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Gastrointestinal: Upper Gastrointestinal Bleeding

    • Several clinical prediction scores have been developed to risk-stratify patients presenting with upper gastrointestinal bleeding (UGIB) and can help guide the sequence of diagnostic tests and subsequent management. The two most commonly used are the Glasgow-Blatchford score and Rockall score. These scoring systems are designed to aid in the identification of patients who will require acute interventions and determine the risk of rebleeding and mortality.
    • Endoscopic intervention is beneficial in high-risk patients with UGIB, reducing the rate of rebleeding, the need for surgical intervention, and mortality. Recent advances in the use of combination therapies and newer mechanical means of hemostasis have increased the success of endoscopic management.
    • Contrast-enhanced, multiphase computed tomography (CT) techniques have improved dramatically over the last decade. CT serves as an excellent complementary test to endoscopic techniques in the management of the hemodynamically stable patient.
    • Transcatheter angiographic embolization is an attractive alternative to surgical intervention in select patients. Advances in catheter-based delivery systems have increased the success rate of angiographic embolization, particularly in patients who have a failed second attempt at endoscopic hemostasis.

Atrial Fibrillation

    • Latest available ACC/AHA guidelines and ongoing controversy around optimal heart rate targets
    • Updated classification for patients with valvular and nonvalvular AF algorithm for maintenance of sinus rhythm
    • 2019 AHA/ACC/HRS and 2020 ESC/EACTS practice guidelines delineated new and modified anticoagulation recommendations pertaining to NOACs.

Injection Sclerotherapy and Ablation

    • Endovenous laser ablation (EVLA) has many similarities to radiofrequency ablation (RFA), with the primary differences related to the catheter and mechanism used to ablate the vein. EVLA uses a bare-tipped or jacket-tipped fiber to deliver laser energy to a target area.
    • The thermal energy generates heat and steam bubbles within the lumen of the target vessel, destroying the endothelial lining of the vessel. This causes an inflammatory and constricting reaction that leads to fibrosis and occlusion of the treated vein.
    • Of note, the incidence of severe postprocedure pain and bruising has been significantly decreased with the advent of the new-generation covered fibers and hemoglobin-targeted chromophore, such that these adverse events are now comparable to those seen with RFA.

Atrial Fibrillation

    • Latest available ACC/AHA guidelines and ongoing controversy around optimal heart rate targets
    • Updated classification for patients with valvular and nonvalvular AF algorithm for maintenance of sinus rhythm
    • 2019 AHA/ACC/HRS and 2020 ESC/EACTS practice guidelines delineated new and modified anticoagulation recommendations pertaining to NOACs.

Practicing Evidence-Based Medicine

    • Even the most competent physician can be prone to misusing epidemiologic concepts. An example of inaccurate decision making, resting on Bayes’s theorem, occurred in a recent study in which primary care physicians were given clinical scenarios. Although the clinicians confidently provided their estimates of the probabilities of given disorders, no consensus could be found among the estimates. Another study assessed the ability of medical students, residents, and attending physicians to correctly determine the positive predictive value of a hypothetical screening test. The vast majority of respondents not only got the question wrong but also had an answer that would have led to the opposite clinical conclusions, guessing an incorrect positive predictive value of 95% when the true answer was 2%.

Cardiac Patients for Non-Cardiac Surgeries

    • Improved survival of patients with congenital heart disease requires all anesthesiologists to be familiar with basic pathophysiological concepts and long term problems after repair or palliation of heart defects.
    • Complex congenital heart defects are nowadays often managed with staged palliations and multiple interventions in the cardiac catheterization laboratory. A thorough understanding of the physiological implications for each of these stages is important for a safe anesthetic management.
    • Minimal invasive surgical techniques can have major implications for patients with single ventricle physiology.
    • Recent advances in the treatment of pulmonary arterial hypertension and heart transplantations will increase the number of imaging studies and interventions for surveillance and therapy adjustments.   

Surgical Management of Ulcerative Colitis

    • As laparoscopic surgery becomes increasingly pervasive, both a hand-assisted and straight laparoscopic colectomy and proctectomy with ileal pouch-anal anastomosis (IPAA) have become more common, with outcomes equivalent to or even improved compared with an open approach.
    • Since the introduction of infliximab, biologic therapy has become more prevalent in the inflammatory bowel disease patient population. These medications should be held as long as possible prior to an elective operation as they have been associated with increased infectious complications following IPAA.
    • Despite biologic therapy, in the setting of an acute flare of ulcerative colitis, 50% of patients treated with intravenous steroids and an induction done of anti–tumor necrosis factor–α will still go on to have a colectomy within the year.
    • The relatively recent introduction of enhanced recovery after surgery protocols in our postoperative care has improved postoperative pain scores and decreased the length of hospital stays. These protocols use a multimodality pain management plan that avoids systemic narcotics, minimizes intravenous fluid administration, enforced early ambulation, and early enteral intake on the night of surgery. The expected length of stay following IPAA is now typically 3 days.
    • As an increasing number of immunosuppressive drugs are being introduced for the treatment of ulcerative colitis, a three-stage approach to IPAA is being more commonly employed. A three–stage approach is used for patients who require emergency surgery, are in poor medical condition due to their underlying disease, or are significantly immunosuppressed.

Liver Failure in the Critical Care Setting

    • Cerebral edema and intracranial hypertension are the major cause of early mortality in acute liver failure (ALF)
    • Liver transplantation is the only proven liver replacement therapy to reduce mortality
    • N-Acetylcysteine (NAC) should be administered to all patients with ALF due to acetaminophen
    • New methods for predicting prognosis, such as the Acute Liver Failure Study Group Index, may offer improved sensitivity in predicting the need for liver transplant or death in ALF.
    • Correction of coagulopathy with fresh frozen plasma in the absence of bleeding or procedures does not improve survival and may precipitate complications.
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