Seminars in Cardiothoracic and Vascular Anesthesia最新文献

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.

Background: The novel method of non-invasive right ventricular (RV) myocardial work (MW) analysis provides a load-independent assessment of RV function by combining myocardial strain with loading conditions. However, its use has not been well described in the perioperative setting to date. We aimed to evaluate the feasibility of assessing RV MW, and to describe the perioperative course of this new technique. Methods: In this retrospective study, patients scheduled for LVAD surgery were evaluated for feasibility of RV MW analysis. Preoperative (T1) and postoperative (T2) transthoracic echocardiography (TTE) included the assessment of conventional echocardiographic measurements, myocardial strain, global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) for the evaluation of RV function. Results: Ten patients had complete TTE data available for RV MW analysis, which indicated significant reduction of effective and ineffective RV MW (GWI, 212 mmHg% (IQR 128; 266) v 96 mmHg% (IQR 63; 150), P = 0.02; GCW, 331 mmHg% (IQR 263; 476) v 198 mmHg% (IQR 136; 274), P < 0.01; GWW, 171 mmHg% (IQR 102; 243) v 98 mmHg% (IQR 48; 153), P = 0.04), while GWE remained stable (69% (IQR 37; 78) v 64% (IQR 61; 78), P = 0.26) after LVAD implantation. Conventional parameters were not able to detect these changes. Moreover, there were different trends of RV MW indices in patients with and without postimplant RV failure. Conclusion: This study demonstrates that non-invasive RV MW assessment is feasible in the perioperative setting of LVAD implantation and provides valuable insights into RV function that are not captured by conventional echocardiographic methods. Further research is warranted to validate these findings.

Introduction: Postoperative atrial fibrillation (POAF) after cardiac surgery is associated with higher morbidity and mortality. This paper presents several studies that conclude the presence of an aberrant p-terminal force vector in lead V1 (PTFV1) has been identified as a significant predictor of atrial fibrillation in the non-surgical population. It is uncertain whether or not there is an association of PTFV1 and new-onset POAF in patients after cardiac surgery. Methods: In this secondary analysis, adult patients undergoing on-pump cardiac surgery for aortocoronary bypasses, valve surgery, combined bypass, and valve surgery were analyzed from 12/2018 to 08/2020. Patients who had a previous occurrence of atrial fibrillation or atrial flutter, patients with pacemakers and/or Implantable Cardioverter-Defibrillators (ICDs), and those who did not have an electrocardiogram (ECG) performed within the 3 months before surgery were excluded. In addition, ECGs that were considered to be of low quality were also removed. Preoperative 12-lead ECGs were examined and the PTFV1 was measured. Secondarily, we examined the P-wave length in lead II, the area under the P-wave in lead II, PR interval, and QRS duration in lead V1 and II. The occurrence of POAF was extracted from the hospital record. Results: Out of a total of 252 patients, 62 patients (24.6%) developed new onset POAF during their hospital stay. POAF occurred primarily in older patients, with poor renal function, and exhibited larger left atria. Analysis of ORs (odds ratios) revealed that age, creatinine clearance, valve surgery, and left atrial volume index (LAVI) were associated with POAF. In the context of the multivariable analysis, it was demonstrated that only age presented a significant correlation with postoperative atrial fibrillation (POAF). There was no observed relationship between any of the parameters based on ECG and the occurrence of POAF. Conclusion: No association was found between PTFV1 or other ECG-based measurements and new onset POAF in cardiac surgery patients. Age was the only independent predictor of POAF.

Internationally, extracorporeal membrane oxygenation (ECMO) is now a core and standard organ support tool to provide tertiary critical care and cardiac services within a network of hospitals and a key tool for running an effective and efficient cardio-respiratory pathways. The letter aims to put the spotlight on some of the missing clinical evidence on respiratory ECMO and including them will help to arrive at a better-informed national ECMO policy decision.

IntroductionPostoperative acute kidney injury (AKI) is a common postoperative complication in cardiac surgery, with varying reported incidences and prognostic factors. Renal hypoperfusion is believed to be a key factor contributing to postoperative AKI. Near-infrared spectroscopy (NIRS) monitoring, which assesses regional tissue saturation (RSO₂), has been suggested as a tool to predict postoperative AKI. The aim of this systematic review was to examine the prognostic value of perioperative NIRS monitoring in predicting postoperative AKI in pediatric patients.Methods and ResultsAfter a systematic search in PubMed, EMBASE, and Cochrane library, twenty studies (1517 patients) were included. The inter-rater agreement on study quality was strong, yet a high risk of bias was identified.ConclusionThe heterogeneity of the results-in part attributable to several potential confounding factors regarding study population, monitoring technique and the definition of AKI-together with the lack of a clear and consistent association between RSO₂ values and AKI, currently preclude recommending NIRS monitoring as a reliable and valid clinical tool to "predict" AKI in the individual patient.

Flash pulmonary edema can affect up to 10% of women with preeclampsia. Although there is growing literature describing the use of extracorporeal membrane oxygenation (ECMO) in pregnant patients, there is very little research describing its use in the setting of preeclampsia. In this case report, an encouraging story of a woman with this complication who was successfully managed is described. In addition, the impact of normal physiologic changes of pregnancy on ECMO management is discussed.

BackgroundWhile several studies have summarised the clinical effectiveness evidence for extracorporeal membrane oxygenation (ECMO), there are no evidence syntheses of the impact of centres' ECMO patient volume on patient outcomes or the impact of bedside ECMO care being delivered by either a perfusionist or a nurse. There is also limited information on the cost-effectiveness of ECMO.PurposeThis review was carried out to evaluate the clinical effectiveness and cost of different service delivery models of pulmonary ECMO to inform NHS Wales commissioning policy.Research DesignThe study utilised rapid review methodology, consisting of a systematic literature search and the inclusion of the highest quality of evidence available.Data CollectionOut of 1997 records identified via literature searches, 12 studies fell within the scope. The 2 meta-analyses comparing ECMO with lung-protective ventilation favoured ECMO.ResultsFive studies looking at the clinical impact of centre patient volume had large heterogeneity. Three studies estimated that with sufficient patient volume, nurse-delivered ECMO was cost-saving, with thresholds varying between 92 and 155 patient days per year. Three studies looked at the cost impact of ECMO delivery, with ECMO being cost incurring, but potentially cost-effective, with costs per patient being lower at higher volume centres.ConclusionsThe available evidence supports the use of ECMO in adult respiratory failure patients, despite it being cost-incurring. ECMO can be nurse-delivered without a significant negative impact on patient care. Yet decision-makers need to consider their local circumstances when making commissioning decisions.