Latest Updates

Anticoagulation and Reversal Agents

Sarah Culbreth, PharmD, BCPS, Jessica Rimsans, PharmD, BCPS, Dirk Varelmann, MD
    • As the direct acting oral anticoagulants (DOACs) have short half-lives, they are able to be continued throughout low bleeding risk procedures, or for high bleeding risk procedures, they may be held 1 to 4 days depending on renal function.
    • Idarucizumab (Praxbind) is a new FDA-approved targeted reversal agent to reverse the effects of dabigatran (Pradaxa) in those with life-threatening bleeding or requiring urgent or emergent surgery.
    • Andexanet alfa is a modified decoy protein newly FDA approved for reversal of apixaban and rivaroxaban, based on results of the ANNEXA-4 trial.

Gynecomastia and Congenital Anomalies of the Breast

    • Minimally invasive management strategies exist for treatment of gynecomastia
    • Various management strategies exist for treatment of Poland syndrome
    • Minimally invasive technologies exist for treatment of congenital breast anomaly reconstruction

Midshaft Hypospadias: Review of Surgical Technique

    • Approaching hypospadias with an algorithm for correction helps eliminate variation in surgical techniques.
    • Understanding the anatomy of the phallus helps the surgeons troubleshoot when they come across challenges in hypospadias repair.
    • Key surgical techniques should be applied to hypospadias surgery to decrease complications and improve outcomes.

Esophageal Adenocarcinoma

Steven N Hochwald, MD, FACS, Rupen Shah, MD
    • Nomograms and consensus management of complications of esophageal surgery
    • Multimodality treatment approaches using neoadjuvant carboplatin, paclitaxel, and radiation therapy followed by surgery
    • Results from minimally invasive treatment approaches
    • Trastuzumab for anti-growth factor treatment in cases of metastatic adenocarcinoma of the esophagus

Hematology: A Review of Venous Thromboembolism and Transfusion Medicine

Maulik Rajyaguru, DO, Jill Yaung, MD
    • For outpatients, recent trials have demonstrated non-vitamin K oral anticoagulants to be just as efficacious in VTE management while significantly decreasing the risk of hemorrhagic events.
    • The CLOTS 1 and 3 trials provide evidence that SCDs but not compression stockings have an additive, preventative effect on the prevention of VTE in immobile patients who suffered a stroke.
    • For the general critical care patient, transfusion for a hemoglobin level greater than 7 g/dL is rarely recommended, except for patients with ischemic heart disease.
    • The minimum platelet count for a bronchoscopy is 30 × 103 platelets/µL.

Anesthesia for Urologic Surgery

Dan B Ellis, MD, Anton Wintner, MD
    • Transurethral resection of the prostate (TURP) is a common technique to treat benign prostatic hypertrophy. However, it may be associated with significant fluid absorption and result in TUR syndrome. Previously a source of significant morbidity following TURP, TUR is characterized by altered mental status, hypertension, nausea, vomiting, and cerebral edema. Fortunately, a change in surgical technique and a change in the irrigant used in the procedure can minimize its occurrence.
    • Extracorporeal shockwave lithotripsy (ESWL) and cystoscopy or ureteroscopy with laser lithotripsy are effective ways to treat obstructing ureteral stones. ESWL and cystoscopy or ureteroscopy have replaced previous techniques that required patients to be submerged in water.
    • Percutaneous ultrasonic lithotripsy is an effective yet more invasive approach to complex kidney stones that cannot be addressed using ESWL or cystoscopy or ureteroscopy. Although percutaneous ultrasonic lithotripsy can be highly effective, it is significantly more invasive as it requires a flank incision.

Cardiovascular System: Heart Diseases

    • MRI safe devices and leads: older implanted devices were considered an absolute contraindication for MRI, depriving patients of the benefits of this important diagnostic imaging modality. Although many of the fears of device malfunction during MRI have been shown to be unfounded, newer devices and leads have been manufactured to ensure safety within the MRI scanner.
    • Leadless pacemakers: a recent innovation is the implantation of miniaturised pacemakers directly into the myocardium, avoiding the need for pacemaker leads.
    • Recent studies suggest improved outcomes by novel cardiac resynchronization therapy pacing modes (LV only modes).
    • Device innovation for MAZE procedures: technologic advances allow reduction of invasiveness of MAZE procedures, such as robotic-assisted procedures, or translate advances in energy delivery developed in transcatheter ablations to the surgical world (cryoMAZE).

The Post-Anesthesia Care Unit

Evan R Bohnenblust, MD
    • When proper monitoring and dosage is used, the incidence of residual neuromuscular blockade is greatly reduced when sugammadex is administered as a reversal agent. (Brueckmann B, Sasaki N, Grobara P, et al. Effects of sugammadex on incidence of postoperative residual neuromuscular blockade: a randomized, controlled study. Br J Anaesth 2015;115:743–51).
    • In patients who have undergone neuraxial anesthesia for lower extremity joint surgery, fast-track discharge from PACU (discharge prior to return of motor function) may significantly reduce total PACU time and is not associated with increased length of stay or 30-day readmission. (Aasvang EK, Jørgensen CC, Laursen MB. Safety aspects of postanesthesia care unit discharge without motor function assessment after spinal anesthesia: a randomized, multicenter, semiblinded, noninferiority, controlled trial. Anesthesiology 2017;126:1043–52).
    • Important risk factors for early PACU delirium may include age, male gender, longer preoperative fasting, higher ASA score, the use of benzodiazepines, opioids, and volatile anesthetics, and transfusion of red blood cells or fresh frozen plasma (Hernandez BA, Lindroth H, Rowley P, et al. Post-anaesthesia care unit delirium: incidence, risk factors and associated adverse outcomes. Br J Anaesth 2017;119:288–90).
    • In patients undergoing major intra-abdominal surgery, the Surgical Apgar Score may provide an objective scoring system to predict the need for postoperative ICU admission (Sobol JB, Gershengorn HB, Wunsch H, et al. The surgical Apgar score is strongly associated with intensive care unit admission after high-risk intraabdominal surgery. Anesth Analg 2013;117:438–46).
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