Journal of cardiothoracic and vascular anesthesia最新文献

Minimally invasive cardiac surgery (MICS) often leads to severe postoperative pain. At present, multimodal analgesia schemes for MICS have attracted much attention, and the application of various chest wall analgesia techniques is becoming increasingly widespread. However, research on anesthesia techniques for postoperative pain management in MICS remains relatively limited at present. We searched for relevant literature and summarized recent related research in eight MICS techniques, including thoracic epidural anesthesia, spinal anesthesia, thoracic paravertebral plane block, erector spinae plane block, serratus anterior plane block, pectoral nerve block, intercostal nerve block, and parasternal block. This article provides an overview of the anatomy and procedures involved in these analgesic techniques, their mechanisms of action, and the latest clinical trial evidence. It also evaluates their progress in MICS, compares their advantages and disadvantages, and discusses practical challenges.

Quality improvement (QI) in medicine serves as the cornerstone of best practices. It enhances medical care by maximizing safety and efficiency while minimizing errors and waste. For a QI initiative to succeed it requires careful strategizing and effective change management plans, including the application of established QI methodologies to ensure sustainable success. Today, QI processes are integral to foundational learning for students and trainees, as well as for maintaining board certification for anesthesiologists. However, many anesthesiologists, including those actively pursuing QI efforts, are often unaware of these methodologies and their associated tools. A successful QI program that leads to sustainable improvement in outcomes relies on methodologies that assess the true current state, define value-added measures, evaluate defects and opportunities for enhancement, implement solutions through a robust change management plan, and ensure the sustainability of the process. This document provides a concise summary of methodologies that can be effectively led and executed by process improvement teams. We examine these methods within the context of cardiac anesthesiology, highlighting one institution's experience in reducing surgical site infections following coronary artery bypass graft surgery. However, these principles are applicable to various healthcare situations and beyond.

Although cardiovascular anesthesiologists play a role in the multidisciplinary heart team, they are generally not involved prior to the diagnosis of coronary artery disease. This work was designed to broadly cover the factors influencing decision-making when proceeding with coronary angiography in a patient with suspected coronary artery disease. The authors cover the principles, rationale, benefits, and downsides of common tests involved.

Objective: To determine the impact of hematocrit on adverse neurologic events after acute type A aortic dissection (ATAAD) repair under deep hypothermic circulatory arrest.

Design: Retrospective study of consecutive aortic surgeries from 2010 to 2021.

Setting: Single institution.

Participants: Patients undergoing open ATAAD repairs, excluding those with preoperative cerebral malperfusion syndrome (defined as neurologic deficit with radiographic evidence of cerebral branch vessel malperfusion).

Interventions: Patients were split into three groups: normal, low, and high hematocrit.

Measurements & main results: A total of 527 patients were included, of which 355 (67.3%) had normal hematocrit, 143 (27.1%) had low hematocrit, and 29 (5.5%) had high hematocrit. Overall, 20 (3.8%) patients had a postoperative stroke, which was comparable across groups (p = 0.59). Patients with normal hematocrit had lower in-hospital mortality (p = 0.02) and lower transfusion rates (p < 0.001), while re-exploration for bleeding was similar across groups (p = 0.68). After multivariable adjustment, there was no association between hematocrit and postoperative stroke (odds ratio [OR]: 1.00, 95% confidence interval [CI]: 0.99, 1.00, p = 0.79). Compared with normal hematocrit, there was no association between low hematocrit (OR: 1.59, 95% CI: 0.77, 3.28, p = 0.21) or high hematocrit (OR: 2.48, 95% CI: 0.74, 8.29, p = 0.14) and in-hospital mortality.

Conclusions: Preoperative hematocrit was not associated with stroke or mortality after ATAAD repair. The rheologic effect of hematocrit on cerebral perfusion under deep hypothermia may be minimal.

Objective(s): Previous literature suggested the advantage of combined short-long axis (CSLA) technique to avoid posterior wall puncture during internal jugular vein (IJV) cannulation. The purpose of this study is to define the best ultrasound-guided IJV cannulation technique regarding the success rate in the first trial of insertion, time to successful central line placement, number of attempts, procedural complications, and operator satisfaction.

Design: Single-blinded, prospective randomized clinical trial.

Setting: Elective cardiac surgeries in a tertiary care center.

Participants: One hundred seventy-eight elective cardiac surgery patients older than 18 years accepted to participate in the study and signed the informed consent.

Interventions: Patients were randomized into two equal groups: medial oblique axis and CSLA. During the technique, vein dimensions, patient characteristics, technique duration, posterior wall puncture, number of attempts, complications, and operator satisfaction were documented.

Measurements and main results: Apart from body weight, there were no significant differences in baseline characteristics between both groups. Compared to the CSLA, the medial oblique approach showed significantly higher first-trial success rate (92.1% v 75.0%, p = 0.002), less time for successful insertion (mean ± SD, 60.9 ± 54.9 seconds v 110.7 ± 101.6 seconds, p < 0.001), accomplishment with fewer attempts (mean ± SD, 1.09 ± 0.28 v 1.44 ± 0.81, p < 0.001), and higher operator satisfaction (mean ± SD, 4.45 ± 0.92 v 3.46 ± 1.32, p < 0.001). No significant difference in complications, including posterior wall puncture (p = 0.469), was noted between both groups.

Conclusions: This study demonstrated the medial oblique axis approach was superior to the CSLA approach regarding first-trial success rate, time to successful line placement, number of attempts, and operator satisfaction when used during elective cannulation of the IJV. However, regarding the incidence of complications, there was no advantage of one approach over the other. Further research is needed to confirm these results among specific groups of operators, with awake patients and in emergent situations.

Objectives: This systematic review aims to tabulate and analyze the published literature regarding pulmonary artery catheter (PAC) entrapment during cardiac surgery.

Design: Systematic review.

Setting: Case reports and series.

Participants: Adults undergoing cardiac surgery.

Interventions: None.

Measurements and main results: 223 distinct incidents of PAC entrapment were published across 77 case reports and 3 retrospective studies. The reported incidence of an entrapped PAC was 137/200,831 (0.068%, 95% confidence interval: 0.067%, 0.069%). Reported PAC entrapment was most seen in the setting of mitral valve surgery and was not discovered until the postoperative period in 77% of cases. Inadvertent fixation to cardiac structures was the most common mechanism of PAC entrapment. A total of 75% of patients with an entrapped PAC required an immediate redo sternotomy for PAC retrieval. After PAC retrieval, these patients still had longer hospital length of stay compared with the Society of Thoracic Surgeons Adult Cardiac Surgery Database averages.

Conclusions: Although PAC entrapment during cardiac surgery is rare, an entrapped PAC increases patient morbidity, delays recovery, and increases hospital length of stay. Surgeons and anesthesiologists are encouraged to be attentive to PAC entrapment before chest closure.

Objective: To compare the effects of fluid bolus therapy (FBT) with 20% albumin to crystalloid FBT on the incidence of cardiac surgery-associated acute kidney injury (CSA-AKI) and its severity and duration.

Design: Secondary analysis of the multicenter, parallel-group, open-label, randomized HAS FLAIR-II trial.

Setting: Six intensive care units.

Participants: Patients who required clinician-determined FBT after cardiac surgery requiring cardiopulmonary bypass.

Interventions: Patients were randomized to receive FBT with 20% albumin (up to 400 mL/day) or crystalloid fluid for all FBTs in the intensive care unit.

Measurements and main results: A total of 452 patients were included in the modified intention-to-treat population (224 in the 20% albumin group and 228 in the crystalloid group). AKI occurred in 54 (24%) patients in the 20% albumin group and 50 (22%) in the crystalloid group (odds ratio: 1.13, 95% confidence interval [CI]: 0.73 to 1.76). However, in patients who developed stages 2 and 3 AKI, those allocated to 20% albumin had a significantly lower median time-weighted average (TWA) creatinine: 144 µmol/L (interquartile range [IQR]: 109 to 162) versus 254 µmol/L (IQR: 182 to 294) than the crystalloid group (difference -105 µmol/L, [95% CI -170 to -41], p = 0.003) and a lower peak serum creatinine (-110 µmol/L [-189 to -32], p = 0.01). The reduced TWA creatinine in the 20% albumin group was seen in patients with both a low (p = 0.04) and normal preoperative serum albumin concentration (p < 0.001).

Conclusions: FBT with 20% albumin compared with crystalloid-based regimen did not reduce the occurrence of AKI in patients after cardiac surgery. However, it reduced the severity and duration of stages 2 and 3 AKI.