Seminars in Cardiothoracic and Vascular Anesthesia最新文献

Background: In cardiac surgery, protamine is used to reverse the effects of heparin after separation from cardiopulmonary bypass (CPB). Excess of protamine has been demonstrated to cause platelet dysfunction and coagulopathy. A protamin-to-heparin ratio of less than 1:1 is endorsed by the European guidelines. Pharmacokinetic models of heparin decay have been proposed to allow for individualised dosing rather than fixed ratios. The objective of this study is to compare three such models in a large cohort of simulated patients. Methods: The doses of protamine were calculated using the models proposed by Meesters et al., Miles et al., and in the PRODOSE trial. We employed data from the VitalDB database to calculate the doses of heparin and randomly generated time intervals in-between. We tested two scenarios: with an initial dose and heparin added to the priming solution, and where additional heparin was administered over the course of the CPB. Results: We simulated 1166 cases with a mean interval between heparin and protamine administration of 90 ± 22 minutes in the first and 140 ± 28 minutes in the second scenario. The PRODOSE formula produced the lowest protamine-to-heparin ratios, followed by Meesters' formula in the first scenario (0.68:1 vs 0.72:1, P < .001) and the Miles' formula in the second scenario (0.55:1 vs 0.62:1, P < .001). Conclusion: The doses calculated with pharmacokinetic models exhibited discrepancies of up to 13.6%. While confirmation of complete reversal with alternative methods is necessary, the models facilitate a more individualised dose selection than the fixed ratios proposed in the literature.

Background: Etomidate has minimal cardiovascular depressant effects at the cost of endogenous cortisol production suppression, whereas propofol has vasodilatory and myocardial depressant properties, which may be poorly tolerated in the cardiac surgical population. To offset the undesirable effects of propofol, ketamine can be co-administered to harness its cardiac stimulatory properties. Though etomidate is a more cardio-stable induction agent than propofol, its superiority over the combination of propofol and ketamine-colloquially known as "ketofol"-remains controversial. Methods: United States National Library of Medicine Database (MEDLINE) and Excerpta Medica Database (EMBASE) were searched for randomized controlled trials published since 2010 comparing etomidate and ketofol relative to propofol alone for induction of general anesthesia for coronary artery bypass grafting (CABG). Key data collected included post-induction nadir mean arterial pressure (MAP), heart rate, cardiac index, systemic vascular resistance (SVR), and serum cortisol levels at 24 hours postoperatively. Variables were compared by calculating a weighted mean difference (WMD) [95% confidence interval (CI)]. Results: This analysis included 15 studies (1125 patients). Anesthetic induction with etomidate was associated with a higher nadir MAP and SVR compared to ketofol during the peri-induction period by WMD 4.77 mmHg [95% CI 0.31, 9.23, P = 0.04] and 42.22 dynes/cm⁵ [95% CI 0.49-83.94, P = 0.05]. However, there was no difference in the frequency of needed boluses of vasopressors or fluids for peri-induction hypotension. Conclusions: Though etomidate appears to provide a superior hemodynamic profile compared to ketofol, both agents require similar degrees of clinical response to hypotension during the induction of CABG surgery patients.

Categorical variables are an integral part of clinical research. This article introduces their uses and most common analyses for clinicians seeking additional statistics exposure to more critically engage with literature and refine their own research endeavors. We describe and demonstrate the two most common tests of association for categorical variables: chi-square and Fisher's exact tests, along with their underlying logic, result interpretations, and relative strengths and weaknesses. We also introduce and explain two of the most common measurements of effect size in analyses of categorical outcomes: relative risk (RR) and odds ratio (OR).

Purpose: Acquired broncho-esophageal fistula (BEF) presents significant challenges in perioperative anesthesia management, especially when direct repair is not feasible. This case report highlights the anesthesia management strategies used during endoscopic submucosal dissection (ESD), an indirect repair method for BEF, focusing on airway preservation and minimizing intraoperative complications. Result: A 64-year-old male with BEF caused by small cell lung cancer underwent ESD. Anesthesia management focused on preserving spontaneous breathing and preventing air leaks through continuous endotracheal aspiration. A double-lumen tracheal tube was used to achieve selective lung ventilation, and recruitment maneuvers were performed postoperatively to improve lung function. The surgery was successfully completed without significant adverse effects, and postoperative follow-up showed improvement in the patient's condition. Conclusion: ESD represents a viable option for the indirect repair of BEF in patients unsuitable for direct surgical repair. Perioperative anesthetic strategies, such as spontaneous breathing preservation and continuous airway suction, may reduce complications. This case highlights the importance of a tailored, multidisciplinary approach in managing complex thoracic surgical cases.

Intraoperative acute pulmonary embolism (PE) is a rare and life-threatening event with symptoms such as pleuritic chest pain, shortness of breath, and anxiety, which are easily masked by general anesthesia. To diagnose PE in a patient under general anesthesia, anesthesiologists must rely on alternative data points such as hypoxia, decreased end-tidal carbon dioxide (ETCO2), tachycardia, electrocardiogram changes, and intraoperative echocardiography. We present a case of acute intraoperative massive PE in a patient undergoing posterior spinal fusion. We discuss the management of acute perioperative PE, focusing on surgical risk, bleeding potential with thrombolytic therapies and anticoagulation, recent advances in catheter-based therapies, and the role of Pulmonary Embolism Response Teams (PERTs) in the assessment and perioperative management of high-risk patients.

Perioperative opioid-related adverse drug events have been associated with increased length of hospitalization, higher costs, and increased patient mortality. Consequently, alternative means of analgesia, which may mitigate these risks, are important to explore. Peripheral nerve blocks (PNBs), including transversus abdominis block (TAPB), quadratus lumborum block (QLB), and erector spinae plane block (ESPB), have been used to reduce opioid requirements after renal transplant and donor nephrectomy. TAPB is most frequently studied; however, few studies compare approaches. PubMed was queried on July 13th 2022 and again on April 14th 2024 for studies on the use of regional analgesia for kidney transplantation and donor nephrectomy. This review surveys 29 publications that empirically investigated use of a PNB alone or as part of enhanced recovery after surgery (ERAS) protocols for patients undergoing renal transplant or donor nephrectomy, summarizing the evidence for each PNB. We found that TAPB was the most studied technique, and that few studies compared analgesic techniques. Overall, this body of research supports the use of TAPB to reduce pain and opioid requirements in the postoperative period after renal transplantation. Fewer studies support the use of TAPB following donor nephrectomy or the use of other PNBs for either procedure. Future studies may further investigate the use of TAPB after donor nephrectomy, compare various PNBs to TAPB, and investigate long-term outcomes.

Background: Dexmedetomidine, a highly selective α2-adrenergic receptor agonist, may help mitigate postoperative complications in patients undergoing aortic vascular surgery. Methodology: A comprehensive search was conducted across PubMed, the Cochrane Library, and Embase to identify studies assessing the efficacy and safety of dexmedetomidine compared with placebo in patients undergoing aortic vascular surgery. A random effects meta-analysis was performed with R version 4.4.1 using the "meta" package. Results: Our analysis included eleven studies, comprising eight RCTs and three cohort studies, with a combined total of 1731 patients. The results showed that dexmedetomidine significantly reduced acute kidney injury (OR 0.49, 95% CI 0.25 to 0.98), ICU length of stay (MD -0.25 days, 95% CI -0.47 to -0.02), postoperative pulmonary complications (OR 0.55, 95% CI 0.32 to 0.94), and CRP levels 24 h post-surgery (MD -24.73 mg/L, 95% CI -46.29 to -3.16) compared to the control group. The length of hospital stay (MD -0.87 days, 95% CI -2.57 to 1.01), postoperative delirium (OR 0.78, 95% CI 0.43 to 1.42), and in-hospital mortality (OR 0.57, 95% CI 0.29 to 1.12) were not significantly different between the two groups. Conclusion: In patients undergoing aortic vascular surgery, dexmedetomidine administration is associated with reduced acute kidney injury, length of ICU stay, postoperative pulmonary complications, and CRP levels 24 h post-surgery.

Objective: Postoperative atrial fibrillation (POAF) occurs in 20%-40% of patients following coronary artery bypass grafting (CABG), contributing to significant morbidity. POAF is linked to elevated catecholamines, oxidative stress, and inflammatory mediators. Dexmedetomidine, a centrally acting alpha-2 agonist with sympatholytic and anti-inflammatory effects, and hydrocortisone, which suppresses inflammatory mediators, may reduce the incidence of POAF. Methods: A prospective, double-blind randomized controlled trial was conducted on 248 patients undergoing elective on-pump CABG at Ain Shams University Hospital. Patients were randomized into 2 groups: the Treatment Group received dexmedetomidine and hydrocortisone, and the Placebo Group received standard care. The primary endpoint was the occurrence of POAF within 7 days postoperatively. Results: All 248 patients (124 per group) completed the study. The combined use of dexmedetomidine and hydrocortisone reduced POAF incidence (4.8% vs 12.9%). ICU and hospital length of stay were also shorter in the Treatment Group (2.77 ± 1.12 vs 3.16 ± 1.34 days, P = .012, and 6.63 ± 1.56 vs 7.11 ± 2 days, P = .035, respectively). No differences in hypotension, bradycardia, or wound infections were observed. Hyperglycemia, defined as blood glucose >180 mg/dl, occurred in 8.1% of the Treatment Group and 6.5% of the Placebo Group. Conclusion: Combining dexmedetomidine and hydrocortisone effectively reduces POAF incidence after CABG, with manageable side effects. Multicenter trials are warranted to confirm these findings. Date and Number of IRB Approval and Clinical Trial Registry Number. Ain Shams University Protocol Record (FMASU R 261/2022), ClinicalTrials.gov Identifier: NCT05674253.