Journal of cardiothoracic and vascular anesthesia最新文献

Objectives: Extracorporeal cardiopulmonary resuscitation (ECPR) can save patients with refractory cardiac arrest; however, according to recent meta-analyses, only 20% of patients achieve favorable outcomes (Modified Rankin Scale 0-3). We aimed to develop and validate an ECPR prediction model to improve patient selection.

Design: Prognostic model development and internal validation study.

Setting: Single-center study.

Participants: All 120 normothermic ECPR patients treated at Sahlgrenska University Hospital between January 2010 and October 2021.

Interventions: None.

Measurements and main results: Multivariable logistic regression was used to develop the PRognostic Evaluation of ECPR (Pre-ECPR) score. Model performance was assessed through the area under curve (AUC) and compared with the Extracorporeal Life Support Organization (ELSO) "Example of selection criteria for ECPR" for 1-year survival with favorable outcomes. The positive predictive value (PPV) was calculated. Favorable outcomes occurred in 27.5% of the patients. The Pre-ECPR score, incorporating age, no-flow/initial rhythm (a composite variable), total cardiac arrest time, signs of life, pupil dilation, regional cerebral oxygen saturation, arterial pH, and end-tidal CO₂, demonstrated an AUC of 0.87 (95% confidence interval [CI] 0.77-0.93). In internal cross-validation, the AUC of 0.79 (95% CI 0.67-0.88) significantly outperformed the ELSO criteria AUC of 0.63 (95% CI 0.54-0.72, p = 0.012). Pre-ECPR score probabilities >6.4% showed 100% sensitivity and a PPV of 40.5% for favorable outcomes.

Conclusions: The Pre-ECPR score combines multiple weighted predictors to provide a single balanced probability of favorable outcomes in ECPR patient selection. In cross-validation, it demonstrated significantly more favorable discriminatory performance than that of the ELSO criteria.

Objective: Conduct a systematic review and meta-analysis of the efficacy of therapeutic plasma exchange (TPE) or intravenous cangrelor to prevent thromboembolism in patients with heparin-induced thrombocytopenia (HIT) who undergo cardiopulmonary bypass (CPB) with heparin.

Design: Systematic review and meta-analysis.

Setting: N/A.

Participants: Adults having cardiac surgery with a history of HIT who received preoperative or intraoperative TPE or intravenous cangrelor as an adjunct to CPB with heparin.

Interventions: None MEASUREMENTS AND MAIN RESULTS: A systematic review was performed using MEDLINE, PubMed, and Google Scholar. The primary outcome was avoidance of thromboembolism (venous or arterial) during or after CPB. Proportional meta-analysis with a random effects model was used to calculate a weighted-pooled proportion/efficacy for the study's primary outcome. Fifty-seven patients in 17 reports received TPE as an adjunctive treatment to prevent HIT-related thrombosis related to heparinization during CPB and 3 (5.3%) experienced thrombosis. Proportional meta-analysis suggested a weighted-pooled freedom from perioperative thromboembolism rate of 91.0% (95% CI 82.6%-96.9%). Fifteen patients in 6 reports received intravenous cangrelor as an adjunctive treatment to prevent HIT-related thrombosis related to heparinization during CPB and 2 (13.3%) experienced thrombosis. Proportional meta-analysis suggested a weighted-pooled freedom from perioperative thromboembolism rate of 83.0% (95% CI 61.2%- 97.6%).

Conclusions: TPE and cangrelor are feasible strategies to prevent thromboembolism in adults with HIT who require CPB with heparin. Given the relatively small number of cases in the published literature and a high likelihood for publication and detection biases, prudence remains warranted when using these strategies.

Objectives: This study aimed to investigate the association between preoperative red blood cell distribution width (RDW) levels and liver injury (LI) after cardiac surgery, to highlight RDW's usefulness in the early identification and intervention for patients at high risk of LI.

Design: A retrospective observational study.

Setting: A university-affiliated teaching hospital and tertiary referral center.

Participants: Adult patients who underwent cardiac and aortic aneurysm surgery at Changhai Hospital in 2021.

Interventions: Postoperative LI was defined by increased liver enzyme levels and/or hyperbilirubinemia, noted from the time of surgery to discharge. Logistic regression analyses were conducted to examine the RDW-LI relationship, with stratified analyses based on age, gender, and anemia. Survival within 30 days was assessed using the Kaplan-Meier method, with survival curve differences analyzed via the log-rank test. The study included 3 sets of sensitivity analyses.

Measurements and main results: Postoperative LI was observed in 75 patients (10%). Multivariate regression analysis showed a significant association between high RDW levels and postoperative LI (adjusted odds ratio, 3.25; p = 0.033; 95% confidence intefal, 1.10-9.63), even after adjusting for all covariates. This association remained consistent across 3 sets of sensitivity analyses. Subgroup analysis showed men had a higher correlation with LI (p for interaction = 0.041). Kaplan-Meier analysis indicated a significantly lower survival rate in the LI group (76%) compared with the non-LI group (99.6%; p < 0.001).

Conclusions: Preoperative RDW levels are significantly associated with postoperative LI. RDW could serve as a significant useful marker for early detection and intervention in patients at high risk of LI, thereby potentially improving patient outcomes.

Objective: Extracorporeal membrane oxygenation (ECMO) requires systemic anticoagulation to reduce the risk of thromboembolic events. Despite its historic role, activated clotting time (ACT) remains a widely used heparin monitoring method. Systematic evidence on the association of ACT-guided monitoring with hemorrhagic or thromboembolic complications does not exist.

Design: Systematic literature review and meta-analysis (Scopus and PubMed, July 2023).

Setting: All cohort studies.

Participants: Patients receiving ECMO support.

Intervention: Anticoagulation monitoring with ACT.

Measurements and main results: We identified 3,177 publications, with 8 studies reporting the average ACT values for patients with and without bleeding. Meta-analysis revealed no significant difference in the compared groups (SMD = 0.69; 95% CI -0.05 to 1.43, p = 0.069; I² = 87.4%). Three studies (n = 117 patients) reported on the average ACT values for patients with thrombosis, without significant differences in ACT between patients with and without thrombosis (SMD = 0.47; 95% CI -0.50 to 1.44, p = 0.342; I² = 81.1%).

Conclusions: Even though ACT is a widely used heparin monitoring tool, the evidence on its association with hemorrhagic or thromboembolic events is still controversial and limited. Further studies are essential to elucidate the role of ACT in anticoagulation monitoring during ECMO support.

Objective: To assess if frailty scoring can predict increased frailty and care dependence requiring a change in living situation in patients with peripheral artery disease (PAD) following major vascular surgery.

Design: A single center, retrospective cohort study.

Setting: Fiona Stanley Hospital, a tertiary center located in Perth, Western Australia.

Participants: Seventy-nine patients with PAD who underwent major vascular surgery at the study hospital in 2022 were enrolled.

Intervention: Baseline Clinical Frailty Scale (CFS) scores were assigned retrospectively. A quantitative analysis using two partitions, CFS 1-3 (not frail) versus 4-9 (frail) was used. Cases were screened for hospital-acquired complications, and records were reviewed to assess the level of care dependence at the time of discharge and 6 months following.

Measurements and main results: The primary outcome was to assess if frailty predicts increased care dependence. Secondary outcomes included unplanned readmissions and hospital-acquired complications in this cohort. A logistic regression was performed to predict the effects of age and baseline, discharge, and 6-month CFS on the likelihood of change in living situation. Baseline frailty was associated with a higher frailty score at discharge (p = 0.001), which persisted at 6 months (p = 0.001). There was no difference in American Society of Anesthesiologists classification, sex, age, 30-day mortality, or in-hospital complications between groups. After correcting for age, a lower baseline CFS (odds ratio 0.19, confidence interval 0.04-0.84, p = 0.028) and discharge CFS (odds ratio 34.00, confidence interval 3.88-298.42, p = 0.001) predicts the likelihood of patients having a change in living situation after surgery.

Conclusions: Frail patients with PAD undergoing major vascular surgery are at significant risk of functional decline, necessitating a change in living situation to meet their increased care needs. This increased care dependence persisted 6 months following discharge.