Vidya Rao

All Publications

• Unexpected Interruptions in the Inhaled Epoprostenol Delivery System: Incidence of Adverse Sequelae and Therapeutic Consequences in Critically Ill Patients. Critical care explorations Block, J. M., Madhok, J., Owyang, C. G., Merriman, K. R., Ruoss, S. J., Rao, V. K. 2021; 3 (10): e0548

  Abstract

  OBJECTIVES: Inhaled epoprostenol is a continuously delivered selective pulmonary vasodilator that is used in patients with refractory hypoxemia, right heart failure, and postcardiac surgery pulmonary hypertension. Published data suggest that inhaled epoprostenol administration via vibrating mesh nebulizer systems may lead to unexpected interruptions in drug delivery. The frequency of these events is unknown. The objective of this study was to describe the incidence and clinical consequences of unexpected interruption in critically ill patients.DESIGN: Retrospective review and analysis.SETTING: Stanford University Hospital, a 605-bed tertiary care center.PATIENTS: Patients receiving inhaled epoprostenol in 2019.INTERVENTIONS: No interventions.MEASUREMENTS AND MAIN RESULTS: Clinical indication, duration of inhaled epoprostenol delivery, mode of respiratory support, and documented unexpected interruption. In 2019, there were 493 administrations of inhaled epoprostenol in 433 unique patients. Primary indications for inhaled epoprostenol were right heart dysfunction (n = 394; 79.9%) and hypoxemia (n = 92; 18.7%). Unexpected delivery interruptions occurred in 31 administrations (6.3%). Median duration of therapy prior to unexpected interruption was 2 days (interquartile range, 2-5 d). Respiratory support at the time of unexpected interruption was mechanical ventilation (61.3%), high-flow nasal cannula (35.5%), and noninvasive positive pressure ventilation (3.2%). Adverse sequelae of unexpected interruption included elevated pulmonary artery pressures (n = 12), systemic hypotension (n = 8), hypoxemia (n = 8), elevated central venous pressure (n = 4), and cardiac arrest (n = 1). Therapeutic interventions following unexpected interruption included initiation of inhaled nitric oxide (n = 21), increase in vasoactive medication (n = 2), and increase in respiratory support (n = 2). Most of the adverse events were Common Terminology Criteria for Adverse Events grade 3 and 4 (93.5%).CONCLUSIONS: A retrospective review of patients receiving inhaled epoprostenol via vibrating mesh nebulizer in 2019 revealed interruptions in 6.3% of administrations with most of these interruptions requiring therapeutic intervention. The true incidence of unexpected interruption and subsequent rate of unexpected interruption's requiring intervention is unknown due to the reliance on unexpected interruption identification and subsequent documentation in the electronic medical record. Sudden interruption in inhaled epoprostenol delivery can result in severe cardiopulmonary compromise, and on rare occasion, death.

  View details for DOI 10.1097/CCE.0000000000000548

  View details for PubMedID 34671745

• The Year in Thoracic Anesthesia: Selected Highlights From 2020. Journal of cardiothoracic and vascular anesthesia Boisen, M. L., Fernando, R. J., Kolarczyk, L., Teeter, E., Schisler, T., La Colla, L., Melnyk, V., Robles, C., Rao, V. K., Gelzinis, T. A. 2021

  Abstract

  Selected highlights in thoracic anesthesia in 2020 include updates in the preoperative assessment and prehabilitation of patients undergoing thoracic surgery; updates in one-lung ventilation (OLV) pertaining to the devices used for OLV; the use of dexmedetomidine for lung protection during OLV and protective ventilation, recommendations for the care of thoracic surgical patients with coronavirus disease 2019; a review of recent meta-analyses comparing truncal blocks with paravertebral and thoracic epidural blocks; and a review of outcomes after initiating the enhanced recovery after surgery guidelines for lung and esophageal surgery.

  View details for DOI 10.1053/j.jvca.2021.04.012

  View details for PubMedID 34053812

• Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part II, Intraoperative Management and Troubleshooting. Anesthesia and analgesia Mazzeffi, M. A., Rao, V. K., Dodd-O, J., Del Rio, J. M., Hernandez, A., Chung, M., Bardia, A., Bauer, R. M., Meltzer, J. S., Satyapriya, S., Rector, R., Ramsay, J. G., Gutsche, J. 2021

  Abstract

  In the second part of the Society of Cardiovascular Anesthesiologists Extracorporeal Membrane Oxygenation (ECMO) working group expert consensus statement, venoarterial (VA) and venovenous (VV) ECMO management and troubleshooting in the operating room are discussed. Expert consensus statements are provided about intraoperative monitoring, anesthetic drug dosing, and management of intraoperative problems in VA and VV ECMO patients.

  View details for DOI 10.1213/ANE.0000000000005733

  View details for PubMedID 34559091

• First lung and kidney multi-organ transplant following COVID-19 Infection. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation Guenthart, B. A., Krishnan, A., Alassar, A., Madhok, J., Kakol, M., Miller, S., Cole, S. P., Rao, V. K., Acero, N. M., Hill, C. C., Cheung, C., Jackson, E. C., Feinstein, I., Tsai, A. H., Mooney, J. J., Pham, T., Elliott, I. A., Liou, D. Z., La Francesca, S., Shudo, Y., Hiesinger, W., MacArthur, J. W., Brar, N., Berry, G. J., McCarra, M. B., Desai, T. J., Dhillon, G. S., Woo, Y. J. 2021

  Abstract

  As the world responds to the global crisis of the COVID-19 pandemic an increasing number of patients are experiencing increased morbidity as a result of multi-organ involvement. Of these, a small proportion will progress to end-stage lung disease, become dialysis dependent, or both. Herein, we describe the first reported case of a successful combined lung and kidney transplantation in a patient with COVID-19. Lung transplantation, isolated or combined with other organs, is feasible and should be considered for select patients impacted by this deadly disease.

  View details for DOI 10.1016/j.healun.2021.02.015

  View details for PubMedID 34059432

• Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation. Anesthesia and analgesia Mazzeffi, M. A., Rao, V. K., Dodd-O, J., Del Rio, J. M., Hernandez, A., Chung, M., Bardia, A., Bauer, R. M., Meltzer, J. S., Satyapriya, S., Rector, R., Ramsay, J. G., Gutsche, J. 2021

  Abstract

  Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.

  View details for DOI 10.1213/ANE.0000000000005738

  View details for PubMedID 34559089

• Corrigendum to 'The Year in Thoracic Anesthesia: Selected Highlights from 2019' [Journal of Cardiothoracic and Vascular Anesthesia 34 (2020) 1733-1744]. Journal of cardiothoracic and vascular anesthesia Boisen, M. L., Schisler, T., Kolarczyk, L., Melnyk, V., Rolleri, N., Bottiger, B., Klinger, R., Teeter, E., Rao, V. K., Gelzinis, T. A. 2020

  View details for DOI 10.1053/j.jvca.2020.06.085

  View details for PubMedID 32680770

• The Year in Thoracic Anesthesia: Selected Highlights from 2019. Journal of cardiothoracic and vascular anesthesia Boisen, M. L., Schisler, T. n., Kolarczyk, L. n., Melnyk, V. n., Rolleri, N. n., Bollinger, B. n., Klinger, R. n., Teeter, E. n., Rao, V. K., Gelzinis, T. A. 2020

  Abstract

  THIS special article is the 4th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan; the associate editor-in-chief, Dr. Augoustides; and the editorial board for the opportunity to expand this series, the research highlights of the year that specifically pertain to the specialty of thoracic anesthesia. The major themes selected for 2019 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in this specialty for 2019 include updates in the preoperative assessment and optimization of patients undergoing lung resection and esophagectomy, updates in one lung ventilation (OLV) and protective ventilation during OLV, a review of recent meta-analyses comparing truncal blocks with paravertebral catheters and the introduction of a new truncal block, meta-analyses comparing nonintubated video-assisted thoracoscopic surgery (VATS) with those performed using endotracheal intubation, a review of the Society of Thoracic Surgeons (STS) recent composite score rating for pulmonary resection of lung cancer, and an update of the Enhanced Recovery After Surgery (ERAS) guidelines for both lung and esophageal surgery.

  View details for DOI 10.1053/j.jvca.2020.03.016

  View details for PubMedID 32430201

• The Year in Thoracic Anesthesia: Selected Highlights From 2018. Journal of cardiothoracic and vascular anesthesia Boisen, M. L., Rolleri, N. n., Gorgy, A. n., Kolarczyk, L. n., Rao, V. K., Gelzinis, T. A. 2019

  View details for DOI 10.1053/j.jvca.2019.03.019

  View details for PubMedID 31494005

• IMPROVING NUTRITION FOR CRITICALLY ILL HEMODYNAMICALLY UNSTABLE POST-CARDIAC SURGERY PATIENTS Modir, R., Hill, C., Rao, V., Oyer, P. LIPPINCOTT WILLIAMS & WILKINS. 2019

  View details for Web of Science ID 000498593400393

• SEROTONIN SYNDROME IN A VENOVENOUS ECMO PATIENT Kapil, S., Khan, S., Rao, V. LIPPINCOTT WILLIAMS & WILKINS. 2019

  View details for Web of Science ID 000498593400109

• The Year in Thoracic Anesthesia: Selected Highlights From 2017 JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA Boisen, M. L., Sardesai, M. P., Kolarczyk, L., Rao, V. K., Owsiak, C. P., Gelzinis, T. A. 2018; 32 (4): 1556–69

  View details for PubMedID 29655515

• Inhaled Nitric Oxide (iNO) and Inhaled Epoprostenol (iPGI(2)) Use in Cardiothoracic Surgical Patients: Is there Sufficient Evidence for Evidence-Based Recommendations? JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA Rao, V., Ghadimi, K., Keeyapaj, W., Parsons, C. A., Cheung, A. T. 2018; 32 (3): 1452–57

  View details for PubMedID 29336971

• Ambulating femoral venoarterial extracorporeal membrane oxygenation bridge to heart-lung transplant. The Journal of thoracic and cardiovascular surgery Shudo, Y., Kasinpila, P., Lee, A. M., Rao, V. K., Woo, Y. J. 2018

  View details for PubMedID 29628344

• Postoperative Respiratory Impairment Is a Real Risk for Our Patients: The Intensivist's Perspective ANESTHESIOLOGY RESEARCH AND PRACTICE Rao, V. K., Khanna, A. K. 2018: 3215923

  Abstract

  Postoperative respiratory impairment occurs as a result of a combination of patient, surgical, and management factors and contributes to both surgical and anesthetic risk. This complication is challenging to predict and has been associated with an increase in mortality and hospital length of stay. There is mounting evidence to suggest that patients remain vulnerable to respiratory impairment well into the postoperative period, with the vast majority of adverse events occurring during the first 24 hours following discharge from anesthesia care. At present, preoperative risk stratification scores may be able to identify patients who are particularly prone to respiratory complications but cannot consistently and globally predict risk in an ongoing fashion as they do not incorporate the impact of intra- and postoperative events. Current postoperative monitoring strategies are not always continuous or comprehensive and do not dependably identify all cases of respiratory impairment or mitigate their sequelae, which may be severe and require the use of increasingly limited intensive care unit resources. As a result, postoperative respiratory impairment has the potential to cause significant downstream effects that can increase cost and adversely impact the care of other patients.

  View details for PubMedID 29853871

  View details for PubMedCentralID PMC5952562

• Management of Patients on Mechanical Circulatory Assist Devices During Noncardiac Surgery. International anesthesiology clinics Rao, V. K., Tsai, A. 2018; 56 (4): e1–e27

  View details for DOI 10.1097/AIA.0000000000000205

  View details for PubMedID 30204602

• ECMO CIRCUIT PATENCY WITHOUT ANTICOAGULATION IN PATIENTS WITH HIGH RISK FOR BLEEDING Mehmood, T., Beg, M., Hennessey, E., Rao, V. LIPPINCOTT WILLIAMS & WILKINS. 2018: 51

  View details for DOI 10.1097/01.ccm.0000528156.49664.b7

  View details for Web of Science ID 000436794300101

• The Year in Thoracic Anesthesia: Selected Highlights from 2016. Journal of cardiothoracic and vascular anesthesia Boisen, M. L., Rao, V. K., Kolarczyk, L., Hayanga, H. K., Gelzinis, T. A. 2017; 31 (3): 791-799

  View details for DOI 10.1053/j.jvca.2017.02.182

  View details for PubMedID 28689818

• Barosinusitis: Comprehensive review and proposed new classification system. Allergy & rhinology (Providence, R.I.) Vaezeafshar, R. n., Psaltis, A. J., Rao, V. K., Zarabanda, D. n., Patel, Z. M., Nayak, J. V. 2017; 8 (3): 109–17

  Abstract

  Barosinusitis, or sinus barotrauma, may arise from changes in ambient pressure that are not compensated by force equalization mechanisms within the paranasal sinuses. Barosinusitis is most commonly seen with barometric changes during flight or diving. Understanding and better classifying the pathophysiology, clinical presentation, and management of barosinusitis are essential to improve patient care.To perform a comprehensive review of the available literature regarding sinus barotrauma.A comprehensive literature search that used the terms "barosinusitis," "sinus barotrauma," and "aerosinusitis" was conducted, and all identified titles were reviewed for relevance to the upper airway and paranasal sinuses. All case reports, series, and review articles that were identified from this search were included. Selected cases of sinus barotrauma from our institution were included to illustrate classic signs and symptoms.Fifty-one articles were identified as specifically relevant to, or referencing, barosinusitis and were incorporated into this review. The majority of articles focused on barosinusitis in the context of a single specific etiology rather than independent of etiology. From analysis of all the publications combined with clinical experience, we proposed that barosinusitis seemed to fall within three distinct subtypes: (1) acute, isolated barosinusitis; (2) recurrent acute barosinusitis; and (3) chronic barosinusitis. We introduced this terminology and suggested independent treatment recommendations for each subtype.Barosinusitis is a common but potentially overlooked condition that is primed by shifts in the ambient pressure within the paranasal sinuses. The pathophysiology of barosinusitis has disparate causes, which likely contribute to its misdiagnosis and underdiagnosis. Available literature compelled our proposed modifications to existing classification schemes, which may allow for improved awareness and management strategies for barosinusitis.

  View details for PubMedID 29070267

• Comparative effectiveness of epsilon-aminocaproic acid and tranexamic acid on postoperative bleeding following cardiac surgery during a national medication shortage JOURNAL OF CLINICAL ANESTHESIA Blaine, K. P., Press, C., Lau, K., Sliwa, J., Rao, V. K., Hill, C. 2016; 35: 516-523

  Abstract

  The aim of this study was to compare the effectiveness of epsilon-aminocaproic acid (εACA) and tranexamic acid (TXA) in contemporary clinical practice during a national medication shortage.A retrospective cohort study.The study was performed in all consecutive cardiac surgery patients (n=128) admitted to the cardiac-surgical intensive care unit after surgery at a single academic center immediately before and during a national medication shortage.Demographic, clinical, and outcomes data were compared by descriptive statistics using χ(2) and t test. Surgical drainage and transfusions were compared by multivariate linear regression for patients receiving εACA before the shortage and TXA during the shortage.In multivariate analysis, no statistical difference was found for surgical drain output (OR 1.10, CI 0.97-1.26, P=.460) or red blood cell transfusion requirement (OR 1.79, CI 0.79-2.73, P=.176). Patients receiving εACA were more likely to receive rescue hemostatic medications (OR 1.62, CI 1.02-2.55, P=.041).Substitution of εACA with TXA during a national medication shortage produced equivalent postoperative bleeding and red cell transfusions, although patients receiving εACA were more likely to require supplemental hemostatic agents.

  View details for DOI 10.1016/j.jclinane.2016.08.037

  View details for Web of Science ID 000389785600092

  View details for PubMedID 27871586

• Salvage Extracorporeal Membrane Oxygenation Prior to "Bridge" Transcatheter Aortic Valve Replacement. Journal of cardiac surgery Chiu, P., Fearon, W. F., Raleigh, L. A., Burdon, G., Rao, V., Boyd, J. H., Yeung, A. C., Miller, D. C., Fischbein, M. P. 2016; 31 (6): 403-405

  Abstract

  We describe a patient who presented in profound cardiogenic shock due to bioprosthetic aortic valve stenosis requiring salvage Extracorporeal Membrane Oxygenation followed by a "bridge" valve-in-valve transcatheter aortic valve replacement. doi: 10.1111/jocs.12750 (J Card Surg 2016;31:403-405).

  View details for DOI 10.1111/jocs.12750

  View details for PubMedID 27109017

• Factor VIII Inhibitor Bypass Activity and Recombinant Activated Factor VII in Cardiac Surgery JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA Rao, V. K., Lobato, R. L., Bartlett, B., Klanjac, M., Mora-Mangano, C. T., Soran, P. D., Oakes, D. A., Hill, C. C., van der Starre, P. J. 2014; 28 (5): 1221-1226

  Abstract

  Postcardiopulmonary bypass hemorrhage remains a serious complication of cardiac surgery. Given concerns regarding adverse effects of blood product transfusion and limited efficacy of current antifibrinolytics, procoagulant medications, including recombinant factor VIIa (rFVIIa) and factor eight inhibitor bypass activity (FEIBA), increasingly have been used in managing refractory bleeding. While effective, these medications are associated with thromboembolic complications. This study compared the efficacy and risk of adverse events of rFVIIa and FEIBA in cardiac surgical patients with refractory bleeding.This retrospective study evaluated 168 patients who underwent cardiac surgery and received either FEIBA or rFVIIa to manage postbypass hemorrhage. Demographic, clinical, and outcomes data were collected and statistical analysis performed to compare thromboembolic event rates, relative efficacy, and 30-day mortality following administration of these medications.Single university hospital.Patients undergoing cardiac surgery.None.Sixty-one patients received rFVIIa, and 107 received FEIBA. Demographics, surgical procedures, and preoperative anticoagulation were similar between the cohorts; however, the rFVIIa cohort had longer durations of cardiopulmonary bypass (305.1 v 243.8 min, p<0.01). There were no significant differences in the number of thromboembolic events, 30-day mortality, or rates of revision surgery. Neither group demonstrated a clear relationship between dosage and occurrence of thromboembolic events. The rFVIIa cohort received more platelets than the FEIBA cohort (3.13 v 1.67 units, p = 0.01), but transfusion rates of other blood products were similar.This study suggests that rFVIIa and FEIBA have similar efficacy and adverse event profiles in managing intractable postbypass hemorrhage in cardiac surgical patients. Further prospective studies are required.

  View details for DOI 10.1053/j.jvca.2014.04.015

  View details for Web of Science ID 000343188500009

• A cost study of postoperative cell salvage in the setting of elective primary hip and knee arthroplasty TRANSFUSION Rao, V. K., Dyga, R., Bartels, C., Waters, J. H. 2012; 52 (8): 1750-1760

  Abstract

  The increasing costs, limited supply, and clinical risks associated with allogeneic blood transfusion have prompted investigation into autologous blood management strategies, such as postoperative red blood cell (RBC) salvage. This study provides a cost comparison of transfusing washed postoperatively salvaged RBCs using an orthopedic perioperative autotransfusion device (OrthoPat, Haemonetics Corporation) versus unwashed shed blood and banked allogeneic blood.Cell salvage data were retrospectively reviewed for a sample of 392 patients who underwent primary hip or knee arthroplasty. Mean unit costs were calculated for washed salvaged RBCs, equivalent units of unwashed shed blood, and therapeutically equivalent volumes of allogeneic RBCs.No initial capital investment was required for the establishment of the postoperative cell salvage program. For patients undergoing total knee arthroplasty (TKA), the mean unit costs for washed postoperatively salvaged cells, unwashed shed blood, and allogeneic banked blood were $758.80, $474.95, and $765.49, respectively. In patients undergoing total hip arthroplasty (THA), the mean unit costs for washed postoperatively salvaged cells, unwashed shed blood, and allogeneic banked blood were $1827.41, $1167.41, and $2609.44, respectively.This analysis suggests that transfusing washed postoperatively salvaged cells using the OrthoPat device is more costly than using unwashed shed blood in both THA and TKA. When compared to allogeneic transfusion, washed postoperatively salvaged cells carry a comparable cost in TKA, but potentially represent a significant savings in patients undergoing THA. Sensitivity analysis suggests that in the case of TKA, however, cost comparability exists within a narrow range of units collected and infused.

  View details for DOI 10.1111/j.1537-2995.2011.03531.x

  View details for Web of Science ID 000307392800017

  View details for PubMedID 22339139

• Recognition of local anesthetic maldistribution in axillary brachial plexus block guided by ultrasound and nerve stimulation JOURNAL OF CLINICAL ANESTHESIA Veneziano, G. C., Rao, V. K., Orebaugh, S. L. 2012; 24 (2): 141-144

  Abstract

  Nerve stimulation may occur despite the presence of a fascial barrier between the needle tip and the nerve, which may prevent appropriate flow or distribution of local anesthetic solution. During an axillary nerve block, ultrasound (US) guidance was used to identify the median nerve. Insertion of a needle with US and nerve stimulator guidance resulted in the appearance of the needle tip in contact with the nerve. However, as local anesthetic injection was begun, it was clear that the injectate was accumulating superficial to the investing fascia of the neurovascular bundle. No injectate was seen below the fascia. With US guidance, the needle was repositioned at a greater depth. Repeat injection of local anesthetic clearly flowed around the nerve.

  View details for DOI 10.1016/j.jclinane.2011.06.009

  View details for Web of Science ID 000301894600012

  View details for PubMedID 22414707

• Analysis of major complications associated with arterial catheterisation QUALITY & SAFETY IN HEALTH CARE Salmon, A. A., Galhotra, S., Rao, V., DeVita, M. A., Darby, J., Hilmi, I., SIMMONS, R. L. 2010; 19 (3): 208-212

  Abstract

  Arterial catheterisation is used for continuous haemodynamic monitoring in patients undergoing surgery and in critical care units. Although it is considered a safe procedure, a major complication such as arterial occlusion and limb gangrene can occur.To determine the incidence, outcome and potential to avoid complications associated with arterial catheterisation.The number of arterial catheterisation was determined using an anaesthesiology and critical care medicine billing database over a period of 4 years (1 January 2003 to 31 December 2006). Possible major complications were identified from two hospital databases; all identified charts were screened and then reviewed by an expert panel that determined causation. A major complication was defined as requiring operative intervention and/or resulting in permanent harm.15 (0.084%) major complications were identified among 17 840 instances of arterial catheterisation insertions. Of 15 arterial catheterisations, nine were performed in the operating room and six in the intensive care unit. Nine patients suffered ischaemic injury, which progressed to gangrene in three patients. Three patients developed haematoma that required surgical evacuation; two of these required vascular repair. One patient had compartment syndrome requiring fasciotomy and two patients had sheared catheter fragments that needed to be removed. All 15 patients had multiple comorbidities, and those in the operating room had an American Society of Anesthesiologists score of >or=3. Seven (46.6%) had arterial catheterisation done under emergent circumstances. Six (40%) died during hospitalisation because of complications unrelated to arterial catheterisation.Arterial catheterisation had a very low rate of major complications. They seem associated with high severity of illness and emergency surgery.

  View details for DOI 10.1136/qshc.2008.028597

  View details for Web of Science ID 000279355700010

  View details for PubMedID 20194221