Silicone tracheobronchial stent: A rare cause for bronchoesophageal fistula and distortion of airway anatomy

Bhupesh Kumar, Ganesh Kumar Munirathinam, Goverdhan Dutt Puri, Anand Kumar Mishra, Virendra Kumar Arya

Annals of Cardiac Anaesthesia 2017 20(3):355-358

Silicone tracheobronchial stents are being increasingly used in a large number of patients for the treatment of tracheal stenosis. One very rare complication due to tracheobronchial stenting is bronchoesophageal fistula (BEF), which has been associated with the use of metallic stents. We report intraoperative management of a patient undergoing repair of a BEF, following previous insertion of a silicone Y-stent that is soft in texture and has not been implicated for this complication till date. In addition, misalignment of this silicone tracheobronchial Y-stent resulted in a tracheal mucosal bulge proximal to the stent that vanished after its removal.

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Risk factors of postcardiotomy ventricular dysfunction in moderate-to-high risk patients undergoing open-heart surgery

Christoph Ellenberger, Tornike Sologashvili, Mustafa Cikirikcioglu, Gabriel Verdon, John Diaper, Tiziano Cassina, Marc Licker

Annals of Cardiac Anaesthesia 2017 20(3):287-296

Introduction: Ventricular dysfunction requiring inotropic support frequently occurs after cardiac surgery, and the associated low cardiac output syndrome largely contributes to postoperative death. We aimed to study the incidence and potential risk factors of postcardiotomy ventricular dysfunction (PCVD) in moderate-to-high risk patients scheduled for open-heart surgery. Methods: Over a 5-year period, we prospectively enrolled 295 consecutive patients undergoing valve replacement for severe aortic stenosis or coronary artery bypass surgery who presented with Bernstein-Parsonnet scores >7. The primary outcome was the occurrence of PCVD as defined by the need for sustained inotropic drug support and by transesophageal echography. The secondary outcomes included in-hospital mortality and the incidence of any major adverse events as well as Intensive Care Unit (ICU) and hospital length of stay. Results: The incidence of PCVD was 28.4%. Patients with PCVD experienced higher in-hospital mortality (12.6% vs. 0.6% in patients without PCVD) with a higher incidence of cardiopulmonary and renal complications as well as a prolonged stay in ICU (median + 2 days). Myocardial infarct occurred more frequently in patients with PCVD than in those without PCVD (19 [30.2%] vs. 12 [7.6%]). By logistic regression analysis, we identified four independent predictors of PCVD: left ventricular ejection fraction <40% (odds ratio [OR] = 6.36; 95% confidence interval [CI], 2.59–15.60), age older than 75 years (OR = 3.35; 95% CI, 1.64–6.81), prolonged aortic clamping time (OR = 3.72; 95% CI, 1.66–8.36), and perioperative bleeding (OR = 2.33; 95% CI, 1.01–5.41). The infusion of glucose-insulin-potassium was associated with lower risk of PCVD (OR = 0.14; 95% CI, 0.06–0.33). Conclusions: This cohort study indicates that age, preoperative ventricular function, myocardial ischemic time, and perioperative bleeding are predictors of PCVD which is associated with poor clinical outcome.

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Methylene blue for post-cardioplumonary bypass vasoplegic syndrome

Neha Pangasa, Rohan Magoon, Vandana Bhardwaj, Amita Sharma, Ameya Karonjkar, Poonam Malhotra Kapoor

Annals of Cardiac Anaesthesia 2017 20(3):381-382



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Neutrophil gelatinase-associated lipocalin as a biomarker for predicting acute kidney injury during off-pump coronary artery bypass grafting

Muralidhar Kanchi, R Manjunath, Jos Massen, Lloyd Vincent, Kumar Belani

Annals of Cardiac Anaesthesia 2017 20(3):297-302

Background: Acute kidney injury (AKI) following cardiac surgery is a major complication resulting in increased morbidity, mortality, and economic burden. In this study, we assessed the usefulness of estimating serum neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker in predicting AKI in patients with stable chronic kidney disease (CKD) and undergoing off-pump coronary artery bypass grafting (OP-CABG). Patients and Methods: We prospectively studied sixty nondialysis-dependent CKD patients with estimated glomerular filtration rate <60 ml/min/1.73 m2 who required elective OP-CABG. Patients were randomized into two groups, Group D received dopamine infusion at 2 μg/kg/min following anesthesia induction till the end of the surgery and Group P did not receive any intervention. Serum creatinine, NGAL, brain natriuretic peptide, and troponin-I were estimated at specified intervals before, during, and after surgery. The results of the study patients were also compared to a simultaneous matched cohort control of thirty patients (Group A) without renal dysfunction who underwent OP-CABG. Results: No patient required renal replacement therapy, and no mortality was observed during perioperative and hospitalization period. Six patients from control group (n = 30), ten patients from placebo group (n = 30), and 12 patients from dopamine group (n = 30) developed stage 1 AKI. However, we did not observe any stage 2 and stage 3 AKI among all the groups. There was a significant increase in serum NGAL levels at the end of surgery and 24 h postoperatively in placebo and dopamine groups as compared to the control. Conclusion: The measurement of NGAL appears to predict the occurrence of AKI after OP-CAB surgery. However, large multicentric studies may be required to confirm the findings of this study.

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Idarucizumab (Praxbind) for reversal of pradaxa prior to emergent repair of contained ruptured transverse arch aneurysm

Erol Vahit Belli, Teng Lee

Annals of Cardiac Anaesthesia 2017 20(3):369-371

Idarucizumab before cardiopulmonary bypass was used for the reversal of dabigatran during an emergent frozen elephant trunk repair of a transverse arch aneurysm. Reversal was successful and minimal not massive transfusion was required with no abnormal sequelae seen with use before cardiopulmonary bypass.

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Coronary artery bypass graft patients' perception about the risk factors of illness: Educational necessities of second prevention

Ali Soroush, Saeid Komasi, Mozhgan Saeidi, Behzad Heydarpour, Danilo Carrozzino, Mario Fulcheri, Paolo Marchettini, Massimo Rabboni, Angelo Compare

Annals of Cardiac Anaesthesia 2017 20(3):303-308

Background: Patients' beliefs about the cause of cardiac disease (perceived risk factors) as part of the global psychological presentation are influenced by patients' health knowledge. Hence, the present study aimed to assess the relationship between actual and perceived risk factors, identification of underestimated risk factors, and indication of underestimation of every risk factor. Materials and Methods: In this cross-sectional study, data of 313 coronary artery bypass graft (CABG) patients admitted to one hospital in the west of Iran were collected through a demographic interview, actual risk factors' checklist, open single item of perceived risk factors, and a life stressful events scale. Data were analyzed by means of Spearman's correlation coefficients and one-sample Z-test for proportions. Results: Although there are significant relations between actual and perceived risk factors related to hypertension, family history, diabetes, smoking, and substance abuse (P < 0.05), there is no relation between the actual and perceived risk factors, and patients underestimate the role of actual risk factors in disease (P < 0.001). The patients underestimated the role of aging (98.8%), substance abuse (95.2%), overweight and obesity (94.9%), hyperlipidemia (93.1%), family history (90.3%), and hypertension (90%) more than diabetes (86.1%), smoking (72.5%), and stress (54.7%). Conclusion: Cardiac patients seem to underestimate the role of aging, substance abuse, obesity and overweight, hyperlipidemia, family history, and hypertension more than other actual risk factors. Therefore, these factors should be highlighted to patients to help them to (i) increase the awareness of actual risk factors and (ii) promote an appropriate lifestyle after CABG surgery.

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Appropriate size of double-lumen tubes in Asians

Chitra Rajeswari Thangaswamy

Annals of Cardiac Anaesthesia 2017 20(3):388-388



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Cardiovascular operation: A significant risk factor of arytenoid cartilage dislocation/subluxation after anesthesia

Seri Tsuru, Mayuko Wakimoto, Takeshi Iritakenishi, Makoto Ogawa, Yukio Hayashi

Annals of Cardiac Anaesthesia 2017 20(3):309-312

Background: Arytenoid cartilage dislocation/subluxation is one of the rare complications following tracheal intubation, and there have been no reports about risk factors leading this complication. From our clinical experience, we have an impression that patients undergoing cardiovascular operations tend to be associated with this complication. Aims: We designed a large retrospective study to reveal the incidence and risk factors predicting the occurrence and to examine whether our impression is true. Settings and Designs: This was a retrospective study. Methods: We retrospectively studied 19,437 adult patients who were intubated by an anesthesiologist in our operation theater from 2002 to 2008. The tracheal intubation was performed by a resident anesthesiologist managing the patients. Only patients whose postoperative voice was disturbed more than 7 days were referred to the Department of Otorhinolaryngology-Head and Neck Surgery and examined using laryngostroboscopy by a laryngologist to diagnose arytenoid cartilage dislocation/subluxation. We evaluated age, sex, weight, height, duration of intubation, difficult intubation, and major cardiovascular operation as risk factors to lead this complication. Statistical Analysis: The data were analyzed by logistic regression analysis to assess factors for arytenoid cartilage dislocation/subluxation after univariate analyses using logistic regression analysis. Results: Our analysis indicated that difficult intubation (odds ratio: 12.1, P = 0.018) and cardiovascular operation (odds ratio: 9.9, P < 0.001) were significant risk factors of arytenoid cartilage dislocation/subluxation. Conclusion: The present study demonstrated that major cardiovascular operation is one of the significant risk factors leading this complication.

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Management of a case of double aortic arch with tracheal compression complicated with postoperative tracheal restenosis

Hemang Gandhi, T Vikram Kumar Naidu, Amit Mishra, Pankaj Garg, Jigar Surti, Visharad Trivedi, Himanshu Acharya

Annals of Cardiac Anaesthesia 2017 20(3):362-364

Tracheal stenosis in association with the double aortic arch (DAA) is uncommon; however, it carries a high risk of morbidity, mortality, and restenosis. Although surgery is the mainstay of managing a case of the DAA with tracheal stenosis, management of tracheal restenosis requires a multidisciplinary approach. In this case report, we present our successful experience in managing a child of DAA with tracheal stenosis who developed tracheal restenosis after sliding tracheoplasty of trachea.

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Propofol versus Ketofol for Sedation of Pediatric Patients Undergoing Transcatheter Pulmonary Valve Implantation: A Double-blind Randomized Study

Rabie Soliman, Mohammed Mofeed, Tarek Momenah

Annals of Cardiac Anaesthesia 2017 20(3):313-317

Objective: The study was done to compare propofol and ketofol for sedation of pediatric patients scheduled for elective pulmonary valve implantation in a catheterization laboratory. Design: This was a double-blind randomized study. Setting: This study was conducted in Prince Sultan Cardiac Centre, Saudi Arabia. Patients and Methods: The study included 60 pediatric patients with pulmonary regurge undergoing pulmonary valve implantation. Intervention: The study included sixty patients, classified into two groups (n = 30). Group A: Propofol was administered as a bolus dose (1–2 mg/kg) and then a continuous infusion of 50–100 μg/kg/min titrated as needed. Group B: Ketofol was administered 1–2 mg/kg and then infusion of 20–60 μg/kg/min. The medication was prepared by the nursing staff and given to anesthetist blindly. Measurements: The monitors included heart rate, mean arterial blood pressure, respiratory rate, temperature, SPO2and PaCO2, Michigan Sedation Score, fentanyl dose, antiemetic medications, and Aldrete score. Main Results: The comparison of heart rate, mean arterial pressure, respiratory rate, temperature, SPO2and PaCO2, Michigan Sedation Score, and Aldrete score were insignificant (P > 0.05). The total fentanyl increased in Group A more than Group B (P = 0.045). The required antiemetic drugs increased in Group A patients more than Group B (P = 0.020). The durations of full recovery and in the postanesthesia care unit were longer in Group A than Group B (P = 0.013, P < 0.001, respectively). Conclusion: The use of propofol and ketofol is safe and effective for sedation of pediatric patients undergoing pulmonary valve implantation in a catheterization laboratory. However, ketofol has many advantages more than the propofol. Ketofol has a rapid onset of sedation, a rapid recovery time, decreased incidence of nausea and vomiting and leads to rapid discharge of patients from the postanesthesia care unit.

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Sugammadex to reverse neuromuscular blockade in a child with a past history of cardiac transplantation

Karen Miller, Brian Hall, Joseph D Tobias

Annals of Cardiac Anaesthesia 2017 20(3):376-378

Sugammadex is a novel agent for the reversal of neuromuscular blockade. The speed and efficacy of reversal with sugammadex are significantly faster than acetylcholinesterase inhibitors, such as neostigmine. Sugammadex also has a limited adverse profile when compared with acetylcholinesterase inhibitors, specifically in regard to the incidence of bradycardia. This adverse effect may be particularly relevant in the setting of a heart transplant recipient with a denervated heart. The authors present a case of an 8-year-old child, status postcardiac transplantation, who required anesthetic care for laparoscopy and lysis of intra-abdominal adhesions. Sugammadex was used to reverse neuromuscular blockade and avoid the potential adverse effects of neostigmine. The unique mechanism of action of sugammadex is discussed, previous reports of its use in this unique patient population are reviewed, and its potential benefits compared to traditional acetylcholinesterase inhibitors are presented.

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Randomized comparative study of intravenous infusion of three different fixed doses of milrinone in pediatric patients with pulmonary hypertension undergoing open heart surgery

Neeraj Kumar Barnwal, Sanjeeta Rajendra Umbarkar, Manjula Sudeep Sarkar, Raylene J Dias

Annals of Cardiac Anaesthesia 2017 20(3):318-322

Background: Pulmonary hypertension secondary to congenital heart disease is a common problem in pediatric patients presenting for open heart surgery. Milrinone has been shown to reduce pulmonary vascular resistance and pulmonary artery pressure in pediatric patients and neonates postcardiac surgery. We aimed to evaluate the postoperative outcome in such patients with three different fixed maintenance doses of milrinone. Methodology: Patients were randomized into three groups. All patients received fixed bolus dose of milrinone 50 μg/kg on pump during rewarming. Following this, patients in low-dose group received infusion of milrinone at the rate of 0.375 μg/kg/min, medium-dose group received 0.5 μg/kg/min, and high-dose group received 0.75 μg/kg/min over 24 h. Heart rate, mean arterial pressure (MAP), mean airway pressure (MaP), oxygenation index (OI), and central venous pressure (CVP) were compared at baseline and 24 h postoperatively. Dose of inotropic requirement, duration of ventilatory support and Intensive Care Unit (ICU) stay were noted. Results: MAP, MaP, OI, and CVP were comparable in all three groups postoperatively. All patients in the low-dose group required low inotropic support while 70% of patients in the high-dose group needed high inotropic support to manage episodes of hypotension (P = 0.000). Duration of ventilatory support and ICU stay in all three groups was comparable (P = 0.412, P = 0.165). Conclusion: Low-dose infusions while having a clinical impact were more beneficial in avoiding adverse events and decreasing inotropic requirement without affecting duration of ventilatory support and duration of ICU stay.

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Asystole following neuromuscular blockade reversal in cardiac transplant patients

Njinkeng J Nkemngu

Annals of Cardiac Anaesthesia 2017 20(3):385-386



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The blalock and taussig shunt revisited

Usha Kiran, Shivani Aggarwal, Arin Choudhary, B Uma, Poonam Malhotra Kapoor

Annals of Cardiac Anaesthesia 2017 20(3):323-330

The systemic to pulmonary artery shunts are done as palliative procedures for cyanotic congenital heart diseases ranging from simple tetralogy of Fallots (TOFs)/pulmonary atresia (PA) to complex univentricular hearts. They allow growth of pulmonary arteries and maintain regulated blood flow to the lungs till a proper age and body weight suitable for definitive corrective repair is reached. We have reviewed the BT shunt with its anaesthtic considerations and management of associated complications.

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View Point

Prabhat Tewari

Annals of Cardiac Anaesthesia 2017 20(3):285-286



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Interesting images: Multiple coronary artery aneurysms

Jonathon M Howard, Omar Viswanath, Alfredo Armas, Orlando Santana, Gerald P Rosen

Annals of Cardiac Anaesthesia 2017 20(3):331-332

We present the case of a 65-year-old male who presented with stable angina and dyspnea on exertion. His initial workup yielded a positive treadmill stress test for reversible apical ischemia, and transthoracic echocardiogram demonstrated impaired systolic function. Cardiac catheterization was then performed, revealing severe atherosclerotic disease including multiple coronary artery aneurysms. As a result, the patient was advised to and subsequently underwent a coronary artery bypass graft. This case highlights the presence of multiple coronary artery aneurysms and the ability to appreciate these pathologic findings on multiple imaging modalities, including coronary angiogram, transesophageal echocardiography, and direct visualization through the surgical field.

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Anesthetic challenges of extrinsic trachea-bronchial compression due to posterior mediastinal mass: Our experience with a large esophageal mucocele

Saipriya Tewari, Puneet Goyal, Amit Rastogi, Aarti Agarwal, PK Singh

Annals of Cardiac Anaesthesia 2017 20(3):359-361

Large posterior mediastinal masses may lead threatening complications such as critical tracheobronchial compression. Airway management in these individuals is a challenge and being a lower airway obstruction; rescue strategies are limited. We encountered one such case of a large esophageal mucocele causing extrinsic tracheobronchial compression. We have described the anesthetic management of this case using awake fiber-optic assessment followed by intubation. Close communication with the surgical team, meticulous planning of airway management, and early drainage of the mucocele are the cornerstones of management in such patients.

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Inadequate venous drainage-transesophageal echocardiography as rescue

Monish S Raut, Arun Maheshwari, Sumir Dubey, Ganesh Shivnani, Sandeep Joshi, Arvind Verma, Swetanka Das

Annals of Cardiac Anaesthesia 2017 20(3):333-334

Malposition of venous cannula can cause inadequate venous drainage during cardiopulmonary bypass. It would be good clinical practice to use TEE to check the position of inferior venous cannula to avoid this problem at the earliest.

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A rare case of acyanotic congenital heart disease, large patent ductus arteriosus with pre-ductal coarctation of descending thoracic aorta with patent ductus arteriosus closure and extra anatomical bypass grafting

Zara Wani, Deepak Tiwari, Rajeev Gehlot, Deepak Kumar, Sushil Chhabra, Meenaxi Sharma

Annals of Cardiac Anaesthesia 2017 20(3):365-368

We report a case of 18-year-old female patient with large patent ductus arteriosus (PDA)-preductal coarctation of descending thoracic aorta. She underwent large PDA closure with a prosthetic graft from ascending aorta to descending thoracic aorta by mid-sternotomy on cardiopulmonary bypass machine under total hypothermic circulatory arrest.

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An antenatal diagnosis: Congenital high airway obstruction

S Miital, A Mittal, R Singal, S Singal, G Sekhon

Annals of Cardiac Anaesthesia 2017 20(3):335-336

Congenital high airway obstruction (CHAOS) is a rare lethal fetal malformation characterised by obstruction to the fetal upper airway, which can be partial or complete. Antenatal diagnosis of CHAOS is important due to recent management options. Diagnosis is made with secondary changes such as hyperechoic enlarged lungs resulting in mediastinal compression, ascites, hydrops, flattened or everted diaphragms and dilated distal airways. We reported a case of CHAOS, antenatally on ultrasonography (USG) at 20 weeks of gestation.

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Torsion of Atypical Meckel’s Diverticulum Treated by Laparoscopic-Assisted Surgery

Introduction. Meckel's diverticulum (MD) is the most common congenital anomaly of the intestine, with an incidence of 2~4%. Of those, only 2% of patients with MD are symptomatic. Torsion of MD is extremely rare, and only a dozen cases have been previously reported. Case Report. The patient was a 49-year-old male who presented to our emergency room with a chief complaint of lower abdominal pain. Computed tomography imaging revealed an irregular polycystic mass connected to the small intestine that measured 7.5 cm in a diameter. A laparoscopic-assisted partial resection of the jejunum was performed. The lesion was found to have caused torsion and was located 130 cm from the ileocecal valve. The specimen was polycystic in appearance and showed communicating links with the submucosal layer of jejunum but not with the lumen. The pathological diagnosis was a torsion of an atypical presentation of MD. Conclusion. This case was different from typical cases of MD in that it was located on significantly oral side and had the appearance of polycystic morphology.

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Small bowel obstruction due to mesenteric abscess caused by Mycobacterium avium complex in an HIV patient: a case report and literature review

Abstract

Small bowel obstruction in HIV patients is reportedly caused by inflammatory pseudotumor, Kaposi's sarcoma, cryptococcal lymphadenopathy and intestinal tuberculosis. The incidence of Mycobacterium avium complex (MAC) infection in HIV patients is 3% for CD4 cell count of 100–199 /mm³. MAC causing small bowel obstruction is rarely reported in the literature. We report a rare case of MAC causing mesenteric abscess with small bowel obstruction in a HIV patient with a CD4 cell count of 144 /mm³. Patient was a 35-year-old HIV-positive male on highly active antiretroviral therapy who presented with partial small bowel obstruction secondary to mesenteric abscess. He underwent operative intervention for drainage with cultures growing MAC.

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Strangulated gallbladder caused by a tip of the omentum attached to the abdominal wall: a case report

Abstract

Strangulation of the gallbladder associated with the omentum is extremely rare and, to our knowledge, only two cases have been previously reported. The patient was a 91-year-old female who presented to our emergency room with a chief complaint of upper abdominal pain. Computed tomography imaging revealed a gourd-shaped gallbladder with biphasic appearance divided clearly at the body. In the fundus side, the wall of the gallbladder was oedematous and thickened, while the neck side was intact. On the second day after onset, a laparoscopic cholecystectomy was performed. A tip of the omentum encircling the gallbladder was adhered to the abdominal wall and was strangling the gallbladder. By cutting the omentum at the attachment site, the strangulation was released. Laparoscopic cholecystectomy was performed, and the patient was discharged with an uneventful course. We experienced an extremely rare case of strangulated gallbladder caused by a tip of the omentum attached to the abdominal wall.

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A case of fatal internal jugular vein perforation during nasogastric tube insertion

Abstract

Nasogastric tube (NGT) insertion is a routine procedure in the management of surgical patients. We report the second case of internal jugular vein perforation during NGT insertion. A 79-year-old man presented with diffuse abdominal pain secondary to a perforated viscus. Abdominal CT revealed pneumoperitoneum, necessitating emergent exploratory laparotomy. On post-operative Day 7, the patient developed mild abdominal distension and subjective nausea for which NGT placement was ordered for decompression. Tube placement was confirmed by insufflation of air without aspiration of gastric contents. Output from the NGT upon placement revealed frank blood. The patient then developed respiratory distress requiring intubation, followed by a fatal arrhythmia. Post-mortem exam revealed the trajectory of the NGT through the pharyngeal wall into the right internal jugular vein. This case illustrates the importance of systematic evaluation of all procedures, as the outcome resulted from failure to recognize the initial error in tube placement.

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Secondary Syphilis Presenting as Glossodynia, Plaques en Prairie Fauchée, and a Split Papule at the Oral Commissure: Case Report and Review

Syphilis has been coined "the great imitator" due to its extreme heterogeneity of presentation and mimicry of other conditions. Therefore, it is essential that physicians be familiar with the full spectrum of its manifestations. Syphilis may also lead to oral lesions that, occasionally, are unaccompanied by concomitant tegumentary findings. Such patients will pose unique diagnostic challenges. We report the case of a 45-year-old HIV-infected male patient in whom secondary syphilis presented with burning mouth and dysgeusia that progressed to glossodynia and odynophagia. Examination revealed painful, shallow erosions on the posterior aspect of the tongue, in a pattern of plaques en prairie fauchée. A painful split papule (fausse perlèche or false angular cheilitis) was also present in the left commissure. There were no cutaneous lesions. The oral lesions were considered highly suggestive of secondary syphilis. A novel VDRL assay (which was previously negative) yielded a titer of 1/128. Complete clinical remission was rapidly achieved after initiation of penicillin therapy. A comprehensive review of the literature on oral manifestations of syphilis is offered.

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Ruxolitinib found to cause eyelash growth: a case report

Hypereosinophilic syndrome is a hematologic disorder in which the eosinophils proliferate.

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Complex regional pain syndrome: diagnosis and treatment

1D012E023E00

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National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period.

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation. (C) 2017 International Anesthesia Research Society

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