Harleen K. Sandhu

Background: An aortic disease diagnosis can be perceived by patients as a stressful and often life-altering event. In addition, an acute event, such as aortic rupture or dissection—and the surgical intervention that will be required to address it—can be viewed as potentially life-threatening and traumatic. Serious health conditions, including stroke and acute coronary syndromes, have been described in the literature to correlate with trauma-like symptoms. Post-traumatic stress disorder (PTSD) is well described in connection with external traumatic events, such as war, assault and similarly catastrophic events. A key element of this type of PTSD is that its occurrence arises secondary to an external traumatizer. However, recent work has suggested that internal events—such as a catastrophic medical event (e.g., acute cardiovascular event and/or surgery)—can trigger PTSD symptoms. An important question is whether medical event-initiated PTSD can (or should) be treated similarly to traditionally defined PTSD, when the triggering threat may persist rather than having been confined to a past event. This systematic review will summarize the literature on the occurrence of PTSD as a consequence of an acute cardiovascular event and attempt to identify effective treatments using meta-analysis, if the literature quantity and quality support it. Methods: The search strategy will include publicly available electronic databases, including MEDLINE via PubMed and OVID, EMBASE via Elsevier, Cumulative Index for Nursing and Allied Health Literature (CINAHL) via EBSCOhost, SCOPUS, PsychInfo, and the Cochrane Library, to identify publications that report the development and/or treatment of PTSD as a consequence of an acute cardiovascular event, which include cardiac arrest, acute coronary syndromes, and acute aortic syndromes. Identification of publications, article classification, methodological review/quality assessment, and data extraction will be performed by two trained experts in cardiovascular epidemiology, with the resolution of disagreements carried out by a third independent reviewer. The review conduct and meta-analysis will follow PRISMA and MOOSE guidelines. Data will be aggregated using random effects models when quantitative data are reliable and heterogeneity is reasonable. If a quantitative synthesis is not possible due to data quality, a narrative synthesis will be conducted. Statistical heterogeneity will be assessed by I² statistics. The quality of evidence will be assessed using the GRADE criteria. Ethics and Dissemination: This study did not require an institutional review board or human subjects protection committee approval given the nature of the study design. The results will be published in a peer-reviewed journal, along with recommendations for future research.

The use of cardiopulmonary bypass (CPB) contributes significantly to intraoperative anemia. The use of a prescriptive circuit that is tailored to the patient size could significantly reduce priming volumes, resulting in less hemodilution. The purpose of this study was to determine whether a prescriptive circuit resulted in decreased hemodilution, reduced blood product usage, and improved outcomes. In total, 204 patients prospectively received the prescriptive protocol between March 2019 and November 2019. This protocol was composed of three circuit sizes: small [body surface area (BSA) ≤ 1.85 m²], medium (BSA 1.86–2.30 m²), and large (BSA ≥ 2.31 m²). Data for CPB and post-bypass transfusions were collected, along with postoperative outcomes. These patients were then 1:2 propensity score matched to 401 patients who were retrospectively reviewed who had undergone cardiac surgery using a one-sized CPB circuit. The prescriptive protocol cohort had more patients with renal disease, whereas the conventional cohort had more history of hypertension. Intraoperative results show the prescriptive circuit had lower mean prime volume and total prime volume after reverse autologous prime (1,084 mL vs. 1,798 mL,p< .0001; 725 mL vs. 1,181 mL,p< .0001). Ultrafiltration was higher in the prescriptive group (872 vs. 645 mL,p< .0001), which likely balanced the increased use of del Nido cardioplegia in the prescriptive group (1,295 vs. 377 mL,p< .0001). The drop in hematocrit (HCT) from baseline was less in the prescriptive group (15.1 ± 4.91 vs. 16.2 ± 4.88,p= .0149), whereas the postoperative HCT was higher (32.79 ± 4.88 vs. 31.68 ± 4.99,p= .0069). Transfusion of packed red cells did not change between the two groups. Implementation of a prescriptive circuit did not reduce on-bypass or intraoperative blood product usage. However, there was a significant reduction in on-bypass hemodilution and increased postoperative HCT.

Objectives: One of the challenges of spine surgery is the need for adequate exposure of the anterolateral spinal column. Improved retractor systems with integrated lighting minimize the need for large thoracotomy, flank, or abdominal incisions. In 2013, we began using the NuVasive MaXcess^® system via a minimal-access lateral incision for thoracic and thoracolumbar spine exposures. These small-access approaches may not offer adequate exposure when bleeding and other complications arise. We sought to determine the feasibility and outcomes of a minimal-access retractor during anterolateral spine exposures. Methods: An institutional-review-board-approved retrospective chart review was performed of all patients who underwent anterolateral thoracic and lumbosacral spine exposure at an academic hospital between December 1999 and April 2017. Cervical and posterior spine exposures were not included. Information regarding patient demographics, comorbid conditions, operative techniques, exposure, estimated blood loss, length of stay, and intraoperative and postoperative complications was collected. Data for standard exposure vs. minimally invasive exposures were compared. Results: Between December 1999 and April 2017, 223 anterolateral spinal exposures were performed at our institution. Of those, 122 (54.7%) patients had true lateral exposures, with 22 (18%) using the minimally invasive retractor. The mean age of our patient population was 57 years (19–89), with 65 (53%) men and a mean body mass index of 29.0 (17.4–58.6). In the standard exposure group, complications occurred in 22 (22%) patients, whereas only two (9%) complications occurred in the minimal-access group. There were no significant differences in overall intraoperative and postoperative complications, except for cardiopulmonary complications, which were reduced in the minimally invasive group (p < 0.019). Patients with minimally invasive exposure had a significantly shorter length of stay than those with standard exposure (7 vs. 13 days, p = 0.001). Conclusions: Minimal-access techniques using advanced retractor systems are both feasible and safe compared to standard techniques allowing for similar lateral spine exposure, but with smaller incisions, fewer cardiopulmonary complications, and shorter lengths of stay.