Journal of cardiothoracic and vascular anesthesia最新文献

Cardiac arrest in the postoperative cardiac surgery patient requires a unique set of management skills that deviates from traditional cardiopulmonary resuscitation and Advanced Cardiovascular Life Support (ACLS). Cardiac Advanced Life Support (CALS) was first proposed in 2005 to address these intricacies. The hallmark of CALS is early chest reopening and internal cardiac massage within 5 minutes of the cardiac arrest in patients unresponsive to basic life support. Since the introduction of CALS, the landscape of cardiac surgery has continued to evolve. Cardiac intensivists encounter more patients who undergo cardiac surgical procedures performed via minimally invasive techniques such as lateral thoracotomy or mini sternotomy, in which an initial bedside sternotomy for cardiac massage is not applicable. Given the heterogeneous nature of the patient population in the cardiothoracic intensive care unit, personnel must expeditiously identify the most appropriate rescue strategy. As such, we have proposed a modified CALS approach to (1) adapt to a newer generation of cardiac surgery patients and (2) incorporate advanced resuscitative techniques. These include rescue-focused cardiac ultrasound to aid in the early identification of underlying pathology and guide resuscitation and early institution of extracorporeal cardiopulmonary resuscitation instead of chest reopening. While these therapies are not immediately available in all cardiac surgery centers, we hope this creates a framework to revise guidelines to include these recommendations to improve outcomes and how cardiac anesthesiologist intensivists' evolving role can aid resuscitation.

Introduction: Fibrosing mediastinitis (FM) is a rare disease characterized by abnormal proliferation of fibrous tissue, causing compression and narrowing of the airway, blood vessels, and other mediastinal structures, including the pulmonary veins. Catheter-based interventions are available as palliative strategies. Due to the complex nature of the disease and the profound respiratory and hemodynamic sequelae that may ensue, anesthetic management requires meticulous interdisciplinary planning.

Methods: We performed a retrospective descriptive study including patients with FM undergoing catheter-based interventions for pulmonary vein stenosis from January 2020 to April 2024. A total of 14 patients underwent chart review, and we reported patient sex, preprocedural pulmonary artery pressures, comorbidities, lung isolation strategies, intraprocedural anesthetic complications, postprocedural intensive care unit admissions, and length of stay.

Results: All patients underwent pulmonary vasculature angioplasty, with or without stent placement, under general anesthesia with lung isolation capabilities and echocardiogram guidance. Eleven of 18 (61%) patients were uncomplicated. Four of 18 (22%) patients required unanticipated postoperative intensive care unit care: 2 (11%) in the setting of pulmonary hemorrhage, 1 due to hypoxic respiratory failure, and 1 due to difficult airway. One patient developed self-limiting postoperative hemoptysis on 2 different occasions, and 1 patient developed a vascular access-related complication. Mean hospital length of stay was 2.6 days (0-13 days), and mean intensive care unit length of stay was 1.75 days (1-4 days). One patient presented 6 weeks postoperatively with massive hemoptysis likely secondary to pulmonary vein rupture and died away after a protracted intensive care unit course.

Conclusion: Patients with FM can achieve successful intraprocedural outcomes by ensuring a comprehensive understanding of the disease, addressing significant anesthetic concerns and considerations, and engaging a multidisciplinary team.

Objectives: Evaluate the correlation of non-invasive echocardiographic estimates of right ventricular systolic pressure with measurements on cardiac catheterization in children with pulmonary hypertension.

Design: Retrospective chart review.

Setting: Quaternary academic children's hospital.

Participants: Patients younger than 18 years with a diagnosis of pulmonary hypertension and confirmatory cardiac catheterization from 2015 to 2018.

Measurements and main results: We analyzed the correlation between measures of right ventricular systolic pressure using nonparametric Spearman rho (ρ) with statistical significance set at p < 0.05.

Results: Children (N = 111) with biventricular circulation, strictly defined pulmonary hypertension, and adequate tricuspid regurgitation on echocardiogram to estimate right ventricular systolic pressure using the modified Bernoulli equation. Median age and weight were 4.3 years and 14.4 kg. Median right ventricular systolic pressure estimated by tricuspid regurgitant velocity on echocardiography was 55 mmHg (IQR 45-75 mmHg) plus right atrial pressure. On cardiac catheterization, median right ventricular systolic pressure was 57 mmHg (IQR 46-75 mmHg). Echocardiographic estimates of right ventricular systolic pressure were moderately well correlated with right ventricular systolic pressure directly measured on catheterization (ρ = 0.44, 95% CI 0.27-0.6, p < 0.001) with a median difference of 4 mmHg (IQR -10 to 17). Subgroup analysis revealed that echocardiography and catheterization measurements correlated well in children with suprasystemic right ventricular pressure on cardiac catheterization (ρ = 0.75, 95% CI 0.51-0.99, p < 0.001) although catheterization measurements were a median of 26 mmHg (IQR 12-31) higher than echocardiographic estimates in this subgroup.

Conclusions: In children with pulmonary hypertension, echocardiographic estimates of right ventricular pressure correlated moderately well with gold standard measurements by cardiac catheterization with stronger correlation in children with suprasystemic right ventricular pressures. This is reassuring for clinicians who must rely on echocardiography for risk stratification before anesthetizing children with pulmonary hypertension.

Objective: This study was designed to explore key safety outcomes after operating room (OR) extubation in minimally invasive cardiac valve surgery.

Design: Single-center retrospective chart review.

Setting: Academic medical center in the United States.

Participants: Patients undergoing valvular surgery via thoracotomy (November 2017-October 2022) at a single institution.

Interventions: The OR extubation protocol was implemented on August 20, 2020.

Measurements and main results: Delirium rates, reintubation rates, and intubation duration were compared before and after OR extubation protocol implementation. Logistic regression identified patient perioperative characteristics associated with unsuccessful OR extubation. Among 312 patients, 254 were extubated in the intensive care unit (ICU) and 58 in the OR. Preoperative demographics were comparable except for the Charlson Comorbidity Index (median: 2.0 ICU extubation v 1.5 OR extubation). Interrupted time series analysis showed no change in postoperative delirium post-OR extubation implementation, with a trend toward decreasing delirium (risk ratio = 0.37, CI: 0.13-1.10, p = 0.07). The postimplementation era also had a lower median intubation duration (8 hours v 13 hours, p < 0.001) without increasing reintubation rates (1.7% v 7.9%, p = 0.159). Increased bypass length (odds ratio = 0.99, CI: 0.98-0.99, p < 0.001), intraoperative morphine milligram equivalents (odds ratio = 0.99, CI: 0.99-1.0, p = 0.009), and preoperative Charlson Comorbidity Index above 3 (odds ratio = 0.42, CI: 0.19-0.95, p = 0.037) were associated with decreased odds of OR extubation.

Conclusions: OR extubation was not associated with increased postoperative delirium or reintubation rates but did decrease intubation duration. Successful OR extubation relies upon the consideration of various patient perioperative characteristics.

Objectives: Perioperative blood pressure control is crucial to ensure organ perfusion and avoid adverse events. However, no consensus on blood pressure targets is available. This study was designed to gain insights into current European perioperative hypertension management practices.

Design: Survey research.

Setting: Online survey.

Participants: The survey was administered to members of the European Association of Cardiothoracic Anaesthesiology and Intensive Care and distributed through the organization's social media.

Interventions: A 22-item questionnaire on the approach to perioperative hypertension control and its pharmacological management.

Measurements and main results: The study included surveys completed between July 1 and October 30, 2023. In total, 339 participants completed the questionnaire; 70% were anesthesiologists, 17% were intensive care physicians, and 12% were cardiac surgeons.

Major findings: More than 50% of respondents declared dealing with perioperative hypertension in 20% to 50% of their surgeries, and most target the 120 to 140 mmHg systolic blood pressure (SBP) range during surgery. Respondents mostly rely on α-adrenoreceptor antagonists (29%), nitrates (23%), and calcium channel blockers (15%) to manage perioperative hypertension. Titratable control was the most appreciated attribute of intravenous antihypertensives. Antihypertensive treatment failure occurred in less than 20% of surgeries, and the highest risk of hypotensive episodes was perceived by participants to be when using nitroglycerin and nitroprusside.

Conclusions: Perioperative SBP targets above 140 mmHg are uncommon among respondents, who predominantly target SBP values between 120 and 140 mmHg. The choice of intravenous antihypertensives is based on their manageability and user experience, and titratable control is the most appreciated characteristic.

Objectives: The aim of this physiological pilot study was to investigate the effect of deep hypothermia on oxygen extraction (OE) and consumption (VO₂) in normothermic conditions (36-37°C), and at different stages of cooling: 30°C, 25°C, and 18°C.

Design: For 3 months, a prospective study was conducted on patients who underwent pulmonary thromboendarterectomy.

Settings: This was a single-center study done in a university teaching hospital.

Participants: Patients who underwent pulmonary thromboendarterectomy during the inclusion period.

Interventions: Hemodynamic and biological data were recorded from arterial and venous blood gas samples withdrawn first at normothermia, then at 30°C, 25°C, and 18°C.

Measurements and main results: 24 patients were included in the final analysis. Indexed VO₂ decreased from 65.9 mL to 25.1 mL of O₂/min/m² between 36°C and 18°C (p < 0.001). The OE decreased from 18% to 9% between 36°C and 18°C (p < 0.001). At normal temperature and 18°C, the median venoarterial difference of O₂ bound to hemoglobin was 2.22 [1.68-2.58] and 0.03 mL [0.01-0.07] of O₂/100 mL of blood, respectively (p < 0.001). Whereas the median venoarterial differences in dissolved O₂ were 0.78 [0.66-0.92] and 1.09 mL [1.03-1.32] of O₂/100 mL of blood, respectively (p = 0.0013).

Conclusion: There were VO₂ and OE decreases of more than half their baseline values at 18°C. Given that metabolic needs are essentially supplied by dissolved O₂ during cooling from 30°C to 18°C, the authors suggest that PaO₂ should be increased during the period of cooling and/or deep hypothermia to prevent hypoxia.