Publications by authors named "Lorenzo De Marchi"

17 Publications

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Adult liver transplant anesthesiology practice patterns and resource utilization in the United States: Survey results from the society for the advancement of transplant anesthesia.

Clin Transplant 2021 Oct 12:e14504. Epub 2021 Oct 12.

Department of Anesthesiology, University of Colorado, Aurora, CO.

Introduction: Liver transplant anesthesiology is an evolving and expanding subspecialty, and programs have, in the past, exhibited significant variations of practice at transplant centers across the United States. In order to explore current practice patterns, the Quality & Standards Committee from the Society for the Advancement of Transplant Anesthesia (SATA) undertook a survey of liver transplant anesthesiology program directors.

Methods: Program directors were invited to participate in an online questionnaire. A total of 110 program directors were identified from the 2018 Scientific Registry of Transplant Recipients (SRTR) database. Replies were received from 65 programs (response rate of 59%).

Results: Our results indicate an increase in transplant anesthesia fellowship training and advanced training in transesophageal echocardiography (TEE). We also find that the use of intraoperative TEE and viscoelastic testing is more common. However, there has been a reduction in the use of veno-venous bypass, routine placement of pulmonary artery catheters and the intraoperative use of anti-fibrinolytics when compared to prior surveys.

Conclusion: The results show considerable heterogeneity in practice patterns across the country that continues to evolve. However, there appears to be a movement towards the adoption of specific structural and clinical practices. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1111/ctr.14504DOI Listing
October 2021

Reply.

Liver Transpl 2021 05;27(5):769

Department of Anesthesiology, University of Colorado, Aurora, CO.

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http://dx.doi.org/10.1002/lt.26042DOI Listing
May 2021

In Response.

A A Pract 2021 02 5;15(2):e01386. Epub 2021 Feb 5.

Department of Anesthesia, Medstar-Georgetown University Hospital, Washington, DC,

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http://dx.doi.org/10.1213/XAA.0000000000001386DOI Listing
February 2021

The Society for the Advancement of Transplant Anesthesia (SATA) enters a new partnership with Clinical Transplantation.

Clin Transplant 2021 02 21;35(2):e14203. Epub 2021 Jan 21.

Department of Anesthesiology and Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, FL, USA.

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http://dx.doi.org/10.1111/ctr.14203DOI Listing
February 2021

Lung Ultrasound in Thoracic Surgery: Confirming Placement of a Pediatric Right Double-Lumen Tube.

A A Pract 2020 Aug;14(10):e01296

From the Department of Anesthesia, MedStar-Georgetown University Hospital, Washington, DC.

In the recent decades, flexible bronchoscopy has replaced lung auscultation to confirm more precisely the placement of a double-lumen endotracheal tube (DLT) for thoracic surgery. However, bronchoscopes are costly and not always available. Lung ultrasound has been described in the literature as an alternative to confirm left DLT placement and lung isolation. In this case report, we describe a pediatric thoracic case in which lung ultrasound was utilized to confirm correct placement of a right-sided DLT.
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http://dx.doi.org/10.1213/XAA.0000000000001296DOI Listing
August 2020

Safety and Benefit of Transesophageal Echocardiography in Liver Transplant Surgery: A Position Paper From the Society for the Advancement of Transplant Anesthesia (SATA).

Liver Transpl 2020 08;26(8):1019-1029

Department of Anesthesia, University of Colorado, Aurora, CO.

More anesthesiologists are routinely using transesophageal echocardiography (TEE) during liver transplant surgery, but the effects on patient outcome are unknown. Transplant anesthesiologists are therefore uncertain if they should undergo additional training and adopt TEE. In response to these clinical questions, the Society for the Advancement of Transplant Anesthesia appointed experts in liver transplantation and who are certified in TEE to evaluate all available published evidence on the topic. The aim was to produce a summary with greater explanatory power than individual reports to guide transplant anesthesiologists in their decision to use TEE. An exhaustive search recovered 51 articles of uncontrolled clinical observations. Topics chosen for this study were effectiveness and safety because they were a major or minor topic in all articles. The pattern of clinical use was a common topic and was included to provide contextual information. Summarized observations showed effectiveness as the ability to make a new and unexpected diagnosis and to direct the choice of clinical management. These were reported in each stage of liver transplant surgery. There were observations that TEE facilitated rapid diagnosis of life-threatening conditions difficult to identify with other types of monitoring commonly used in the operating room. Real-time diagnosis by TEE images made anesthesiologists confident in their choice of interventions, especially those with a high risk of complications such as use of anticoagulants for intracardiac thrombosis. The summarized observations in this systematic review suggest that TEE is an effective form of monitoring with a safety profile similar to that in cardiac surgery patients.
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http://dx.doi.org/10.1002/lt.25800DOI Listing
August 2020

Intraoperative Transesophageal Echocardiogram During Orthotopic Liver Transplantation: TEE to the Rescue!

Semin Cardiothorac Vasc Anesth 2018 Jun 9;22(2):146-149. Epub 2018 Feb 9.

1 MedStar Georgetown University Hospital, Washington, DC, USA.

Supported by a growing number of studies and case reports in the literature, perioperative use of TEE in non-cardiac cases has significantly increased the past two decades. The utility of TEE in monitoring hemodynamic, and diagnosing causes of hypotension refractory to conventional therapy, have made it an almost indispensible tool during major surgeries, such liver transplantation. Despite this fact, compared to the adult population, there is a lack of an equivalent amount of literature on the perioperative use of TEE in pediatric cases. In our case we report the utilization of TEE during a pediatric liver transplant, to diagnose a post reperfusion suprahepatic anastomosis stricture. In this case, the cooperation of the anesthesia, the surgical, and the cardiology teams, helped in resolving the case, allowing a positive outcome for the patient. To our knowledge, this is the first case describing the use of TEE during a pediatric liver transplant.
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http://dx.doi.org/10.1177/1089253218757032DOI Listing
June 2018

Left video-assisted thoracic surgery thymectomy.

J Vis Surg 2017 10;3:47. Epub 2017 Apr 10.

Division of Thoracic Surgery, Department of Surgery, Medstar Georgetown University Hospital, Washington, DC, 20007, USA.

Video-assisted thoracic surgery (VATS) for the management of non-thymomatous myasthenia gravis (MG) as well as the management of small thymomas and other benign thymic pathology has been gaining in acceptance and popularity as an alternative to the traditional median sternotomy approach. Although VATS thymectomy has been described in several variations, our current preference is a left sided VATS approach due to the exposure it provides in critical areas of dissection. Here we describe our technique for the left sided VATS thymectomy including patient selection, preoperative preparation, operative steps, and postoperative care. We also share pitfalls and tips to prevent them at each step of the procedure learned from our experience with this approach.
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http://dx.doi.org/10.21037/jovs.2017.02.13DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637749PMC
April 2017

POCUS in perioperative medicine: a North American perspective.

Crit Ultrasound J 2017 Oct 9;9(1):19. Epub 2017 Oct 9.

Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street EN 3-400, Toronto, ON, M5G 2C4, Canada.

Ultrasound (US) performed at the point of care has found fertile ground in perioperative medicine. In the hands of anesthesiologists, transesophageal echocardiography (TEE) has become established as a powerful diagnostic and monitoring tool in the perioperative care of cardiac and non-cardiac patients. A number of point-of-care US (POCUS) applications are relevant to perioperative care, including airway, cardiac, lung and gastric US. Although guidelines exist to define the scope of practice for basic and advanced TEE, there remains a lack of such guidelines for perioperative point-of-care ultrasound (POCUS), despite a number of recent calls for action in the academic anesthesia community. POCUS training has been integrated into anesthesia residency curricula in Canada and the United States of America (USA). However, a nation-wide curriculum is still lacking. Many limitations to the development of perioperative POCUS curricula exist, including the need to define the scope of practice and design integrated longitudinal learning approaches. The main anesthesiologist societies in both the USA and Canada are promoting the development of guidelines and have introduced POCUS courses into their national conferences. Although bedside US imaging has been integrated into the curricula of many medical schools in North America, the need for specific national guidelines for the training and practice of POCUS in the perioperative setting by anesthesiologists is crucial to the further development of POCUS in perioperative medicine.
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http://dx.doi.org/10.1186/s13089-017-0075-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5633585PMC
October 2017

Liposomal bupivacaine versus bupivacaine/epinephrine after video-assisted thoracoscopic wedge resection†.

Interact Cardiovasc Thorac Surg 2017 06;24(6):925-930

Division of Thoracic Surgery, Department of General Surgery, Georgetown University Hospital, Washington, DC, USA.

Objectives: The purpose of this research is to compare liposomal bupivacaine and bupivacaine/epinephrine for intercostal blocks related to analgesic use and length of stay following video-assisted thoracoscopic wedge resection.

Methods: A retrospective study of patients undergoing video-assisted thoracoscopic wedge resection from 2010 to 2015 was performed. We selected patients who stayed longer than 24 h in hospital. Primary outcomes were length of stay and postoperative analgesic use at 12-h intervals from 24 to 72 h.

Results: Intercostal blocks were performed with liposomal bupivacaine in 62 patients and bupivacaine/epinephrine in 51 patients. A Wilcoxon signed-rank test evaluated differences in median postoperative analgesic use and length of stay. Those who received liposomal bupivacaine consumed fewer analgesics than those who received bupivacaine/epinephrine, with a statistically significant difference from 24 to 36 h (20.25 vs 45.0 mg; P  = 0.0059) and from 60 to 72 h postoperatively (15.0 vs 33.75 mg; P  = 0.0350). In patients who stayed longer than 72 h, the median cumulative analgesic consumption in those who received liposomal bupivacaine was statistically significantly lower than those who received bupivacaine/epinephrine (120.0 vs 296.5 mg; P  = 0.0414). Median length of stay for the liposomal bupivacaine and bupivacaine/epinephrine groups were 45:05 h and 44:29 h, respectively. There were no adverse events related to blocks performed with liposomal bupivacaine.

Conclusions: Thoracic surgery patients who have blocks performed with liposomal bupivacaine require fewer analgesics postoperatively. This may decrease complications related to poor pain control and decrease side effects related to narcotic use in our patient population.
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http://dx.doi.org/10.1093/icvts/ivx044DOI Listing
June 2017

Pathogenic Link Between Postextubation Pneumonia and Ventilator-Associated Pneumonia: An Experimental Study.

Anesth Analg 2017 04;124(4):1339-1346

From the *Anesthesia Center for Critical Care Research, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; †Department of Health Science, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy; ‡Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy; §Department of Anesthesia, Medstar-Georgetown University Hospital, Washington, DC; and ‖Pulmonary and Critical Care Medicine Branch, Section of Pulmonary and Cardiac Assist Devices, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.

Background: The presence of an endotracheal tube is the main cause for developing ventilator-associated pneumonia (VAP), but pneumonia can still develop in hospitalized patients after endotracheal tube removal (postextubation pneumonia [PEP]). We hypothesized that short-term intubation (24 hours) can play a role in the pathogenesis of PEP. To test such hypothesis, we initially evaluated the occurrence of lung colonization and VAP in sheep that were intubated and mechanically ventilated for 24 hours. Subsequently, we assessed the incidence of lung colonization and PEP at 48 hours after extubation in sheep previously ventilated for 24 hours.

Methods: To simulate intubated intensive care unit patients placed in semirecumbent position, 14 sheep were intubated and mechanically ventilated with the head elevated 30° above horizontal. Seven of them were euthanized after 24 hours (Control Group), whereas the remaining were euthanized after being awaken, extubated, and left spontaneously breathing for 48 hours after extubation (Awake Group). Criteria of clinical diagnosis of pneumonia were tested. Microbiological evaluation was performed on autopsy in all sheep.

Results: Only 1 sheep in the Control Group met the criteria of VAP after 24 hours of mechanical ventilation. However, heavy pathogenic bacteria colonization of trachea, bronchi, and lungs (range, 10-10 colony-forming unit [CFU]/g) was reported in 4 of 7 sheep (57%). In the Awake Group, 1 sheep was diagnosed with VAP and 3 developed PEP within 48 hours after extubation (42%), with 1 euthanized at 30 hours because of respiratory failure. On autopsy, 5 sheep (71%) confirmed pathogenic bacterial growth in the lower respiratory tract (range, 10-10 CFU/g).

Conclusions: Twenty-four hours of intubation and mechanical ventilation in semirecumbent position leads to significant pathogenic colonization of the lower airways, which can promote the development of PEP. Strategies directed to prevent pathogenic microbiological colonization before and after mechanical ventilation should be considered to avert the onset of PEP.
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http://dx.doi.org/10.1213/ANE.0000000000001899DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5374725PMC
April 2017

Foreign body entrapment during thoracic surgery-time for closed loop communication.

Eur J Cardiothorac Surg 2017 May;51(5):852-855

Department of Medicine, MEDSTAR Georgetown University Hospital, Washington, DC, USA.

Objectives: During general thoracic surgery procedures, devices are often placed in the airway and oesophagus. This creates an opportunity for foreign body entrapment (FBE) during pulmonary and foregut surgery. Like retained foreign bodies (RFB), FBE is an entirely preventable event. Unlike RFB, there is minimal literature on FBE, thus little is known about its occurrence, risk factors, and prevention.

Methods: A survey was distributed to 215 surgeons of the General Thoracic Surgical Club. The survey included questions about socio-demographics, procedural volume, occurrence of FBE and factors leading to FBE.

Results: There were 110 responses (51%, 110/215). The majority of respondents worked in academic hospitals (75%, 82/110), in urban environments (63%, 69/110), and were male (85%, 94/110). One hundred and four respondents performed pulmonary resections and 92 performed foregut surgeries. In the pulmonary group, 40% (42/104) reported FBE with 67% (23/42) in open procedures. In the foregut group 38% (35/92) reported FBE with 69% (24/35) in open procedures. With both groups combined, 54.5% (60/110) of respondents reported FBE at least once and 29% (24/110) reported more than one FBE in their career. The most frequently reported contributing factor was communication errors between the surgical and anaesthesia teams.

Conclusions: FBE during general thoracic procedures occurs in both minimally invasive and open pulmonary and foregut procedures. The greatest risk factor is communication error. Specific routine closed loop communication with the anaesthesia team prior to stapling/suturing the airway or oesophagus would minimize the risk of FBE.
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http://dx.doi.org/10.1093/ejcts/ezw427DOI Listing
May 2017

Hemodynamic monitoring during liver transplantation: A state of the art review.

World J Hepatol 2015 Jun;7(10):1302-11

Mona Rezai Rudnick, Lorenzo De Marchi, Jeffrey S Plotkin, Department of Anesthesiology, Georgetown University Hospital, NW Washington, DC 20007, United States.

Orthotopic liver transplantation can be marked by significant hemodynamic instability requiring the use of a variety of hemodynamic monitors to aide in intraoperative management. Invasive blood pressure monitoring is essential, but the accuracy of peripheral readings in comparison to central measurements has been questioned. When discrepancies exist, central mean arterial pressure, usually measured at the femoral artery, is considered more indicative of adequate perfusion than those measured peripherally. The traditional pulmonary artery catheter is less frequently used due to its invasive nature and known limitations in measuring preload but still plays an important role in measuring cardiac output (CO) when required and in the management of portopulmonary hypertension. Pulse wave analysis is a newer technology that uses computer algorithms to calculate CO, stroke volume variation (SVV) and pulse pressure variation (PPV). Although SVV and PPV have been found to be accurate predicators of fluid responsiveness, CO measurements are not reliable during liver transplantation. Transesophageal echocardiography is finding an increasing role in the real-time monitoring of preload status, cardiac contractility and the diagnosis of a variety of pathologies. It is limited by the expertise required, limited transgastric views during key portions of the operation, the potential for esophageal varix rupture and difficulty in obtaining quantitative measures of CO in the absence of tricuspid regurgitation.
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http://dx.doi.org/10.4254/wjh.v7.i10.1302DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450194PMC
June 2015

Dexmedetomidine sedation for awake tracheotomy: case report and literature review.

J Clin Anesth 2010 Aug;22(5):360-2

Department of Anesthesia, Georgetown University Hospital, Washington, DC 20007, USA.

The safe administration of conscious sedation in a patient with a critical airway who underwent awake tracheotomy using dexmedetomidine, a selective alpha(2)-agonist with sympatholytic, anxiolytic, analgesic, and sedative properties, is presented. Unlike other commonly used sedative agents, dexmedetomidine provided adequate sedation with minimal respiratory depression.
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http://dx.doi.org/10.1016/j.jclinane.2009.04.008DOI Listing
August 2010

Evaluation of continuous aspiration of subglottic secretion in an in vivo study.

Crit Care Med 2004 Oct;32(10):2071-8

Section on Pulmonary and Cardiac Assist Devices, Pulmonary and Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.

Objective: Continuous aspiration of subglottic secretions (CASS) is believed to lower the incidence of ventilator-associated pneumonia. Animal studies to establish safety and efficacy of CASS have not been conducted.

Design: Prospective randomized animal study.

Setting: Animal-research facility at the U.S. National Institutes of Health.

Subjects: Twenty-two sheep.

Interventions: Sheep were randomized into three groups. In group C (control), eight sheep were kept prone, intubated with a standard endotracheal tube (ETT), and mechanically ventilated for 72 hrs with head and ETT elevated at an angle of 30 degrees. In group CASS-HU (CASS, head up), seven sheep were managed as group C and intubated with a Hi-Lo Evac, Mallinckrodt ETT (CASS suction kept at < or =20 mm Hg). In group CASS-HD (CASS, head down), seven sheep were kept prone with CASS, and the ETT and trachea were horizontal to promote spontaneous drainage of mucus from the ETT.

Measurements And Results: The lower respiratory tract in the CASS-HU group was heavily colonized in all seven sheep (median 4.6 x 10(9), range, 1.5 x 10(8) to 7.9 x 10(9) colony-forming units/g), with a reduction of lung bacterial colonization compared with the C group (p = .05). In group CASS-HD, the lower respiratory tract was not colonized in six of seven sheep. One sheep showed low levels of bacterial growth (median, 0; range, 0-2.2 x 10(5)). At autopsy, in all 14 sheep with CASS, we found tracheal mucosal injury of different degrees of severity at the level of the suction port of the ETT.

Conclusions: In group CASS-HU, regardless of finding a marginal decrease of the bacterial colonization of the lower airways, there was pervasive trachea-bronchial-lung bacterial colonization. Second, there was minimal, or absent, bacterial colonization when the orientation of the CASS ETT was at, or just below, horizontal. Third, there was widespread injury to tracheal mucosa/submucosa from the use of CASS. Note that results of studies conducted in an animal model are always difficult to extrapolate to the clinical practice due to anatomical and functional differences.
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http://dx.doi.org/10.1097/01.ccm.0000142575.86468.9bDOI Listing
October 2004

Endotracheal tubes coated with antiseptics decrease bacterial colonization of the ventilator circuits, lungs, and endotracheal tube.

Anesthesiology 2004 Jun;100(6):1446-56

Pulmonary Critical Care Medicine Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892, USA.

Background: Formation of a bacterial biofilm within the endotracheal tube (ETT) after tracheal intubation is rapid and represents a ready source of lung bacterial colonization. The authors investigated bacterial colonization of the ventilator circuit, the ETT, and the lungs when the ETT was coated with silver-sulfadiazine and chlorhexidine in polyurethane, using no bacterial/viral filter attached to the ETT.

Methods: Sixteen sheep were randomized into two groups. Eight sheep were intubated with a standard ETT (control group), and eight were intubated with a coated ETT (study group). Animals were mechanically ventilated for 24 h. At autopsy, the authors sampled the trachea, bronchi, lobar parenchyma, and ETT for quantitative bacterial cultures. Qualitative bacterial cultures were obtained from the filter, humidifier, inspiratory and expiratory lines, and water trap. ETTs were analyzed with light microscopy, scanning electron microscopy, and laser scanning confocal microscopy.

Results: In the control group, all eight ETTs were heavily colonized (10(5)-10(8) colony-forming units [cfu]/g), forming a thick biofilm. The ventilator circuit was always colonized. Pathogenic bacteria colonized the trachea and the lungs in five of eight sheep (up to 10(9) cfu/g). In the study group, seven of eight ETTs and their ventilator circuits showed no growth, with absence of a biofilm; one ETT and the respective ventilator circuit showed low bacterial growth (10(3)-10(4) cfu/g). The trachea was colonized in three sheep, although lungs and bronchi showed no bacterial growth, except for one bronchus in one sheep.

Conclusions: Coated ETTs induced a nonsignificant reduction of the tracheal colonization, eliminated (seven of eight) or reduced (one of eight) bacterial colonization of the ETT and ventilator circuits, and prevented lung bacterial colonization.
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http://dx.doi.org/10.1097/00000542-200406000-00017DOI Listing
June 2004
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