defined as those within 0.2cm of the true surgical score, using the 3D technique (66%) was significantly better than the rate of highly successful measurements using the 2D technique (25%), p< 0.01, 2-sided. Three-dimensional imaging and measurement of the TV annular diameter is feasible in the OR setting. The superiority of the 3D measurements versus 2D measurements allows for greater precision and accuracy and may guide better intraoperative surgical decision-making.

Building a collaborative culture in cardiothoracic operating rooms: pre and postintervention study protocol for evaluation of the implementation of teamSTEPPS training and the impact on perceived psychological safety

IntroductionThe importance of effective communication, a key component of teamwork, is well recognised in the healthcare setting. Establishing a culture that encourages and empowers team members to speak openly in...

A System for Anesthesia Drug Administration Using Barcode Technology: The Codonics Safe Label System and Smart Anesthesia Manager.

Many anesthetic drug errors result from vial or syringe swaps. Scanning the barcodes on vials before drug preparation, creating syringe labels that include barcodes, and scanning the syringe label barcodes before drug administration may help to prevent errors. In contrast, making syringe labels by hand that comply with the recommendations of regulatory agencies and standards-setting bodies is tedious and time consuming. A computerized system that uses vial barcodes and generates barcoded syringe labels could address both safety issues and labeling recommendations. We measured compliance of syringe labels in multiple operating rooms (ORs) with the recommendations of regulatory agencies and standards-setting bodies before and after the introduction of the Codonics Safe Label System (SLS). The Codonics SLS was then combined with Smart Anesthesia Manager software to create an anesthesia barcode drug administration system, which allowed us to measure the rate of scanning syringe label barcodes at the time of drug administration in 2 cardiothoracic ORs before and after introducing a coffee card incentive. Twelve attending cardiothoracic anesthesiologists and the OR satellite pharmacy participated. The use of the Codonics SLS drug labeling system resulted in >75% compliant syringe labels (95% confidence interval, 75%-98%). All syringe labels made using the Codonics SLS system were compliant. The average rate of scanning barcodes on syringe labels using Smart Anesthesia Manager was 25% (730 of 2976) over 13 weeks but increased to 58% (956 of 1645) over 8 weeks after introduction of a simple (coffee card) incentive (P < 0.001). An anesthesia barcode drug administration system resulted in a moderate rate of scanning syringe label barcodes at the time of drug administration. Further, adaptation of the system will be required to achieve a higher utilization rate.

A Model to Create an Efficient and Equitable Admission Policy for Patients Arriving to the Cardiothoracic ICU*

To develop queuing and simulation-based models to understand the relationship between ICU bed availability and operating room schedule to maximize the use of critical care resources and minimize case cancellation while providing equity to patients and surgeons. Retrospective analysis of 6-month unit admission data from a cohort of cardiothoracic surgical patients, to create queuing and simulation-based models of ICU bed flow. Three different admission policies (current admission policy, shortest-processing-time policy, and a dynamic policy) were then analyzed using simulation models, representing 10 yr worth of potential admissions. Important output data consisted of the "average waiting time," a proxy for unit efficiency, and the "maximum waiting time," a surrogate for patient equity. A cardiothoracic surgical ICU in a tertiary center in New York, NY. Six hundred thirty consecutive cardiothoracic surgical patients admitted to the cardiothoracic surgical ICU. None. Although the shortest-processing-time admission policy performs best in terms of unit efficiency (0.4612 days), it did so at expense of patient equity prolonging surgical waiting time by as much as 21 days. The current policy gives the greatest equity but causes inefficiency in unit bed-flow (0.5033 days). The dynamic policy performs at a level (0.4997 days) 8.3% below that of the shortest-processing-time in average waiting time; however, it balances this with greater patient equity (maximum waiting time could be shortened by 4 days compared to the current policy). Queuing theory and computer simulation can be used to model case flow through a cardiothoracic operating room and ICU. A dynamic admission policy that looks at current waiting time and expected ICU length of stay allows for increased equity between patients with only minimum losses of efficiency. This dynamic admission policy would seem to be a superior in maximizing case-flow. These results may be generalized to other surgical ICUs.

SUNAMO atrial retractor—a custom-made retractor for small left atrium

Many types of atrial retractors are available in practice. Though they have been used routinely for all types of procedures requiring exposure of mitral valve, we felt that these being rigid and having a fixed design and size, not suitable in certain conditions of redo mitral valve procedures where the left atrium is too small to accommodate the retractor. Moreover atrial wall in such situation is more fragile that little more pull on the retractor would cause tear in the wall of the atrial tissue. We have made a novel flexible type of retractor which can be assembled on the table with materials that are readily available in a cardiothoracic operating room.

Maximizing the GlideScope® videolaryngoscope display using the video output port

To the Editor, Difficulties with tracheal intubation significantly contribute to the morbidity and mortality associated with anesthesia. The ideal device in a difficult airway scenario, especially an unanticipated difficult airway, is one that is designed to be used as a standard laryngoscope but also provides improved views of the larynx. The GlideScope videolaryngoscope (GVL; Verathon, Bothell, WA, USA) is a camera laryngoscope, which displays a colour view of the pharyngeal and laryngeal structures on a dedicated 7-in. liquid crystal display (LCD) monitor. Despite the excellent experience with this device in improving glottis visualization and achieving a high first-time endotracheal intubation success rate, there have been previous descriptions of difficulties directing and advancing the endotracheal tube through the vocal cords and reports of complications associated with its use. We have encountered two additional problems with the GVL. First, the screen has a tendency to reflect the operating room lights causing it to glare and therefore lessen the image quality. Second, when several anesthesia team members were required to assist with a difficult airway, optimal positioning of the mobile stand was cumbersome, making it difficult for some team members to see the 7-in. monitor. A key feature of the GVL system is its video output, which can be used to display the video on a separate screen. At our institution, each cardiothoracic operating room is equipped with the Black Diamond Video Distribution System (Alameda, CA, USA), which permits the display of different sources of digital information in up to four overhead 46-in. high definition (HD) 1080p LCD monitors (Fig. 1a, b). Herein we describe the use of an interface that simultaneously transfers and displays the GVL image on two of the overhead monitors. We added three components to the GVL monitor to transfer and process the video: (1) a video output cable P/N 0600-0239 (Verathon, Bothell, WA, USA), which allows the connection to any NTSC-compatible device; (2) an SDDVI converter (Black Diamond Video, Alameda, CA, USA); and (3) a digital video interfacing (DVI)-I dual link cable. The video output cable allows the connection of the GVL video output (resolution 320 9 240) to the SD-DVI converter. The converter performs the video processing to provide a smooth clear HD video, and its output connects to a convenient DVI-I dual link wall plate connector via a 15-ft DVI cable (Fig. 1c). This HD video is transmitted to the video distribution system console where it can be selected for simultaneous display on the 46-in. HD monitors (model LN46A550P3F, Samsung Electronics America, Mount Arlington, NJ, USA). In the first 20 cases, our initial experience with the system was excellent. Being able to enlarge the image better defines and identifies anatomic structures, and, due to the strategic position of the 46-in. HD screens, the images can be seen by all members of the anesthesia team during the procedure. The interface system is attached to the mobile stand such that only the connection to the wall plate is necessary to allow for immediate display of the image on the overhead monitors. Also, we have not observed any interference between the operating room lights and the 46-in. HD screens. In conclusion, improving the image display can potentially increase the success rate of procedures and minimize associated complications. Furthermore, the GVL is S. Bustamante, MD (&) J. Trepal E. Kraenzler, MD Cleveland Clinic, Cleveland, USA e-mail: bustams@ccf.org

Determination of fentanyl in human breath by solid-phase microextraction and gas chromatography–mass spectrometry

Fentanyl, a kind of intravenous narcotic analgesic, is widely used in clinical anesthesia. As a potential pollution, it was detected in both the air of the cardiothoracic operating room and patients' expiratory circuit. However, whether the fentanyl in patients' expiratory circuit is exhaled by patients is unknown. In this study, breath samples were taken from the expiratory circuits of anesthetic machine linked to the patients who received intravenous fentanyl, a solid-phase microextraction (SPME) coupled with gas chromatography–mass spectrometry (GC–MS) method was developed to detect and quantify fentanyl in breath samples. The parameters influencing adsorption (extraction time, temperature,) and desorption (desorption time) of the analyte on the fiber were investigated and validated for method development. The developed method was proved to be simple, easy, and inexpensive and offer high sensitivity and reproducibility. Linear range was obtained from 0.05 ng/mL to 0.8 ng/mL. The limit of detection was 0.01 ng/mL while an interday precision of less than 12.13% ( n = 5) could be achieved. Six patients were involved in this study; results showed presence of fentanyl in the breath of patients who received intravenous fentanyl, and fentanyl concentrations in breath varied from 6.00 to 20.89 pg/mL. In conclusion, fentanyl can be exhaled by patients who received intravenous fentanyl.

Case-Control Study of Surgical Site Infections Associated With Pacemakers and Implantable Cardioverter-Defibrillators

In 2000, the rate of surgical site infections (SSIs) associated with pacemaker and implantable cardioverter-defibrillator (ICD) procedures performed in the cardiothoracic operating rooms of hospital A was 16% (19 of 116 procedures resulted in infections). This study investigates risks for SSI associated with these procedures in the cardiothoracic operating room. Unmatched 1 : 3 case-control study performed over a 12-month period among patients who had undergone implantation of a pacemaker and/or ICD. A standardized observation scrutinized infection control practices in the area where the procedures were performed. The cardiothoracic operating rooms of hospital A, which belongs to a hospital consortium in the midwestern United States. Patients with SSI were identified as case patients. Control patients were chosen from the group of uninfected patients who had procedures performed during the same period as case patients. A total of 19 SSIs associated with pacemaker and ICD procedures were retrospectively identified among the patients who underwent procedures in these cardiothoracic operating rooms. Culture samples were obtained from 7 patients; 2 yielded coagulase-negative Staphylococcus on culture, 2 yielded Staphylococcus aureus, 1 yielded Serratia marcescens, and 2 showed no growth. In the case-control study, age, race, sex, diabetes mellitus, smoking history, timing of antibiotic therapy, and hair removal did not differ significantly between case patients and control patients. Case patients were more likely to have an abdominal device in place (odds ratio [OR], 5.5 [95% confidence interval {CI}, 1.6-19.3]; P=.006) and less likely to have received a new implant (OR 0.3 [95% CI, 0.1-0.8]; P=.02) or to have had new leads placed (OR, 0.2 [95% CI, 0.1-0.6]; P=.003). Abdominal placement of implanted devices was associated with occurrence of an SSI after pacemaker and/or ICD procedures.