Journal of cardiothoracic and vascular anesthesia最新文献

Objectives: To determine whether preoperative platelet (PLT) count independently predicts in-hospital mortality in patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Design: Secondary analysis of a prospectively maintained institutional registry.

Setting: A single academic medical center.

Participants: A total of 582 adult patients were supported with VA-ECMO between January 2015 and December 2019.

Interventions: None.

Measurements and main results: Pre-cannulation PLT counts were used to categorize patients into four groups: G1, 100 × 10⁹/L or less; G2, greater than 100 × 10⁹/L to 200 × 10⁹/L; G3, greater than 200 × 10⁹/L to 300 × 10⁹/L; and G4, greater than 300 × 10⁹/L. The primary outcome was in-hospital mortality. Multivariable logistic regression, curve fitting analysis, and interaction analyses were performed. After adjustment, each 10 × 10⁹/L increase in PLT count was associated with a 4% lower odds of in-hospital mortality (adjusted odds ratio, 0.96; 95% confidence interval, 0.94-0.98; p = 0.0002). Compared with G1, the adjusted odds ratios for mortality were 0.51 for G2, 0.32 for G3, and 0.28 for G4 (p for trend < 0.0001). Subgroup analyses revealed significant interactions with diabetes and preoperative anticoagulation (p < 0.05), with a more pronounced predictive value in anticoagulated patients.

Conclusions: A lower preoperative PLT count is independently associated with increased in-hospital mortality in VA-ECMO patients. This parameter may aid in early risk stratification and help identify patients who could benefit from closer monitoring of hemostatic parameters.

Objectives: Assessing fluid responsiveness using the passive leg raise test is crucial for optimizing cardiac preload and maintaining cardiac output. Patients recovering from coronary artery bypass graft surgery (CABG) are at risk of hemodynamic instability. Electrical Cardiometry has been compared with the pulmonary artery thermodilution method for measuring cardiac output and other hemodynamic parameters in various clinical settings. This study was designed to compare the accuracy of Electrical Cardiometry with the thermodilution method in measuring hemodynamic changes in patients after off-pump CABG surgery. Additionally, the effect of the passive leg raise test on fluid responsiveness was assessed.

Design: Prospective, observational, comparative study.

Setting: Tertiary care cardiac center.

Participants: Thirty patients who underwent off-pump CABG surgery were evaluated in the cardiac surgical intensive care unit.

Interventions: Simultaneous measurements of cardiac output and other hemodynamic indices were taken using both pulmonary artery thermodilution and Electrical Cardiometry methods at three predefined time points.

Measurements and main results: Moderate correlations (r = 0.413 and 0.523) were found between the two methods, both before and after the passive leg raise test. Bland-Altman analysis revealed a bias of 1.68 L/min, a precision of 0.533 L/min, and wide limits of agreement (-2.55 to -0.8 L/min). The percentage errors between the methods were 38.62% and 34.24% before and after the passive leg raise test, respectively. The passive leg raise did not significantly predict fluid responsiveness in either intubated or extubated patients. Moreover, Electrical Cardiometry consistently reported higher values.

Conclusions: The agreement between thermodilution-derived parameters and Electrical Cardiometry-derived hemodynamic indices was clinically unacceptable; therefore, these two techniques cannot be used interchangeably in cardiac surgical patients.

Fluid management in patients with cardiovascular disease and after cardiac surgery remains clinically challenging because of the interplay of surgical trauma, effects of anesthesia, and cardiopulmonary bypass. Both restrictive and liberal fluid management strategies are associated with adverse outcomes. At the same time, current methods for assessing hydration status are limited by invasiveness, operator dependence, or poor reliability. Bioelectrical impedance analysis (BIA) offers a rapid, noninvasive, and cost-effective alternative for evaluating hydration and body composition. Through the measurement of resistance and reactance, BIA provides estimations of total, intracellular, and extracellular water, as well as the degree of overhydration, using BIA-derived indices. Bioelectrical impedance vector analysis and phase angle provide further insights into hydration status, cellular integrity, and prognosis. Evidence supports the value of BIA for detecting overhydration, monitoring decongestion, and predicting outcomes such as mortality, rehospitalization, and cardiac cachexia in congenital and chronic heart failure. In acute heart failure, BIA-derived indices are associated with biomarkers, imaging, and clinical improvements while adding diagnostic and prognostic value. In cardiac surgery, perioperative BIA detects shifts in fluid compartments, helps predict postoperative complications, and is associated with intensive care unit and overall hospital length of stay, as well as mechanical ventilation duration. Despite concerns regarding interference with implantable cardiac devices, multiple studies demonstrate its safety in this population. Overall, BIA represents a promising adjunct to conventional monitoring, offering objective and dynamic fluid assessment that may improve individualized management and risk assessment in cardiovascular care.

Objectives: To describe the incidence and baseline characteristics of upper gastrointestinal bleeding (UGIB) within 3 and 7 days of transesophageal echocardiography (TEE) in transcatheter structural heart interventions (SHIs) and cardiac surgery using uniform diagnostic criteria.

Design: A descriptive epidemiological study using an administrative database.

Setting: JMDC hospital database between April 2014 and December 2023.

Participants: Patients aged ≥18 years who underwent SHI (n = 5,758) or cardiac surgery (n = 32,035) with same-day TEE. The exclusion criteria were multiple SHI procedures; combined SHI with cardiovascular surgery; UGIB, mechanical circulatory support, or prior TEE within 7 days preoperatively; and missing anesthesia duration data.

Interventions: None.

Measurements and main results: The incidence proportion of UGIB within 3 days postoperatively was comparable between SHI and cardiac surgery cohorts (0.17%; 95% CI, 0.09%-0.32% v 0.18%; 95% CI, 0.14%-0.24%). Among patients with UGIB by day 7, 48% (10/21) in SHI and 57% (59/104) in cardiac surgery presented within 3 days. In-hospital mortality was higher with UGIB within 3 days than without UGIB in both the SHI (20.0% v 1.3%) and cardiac surgery (8.5% v 4.5%) cohorts. Prolonged duration of anesthesia was associated with increased UGIB in both groups. Additional factors associated with UGIB differed by procedure type.

Conclusions: Using identical diagnostic criteria, this study demonstrates similar incidence proportions of UGIB in the SHI and cardiac surgery cohorts, with approximately half of cases presenting within 3 days. The increased mortality observed in both groups underscores the need for careful monitoring for UGIB.

Objectives: This non-inferiority trial compared intravenous esketamine with erector spinae plane block (ESPB) for postoperative recovery quality and analgesic efficacy in patients undergoing video-assisted thoracoscopic surgery (VATS).

Design: Randomized controlled non-inferiority study.

Setting: Single-center, university hospital.

Participants: One hundred twelve patients undergoing VATS.

Interventions: The esketamine group received intravenous esketamine (0.25-mg/kg bolus + 0.25-mg/kg/h infusion) combined with a sham ESPB (25 mL of saline solution). The ESPB group received active ESPB (25 mL of 0.375% ropivacaine) plus intravenous saline solution.

Measurements and main results: Outcomes included 15-item quality of recovery (Quality of Recovery-15 [QoR-15]) scores, postoperative pain scores, Hospital Anxiety and Depression Scale (HADS) scores, and perioperative hemodynamic changes. The differences in the QoR-15 scores between the groups on postoperative day 1 (mean difference, 1.0; 95% confidence interval [CI], -2.9 to 4.8; p = 0.622) and postoperative day 2 (mean difference, 0.4; 95% CI, -3.4 to 4.3; p = 0.833) met the non-inferiority criterion (-6 points). The ESPB group showed significantly lower pain scores during coughing at 4 hours (p = 0.026) and 8 hours (p = 0.006) postoperatively. The esketamine group had lower HADS scores and a lower incidence of hypotension.

Conclusions: Intravenous esketamine provides postoperative recovery quality that is non-inferior to ESPB after VATS, primarily because of its beneficial effects on mood, which compensates for its weaker early analgesia. Thus, esketamine may serve not as a direct analgesic substitute for ESPB, but as a rescue option when ESPB is not feasible, or as an analgesic adjunct with anxiolytic and antidepressant effects.

Objectives: To evaluate the association between intraoperative indexed oxygen delivery (DO₂i) during cardiopulmonary bypass (CPB) and postoperative outcomes in patients undergoing reoperative cardiac surgery.

Design: Retrospective cohort study.

Setting: A tertiary academic cardiac surgery center.

Participants: A total of 343 patients who underwent reoperative cardiac procedures between January 2011 and January 2021.

Interventions: Patients were stratified by the median DO₂i threshold predictive of in-hospital mortality, identified using Youden's Index.

Measurements and main results: Median DO₂i was 300.8 ± 52.3 mL/min/m². In-hospital mortality was 14.6%. A median DO₂i <289.4 mL/min/m² predicted mortality (area under the curve = 0.756, sensitivity 78%, specificity 64%). Multivariable analysis showed that each 1 mL/min/m² decrease in DO₂i increased mortality risk by 1.6% (odds ratio [OR] 1.016, 95% confidence interval [CI] 1.007-1.024). DO₂i below the threshold was associated with a fourfold higher mortality risk (OR 4.12, 95% CI 1.18-9.49). After inverse-probability-of-treatment weighting, patients with low DO₂i had higher mortality (21.6% v 6.6%; p < 0.001), acute kidney injury (p = 0.042), cardiac morbidity (51.1% v 38.5%; p < 0.001), and prolonged ventilation (14.3% v 8.3%; p = 0.015).

Conclusions: Reduced intraoperative DO₂i was independently associated with increased risk of mortality and major morbidity following reoperative cardiac surgery. Incorporating continuous DO₂i monitoring and optimization into CPB management may improve outcomes in this high-risk population.