Transesophageal echocardiography in minimally invasive cardiac surgery Purpose of review Transesophageal echocardiography (TEE) has made its way into the cardiac surgery realm and spurred the development of many interventions. In the domain of minimally invasive cardiac surgery (MICS), TEE has become central to reducing cardiovascular complications. Recent findings Real-time three-dimensional TEE is a key contributor to the safe and precise deployment of the PASCAL mitral valve repair system, which is showing great potential in ongoing studies. The current data on outcomes of transcatheter aortic valve replacement show that preprocedural three-dimensional TEE and multidetector computed tomography (CT) perform similarly in aortic root assessment. Three-dimensional color Doppler TEE has been suggested to be more appropriate in quantifying residual mitral regurgitation and evaluating the success of surgical or percutaneous closure. A three-dimensional TEE-derived aortomitral angle may be valuable in predicting and detecting dynamic left ventricular outflow tract obstruction, thereby enhancing the safety of transcatheter mitral valve replacement. Summary Advanced imaging modalities are essential for the sustained growth of MICS, particularly with the evolution of novel transcatheter systems. These techniques rely on exceptional imaging quality at all stages of the perioperative period to modify surgical-risk and improve patient outcomes. TEE has the additional benefit of providing real-time information on intrathoracic structures to guide intraoperative management. Video abstracts 1a: http://links.lww.com/COAN/A55; 1b: http://links.lww.com/COAN/A56; 2: http://links.lww.com/COAN/A57; 3a: http://links.lww.com/COAN/A58; 3b: http://links.lww.com/COAN/A59; 4: http://links.lww.com/COAN/A60; 5a: http://links.lww.com/COAN/A61; 5b: http://links.lww.com/COAN/A62. Correspondence to Justiaan L. Swanevelder, MB ChB, MMed (Anes), FCA (SA), FRCA, Professor and Head of Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, South Africa. Tel: +27 21 404 5004/+27 72 428 3670; e-mail: justiaan.swanevelder@uct.ac.za Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.co-anesthesiology.com). Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Effect of left ventricular diastolic dysfunction on development of primary graft dysfunction after lung transplant Purpose of review Primary graft dysfunction (PGD) is one of the most common complications after lung transplant and is associated with significant early and late morbidity and mortality. The cause of primary graft dysfunction is often multifactorial involving patient, donor, and operational factors. Diastolic dysfunction is increasingly recognized as an important risk factor for development of PGD after lung transplant and here we examine recent evidence on the topic. Recent findings Patients with end-stage lung disease are more likely to suffer from cardiovascular disease including diastolic dysfunction. PGD as result of ischemia–reperfusion injury after lung transplant is exacerbated by increased left atrial pressure and pulmonary venous congestion impacted by diastolic dysfunction. Recent studies on relationship between diastolic dysfunction and PGD after lung transplant show that patients with diastolic dysfunction are more likely to develop PGD with worse survival outcome and complicated hospital course. Summary Patients with diastolic dysfunction is more likely to suffer from PGD after lung transplant. From the lung transplant candidate selection to perioperative and posttransplant care, thorough evaluation and documentation diastolic dysfunction to guide patient care are imperative. Correspondence to Jeongae Yoon, MD, Department of Anesthesiology, University of Maryland Medical Center, Baltimore, MD, USA. Tel: +1 202 431 0598; e-mail: jeongaeyoon@som.umaryland.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Impact of geriatric co-management programmes on outcomes in older surgical patients: update of recent evidence Purpose of review To determine the impact of geriatric co-management programmes on outcomes in older patients undergoing a surgical procedure. Recent findings Twelve programmes were identified. Time to surgery was decreased in two of four studies [pooled mean difference = −0.7 h (95% CI, −3.1 to 4.4)]. The incidence of complications was reduced in two of seven studies (pooled absolute risk reduction = −4% (95% CI −10 to 2%)). Length of stay was reduced in four of eight studies [pooled mean difference = −1.4 days (95% CI −2.7 to −0.1)]. In-hospital mortality was reduced in one of six studies [pooled absolute risk reduction = −2% (95% CI −4 to −0%)]. Unplanned hospital readmissions at 30 days follow-up was reduced in two of three studies [pooled absolute risk reduction = −3% (95% CI −5 to −0%)]. Summary There was a shorter length of stay, less mortality and a lower readmission rate. However, there was uncertainty whether the results are clinically relevant and the GRADE of evidence was low. It was uncertain whether the outcomes time to surgery and complications were improved. The evidence is limited to hip fracture patients. Correspondence to Mieke Deschodt, Gerontology and Geriatrics, UZ Herestraat 49 - Box 7003 35, 3000 Leuven, Belgium. Tel: +32 16 37 76 92; e-mail: mieke.deschodt@kuleuven.be Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Pharmacodynamics and pharmacokinetics in older adults Purpose of review With the growing of the aging population, increased and new methods of anesthesia and surgery allow for surgery and other interventions in older adults. Pharmacokinetics and pharmacodynamics of drugs in older adults differ from those in younger and middle-aged adults. However, the geriatric population is frequently neglected in the context of clinical trials. The present review focuses on the consequences of multimorbidity and pharmacokinetic and pharmacodynamic alterations and their implications on anesthesia. Recent findings Physiologically based pharmacokinetic and pharmacodynamic modeling may serve as an option to better understand the influence of age on drugs used for anesthesia. However, difficulties to adequately characterize geriatric patients are described. Summary Further research of drug effects in the aging population may include physiologically based pharmacokinetic and pharmacodynamic complex models and randomized controlled trials with thoroughly conducted geriatric assessments. Correspondence to Petra A. Thürmann, Helios University Hospital Wuppertal, Chair of Clinical Pharmacology, University Witten/Herdecke, Heusnerstr. 40, D-42283 Wuppertal, Germany. Tel: +49 202 896 1851; fax: +49 202 896 1852; e-mail: petra.thuermann@uni-wh.de Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Antifungal use in the surgical ICU patient Purpose of review The successful treatment of surgical fungal infections depends of a timely and adequate source control alongside with the use of prompt systemic antifungals. The main challenge of antifungal use in critically ill surgical patients is to find a balance between rational versus indiscriminate use in order to accomplish an antifungal stewardship program. Recent findings Surgical fungal infections represent an important burden in the daily clinical activity in many ICUs. The efficacy of the available antifungal drugs has not been adequately assessed in randomized controlled trials with surgical fungal infections in ICU patients. Most clinical experience is limited to case reports or uncontrolled case series. Due to the lack of adequate scientific evidence to assess the role of the different antifungals in surgical ICU patients, it is usually suggested to follow the recommendations for invasive candidiasis and candidemia. Summary Antifungal use in the surgical patients admitted to an ICU is a complex matter and there are several elements to consider like the presence of septic shock and multiorgan failure, local epidemiology and antifungal resistance, among others. The proper use of antifungals alongside early recognition and prompt source control, are critical factors for improved outcomes. Correspondence to Dr. Pedro Póvoa, Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, CHLO, Estrada do Forte do Alto do Duque, 1449-005 Lisbon, Portugal. E-mail: pedrorpovoa@gmail.com Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Antibiotic dosing during extracorporeal membrane oxygenation: does the system matter? Purpose of review The aims of this review are to discuss the impact of extracorporeal membrane oxygenation (ECMO) on antibiotic pharmacokinetics and how this phenomenon may influence antibiotic dosing requirements in critically ill adult ECMO patients. Recent findings The body of literature describing antibiotic pharmacokinetic and dosing requirements during ECMO support in critically adult patients is currently scarce. However, significant development has recently been made in this research area and more clinical pharmacokinetic data have emerged to inform antibiotic dosing in these patients. Essentially, these clinical data highlight several important points that clinicians need to consider when dosing antibiotics in critically ill adult patients receiving ECMO: physicochemical properties of antibiotics can influence the degree of drug loss/sequestration in the ECMO circuit; earlier pharmacokinetic data, which were largely derived from the neonatal and paediatric population, are certainly useful but cannot be extrapolated to the critically ill adult population; modern ECMO circuitry has minimal adsorption and impact on the pharmacokinetics of most antibiotics; and pharmacokinetic changes in ECMO patients are more reflective of critical illness rather than the ECMO therapy itself. Summary An advanced understanding of the pharmacokinetic alterations in critically ill patients receiving ECMO is essential to provide optimal antibiotic dosing in these complex patients pending robust dosing guidelines. Antibiotic dosing in this patient population should generally align with the recommended dosing strategies for critically ill patients not on ECMO support. Performing therapeutic drug monitoring (TDM) to guide antibiotic dosing in this patient population appears useful. Correspondence to Jason A. Roberts, University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, 4029 QLD, Australia. E-mail: j.roberts2@uq.edu.au Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Postoperative neurocognitive disorders Purpose of review Alterations in cognitive functions are common in the perioperative course. Although often unnoticed by physicians, these alterations might have distinct long-term consequences for the patient with regard to everyday functioning, self-dependency, and quality of life. In recent years, however, perioperative cognition has gained increased interest, both by clinicians and scientists, and knowledge of the preventive measures of postoperative cognitive decline has become mandatory for anesthetists and surgeons. Recent findings This review offers a brief overview of the current state of knowledge concerning perioperative changes in cognition, including its pathophysiology and prevention strategies. Summary Postoperative neurocognitive disorders are frequent complications, especially in elderly patients, with postoperative delirium being its most pronounced and acute postoperative form, predisposing the patient for long-term cognitive impairment. The incidence of postoperative cognitive decline can be reduced by implementing preventive measures during perioperative patient care as recommended by national and international guidelines. Correspondence to Cynthia Olotu, MD, Department of AnaesthesiologyUniversity Medical Center Hamburg, Martini Street 52, 20251 Hamburg, Germany. Tel: +49 40 7410 52415; fax: +49 40 7410 - 44963; e-mail: c.olotu@uke.de Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Right ventricular function during and after thoracic surgery Purpose of review Right ventricular (RV) dysfunction following thoracotomy and pulmonary resection is a known phenomenon but questions remain about its mechanism, risk factors, and clinical significance. Acute RV dysfunction can present intraoperatively and postoperatively, persisting for 2 months after surgery. Recent findings Recently, the pulmonology literature has emphasized pulmonary arterial capacitance, rather than pulmonary vascular resistance, as a marker to predict disease progression and outcome in patients with pulmonary hypertension and heart failure. Diagnostic focus has emerged on the use of cardiac MRI and new echocardiographic parameters to better quantify the presence of RV dysfunction and the role of pulmonary capacitance in its development. Summary In this review, we examine the most recent literature on RV dysfunction following lung resection, including possible mechanisms, time span of RV dysfunction, and available diagnostic modalities. The clinical relevance of these factors on preoperative assessment and risk stratification are presented. Correspondence to Theresa Gelzinis, MD, Associate Professor, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15217, USA. work. Tel: +1 412 647 3260; +1 412 292 656 (home); fax: +1 412 647 6290; e-mail: gelzinista@anes.upmc.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Circulatory support during lung transplantation Purpose of review Lung transplantation can be performed off-pump, with sequential one-lung ventilation, or using mechanical circulatory support (MCS). MCS can either be in the form of cardiopulmonary bypass (CPB) or veno-arterial or veno-venous extracorporeal membrane oxygenation (VA ECMO or VV ECMO). This article reviews the indications, benefits and limitations of these different techniques and evaluates their effect on outcomes. Recent findings Recently, there has been a shift toward intraoperative ECMO support and away from CPB. The first results of this strategy are promising. The use of intraoperative ECMO with the possibility of prolongation of MCS into the postoperative period has been shown to lead to improved survival when compared with lung transplants not receiving ECMO. Recipients of organs from extended criteria donors show encouraging survival rates when the lungs are reperfused using MCS. A recent metaanalysis comparing ECMO versus CPB showed favourable outcomes supporting the use of ECMO despite not finding a difference in mortality between the two methods. Summary The trend toward ECMO and away from cardiopulmonary bypass is backed up with good survival rates. However, to date, there has not been a randomized controlled trial to further guide the choice of MCS strategy for lung transplantation. Correspondence to Florian Falter, Department of Anaesthesia, Royal Papworth Hospital, Papworth Road, Cambridge, CB2 0AY, UK. Tel: +44 1223 6380000; e-mail: florian.falter@gmail.com Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

How to communicate between surgeon and intensivist? Purpose of review Communication and teamwork are essential to enhance the quality of care, especially in operating rooms and ICUs. In these settings, the effective interprofessional collaboration between surgeons and intensivists impacts patients’ outcome. This review discusses current opinions and evidence for improving communication strategies and the relationship between surgeons and intensivists/anesthesiologist. Recent findings Effective teamwork has been demonstrated to improve patient outcome and foster healthier relationships between professionals. With the expansion of new medical superspecialist disciplines and the latest medical developments, patient care has been put through a progressive fragmentation, rather than a holistic approach. Operating theaters and ICU are the common fields where surgeons and anesthesiologists/intensivists work. However, communication challenges may frequently arise. Therefore, effective communication, relational coordination, and team situation awareness are considered to affect quality of teamwork in three different phases of the patient-centered care process: preoperatively, intraoperatively, and postoperatively. Summary Although limited, current evidence suggests to improve communication and teamwork in patient perioperative care. Further research is needed to strengthen the surgeon–intensivist relationship and to deliver high-quality patient care. Correspondence to Cesare Gregoretti, Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, via del vespro 129, 90127 Palermo, Italy. E-mail: c.gregoretti@gmail.com Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.