<div><h3>Objective</h3><div>Bochdalek hernia in adults may remain asymptomatic for years and may present acutely with respiratory or gastro-intestinal complications. Our patient with multiple comorbidities presented with CO2 narcosis and posed serious challenges in perioperative period.</div></div><div><h3>Design and method</h3><div>A 57-year-old gentleman presented with Type 2 respiratory failure (PCO2>100 mmHg) and obtundation in Emergency Room. He was known case of childhood Poliomyelitis with residual weakness (wheelchair bound), severe thoracolumbar kyphoscoliosis, obesity with obstructive sleep apnoea, diabetic, hypertensive, hypothyroid. Chest X-ray showed huge translucent area in left chest and tip of nasogastric tube in-situ. The HRCT confirmed large Bochdalek hernia(left). Patient was completely NIV (non invasive ventilation) dependent in ITU but still was hypercarbic (PCO2 70+ mmHg) and hypoxic(PO2 70mmHg in 70%FiO2) and hence surgical repair was planned. He had anticipated difficult airway (Mallampati 3, short neck, anterior larynx) with very poor functional capacity. Pre operative Echocardiography showed normal left and right ventricular function. Routine blood investigations were normal .Proper patient consent was obtained. In operation theatre standard ASA monitors were attached. After awake invasive lines (left20G radial line and right internal jugular 7.5Fr 5 lumen central venous line under local anaesthesia guided by live ultrasonography),he was preoxygenated with 100% O2 via NIV. Maximum SPO2 acquired with 100% Fio2 on NIV was 96%. After induction of general anaesthesia(Propofol,Fentanyl,Cisatracurium followed by Sevoflurane, Air, Oxygen) he was intubated electively with video-laryngoscope at single attempt. Then single lumen bronchial blocker was inserted to isolate left lung. Left thoracotomy and mesh repair of the huge diaphragmatic hernia was performed. Contents of the hernia were omentum ,stomach,mesentry and left colon.Part of left lower lung was found to be hypoplastic and wedge resection was done. Intercostal regional block and local infiltration to skin incision were administered. Patient got extubated next day but after extubation he had moderate hypercarbia and developed a pneumonia on day3 of post operative period. He was intubated again in ITU and eventually needing a tracheostomy to wean off ventilator. Tracheostomy was closed on day41. Eventually he was discharged on day 49.</div></div><div><h3>Results and conclusions</h3><div>Bochdalek hernia is congenital defect resulting from developmental failure of diaphragm located in the posterior insertion. Left posterolateral hernias are more frequent (85%) as compared to the right side (13%) and bilateral are (2%).Mostly Bochdalek hernia is diagnosed in children and in neonates and present clinical symptoms caused by associated pulmonary insufficiency. In adults asymptomatic Bochdalek hernia is rare (0.17% of the adult population).It tends to affect women(77%) mostly
{"title":"PERIOPERATIVE CHALLENGES AND MANAGEMENT OF AN ADULT PATIENT WITH LARGE LEFT SIDED BOCHDALEK HERNIA PRESENTING WITH CO2 NARCOSIS: A CASE REPORT","authors":"Arupratan Maiti , Amrita Guha , Ranjeeta Kumari , Tamasish Mukherjee , Arpan Chakraborty","doi":"10.1053/j.jvca.2024.09.070","DOIUrl":"10.1053/j.jvca.2024.09.070","url":null,"abstract":"<div><h3>Objective</h3><div>Bochdalek hernia in adults may remain asymptomatic for years and may present acutely with respiratory or gastro-intestinal complications. Our patient with multiple comorbidities presented with CO2 narcosis and posed serious challenges in perioperative period.</div></div><div><h3>Design and method</h3><div>A 57-year-old gentleman presented with Type 2 respiratory failure (PCO2>100 mmHg) and obtundation in Emergency Room. He was known case of childhood Poliomyelitis with residual weakness (wheelchair bound), severe thoracolumbar kyphoscoliosis, obesity with obstructive sleep apnoea, diabetic, hypertensive, hypothyroid. Chest X-ray showed huge translucent area in left chest and tip of nasogastric tube in-situ. The HRCT confirmed large Bochdalek hernia(left). Patient was completely NIV (non invasive ventilation) dependent in ITU but still was hypercarbic (PCO2 70+ mmHg) and hypoxic(PO2 70mmHg in 70%FiO2) and hence surgical repair was planned. He had anticipated difficult airway (Mallampati 3, short neck, anterior larynx) with very poor functional capacity. Pre operative Echocardiography showed normal left and right ventricular function. Routine blood investigations were normal .Proper patient consent was obtained. In operation theatre standard ASA monitors were attached. After awake invasive lines (left20G radial line and right internal jugular 7.5Fr 5 lumen central venous line under local anaesthesia guided by live ultrasonography),he was preoxygenated with 100% O2 via NIV. Maximum SPO2 acquired with 100% Fio2 on NIV was 96%. After induction of general anaesthesia(Propofol,Fentanyl,Cisatracurium followed by Sevoflurane, Air, Oxygen) he was intubated electively with video-laryngoscope at single attempt. Then single lumen bronchial blocker was inserted to isolate left lung. Left thoracotomy and mesh repair of the huge diaphragmatic hernia was performed. Contents of the hernia were omentum ,stomach,mesentry and left colon.Part of left lower lung was found to be hypoplastic and wedge resection was done. Intercostal regional block and local infiltration to skin incision were administered. Patient got extubated next day but after extubation he had moderate hypercarbia and developed a pneumonia on day3 of post operative period. He was intubated again in ITU and eventually needing a tracheostomy to wean off ventilator. Tracheostomy was closed on day41. Eventually he was discharged on day 49.</div></div><div><h3>Results and conclusions</h3><div>Bochdalek hernia is congenital defect resulting from developmental failure of diaphragm located in the posterior insertion. Left posterolateral hernias are more frequent (85%) as compared to the right side (13%) and bilateral are (2%).Mostly Bochdalek hernia is diagnosed in children and in neonates and present clinical symptoms caused by associated pulmonary insufficiency. In adults asymptomatic Bochdalek hernia is rare (0.17% of the adult population).It tends to affect women(77%) mostly","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"38 12","pages":"Pages 39-40"},"PeriodicalIF":2.3,"publicationDate":"2024-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142530524","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-25DOI: 10.1053/j.jvca.2024.09.038
Stefano Italiano , Manuel Lopez Baamonde , Jorge Luis Aliaga Medina , Pau Mingarro Cubells , Juan Manuel Perdomo Linares , Alvaro Bunuel , Mireia Pozo Albiol , Samira Martinez Otero , Cristina Ibañez Esteve , Maria José Arguis Gimenez , Maria José Carretero Casado , Marc Gimenez Mila , Purificación Matute Jimenez , Irene Rovira Canudas , Felipe Unigarro Londoño , Ricard Navarro Ripoll
<div><h3>Objective</h3><div>Robotic cardiac surgery (RCS) has been demonstrated to be feasible and safe by many groups. Several studies reported better outcomes of RCS (lower complication rate, reduced length of stay, improved quality of life) compared to non-robotic technique In minimally invasive cardiac surgery locoregional aneasthesia (LRA) has been demonstrated to improve postoperative pain control. Specific to RCS, the optimal LRA technique has yet to be determined. Erector spinae plane (ESP) block is an easy-to-perform technique that can provide an adequate pain control in chest surgery, reducing the postoperative dose of opioids.</div><div>The aim of the present study is to assess the beneficial effects of continuous unilateral ESP block in the management of the postoperative pain after RCS.</div></div><div><h3>Design and method</h3><div>Design</div><div>A randomized controlled trial.</div><div>Setting</div><div>Single-center, university tertiary-care institution.</div><div>Participants</div><div>Patients undergoing non-coronary robotic-assisted cardiac surgery.</div><div>Interventions</div><div>Patients were randomized to the “ESP” group, receiving an ESP block (intraoperative loading dose of 20 ml followed by continuous infusion of ropivacaine 0.2% for 24 hours) versus “control” group, receiving conventional perioperative pain management (continuous infusion of intravenous morphine). In addition, all patients received multimodal analgesia including acetaminophen, dexamethasone and patient-controlled analgesia with intravenous morphine.</div><div>Measurements</div><div>The primary outcomes were morphine consumption at 12 and 24 hours, as well as the total postoperative dose. The secondary outcomes were pain scores on a Numeric Rating Scale (NRS) at 6, 12, 24, and 48 hours after surgery.</div></div><div><h3>Results and conclusions</h3><div>Main Results</div><div>Fifty-four patients were randomized. However, 24 patients were withdrawn from the trial for various reasons. The main reasons included inability to assess analgesia (n=5), seizures (n=3), and other issues (n=16), such as catheter dysfunction or removal, reconversion to sternotomy, and postoperative bleeding. The data from the remaining 30 patients were analysed appropriately.</div><div>ESP block was successfully performed in all patients in the intervention group without observing any perioperative adverse effects. In comparison with the control group, a trend of lower opioid consumption was observed in the ESP group, with a significant difference in morphine use 12 hours after surgery (p = 0.049, Table 1 and Figure 1). No difference was observed in postoperative pain scores measured by the NRS (Table 2 and Figure 2).</div><div>Table 1: Comparison of the postoperative opioid consumption between ESP group and control group. Data expressed as median (interquartile range).</div><div>Figure 1: Box-plot representing the data of Table 1.</div><div>Table 2: Comparison of the postoperativ
{"title":"Opioid-sparing effect of Continuous Erector Spinae Plane Block in Robotic Cardiac Surgery: Preliminary Results of a Randomized Clinical Trial","authors":"Stefano Italiano , Manuel Lopez Baamonde , Jorge Luis Aliaga Medina , Pau Mingarro Cubells , Juan Manuel Perdomo Linares , Alvaro Bunuel , Mireia Pozo Albiol , Samira Martinez Otero , Cristina Ibañez Esteve , Maria José Arguis Gimenez , Maria José Carretero Casado , Marc Gimenez Mila , Purificación Matute Jimenez , Irene Rovira Canudas , Felipe Unigarro Londoño , Ricard Navarro Ripoll","doi":"10.1053/j.jvca.2024.09.038","DOIUrl":"10.1053/j.jvca.2024.09.038","url":null,"abstract":"<div><h3>Objective</h3><div>Robotic cardiac surgery (RCS) has been demonstrated to be feasible and safe by many groups. Several studies reported better outcomes of RCS (lower complication rate, reduced length of stay, improved quality of life) compared to non-robotic technique In minimally invasive cardiac surgery locoregional aneasthesia (LRA) has been demonstrated to improve postoperative pain control. Specific to RCS, the optimal LRA technique has yet to be determined. Erector spinae plane (ESP) block is an easy-to-perform technique that can provide an adequate pain control in chest surgery, reducing the postoperative dose of opioids.</div><div>The aim of the present study is to assess the beneficial effects of continuous unilateral ESP block in the management of the postoperative pain after RCS.</div></div><div><h3>Design and method</h3><div>Design</div><div>A randomized controlled trial.</div><div>Setting</div><div>Single-center, university tertiary-care institution.</div><div>Participants</div><div>Patients undergoing non-coronary robotic-assisted cardiac surgery.</div><div>Interventions</div><div>Patients were randomized to the “ESP” group, receiving an ESP block (intraoperative loading dose of 20 ml followed by continuous infusion of ropivacaine 0.2% for 24 hours) versus “control” group, receiving conventional perioperative pain management (continuous infusion of intravenous morphine). In addition, all patients received multimodal analgesia including acetaminophen, dexamethasone and patient-controlled analgesia with intravenous morphine.</div><div>Measurements</div><div>The primary outcomes were morphine consumption at 12 and 24 hours, as well as the total postoperative dose. The secondary outcomes were pain scores on a Numeric Rating Scale (NRS) at 6, 12, 24, and 48 hours after surgery.</div></div><div><h3>Results and conclusions</h3><div>Main Results</div><div>Fifty-four patients were randomized. However, 24 patients were withdrawn from the trial for various reasons. The main reasons included inability to assess analgesia (n=5), seizures (n=3), and other issues (n=16), such as catheter dysfunction or removal, reconversion to sternotomy, and postoperative bleeding. The data from the remaining 30 patients were analysed appropriately.</div><div>ESP block was successfully performed in all patients in the intervention group without observing any perioperative adverse effects. In comparison with the control group, a trend of lower opioid consumption was observed in the ESP group, with a significant difference in morphine use 12 hours after surgery (p = 0.049, Table 1 and Figure 1). No difference was observed in postoperative pain scores measured by the NRS (Table 2 and Figure 2).</div><div>Table 1: Comparison of the postoperative opioid consumption between ESP group and control group. Data expressed as median (interquartile range).</div><div>Figure 1: Box-plot representing the data of Table 1.</div><div>Table 2: Comparison of the postoperativ","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"38 12","pages":"Pages 15-16"},"PeriodicalIF":2.3,"publicationDate":"2024-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142531032","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<div><h3>Objective</h3><div>Cardiovascular damage is a common complication of sepsis, with an incidence of 10% to 70%. Septic cardiomyopathy (SCM) occurs in ICUs as a reversible myocardial damage in sepsis patients. Despite various proposed diagnostic tools, none are specifically tailored for SCM. This study aims to evaluate different echocardiography-based diagnostic tools and determine the SCM rate in our population.</div></div><div><h3>Design and method</h3><div>A single-centre, prospective observational study was conducted at a tertiary reference hospital from March to May 2024. Patients meeting Sepsis-3 criteria, aged over 18 years, and treated in the ICU were included. Ethical approval was obtained from the regional ethical committee. Transthoracic echocardiogram (TTE) and hemodynamic measurements were performed within 48 hours of patient identification and repeated within 10 days. A diagnosis of septic cardiomyopathy (SCMP) was evaluated using three different diagnostic tools: left ventricular ejection fraction (LVEF <50% or >10% decrease from baseline), cardiac power output (CPO <0.6W), and afterload-related cardiac performance (ACP <80%) based on values reported in the literature. Demographic and descriptive data were extracted from electronic medical records.</div></div><div><h3>Results and conclusions</h3><div>Results: Thirty-eight patients (mean age 61±13 years; 63.2% males) were enrolled. The median SOFA score was 9.5 [IQR, 8-11], APACHE II score 19 [16-22], and SAPS II 42 [32-51]. Median lactate levels were 3.1 [2.1-4.9] mmol/L, WBC count 16 [12-21] x10^9/L, PCT 11.2 [3.5–31.7] ng/mL, CRP 300 [179-407] mg/L, and troponin I 214 [47-627] ng/L. The median time between TTEs was 6 [4-9] days.</div><div>In patients diagnosed with SCMP based on LVEF, seven (19.4%) had SCMP, showing significantly lower velocity time integral (VTI: 13.2±3.3 vs 18.1±4.7 cm, p=0.013) and stroke volume (SV: 50.4±13.8 vs 67.7±18.5 ml, p=0.026), and higher heart rate (HR: 106±14 vs 87±20 bpm, p=0.028) compared to non-SCMP patients (n=31, 80.6%). For CPO-based diagnosis, six patients (20.7%) had SCMP, with significantly lower VTI (13.2±2.8 vs 17.9±4.9, p=0.029), SV (47.2±11.5 vs 67.5±18.5 ml, p=0.015), and cardiac output (CO: 3.9±0.5 vs 6.1±1.7 L/min, p<0.001), and a trend towards lower cardiac index (CI: 1.7±0.5 vs 2.6±0.8 L/min/m2, p=0.07) compared to twenty-nine non-SCMP patients. The prevalence of SCMP based on ACP was higher than in the LVEF or CPO group, with eighteen patients (51.4%) diagnosed with SCMP. Seventeen patients had slightly restricted cardiac function (ACP 60-80%) and one had moderately restricted cardiac function (ACP 40-60%). Comparatively, ACP-based SCMP patients had significantly lower mean arterial pressure (MAP: 98±17 vs 109±12 mmHg, p=0.025), CI (2.2±0.7 vs 2.8±0.8 l/min/m2, p=0.011), CO (4.6 [4.0-5.5] vs 6.4 [5.5-7.1] L/min, p=0.005), and SV (55 [43-66] vs 70 [59-82] ml, p=0.013), but higher central venous pressure (CVP: 1
目的心血管损伤是败血症的常见并发症，发生率为 10%-70%。脓毒症心肌病（SCM）发生在重症监护病房，是脓毒症患者心肌的一种可逆性损伤。尽管提出了多种诊断工具，但没有一种是专门针对 SCM 的。本研究旨在评估不同的超声心动图诊断工具，并确定我国人群中的 SCM 发生率。设计与方法 2024 年 3 月至 5 月，在一家三级参考医院开展了一项单中心前瞻性观察研究。研究对象包括符合败血症-3 标准、年龄在 18 岁以上、在重症监护室接受治疗的患者。研究获得了地区伦理委员会的伦理批准。经胸超声心动图（TTE）和血液动力学测量在患者确认后 48 小时内进行，并在 10 天内重复进行。脓毒性心肌病（SCMP）的诊断使用三种不同的诊断工具进行评估：左室射血分数（LVEF <50%或>比基线下降10%）、心脏动力输出（CPO <0.6W）和与后负荷相关的心脏性能（ACP <80%），以文献报道的数值为基础。从电子病历中提取了人口统计学和描述性数据：38名患者（平均年龄61±13岁；63.2%为男性）入组。中位 SOFA 评分为 9.5 [IQR，8-11]，APACHE II 评分为 19 [16-22]，SAPS II 评分为 42 [32-51]。乳酸水平中位数为 3.1 [2.1-4.9] mmol/L，白细胞计数为 16 [12-21] x10^9/L，PCT 为 11.2 [3.5-31.7] ng/mL，CRP 为 300 [179-407] mg/L，肌钙蛋白 I 为 214 [47-627] ng/L。在根据 LVEF 诊断为 SCMP 的患者中，7 人（19.4%）患有 SCMP，其速度时间积分明显较低（VTI：13.2±3.3 vs 18.1±4.7cm，P＜0.05）。1±4.7厘米，P=0.013）和搏出量（SV：50.4±13.8 vs 67.7±18.5毫升，P=0.026），心率（HR：106±14 vs 87±20bpm，P=0.028）较非SCMP患者（31人，80.6%）高。对于基于 CPO 的诊断，6 名患者（20.7%）患有 SCMP，其 VTI（13.2±2.8 vs 17.9±4.9，p=0.029）、SV（47.2±11.5 vs 67.5±18.5ml，p=0.015）和心输出量（CO：3.9±0.5 vs 6.1±1.7 L/min，p<0.001），与 29 例非 SCMP 患者相比，心脏指数呈下降趋势（CI：1.7±0.5 vs 2.6±0.8 L/min/m2，p=0.07）。基于 ACP 的 SCMP 患病率高于 LVEF 或 CPO 组，有 18 名患者（51.4%）被诊断为 SCMP。其中 17 名患者心功能轻度受限（ACP 60-80%），1 名患者心功能中度受限（ACP 40-60%）。相比之下，基于 ACP 的 SCMP 患者的平均动脉压（MAP：98±17 vs 109±12 mmHg，P=0.025）、CI（2.2±0.7 vs 2.8±0.8 l/min/m2，P=0.011）、CO（4.6 [4.0-5.5] vs 6.4 [5.5-7.1] L/min，p=0.005）和 SV（55 [43-66] vs 70 [59-82] ml，p=0.013），但中心静脉压（CVP：15±6 vs 11±6 mmHg，p=0.032）高于 17 名非 SCMP 患者。在乳酸水平、VIS 评分和存活率方面，SCMP 组和非 SCMP 组无明显差异。要确定单核细胞增多症的最佳诊断工具，还需要进行进一步的分析，这需要更大的样本群。
{"title":"Diagnostic Tools and Prevalence of Septic Cardiomyopathy in Sepsis and Septic Shock: A Prospective Pilot Study","authors":"Lina Puodziukaite , Dziugile Kersnauskaite , Sigita Glaveckaite , Giedrius Davidavicius , Tomas Jovaisa","doi":"10.1053/j.jvca.2024.09.028","DOIUrl":"10.1053/j.jvca.2024.09.028","url":null,"abstract":"<div><h3>Objective</h3><div>Cardiovascular damage is a common complication of sepsis, with an incidence of 10% to 70%. Septic cardiomyopathy (SCM) occurs in ICUs as a reversible myocardial damage in sepsis patients. Despite various proposed diagnostic tools, none are specifically tailored for SCM. This study aims to evaluate different echocardiography-based diagnostic tools and determine the SCM rate in our population.</div></div><div><h3>Design and method</h3><div>A single-centre, prospective observational study was conducted at a tertiary reference hospital from March to May 2024. Patients meeting Sepsis-3 criteria, aged over 18 years, and treated in the ICU were included. Ethical approval was obtained from the regional ethical committee. Transthoracic echocardiogram (TTE) and hemodynamic measurements were performed within 48 hours of patient identification and repeated within 10 days. A diagnosis of septic cardiomyopathy (SCMP) was evaluated using three different diagnostic tools: left ventricular ejection fraction (LVEF <50% or >10% decrease from baseline), cardiac power output (CPO <0.6W), and afterload-related cardiac performance (ACP <80%) based on values reported in the literature. Demographic and descriptive data were extracted from electronic medical records.</div></div><div><h3>Results and conclusions</h3><div>Results: Thirty-eight patients (mean age 61±13 years; 63.2% males) were enrolled. The median SOFA score was 9.5 [IQR, 8-11], APACHE II score 19 [16-22], and SAPS II 42 [32-51]. Median lactate levels were 3.1 [2.1-4.9] mmol/L, WBC count 16 [12-21] x10^9/L, PCT 11.2 [3.5–31.7] ng/mL, CRP 300 [179-407] mg/L, and troponin I 214 [47-627] ng/L. The median time between TTEs was 6 [4-9] days.</div><div>In patients diagnosed with SCMP based on LVEF, seven (19.4%) had SCMP, showing significantly lower velocity time integral (VTI: 13.2±3.3 vs 18.1±4.7 cm, p=0.013) and stroke volume (SV: 50.4±13.8 vs 67.7±18.5 ml, p=0.026), and higher heart rate (HR: 106±14 vs 87±20 bpm, p=0.028) compared to non-SCMP patients (n=31, 80.6%). For CPO-based diagnosis, six patients (20.7%) had SCMP, with significantly lower VTI (13.2±2.8 vs 17.9±4.9, p=0.029), SV (47.2±11.5 vs 67.5±18.5 ml, p=0.015), and cardiac output (CO: 3.9±0.5 vs 6.1±1.7 L/min, p<0.001), and a trend towards lower cardiac index (CI: 1.7±0.5 vs 2.6±0.8 L/min/m2, p=0.07) compared to twenty-nine non-SCMP patients. The prevalence of SCMP based on ACP was higher than in the LVEF or CPO group, with eighteen patients (51.4%) diagnosed with SCMP. Seventeen patients had slightly restricted cardiac function (ACP 60-80%) and one had moderately restricted cardiac function (ACP 40-60%). Comparatively, ACP-based SCMP patients had significantly lower mean arterial pressure (MAP: 98±17 vs 109±12 mmHg, p=0.025), CI (2.2±0.7 vs 2.8±0.8 l/min/m2, p=0.011), CO (4.6 [4.0-5.5] vs 6.4 [5.5-7.1] L/min, p=0.005), and SV (55 [43-66] vs 70 [59-82] ml, p=0.013), but higher central venous pressure (CVP: 1","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"38 12","pages":"Pages 7-8"},"PeriodicalIF":2.3,"publicationDate":"2024-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142530446","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Cardiopulmonary bypass surgery involves heparinization with high dose of unfractioned heparin. In case of ATIII deficiency, it necessitates preoperative AIII supplementation and a careful following during the peri and postoperative course to avoid both hemorrhagic and thrombotic complications. Previous authors reported their experiences during conventional cardiac or thoracic aorta surgery and sometimes suggested to overcorrect ATIII activity (> 120%). However, management of ATIII deficiency during deep hypothermic circulatory arrest CPB for pulmonary thromboendarterectomy (PTE) has not been reported yet.
Design and method
We report the management of a patient with a type 1 congenital AT III deficiency that underwent PTE. Preoperative AT III activity level was 36%. A single dose of AT III 50 IU/kg (35000 IU) was administered ten minutes before full heparinization. ATIII activity level reached 85%. After a standard dose of unfractioned heparin of 300 IU/kg (22 000 IU) the activated clotting time (ACT) reached 650 seconds. ACT was monitored every 20 minutes and ATIII activity level drops initially then remained stable above 50% during the entire procedure. Also, ACT was constantly above 450 seconds without any needs for unfractioned heparin reinjection. No bleeding or thromboembolic events were reported during the postoperative course. Anticoagulation was started with intravenous heparin 6 hours after surgery. ATIII was supplemented at three occasion when activity drop below 50%.
Results and conclusions
Preoperative supernormal ATIII supplementation seems not mandatory to achieve optimal heparin anticoagulation for CPB. Smaller target seems equally effective and could reduce the risk of bleeding at the time of CPB weaning and in the early postoperative period.
心肺旁路手术需要使用大剂量的非减量肝素。如果存在 ATIII 缺乏症，则需要在术前补充 AIII，并在围手术期和术后仔细跟踪，以避免出现出血和血栓并发症。之前的作者报告了他们在常规心脏或胸主动脉手术中的经验，有时建议过度纠正 ATIII 活性（120%）。我们报告了一名接受肺血栓内膜剥脱术（PTE）的 1 型先天性 AT III 缺乏症患者的治疗情况。术前 AT III 活性水平为 36%。在完全肝素化前 10 分钟给予单剂量 AT III 50 IU/kg（35000 IU）。ATIII 活性水平达到 85%。注射标准剂量的非减量肝素 300 IU/kg（22000 IU）后，活化凝血时间（ACT）达到 650 秒。每隔 20 分钟对活化凝血时间进行一次监测，ATIII 活性水平最初有所下降，但在整个过程中一直稳定在 50% 以上。此外，活化凝血时间（ACT）一直保持在 450 秒以上，无需再次注射非减量肝素。术后未发生出血或血栓栓塞事件。术后 6 小时开始静脉注射肝素进行抗凝。结果和结论术前超常ATIII补充似乎并非实现CPB最佳肝素抗凝的必要条件。较小的目标似乎同样有效，可以降低 CPB 断流时和术后早期的出血风险。
{"title":"Pulmonary thromboendarterectomy with deep hypothermic circulatory arrest in a patient with a congenital Antithrombin III deficiency: A clinical challenge.","authors":"DANIELA IOLANDA ION , MARIA-CRISTINA KASSAB , ELIE FADEL , THIBAUT GENTY , SYLVAIN DIOP","doi":"10.1053/j.jvca.2024.09.053","DOIUrl":"10.1053/j.jvca.2024.09.053","url":null,"abstract":"<div><h3>Objective</h3><div>Cardiopulmonary bypass surgery involves heparinization with high dose of unfractioned heparin. In case of ATIII deficiency, it necessitates preoperative AIII supplementation and a careful following during the peri and postoperative course to avoid both hemorrhagic and thrombotic complications. Previous authors reported their experiences during conventional cardiac or thoracic aorta surgery and sometimes suggested to overcorrect ATIII activity (> 120%). However, management of ATIII deficiency during deep hypothermic circulatory arrest CPB for pulmonary thromboendarterectomy (PTE) has not been reported yet.</div></div><div><h3>Design and method</h3><div>We report the management of a patient with a type 1 congenital AT III deficiency that underwent PTE. Preoperative AT III activity level was 36%. A single dose of AT III 50 IU/kg (35000 IU) was administered ten minutes before full heparinization. ATIII activity level reached 85%. After a standard dose of unfractioned heparin of 300 IU/kg (22 000 IU) the activated clotting time (ACT) reached 650 seconds. ACT was monitored every 20 minutes and ATIII activity level drops initially then remained stable above 50% during the entire procedure. Also, ACT was constantly above 450 seconds without any needs for unfractioned heparin reinjection. No bleeding or thromboembolic events were reported during the postoperative course. Anticoagulation was started with intravenous heparin 6 hours after surgery. ATIII was supplemented at three occasion when activity drop below 50%.</div></div><div><h3>Results and conclusions</h3><div>Preoperative supernormal ATIII supplementation seems not mandatory to achieve optimal heparin anticoagulation for CPB. Smaller target seems equally effective and could reduce the risk of bleeding at the time of CPB weaning and in the early postoperative period.</div></div>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"38 12","pages":"Page 27"},"PeriodicalIF":2.3,"publicationDate":"2024-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142531540","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-25DOI: 10.1053/j.jvca.2024.09.051
Jane Heggie , Marjan Jariani , Jodie Beuth , Loretta Tsui Ho , Sara Thorne , Rafa Alonzo-Gonzales , Heather Ross , David Barron
Objective
This study aimed to ascertain socioeconomic factors affecting access to adult congenital cardiac services and adult congenital cardiac surgical services in Ontario.
Design and method
Hospital records identified 2232 patients with complex congenital heart disease referred from the regional pediatric cardiac surgery center to the regional adult congenital cardiac disease (ACHD) center 2004-2016 specifically for complex ACHD, with follow up of 3 years to the end of 2019. The ACHD center identified 259 congenital cardiac surgery patients who turned 18 between 2004-2016 coincident with the transfer cohort and had surgery between 2004 and 2019. Of the 259, 106 were part of the referral cohort and the remainder were followed elsewhere in the country or were new Canadians.
Environics data identified socioeconomic variables associated with postal address at time of transfer. Failed transfer (FT) was defined as no visit to the ACHD center 3 years after graduation from the pediatric center, lost to follow-up (LTFU) was defined as a gap in care of 5 years or more. Navigation of a cardiac surgical (CS) pathway was defined as having cardiac surgery during the study period of 2004-2019 allowing for a 3 year follow up from the end 2016 as per the definition of transfer.
Continuous variables were summarized as medians and interquartile ranges. Between-group comparisons were evaluated using Wilcoxon rank-sum tests for continuous and Fisher's exact tests for dichotomous and polytomous variables.
Results and conclusions
FT occurred in 11% and LTFU in 26%. There was a 2% overlap between the FT and LTFU groups.
FT was associated with an address with no car access (p=.016), being employed (p=.019), working from home (p=.017), living closer to, or in the same city as the ACHD center (p=.002, .001)
Factors associated with LTFU were an address associated with lower income (p =.001), higher unemployment (p=.018), lower high school graduation (p=.022), no car access (p=.003).
Factors associated with cardiac surgery included an address associated with higher household income (p<.001), high school certificate, college degree, bachelor's degree or diploma, and university degree higher than a bachelors (p=.005, .006, .004, .038), access to a car for travel to work (p<.001), Canadian citizenship (p=.041) and French or English as the primary language in the home (p=.038)
Conclusions
Young adults with adverse socioeconomic factors face barriers in transferring from child to ACHD services, and to maintaining care in adulthood. Patients that have navigated cardiac surgery live in wealthier neighbourhoods with higher education and are more likely to be citizens with a predominance of one of the two official languages.
{"title":"Socioeconomic Barriers for Young Adults with Congenital Heart Disease in Accessing Cardiac Care in a Regional Reference Center","authors":"Jane Heggie , Marjan Jariani , Jodie Beuth , Loretta Tsui Ho , Sara Thorne , Rafa Alonzo-Gonzales , Heather Ross , David Barron","doi":"10.1053/j.jvca.2024.09.051","DOIUrl":"10.1053/j.jvca.2024.09.051","url":null,"abstract":"<div><h3>Objective</h3><div>This study aimed to ascertain socioeconomic factors affecting access to adult congenital cardiac services and adult congenital cardiac surgical services in Ontario.</div></div><div><h3>Design and method</h3><div>Hospital records identified 2232 patients with complex congenital heart disease referred from the regional pediatric cardiac surgery center to the regional adult congenital cardiac disease (ACHD) center 2004-2016 specifically for complex ACHD, with follow up of 3 years to the end of 2019. The ACHD center identified 259 congenital cardiac surgery patients who turned 18 between 2004-2016 coincident with the transfer cohort and had surgery between 2004 and 2019. Of the 259, 106 were part of the referral cohort and the remainder were followed elsewhere in the country or were new Canadians.</div><div>Environics data identified socioeconomic variables associated with postal address at time of transfer. Failed transfer (FT) was defined as no visit to the ACHD center 3 years after graduation from the pediatric center, lost to follow-up (LTFU) was defined as a gap in care of 5 years or more. Navigation of a cardiac surgical (CS) pathway was defined as having cardiac surgery during the study period of 2004-2019 allowing for a 3 year follow up from the end 2016 as per the definition of transfer.</div><div>Continuous variables were summarized as medians and interquartile ranges. Between-group comparisons were evaluated using Wilcoxon rank-sum tests for continuous and Fisher's exact tests for dichotomous and polytomous variables.</div></div><div><h3>Results and conclusions</h3><div>FT occurred in 11% and LTFU in 26%. There was a 2% overlap between the FT and LTFU groups.</div><div>FT was associated with an address with no car access (p=.016), being employed (p=.019), working from home (p=.017), living closer to, or in the same city as the ACHD center (p=.002, .001)</div><div>Factors associated with LTFU were an address associated with lower income (p =.001), higher unemployment (p=.018), lower high school graduation (p=.022), no car access (p=.003).</div><div>Factors associated with cardiac surgery included an address associated with higher household income (p<.001), high school certificate, college degree, bachelor's degree or diploma, and university degree higher than a bachelors (p=.005, .006, .004, .038), access to a car for travel to work (p<.001), Canadian citizenship (p=.041) and French or English as the primary language in the home (p=.038)</div></div><div><h3>Conclusions</h3><div>Young adults with adverse socioeconomic factors face barriers in transferring from child to ACHD services, and to maintaining care in adulthood. Patients that have navigated cardiac surgery live in wealthier neighbourhoods with higher education and are more likely to be citizens with a predominance of one of the two official languages.</div></div>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"38 12","pages":"Pages 25-26"},"PeriodicalIF":2.3,"publicationDate":"2024-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142531545","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-25DOI: 10.1053/j.jvca.2024.09.089
Nishant Kanitkar , Thomas Springthorpe , Luke Costello , Lauren Tully , Martin Yates
Objective
Prevention of common post-operative complications of cardiac surgery necessitates the prescription and early administration of a set ‘bundle’ of medications. Unfortunately, frequent turnover of prescribing staff poses challenges for maintaining consistent practices, leading to delayed administration and an increased risk of complications. Our audit aimed to evaluate the effectiveness of current post-operative prescribing, identify areas for improvement, and implement targeted interventions to enhance compliance with prescribing standards.
Design and method
Three successive audits were undertaken, each encompassing one week of typical cardiothoracic cases in December 2022, July 2023, and December 2023 respectively. Each cycle involved classifying prescribed medications into categories of prescribed/not prescribed and administered/not administered, assessed both pre- and post-ward round. The first cycle assessed baseline prescribing practices, the second implemented computerised prescription bundles and educational interventions for training staff, and the third encompassed visual instructions attached to both the admission pro forma and physical workstations. Prescription compliance was measured as the number of prescribed medications administered by the end of day one post-op as a percentage of the total number of indications. Errors were categorised into erroneously not prescribed and erroneously not administered in the second and third cycles only. Medications that were documented as intentionally held were categorised as compliant.
Results and conclusions
Results
There were 60, 25, and 45 patients included within the first, second and third cycles respectively. Mean (SD) prescription compliance was 79.0 (21.5), 89.1 (9.6) and 89.0 (12.4) per cent respectively. Prescription compliance pre-ward round was 51.8 and 44.9 per cent in the second and third cycles respectively. The second cycle contained 312 indicated prescriptions (versus 507 in the third), of which 6.1 (3.5) per cent were erroneously not prescribed and 5.4 (7.1) per cent were prescribed but erroneously not administered. By the third cycle, all medications were above 80% compliance with the exception of clopidogrel and the day-zero stat dose of pantoprazole.
Conclusion
Targeted interventions including prescriber education and computerised bundles can improve prescribing practices in a high-turnover cardiothoracic unit. Poor compliance with clopidogrel prescribing may be related to unclear post-operative instructions, and pantoprazole to an incorrect default prescription in the medication bundle. Ongoing efforts will focus on maintaining overall prescribing standards, encouraging pre-ward round prescription and administration and addressing specific challenges related to certain medications.
{"title":"IMPROVING POST-OPERATIVE MEDICATION COMPLIANCE IN A HIGH-TURNOVER CARDIOTHORACIC UNIT","authors":"Nishant Kanitkar , Thomas Springthorpe , Luke Costello , Lauren Tully , Martin Yates","doi":"10.1053/j.jvca.2024.09.089","DOIUrl":"10.1053/j.jvca.2024.09.089","url":null,"abstract":"<div><h3>Objective</h3><div>Prevention of common post-operative complications of cardiac surgery necessitates the prescription and early administration of a set ‘bundle’ of medications. Unfortunately, frequent turnover of prescribing staff poses challenges for maintaining consistent practices, leading to delayed administration and an increased risk of complications. Our audit aimed to evaluate the effectiveness of current post-operative prescribing, identify areas for improvement, and implement targeted interventions to enhance compliance with prescribing standards.</div></div><div><h3>Design and method</h3><div>Three successive audits were undertaken, each encompassing one week of typical cardiothoracic cases in December 2022, July 2023, and December 2023 respectively. Each cycle involved classifying prescribed medications into categories of prescribed/not prescribed and administered/not administered, assessed both pre- and post-ward round. The first cycle assessed baseline prescribing practices, the second implemented computerised prescription bundles and educational interventions for training staff, and the third encompassed visual instructions attached to both the admission pro forma and physical workstations. Prescription compliance was measured as the number of prescribed medications administered by the end of day one post-op as a percentage of the total number of indications. Errors were categorised into erroneously not prescribed and erroneously not administered in the second and third cycles only. Medications that were documented as intentionally held were categorised as compliant.</div></div><div><h3>Results and conclusions</h3><div>Results</div><div>There were 60, 25, and 45 patients included within the first, second and third cycles respectively. Mean (SD) prescription compliance was 79.0 (21.5), 89.1 (9.6) and 89.0 (12.4) per cent respectively. Prescription compliance pre-ward round was 51.8 and 44.9 per cent in the second and third cycles respectively. The second cycle contained 312 indicated prescriptions (versus 507 in the third), of which 6.1 (3.5) per cent were erroneously not prescribed and 5.4 (7.1) per cent were prescribed but erroneously not administered. By the third cycle, all medications were above 80% compliance with the exception of clopidogrel and the day-zero stat dose of pantoprazole.</div></div><div><h3>Conclusion</h3><div>Targeted interventions including prescriber education and computerised bundles can improve prescribing practices in a high-turnover cardiothoracic unit. Poor compliance with clopidogrel prescribing may be related to unclear post-operative instructions, and pantoprazole to an incorrect default prescription in the medication bundle. Ongoing efforts will focus on maintaining overall prescribing standards, encouraging pre-ward round prescription and administration and addressing specific challenges related to certain medications.</div></div>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"38 12","pages":"Page 54"},"PeriodicalIF":2.3,"publicationDate":"2024-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142530682","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-25DOI: 10.1053/j.jvca.2024.09.040
BERTRAND ROZEC , PROVENCHERE SOPHIE , COLSON PASCAL , SENARD MARC , GAUDRIOT BAPTISTE , CHOLLEY BERNARD , OUATTARA ALEXANDRE , MAURIAT PHILIPPE , FELLAHI JEAN-LUC
Objective
Withdrawn in the early 2000s, aprotinin marketing authorization was reinstated by the European Medicine Agency with a restrictive indication (isolated coronary artery bypass grafting, iCABG) and pending a safety registry (NAPaR) intended to record the pattern of use of aprotinin and assess patient safety (1). Despite a ¾ off-label use, it was completed without any safety signal (2). Two different dose regimen were used: full-dose (FD) and half-dose (HD) aprotinin. The objective was to compare both efficacy and safety of each dose regimen in cardiac surgery with cardiopulmonary bypass.
Design and method
Between Feb. 2016 and Aug. 2022, 6,730 adult patients received aprotinin across nine European countries and were included in the registry. To reduce biases and to well balance the probability of receiving each aprotinin dose regimen, we built a propensity score (PS) based on preoperative patients’ characteristics: gender, age, BMI, redo surgery, severe renal impairment, active endocarditis, antiplatelet /anticoagulant agents, emergency surgery, and procedure type (on label/off-label). Then, we performed a regression on the PS-Inverse Probability of Treatment Weighting (IPTW) cohort to analyze the outcomes. The primary outcome was the rate of reoperation for bleeding or tamponade. Three safety outcomes were also investigated: in-hospital mortality, major adverse cardiovascular and cerebral events (MACCE) and renal injury.
Results and conclusions
Among the 6,730 patients, 5,359 had a full set of data allowing building the PS. Reoperation was significantly reduced in FD vs. HD aprotinin, whereas renal injury was slightly increased (Table 1). No difference was found on both mortality and MACCE.
In cardiac surgery with cardiopulmonary bypass, the FD regimen of aprotinin was associated with a decrease in postoperative reoperation for bleeding at the expense of a slight increase in renal injury without any other safety risk. A large multicenter randomized trial is mandatory to consolidate these results.
{"title":"EFFICACY AND SAFETY OF APROTININ IN CARDIAC SURGERY: A COMPARISON BETWEEN TWO DOSE REGIMEN (eNAPAR)","authors":"BERTRAND ROZEC , PROVENCHERE SOPHIE , COLSON PASCAL , SENARD MARC , GAUDRIOT BAPTISTE , CHOLLEY BERNARD , OUATTARA ALEXANDRE , MAURIAT PHILIPPE , FELLAHI JEAN-LUC","doi":"10.1053/j.jvca.2024.09.040","DOIUrl":"10.1053/j.jvca.2024.09.040","url":null,"abstract":"<div><h3>Objective</h3><div>Withdrawn in the early 2000s, aprotinin marketing authorization was reinstated by the European Medicine Agency with a restrictive indication (isolated coronary artery bypass grafting, iCABG) and pending a safety registry (NAPaR) intended to record the pattern of use of aprotinin and assess patient safety (1). Despite a ¾ off-label use, it was completed without any safety signal (2). Two different dose regimen were used: full-dose (FD) and half-dose (HD) aprotinin. The objective was to compare both efficacy and safety of each dose regimen in cardiac surgery with cardiopulmonary bypass.</div></div><div><h3>Design and method</h3><div>Between Feb. 2016 and Aug. 2022, 6,730 adult patients received aprotinin across nine European countries and were included in the registry. To reduce biases and to well balance the probability of receiving each aprotinin dose regimen, we built a propensity score (PS) based on preoperative patients’ characteristics: gender, age, BMI, redo surgery, severe renal impairment, active endocarditis, antiplatelet /anticoagulant agents, emergency surgery, and procedure type (on label/off-label). Then, we performed a regression on the PS-Inverse Probability of Treatment Weighting (IPTW) cohort to analyze the outcomes. The primary outcome was the rate of reoperation for bleeding or tamponade. Three safety outcomes were also investigated: in-hospital mortality, major adverse cardiovascular and cerebral events (MACCE) and renal injury.</div></div><div><h3>Results and conclusions</h3><div>Among the 6,730 patients, 5,359 had a full set of data allowing building the PS. Reoperation was significantly reduced in FD vs. HD aprotinin, whereas renal injury was slightly increased (Table 1). No difference was found on both mortality and MACCE.</div><div>In cardiac surgery with cardiopulmonary bypass, the FD regimen of aprotinin was associated with a decrease in postoperative reoperation for bleeding at the expense of a slight increase in renal injury without any other safety risk. A large multicenter randomized trial is mandatory to consolidate these results.</div></div>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"38 12","pages":"Page 17"},"PeriodicalIF":2.3,"publicationDate":"2024-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142531034","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<div><h3>Objective</h3><div>We report a case of a 58-year-old male suffering from primary pulmonary arterial hypertension (PH), Eisenmenger's syndrome (ES) and ischemic heart disease who has already undergone multiple revascularizations and is a candidate for en bloc heart-lung transplantation.</div></div><div><h3>Design and method</h3><div>The patient acceded to our center with pneumonia and consequent worsening of respiratory symptoms and asthenia. The echocardiogram demonstrated a severely dilated and hypokinetic right ventricle with a systolic-diastolic D-shape and massive tricuspid regurgitation besides a dilated and fixed inferior vena cava. Considering the clinical worsening with advanced cardiorespiratory failure and the lability of hemodynamic compensation, hospitalization in cardiac intensive care was proposed. Upon admission, the patient presented a picture of predominantly right-sided SCAI D cardiogenic shock in type I PH and severe hypoxia.</div><div>Initially, the hemodynamic instability was successfully medically managed with epinephrine intravenous (IV) infusion, a combination of multiple pulmonary vasodilators (Milrinone EV, Epoprostenol EV, Treprostinil continuous SC infusion and iNO) and Non-Invasive Ventilation (NIV). The patient was then included in the emergency transplantation list.</div><div>Unfortunately, pneumonia severely worsened the pulmonary oxygenation with subsequent right ventricle de-compensation, increasing the right-to-left shunt and precipitating the cardiorespiratory equilibrium.</div><div>We discussed the possibility of supporting the patient with veno-venous (VV) ECMO, but the RV failure was too severe (TAPSE 11 mm, FAC 20%, PAPs 92 mmHg, CVP 18 mmHg) and unresponsive to maximal medical therapy to allow the venous-venous support adequate effectiveness. Therefore, we decided to assist the patient with an awake femoral-femoral veno-arterial (VA) ECMO bridge-to-transplantation.</div><div>As expected, it was not a simple mechanical circulatory support (MCS) management: the good LV function and the severe RV dilation made it impossible to obtain full drainage of the heart, which continued to eject de-oxygenated blood in ascending aorta. Veno-arterial-venous (VAV) ECMO was considered, but the incomplete RV drainage made it impossible to avoid liver stasis and a VAV configuration was considered inapplicable to manage the Harlequin Syndrome which occurred. Therefore, to improve the oxygenation in the “upper circulation” and, at the same time, to maintain the patient awake and able to prosecute physiotherapy, we assisted the patient with High-Flow Nasal Cannula (HFNC 50 L/min FiO2 100%) connected to an inhaled Nitric Oxide circuit (iNO 20ppm).</div><div>In this way, we managed to assist the patient for 10 days, up to organs arrival, and the the patient was successfully transplanted.</div></div><div><h3>Results and conclusions</h3><div>This case highlights the complexity and still the feasibility of VA ECMO support,
{"title":"VENO-ARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION SUPPORT AS A BRIDGE TO HEART-LUNG TRANSPLANTATION IN A PATIENT AFFECTED BY EINSENMENGER'S SYNDROME COMPLICATED BY PNEUMONIA AND SEVERE RIGHT VENTRICULAR FAILURE","authors":"Anita Ferraro , Matteo Giunta , Cecilia Marasco , Giulia Gamba , Andrea Costamagna , Anna Trompeo , Massimo Boffini , Luca Brazzi","doi":"10.1053/j.jvca.2024.09.078","DOIUrl":"10.1053/j.jvca.2024.09.078","url":null,"abstract":"<div><h3>Objective</h3><div>We report a case of a 58-year-old male suffering from primary pulmonary arterial hypertension (PH), Eisenmenger's syndrome (ES) and ischemic heart disease who has already undergone multiple revascularizations and is a candidate for en bloc heart-lung transplantation.</div></div><div><h3>Design and method</h3><div>The patient acceded to our center with pneumonia and consequent worsening of respiratory symptoms and asthenia. The echocardiogram demonstrated a severely dilated and hypokinetic right ventricle with a systolic-diastolic D-shape and massive tricuspid regurgitation besides a dilated and fixed inferior vena cava. Considering the clinical worsening with advanced cardiorespiratory failure and the lability of hemodynamic compensation, hospitalization in cardiac intensive care was proposed. Upon admission, the patient presented a picture of predominantly right-sided SCAI D cardiogenic shock in type I PH and severe hypoxia.</div><div>Initially, the hemodynamic instability was successfully medically managed with epinephrine intravenous (IV) infusion, a combination of multiple pulmonary vasodilators (Milrinone EV, Epoprostenol EV, Treprostinil continuous SC infusion and iNO) and Non-Invasive Ventilation (NIV). The patient was then included in the emergency transplantation list.</div><div>Unfortunately, pneumonia severely worsened the pulmonary oxygenation with subsequent right ventricle de-compensation, increasing the right-to-left shunt and precipitating the cardiorespiratory equilibrium.</div><div>We discussed the possibility of supporting the patient with veno-venous (VV) ECMO, but the RV failure was too severe (TAPSE 11 mm, FAC 20%, PAPs 92 mmHg, CVP 18 mmHg) and unresponsive to maximal medical therapy to allow the venous-venous support adequate effectiveness. Therefore, we decided to assist the patient with an awake femoral-femoral veno-arterial (VA) ECMO bridge-to-transplantation.</div><div>As expected, it was not a simple mechanical circulatory support (MCS) management: the good LV function and the severe RV dilation made it impossible to obtain full drainage of the heart, which continued to eject de-oxygenated blood in ascending aorta. Veno-arterial-venous (VAV) ECMO was considered, but the incomplete RV drainage made it impossible to avoid liver stasis and a VAV configuration was considered inapplicable to manage the Harlequin Syndrome which occurred. Therefore, to improve the oxygenation in the “upper circulation” and, at the same time, to maintain the patient awake and able to prosecute physiotherapy, we assisted the patient with High-Flow Nasal Cannula (HFNC 50 L/min FiO2 100%) connected to an inhaled Nitric Oxide circuit (iNO 20ppm).</div><div>In this way, we managed to assist the patient for 10 days, up to organs arrival, and the the patient was successfully transplanted.</div></div><div><h3>Results and conclusions</h3><div>This case highlights the complexity and still the feasibility of VA ECMO support, ","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"38 12","pages":"Pages 45-46"},"PeriodicalIF":2.3,"publicationDate":"2024-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142530453","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-25DOI: 10.1053/j.jvca.2024.09.026
Gagan Singh
<div><h3>Objective</h3><div>To audit central venous catheter care in our current practice based upon the current guidelines.</div></div><div><h3>Design and method</h3><div>The data was collected over a period of 15 days during the month of July 2023. All the patients in ITU were assessed at random times and the data regarding care and maintenance of central lines was noted. Bed side nursing staff was kept blind regarding the ongoing audit.</div></div><div><h3>Results and conclusions</h3><div>1. Total number of patients analysed N= 176</div><div>2. Number of central lines N= 229</div><div>3. Total number of lumens N= 799</div><div>4. Total number of lumens in use 63.95% (511/799)</div><div>5. 3-way tap turned OFF to patient (Y/N) 3.7% (130/5)</div><div>6. Blue clips applied when not in use (Y/N) 5.2% (128/7)</div><div>7. Caps missing for the 3 way taps (Y/N) 2.8% (5/171)</div><div>8. Integrity of central line dressing (Y/N) 10.8% (157/19)</div><div>9. Air in infusion bags 0 %</div><div>10. Air-eliminating filter on infusion tubing sets No</div><div>11. Air in line sensor in infusion pump No</div><div>12. Any tubing misconnections No</div><div>13. Any break in the closed system No</div></div><div><h3>Conclusion</h3><div>• The risk of venous air embolism can be reduced by regular education and training of staff, keeping up to date with the current guidelines and re-auditing regularly.</div><div>Recommendations</div><div>1. During insertion</div><div>• All lumens should be flushed and Luer–lock connections with self-sealing valves should be applied.</div><div>• CVP can be raised (to decrease the pressure gradient) by placing the patient in Trendelenburg position. The use of ultrasound can help to assess the degree of hydration and the need for Trendelenburg position.</div><div>• When no guide wire in place, the needle hub should be occluded with thumb.</div><div>• Line should be properly secured to the skin as accidental removal or partial removal can lead to air embolism.</div><div>2. Maintenance and care</div><div>• All connections should be tight, and all unused hubs are closed and locked when not in use.</div><div>• Regular inspection of the catheter for connections, cracks, or broken seals.</div><div>• Syringes should be fully primed and de-aired.</div><div>• Syringes should be kept vertical above the IV connector and not emptied completely.</div><div>• Infusion pumps should have air-in-line sensors for all continuous infusions.</div><div>• Fluid warmers, high volume resuscitation devices and extra-corporeal circuits should have bubble removal /warning systems.</div><div>• Special care during patient transfer or movement as accidental pulling of the catheter can lead to breakage or exposure of proximal orifice of multi-lumen catheter.</div><div>3. Removal</div><div>• The insertion site should be below the level of the heart at the time of removal.</div><div>• CVP can be raised during removal by keeping the patient in a head down or Trendelenburg
{"title":"AUDIT OF CENTRAL VENOUS CATHETER CARE AND MAINTENANCE IN A CARDIAC SURGERY UNIT","authors":"Gagan Singh","doi":"10.1053/j.jvca.2024.09.026","DOIUrl":"10.1053/j.jvca.2024.09.026","url":null,"abstract":"<div><h3>Objective</h3><div>To audit central venous catheter care in our current practice based upon the current guidelines.</div></div><div><h3>Design and method</h3><div>The data was collected over a period of 15 days during the month of July 2023. All the patients in ITU were assessed at random times and the data regarding care and maintenance of central lines was noted. Bed side nursing staff was kept blind regarding the ongoing audit.</div></div><div><h3>Results and conclusions</h3><div>1. Total number of patients analysed N= 176</div><div>2. Number of central lines N= 229</div><div>3. Total number of lumens N= 799</div><div>4. Total number of lumens in use 63.95% (511/799)</div><div>5. 3-way tap turned OFF to patient (Y/N) 3.7% (130/5)</div><div>6. Blue clips applied when not in use (Y/N) 5.2% (128/7)</div><div>7. Caps missing for the 3 way taps (Y/N) 2.8% (5/171)</div><div>8. Integrity of central line dressing (Y/N) 10.8% (157/19)</div><div>9. Air in infusion bags 0 %</div><div>10. Air-eliminating filter on infusion tubing sets No</div><div>11. Air in line sensor in infusion pump No</div><div>12. Any tubing misconnections No</div><div>13. Any break in the closed system No</div></div><div><h3>Conclusion</h3><div>• The risk of venous air embolism can be reduced by regular education and training of staff, keeping up to date with the current guidelines and re-auditing regularly.</div><div>Recommendations</div><div>1. During insertion</div><div>• All lumens should be flushed and Luer–lock connections with self-sealing valves should be applied.</div><div>• CVP can be raised (to decrease the pressure gradient) by placing the patient in Trendelenburg position. The use of ultrasound can help to assess the degree of hydration and the need for Trendelenburg position.</div><div>• When no guide wire in place, the needle hub should be occluded with thumb.</div><div>• Line should be properly secured to the skin as accidental removal or partial removal can lead to air embolism.</div><div>2. Maintenance and care</div><div>• All connections should be tight, and all unused hubs are closed and locked when not in use.</div><div>• Regular inspection of the catheter for connections, cracks, or broken seals.</div><div>• Syringes should be fully primed and de-aired.</div><div>• Syringes should be kept vertical above the IV connector and not emptied completely.</div><div>• Infusion pumps should have air-in-line sensors for all continuous infusions.</div><div>• Fluid warmers, high volume resuscitation devices and extra-corporeal circuits should have bubble removal /warning systems.</div><div>• Special care during patient transfer or movement as accidental pulling of the catheter can lead to breakage or exposure of proximal orifice of multi-lumen catheter.</div><div>3. Removal</div><div>• The insertion site should be below the level of the heart at the time of removal.</div><div>• CVP can be raised during removal by keeping the patient in a head down or Trendelenburg","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"38 12","pages":"Pages 6-7"},"PeriodicalIF":2.3,"publicationDate":"2024-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142530515","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A 32 year old male patient with history of IV drug abuse with heavy alcohol intake presented to the hospital with high fever, rigors, shortness of breath and productive cough. Physical examination revealed malnutrition, diffuse petechial lesions and significant peripheral edema. Echocardiographic evaluation revealed 3.4 × 2.9 cm vegetation attached to all 3 leaflets of Tricuspid Valve with CTPA scan suggestive of pulmonary embolism to left lower lobe.
Design and method
Our team optimised patient from haematological, microbiological, nutritional and psychological aspect for 21 days. Multidisciplinary team decided for a surgical intervention as a lifesaving procedure in this complex situation with high risk. Despite sequential echo assessment prior to the day of surgery incidental finding on Intraoperative TOE assessment was a new vegetation on Non coronary and left coronary cusp with mild to mod Aortic regurgitation. Tricuspid valve was replaced with bio prosthetic valve and aortic valve vegetation and perforation was repaired with a small pericardial strip.
In the post-operative period patient was haemodynamically stable on minimum inotropic support. He required CVVH Support for 2 days. Full recovery was achieved in next 7 days and patient was discharged home.
Results and conclusions
Discussion-Infective endocarditis with pulmonary embolism, anaemia, thrombocytopenia, coagulopathy and immunological dysregulation made our patient challenging one to manage . We emphasise on multidisciplinary approach in managing and optimising such complex case prior to surgery along with the importance of peri-operative transoesophageal echocardiography in the decision making process which has lead us to a successful outcome.
{"title":"CASE REPORT - A COMPLEX CASE OF INFECTIVE ENDOCARDITIS, PULMONARY EMBOLISM.","authors":"Ketki Deshmukh , Mariarita Maccaroni , Hannah Yonis , Youssef Abouelela","doi":"10.1053/j.jvca.2024.09.039","DOIUrl":"10.1053/j.jvca.2024.09.039","url":null,"abstract":"<div><h3>Objective</h3><div>A 32 year old male patient with history of IV drug abuse with heavy alcohol intake presented to the hospital with high fever, rigors, shortness of breath and productive cough. Physical examination revealed malnutrition, diffuse petechial lesions and significant peripheral edema. Echocardiographic evaluation revealed 3.4 × 2.9 cm vegetation attached to all 3 leaflets of Tricuspid Valve with CTPA scan suggestive of pulmonary embolism to left lower lobe.</div></div><div><h3>Design and method</h3><div>Our team optimised patient from haematological, microbiological, nutritional and psychological aspect for 21 days. Multidisciplinary team decided for a surgical intervention as a lifesaving procedure in this complex situation with high risk. Despite sequential echo assessment prior to the day of surgery incidental finding on Intraoperative TOE assessment was a new vegetation on Non coronary and left coronary cusp with mild to mod Aortic regurgitation. Tricuspid valve was replaced with bio prosthetic valve and aortic valve vegetation and perforation was repaired with a small pericardial strip.</div><div>In the post-operative period patient was haemodynamically stable on minimum inotropic support. He required CVVH Support for 2 days. Full recovery was achieved in next 7 days and patient was discharged home.</div></div><div><h3>Results and conclusions</h3><div>Discussion-Infective endocarditis with pulmonary embolism, anaemia, thrombocytopenia, coagulopathy and immunological dysregulation made our patient challenging one to manage . We emphasise on multidisciplinary approach in managing and optimising such complex case prior to surgery along with the importance of peri-operative transoesophageal echocardiography in the decision making process which has lead us to a successful outcome.</div></div>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":"38 12","pages":"Page 16"},"PeriodicalIF":2.3,"publicationDate":"2024-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142531033","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：