Journal of Cardiothoracic and Vascular Anesthesia

Masthead

2012-06-01

Editorial Board

2012-06-01

Articles to Appear in Future Issues

2012-06-01

Guide for Authors

2012-06-01

EACTA Meeting - EACTA Echo 2012

2012-06-01

EACTA Meeting - Barcelona 2013

2012-06-01

Emergent Echocardiography in Noncardiac Surgical Patients

Kent H. Rehfeldt, Harish Ramakrishna — 2012-03-13

THE USE OF transesophageal echocardiography (TEE) during noncardiac surgery has grown exponentially in recent decades. In addition to its potential value as an intraoperative monitor in select situations, the diagnostic application of intraoperative TEE in patients with unexplained, persistent, or life-threatening hypotension has been recognized and endorsed strongly by a recent task force of the American Society of Anesthesiologists. In fact, as early as 1996, a joint task force of the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists noted that the emergent use of TEE in patients with cardiovascular collapse falls within the “customary practice of anesthesiology.”

Use of Rapid “Rescue” Perioperative Echocardiography to Improve Outcomes After Hemodynamic Instability in Noncardiac Surgical Patients

Sasha K. Shillcutt, Nicholas W. Markin, Candice R. Montzingo, Tara R. Brakke — 2012-01-06

Objective: To investigate if modified “rescue” echocardiography enhanced management during perioperative hemodynamic instability in patients undergoing noncardiac surgery. Design: A retrospective analysis of the medical data. Setting: Perioperative setting at a single academic medical center. Participants: Thirty-one adult patients undergoing noncardiac surgery who experienced perioperative hemodynamic instability and were evaluated by either transthoracic echocardiography (TTE, n = 9) or transesophageal echocardiography (TEE, n = 22). Interventions: None. Measurements and Main Results: Rapid “rescue” echocardiography was performed on each patient looking for a specific cause for the patient's perioperative compromise. Echocardiography results, medical management, surgical management, and patient outcomes were all reviewed from the medical record and the department database. All patients were found to have an explainable diagnosis for the hemodynamic instability on the echocardiographic examination. The most common diagnoses were left-heart dysfunction (n = 16), right-heart dysfunction (n = 9), hypovolemia (n = 5), pulmonary embolus (n = 5), and myocardial ischemia (n = 4). Based on findings at echocardiography, 4 patients (13%) underwent and survived an emergent secondary procedure. All 31 patients recovered during their surgical procedure, and 25 (81%) progressed to hospital discharge. Conclusions: Both TTE and TEE can play a critical role in the diagnosis and management of perioperative hemodynamic instability.

Intraoperative Changes in Regional Wall Motion: Can Postoperative Coronary Artery Bypass Graft Failure Be Predicted?

2012-03-30

Objective: To evaluate the accuracy of new intraoperative regional wall motions abnormalities (RWMAs) detected by transesophageal echocardiography (TEE) to predict early postoperative coronary artery graft failure. Design: A retrospective study. Setting: A tertiary care university hospital. Patients: Five thousand nine hundred ninety-eight patients who underwent coronary artery bypass graft (CABG) surgery. Interventions: An evaluation of RWMAs recorded with intraoperative TEE before and after cardiopulmonary bypass (CPB) in patients who had coronary angiography for suspected postoperative myocardial ischemia based on electrocardiogram (ECG), CK-MB, troponin T, hemodynamic compromise, low cardiac output, and malignant ventricular arrhythmia. Sensitivity, specificity, positive and negative predictive values, odds ratio, 95% confidence interval, and chi-square analysis were used. Measurements and Main Results: Thirty-nine patients (0.7%) underwent early coronary angiography for the suspicion of early graft dysfunction. Of the 32 patients with diagnosed early graft dysfunction, 5 patients (15.6%) had shown new intraoperative RWMAs as detected by TEE, 21 patients (65.6%) had no new RWMAs, no report was available in 5 patients (15.6%), and 1 examination (3.1%) was excluded because of poor imaging quality. The sensitivity of TEE to predict graft failure was 15.6%, the specificity was 57.1%, and the positive predictive and negative values were 62.5% and 12.9%, respectively. The odds ratio and 95% confidence interval was 0.1190 (0.0099-1.4257) when TEE was positive compared with coronary angiography. No association was found between new RWMAs detected with TEE and graft failure as documented with coronary angiography (p = 0.106). Conclusions: In this retrospective study, RWMAs detected with TEE were of limited value to predict early postoperative CABG failure.

Cardiopulmonary Bypass Transiently Inhibits Intraventricular Vortex Ring Formation in Patients Undergoing Coronary Artery Bypass Graft Surgery

Paul S. Pagel, Sweeta D. Gandhi, Zafar Iqbal, Judith A. Hudetz — 2011-12-26

Objective: Transmitral blood flow during early left ventricular (LV) filling produces an intraventricular rotational body of fluid known as a “vortex ring” that enhances the hydraulic efficiency of early LV filling. The authors tested the hypothesis that exposure to cardiopulmonary bypass (CPB) attenuates intraventricular vortex formation time (VFT) in patients with normal preoperative LV systolic and diastolic function undergoing coronary artery bypass graft (CABG) surgery. Design: A prospective, observational study. Participants: Ten men (65 ± 4 years, 91 ± 11 kg, and 175 ± 8 cm) with a normal preoperative LV ejection fraction (58% ± 6%) scheduled for elective CABG surgery were studied after institutional review board approval. Interventions: None. Measurements and Main Results: Anesthesia was induced with etomidate, fentanyl, and rocuronium and maintained with isoflurane. Myocardial protection during CPB consisted of antegrade and retrograde cold blood cardioplegia administered at 15-minute intervals, systemic and topical hypothermia, and warm continuous antegrade cardioplegia before aortic cross-clamp removal. The peak early LV filling and atrial systole blood flow velocities (E and A, respectively) and corresponding velocity-time integrals (VTI-E and VTI-A, respectively) were obtained with pulse-wave Doppler echocardiography and used to determine E/A and atrial filling fraction (β, VTI-A/[VTI-E + VTI-A]), respectively. Mitral valve diameter (D) was calculated as the average of minor and major axis lengths obtained in the midesophageal bicommissural and long-axis transesophageal echocardiographic imaging planes, respectively. VFT was calculated 30 minutes before and 15, 30, and 60 minutes after CPB as 4 × (1 - β) × stroke volume (SV)/πD3, where SV is the stroke volume measured using thermodilution. All patients separated from CPB in sinus rhythm without pacing or vasoactive drug support. Systemic and pulmonary hemodynamics were similar before compared with all times after CPB. CPB significantly (p < 0.05) reduced VFT (5.3 ± 1.8 to 4.0 ± 1.5 15 minutes after CPB); the recovery of VFT (to 4.7 ± 1.6, p > 0.05 v baseline) was noted 60 minutes after CPB. A reduction in E/A (1.26 ± 0.22 to 0.96 ± 0.27) and an increase in β (0.33 ± 0.04 to 0.41 ± 0.07) occurred 15 minutes after CPB. E/A and β also recovered gradually toward control values after CPB (1.25 ± 0.22 and 0.36 ± 0.04, respectively, 60 minutes after CPB; p > 0.05 v. baseline). Conclusions: The results indicated that CPB transiently attenuate VFT in patients with normal preoperative LV systolic and diastolic function undergoing CABG surgery. These data suggest that CPB adversely affects diastolic transmitral flow efficiency by reducing intraventricular vortex ring formation in vivo.

Respiratory Variations of R-Wave Amplitude in Lead II Are Correlated With Stroke Volume Variations Evaluated by Transesophageal Doppler Echocardiography

2012-03-29

Objective: The authors hypothesized that variations in electrocardiographically derived R-wave amplitude might be correlated with mechanical ventilation-induced variations in stroke volume as determined by transesophageal echocardiography. Design: Observational prospective study. Setting: Single university hospital. Participants: Thirty-four patients undergoing coronary artery bypass surgery. Interventions: None. Measurements and Main Results: Respiratory R-wave variations in lead II (ΔRII) were correlated with aortic velocity time integral variations (r = 0.82, p < 0.0001). Respiratory R-wave variations in leads III and aVF and pulse pressure variation also were correlated with aortic velocity time integral variations (r = 0.49, p = 0.015; r = 0.61, p = 0.0016; and r = 0.72, p < 0.0001, respectively). R-wave respiratory variations in lead V5 were not correlated with aortic velocity time integral variations. ΔRII was correlated with pulse pressure variation (r = 0.71, p < 0.0001). A ΔRII cutoff value of 15% accurately predicted stroke volume variations >15%, with a specificity of 92%, a sensitivity of 86%, a positive likelihood ratio of 11.1, a negative likelihood ratio of 0.15, a positive predictive value of 95%, and a negative predictive value of 80%. Conclusions: ΔRII is correlated with stroke volume variations as determined by transesophageal echocardiography in mechanically ventilated patients and can identify the stroke volume variation cutoff of 15%, previously determined to be the cutoff for volume responsiveness.

Pulse Pressure Variation Predicts Fluid Responsiveness in Elderly Patients After Coronary Artery Bypass Graft Surgery

2011-11-18

Objective: To assess the ability of pulse pressure variation to predict fluid responsiveness in mechanically ventilated elderly patients after coronary artery bypass graft surgery. Design: A prospective, interventional study. Setting: An academic, tertiary referral hospital. Participants: Sixty patients >70 years old and mechanically ventilated after coronary artery bypass graft surgery. Interventions: Intravascular volume expansion using 6% hydroxyethyl starch solution, 7 mL/kg over 20 minutes. Measurements and Main Results: Heart rate, arterial blood pressure, pulse pressure variation, central venous pressure, pulmonary artery occlusion pressure, and stroke volume index were measured immediately before and after volume expansion. Fluid responsiveness was defined as an increase in stroke volume index ≥15% after volume expansion. Forty-one patients were fluid responders and 19 patients were nonresponders. In contrast to central venous pressure or pulmonary artery occlusion pressure, pulse pressure variation was higher in the responders than in the nonresponders (22 ± 6% v 9.3 ± 3%, p = 0.001) and correlated with the percent changes in the stroke volume index after volume expansion (r = 0.47, p = 0.001). The area under the receiver operating characteristic curve for pulse pressure variation was 0.85 (95% confidence interval 0.75–0.94). The threshold value of 11.5% allowed the discrimination between responders and nonresponders with a sensitivity of 80% and a specificity of 74%. Conclusions: Pulse pressure variation is a reliable predictor of fluid responsiveness in mechanically ventilated elderly patients after coronary artery bypass graft surgery.

Impact of Patients' Positions on the Incidence of Arrhythmias During Pulmonary Artery Catheterization

2012-01-04

Objective: The complication of cardiac arrhythmias during pulmonary artery catheterization (PAC) may be related to the position of the patient. Therefore, the purpose of this study was to determine the effects of patients' positions on incidence of arrhythmias and the time required to place the pulmonary artery catheter. Design: A prospective, double-blind, randomized, controlled study. Setting: A tertiary university hospital. Participants: One hundred forty patients undergoing elective coronary artery bypass graft surgery. Interventions: Patients were divided into 2 groups. In the study group (n = 70), patients were positioned with their head down at 10° first and then 10° up and tilted right laterally when the PACs were passed from the right atrium to the right ventricle and then the right ventricle to the pulmonary capillary wedge position, respectively. In the control group (n = 70), patients remained in a supine position during pulmonary artery catheterization. Measurement and Main Result: During the catheterization, arrhythmias were recorded and classified into benign (1-3 premature ventricular contractions) and severe (more than 3 premature ventricular contractions or nonsustained ventricular tachycardia). The time for PACs to pass from the right atrium to the right ventricle and the right ventricle to the pulmonary capillary wedge position was measured as T1 and T2, respectively. The incidence of benign arrhythmias between groups was not significantly different (49% for study and 34% for control group, p = 0.196), whereas the incidence of severe arrhythmias was significantly higher in the control group (20% v 5.8%, p = 0.036). The time used for each technique (T1 and T2) in both groups was not significantly different (p = 0.362 and 0.468, respectively). One patient in the study group was excluded because of difficulty in passing the catheter from the right atrium to the right ventricle. Conclusions: Adjusting patients in the head-up and right lateral position while passing the PAC can reduce the incidence of severe arrhythmias, but not in the time taken to place it. This position may have clinical implications, particularly in high-risk patients.

Volatile Anesthetics Reduce Biochemical Markers of Brain Injury and Brain Magnesium Disorders in Patients Undergoing Coronary Artery Bypass Graft Surgery

2011-12-30

Objectives: Neuropsychological disorders are some of the most common complications of coronary artery bypass graft (CABG) surgery. The early diagnosis of postoperative brain damage is difficult and mainly based on the observation of specific brain injury markers. The aim of this study was to analyze the effects of volatile anesthesia (VA) on plasma total and ionized arteriovenous magnesium concentrations in the brain circulation (a-vtMg and a-viMg), plasma matrix metalloproteinase-9 (MMP-9), and glial fibrillary acidic protein (GFAP) in adult patients undergoing CABG surgery. Design: An observational study. Setting: The Department of Cardiac Surgery in a Medical University Hospital. Patients and Methods: Studied parameters were measured during surgery and in the early postoperative period. Patients were assigned to 3 groups: group O, patients who did not receive VA; group ISO, patients who received isoflurane; and group SEV, patients who received sevoflurane. Results: Ninety-two patients were examined. CABG surgery increased MMP-9 and GFAP. The highest MMP-9, GFAP, and the most dramatic disorders in a-vtMg and a-viMg were noted in group O. Conclusions: Cardiac surgery increased plasma MMP-9 and GFAP concentrations. Changes in MMP-9, GFAP, and arteriovenous tMg and iMg were significantly higher in group O. Volatile anesthetics, such as ISO or SEV, reduced plasma MMP-9, GFAP concentrations, and disturbances in a-vtMg and a-viMg.

Morphine Reduces the Threshold of Remote Ischemic Preconditioning Against Myocardial Ischemia and Reperfusion Injury in Rats: The Role of Opioid Receptors

Yao Lu, Chun-Shan Dong, Jun-ma Yu, Hong Li — 2011-10-10

Objectives: Opioid receptors mediate the cardioprotection of remote ischemic preconditioning (RIPC). The authors tested the hypothesis that morphine reduces the threshold of cardioprotection produced by RIPC. Methods: A randomized, prospective study. Setting: A university research laboratory. Participants: Forty-five male Sprague-Dawley rats. Interventions: Anesthetized, open-chest, male Sprague-Dawley rats were assigned randomly to 1 of 7 treatment groups. RIPC1 and RIPC3 were, respectively, induced by 1 or 3 cycles of 5 minutes of femoral artery ischemia interspersed with 5 minutes of reperfusion. Morphine (MOR, 0.1 mg/kg) and the opioid receptor antagonist naloxone (NAL, 6 mg/kg) were administered 30 minutes before sustaining ischemia. MOR + RIPC1 and NAL + MOR + RIPC1 groups received the combination of MOR and RIPC1 in the absence or presence of NAL before coronary artery occlusion. Ischemia and reperfusion injury then were induced by 30 minutes of left coronary artery occlusion followed by 120 minutes of reperfusion. Measurements and Main Results: Infarct size, as a percentage of the area at risk, was determined by 2,3,5-triphenyltetrazolium staining. RIPC3 and the combination of MOR and RIPC1 groups significantly reduced the infarct size compared with the control group. RIPC1, MOR, and NAL did not affect infarct size. NAL pretreatment reversed cardioprotection of the combination of MOR and RIPC1 treatments. Conclusions: MOR reduces the threshold of RIPC, and opioid receptors mediate this augmentative effect.

Fenoldopam and Acute Renal Failure in Cardiac Surgery: A Meta-Analysis of Randomized Placebo-Controlled Trials

2012-03-30

Objective: Because at present no pharmacologic prevention or treatment of acute kidney injury seems to be available, the authors updated a meta-analysis to investigate the effects of fenoldopam in reducing acute kidney injury in patients undergoing cardiac surgery, focusing on randomized placebo-controlled studies only. Design: A meta-analysis of randomized, placebo-controlled trials. Setting: Hospitals. Participants: A total of 440 patients from 6 studies were included in the analysis. Interventions: None. The ability of fenoldopam to reduce acute kidney injury in the perioperative period when compared with placebo was investigated. Measurements and Main Results: Google Scholar and PubMed were searched (updated January 1, 2012). Authors and external experts were contacted. Pooled estimates showed that fenoldopam consistently and significantly reduced the risk of acute kidney injury (odds ratio [OR] = 0.41; 95% confidence interval [CI], 0.23-0.74; p = 0.003), with a higher rate of hypotensive episodes and/or use of vasopressors (30/109 [27.5%] v 21/112 [18.8%]; OR = 2.09; 95% CI, 0.98-4.47; p = 0.06) and no effect on renal replacement therapy, survival, and length of intensive care unit or hospital stay. Conclusions: This analysis suggests that fenoldopam reduces acute kidney injury in patients undergoing cardiac surgery. Because the number of the enrolled patients was small and there was no effect on renal replacement therapy or survival, a large, multicenter, and appropriately powered trial is needed to confirm these promising results.

Vascular Surgery Patients Prescribed Preoperative β-Blockers Experienced a Decrease in the Maximal Heart Rate Observed During Induction of General Anesthesia

2011-12-06

Objective: To investigate the association of preoperative β-blocker usage and maximal heart rates observed during the induction of general anesthesia. Design: Retrospective descriptive, univariate, and multivariate analyses of electronic hospital and anesthesia medical records. Setting: A tertiary-care medical center within the Veterans Health Administration. Participants: Consecutive adult elective and emergent patients presenting for vascular surgery during calendar years 2005 to 2011. Interventions: None. Measurements and Main Results: Of the 430 eligible cases, 218 were prescribed β-blockers, and 212 were not taking β-blockers. The two groups were comparable across baseline patient factors (ie, demographic, morphometric, surgical duration, and surgical procedures) and induction medication doses. The β-blocker group experienced a lower maximal heart rate during the induction of general anesthesia compared with the non–β-blocker group (105 ± 41 beats/min v 115 ± 45 beats/min, respectively; p < 0.01). Adjusted linear regression found a statistically significant association between lower maximal heart rate and the use of β-blockers (β = −11.1 beats/min, p < 0.01). There was no difference between groups in total intraoperative β-blocker administration. Conclusions: Preoperative β-blockade of vascular surgery patients undergoing general anesthesia is associated with a lower maximal heart rate during anesthetic induction. There may be potential benefits in administering β-blockers to reduce physiologic stress in this surgical population at risk for perioperative cardiac morbidity. Future research should further explore intraoperative hemodynamic effects in light of existing practice guidelines for optimal medication selection, dosage, and heart rate control.

Socioeconomic Position Is Not Associated With 30-Day or 1-Year Mortality in Demographically Diverse Vascular Surgery Patients

Michael Mazzeffi, Hung-Mo Lin, Brigid C. Flynn — 2011-10-28

Objectives: Disparities in outcomes after surgical procedures have been attributed to race, sex, use of private insurance, and socioeconomic position (SEP). The purpose of this study was to determine the impact of SEP on mortality after lower-extremity bypass (LEB) surgery in a diverse patient population with extremes of SEP. Design: Analysis of an electronic medical database. Setting: A tertiary care hospital in a demographically diverse section of a large metropolitan area. Participants: Six hundred nine (158 white men, 156 nonwhite men, 100 white women, and 195 non-white women) patients undergoing infrarenal lower-extremity arterial bypass surgery from July 1, 2002, to December 31, 2007. Measurements and Results: SEP was estimated using data from the 2000 US Census. The effects of race, sex, various comorbidities, the Revised Cardiac Risk Index, American Society of Anesthesiologists physical status, use of private insurance, indication for bypass surgery, and SEP on all-cause mortality was analyzed. SEP differed significantly among the 4 race-sex groups, with white men having the highest position (mean = 2.38) and non-white men having the lowest position (mean = −3.02). There was no statistically significant association in 30-day mortality among race-sex groups or with SEP. One-year mortality differed significantly between men and women for the entire cohort (13.7% and 24.1%, respectively; p < 0.01) but not among race groups or SEP. Conclusions: Disparities in SEP are not associated with short- or long-term mortality after LEB surgery. Other comorbid risk factors are more important when determining outcomes and should be the focus of interventions to improve outcomes.

Characterization of Pulmonary and Systemic Inflammatory Responses Produced by Lung Re-expansion After One-Lung Ventilation

2011-11-30

Objectives: To characterize the pulmonary and systemic inflammatory responses of rats undergoing 1-hour or 3-hour one-lung ventilation (OLV) with subsequent 1-hour lung re-expansion. Design: A prospective, randomized, controlled animal experiment. Setting: University laboratory. Participants: Thirty male Wistar rats were used. Interventions: Rats were subjected to 1- or 3-hour OLV followed or not by 1-hour lung re-expansion. Control rats received no ventilation. Measurements and Main Results: Pulmonary protein extravasation, pulmonary myeloperoxidase (MPO) activity, cytokine levels in serum and bronchoalveolar lavage (BAL), counts of total and differential cells in BAL fluid, gasometric data, and mean arterial blood pressure (MABP) were all evaluated. Bronchial occlusion for 1 or 3 hours with no lung re-expansion did not significantly change the protein extravasation in the right and left lungs compared with the control group. However, rats submitted to 1- or 3-hour OLV followed by lung re-expansion exhibited pulmonary edema formation and neutrophil recruitment as well as a higher MPO activity in comparison with control rats. Increased levels of interleukin (IL)-6, IL-1β, and tumor necrosis factor-α in BAL fluid were observed. Increased levels of IL-6 and IL-10 in serum also were detected. Blood gas and MABP did not differ between groups. Conclusions: Lung re-expansion after bronchial occlusion evokes an acute lung inflammatory response, which has been shown to be more pronounced in long periods of bronchial occlusion in terms of cytokine inflammatory response. In addition, the magnitude of this inflammatory response also can be detected systemically.

Anesthetic Management of Patients Undergoing Pulmonary Vein Isolation for Treatment of Atrial Fibrillation Using High-Frequency Jet Ventilation

2012-01-24

Objectives: The aim of this study was to describe anesthetic management and perioperative complications in patients undergoing pulmonary vein isolation for the treatment of atrial fibrillation under general anesthesia using high-frequency jet ventilation. The authors also identified variables associated with longer ablation times in this patient cohort. Design: A retrospective observational study. Setting: The electrophysiology laboratory in a major university hospital. Participants: One hundred eighty-eight consecutive patients undergoing pulmonary vein isolation under general anesthesia with high-frequency jet ventilation. Interventions: High-frequency jet ventilation was used as the primary mode of ventilation under general anesthesia. Measurements and Main Results: High-frequency jet ventilation was performed successfully throughout the ablation procedure in 175 cases of the study cohort. The remaining 13 patients had to be converted to conventional positive-pressure ventilation because of high PaCO2 or low PaO2 on arterial blood gas measurements. Variables associated with a shorter ablation time included a higher ejection fraction (p = 0.04) and case volume performed by each electrophysiologist in the study group (p = 0.001). Conclusions: High-frequency jet ventilation is generally a safe technique that can be used in catheter ablation treatment under general anesthesia.

Parasternal Intercostal Block With Ropivacaine for Postoperative Analgesia in Pediatric Patients Undergoing Cardiac Surgery: A Double-Blind, Randomized, Controlled Study

2011-12-19

Objective: The objective of this study was to assess the effectiveness of 0.5% ropivacaine used for parasternal intercostal blocks for postoperative analgesia in pediatric patients undergoing cardiac surgery. Design: A randomized, controlled, prospective, double-blind study. Setting: A tertiary care teaching hospital. Participants: Thirty children scheduled for cardiac surgery with a median sternotomy. Interventions: A 0.5% ropivacaine injection with 5 doses of 0.5 to 2.0 mL on each side in the 2nd to 6th parasternal intercostal space with a total dose of ropivacaine below 5 mg/kg or the same volume of saline before sternal wound closure. Measurements and Main Results: The time to extubation was significantly lower in patients administered the parasternal blocks with ropivacaine than in the control group; the mean values were 2.66 hours and 5.31 hours, respectively (p < 0.001). The pain scores were lower in the ropivacaine group compared with the saline group; mean values were 2.20 for the ropivacaine group and 4.83 for the saline group on a scale of 10. The cumulative fentanyl dose requirement over a 24-hour period was higher in the saline group than the ropivacaine group (p < 0.001). Conclusions: Parasternal blocks with ropivacaine appear to be a simple, safe, and useful technique of supplementation of postoperative analgesia in pediatric patients undergoing cardiac surgery with a median sternotomy.

Postoperative Respiratory Failure After Cardiac Surgery: Use of Noninvasive Ventilation

Manuel García-Delgado, Inés Navarrete, Maria José García-Palma, Manuel Colmenero — 2012-01-19

Objectives: To analyze the use of noninvasive ventilation (NIV) in respiratory failure after extubation in patients after cardiac surgery, the factors associated with respiratory failure, and the need for reintubation. Design: Retrospective observational study. Setting: Intensive care unit in a university hospital. Participants: Patients (n = 63) with respiratory failure after extubation after cardiac surgery over a 3-year period. Interventions: Mechanical NIV. Measurements and Main Results: Demographic and surgical data, respiratory history, causes of postoperative respiratory failure, durations of mechanical ventilation and spontaneous breathing, gas exchange values, and the mortality rate were recorded. Of 1,225 postsurgical patients, 63 (5.1%) underwent NIV for respiratory failure after extubation. The median time from extubation to the NIV application was 40 hours (18-96 hours). The most frequent cause of respiratory failure was lobar atelectasis (25.4%). The NIV failed in 52.4% of patients (33/63) who had a lower pH at 24 hours of treatment (7.35 v 7.42, p = 0.001) and a higher hospital mortality (51.5% v 6.7%, p = 0.001) than those in whom NIV was successful. An interval <24 hours from extubation to NIV was a predictive factor for NIV failure (odds ratio, 4.6; 95% confidence interval, 1.2-17.9), whereas obesity was associated with NIV success (odds ratio, 0.22; 95% confidence interval, 0.05-0.91). Conclusions: Reintubation was required in half of the NIV-treated patients and was associated with an increased hospital mortality rate. Early respiratory failure after extubation (≤24 hours) is a predictive factor for NIV failure.

The Effect of Different Lung-Protective Strategies in Patients During Cardiopulmonary Bypass: A Meta-Analysis and Semiquantitative Review of Randomized Trials

2012-03-30

Objectives: A variety of lung-protective techniques, including continuous positive airway pressure and vital capacity maneuvers, have been suggested as beneficial when applied during cardiopulmonary bypass (CPB). To better define the efficacy of these techniques, a systematic review of different ventilation strategies during and after CPB was performed. Design: A systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Setting: Hospitals. Participants: Eight hundred fourteen participants of 16 randomized controlled trials. Interventions: Continuous positive airway pressure (CPAP), low-volume ventilation, or vital capacity maneuvers (VCMs) during CPB. Measurements and Main Results: The methodologic validity of the included trials was scored according to the Oxford scale. Included trials had to report on at least 1 of the following parameters: oxygenation, oxygenation index, alveolar-arterial oxygen difference, or shunt fraction. The average quality of the included trials was as low as 2 on a scale from 1 to 5. The use of CPAP or VCM during CPB led to a significant increase in oxygenation parameters immediately after weaning from CPB, but this effect was not sustainable and did not improve patient outcome. Conclusions: This meta-analysis showed that the positive effects of the designated techniques are probably short-lived with a questionable impact on the long-term clinical outcome of the treated patients. Based on the available data, it might be impossible to advise an optimal or best-evidence strategy of lung preservation during CPB.

Magic Bullets in Cardiac Anesthesia and Intensive Care

Giovanni Landoni, Laura Ruggeri, Alberto Zangrillo — 2012-03-29

Even if the first quasi-randomized study in history was published in 1747, there is still a need for evidence-based medicine. In the specific field of cardiac anesthesia, there are few magic bullets (ie, drugs/techniques/strategies that might reduce perioperative mortality), and a recent international consensus conference attempted to list them all. In the absence of evidence-based medicine, medical decisions are made by eminence, experience, or physiopathologic reasoning. Even if increased or decreased mortality could be observed when administering almost every drug used in the current clinical context, if correctly studied, research is slowed by bureaucracy, which, together with ignorance, is indirectly killing thousands of patients per year. Patients should be fully aware of the reduced complication rates and the improved outcomes that occur in patients involved in randomized “researcher-driven” clinical trials, the so-called “Hawthorne effect.” In conclusion, physicians have to do their best although they sometimes have little information. Their ability must counteract the lack of scientific evidences. Caring for critical patients involves making decisions based on realistic tradeoffs of clinical benefit and side effects, but too often these choices are made on the basis of extrapolations and educated guesses.

Transesophageal Echocardiography in the Management of Right Ventricular Bullet Embolization From the Left Brachiocephalic Vein

Wayne Soong, Anna Katharina Beckmann, Louis Lin, Umraan S. Ahmad, Edwin C. McGee — 2011-05-05

BULLET EMBOLIZATION to the heart is a very rare occurrence that provides a diagnostic and therapeutic quandary. Although whether and how to intervene remain debatable, deciding on a care plan depends on accurate localization of the foreign body. A case of bullet migration from the left brachiocephalic vein to the right ventricle is presented. Preoperative and intraoperative transesophageal echocardiography (TEE) proved essential to successful treatment.

Do Not Blame the Arterial Catheter: A Case Report of Intraoperative Acute Leriche Syndrome

Vijish Venugopal, Mahadevan Ramachandran — 2011-03-28

COMPLETE AORTIC OCCLUSION is rare but potentially catastrophic. Acute aortic occlusion carries an early mortality of 31% to 52% and is caused either by embolic occlusion of the infrarenal aorta at its bifurcation, known as a “saddle embolus,” or by acute thrombosis of the abdominal aorta. Between 75% and 80% of cases of thrombotic aortic occlusion occur in the setting of underlying severe aortoiliac atherosclerotic occlusive disease, often precipitated by a low-flow state secondary to heart failure or dehydration. Intraoperative acute occlusion of the aorta (acute Leriche syndrome) during extracorporeal circulation is not common, and case reports regarding this are rare. Its detection early in the course of events is essential to prevent the catastrophe of losing the lower limbs because of ischemia.

Use of Venovenous Extracorporeal Membrane Oxygenation Under Regional Anesthesia for a High-Risk Rigid Bronchoscopy

2011-05-05

THERE ARE NUMEROUS indications for stent placement in the central respiratory tract. The mobilization or removal of such stents using a rigid bronchoscope may expose patients to potentially severe respiratory complications. Recently, Chen reported the use of venoarterial extracorporeal membrane oxygenation (ECMO) during withdrawal of a stent covering the lower part of the trachea and the proximal part of the left mainstem bronchus. The first attempt resulted in almost complete obstruction of the trachea requiring resuscitation maneuvers. After conducting a thorough neurologic assessment of the patient, a 2nd attempt was performed on the following day. In order to ensure adequate oxygenation, the patient was put on venoarterial ECMO support under general anesthesia. The use of venovenous (VV) ECMO support set up under local anesthesia before the administration of general anesthesia in order to prevent oxygenation impairment because of the complexity of managing the airway or as a result of surgical intervention is reported.

Air Lock and Embolism Upon Attempted Initiation of Cardiopulmonary Bypass While Using Vacuum-Assisted Venous Drainage

Thomas M. Burch, Adair Q. Locke — 2011-04-08

VACUUM-ASSISTED VENOUS DRAINAGE (VAVD) for cardiopulmonary bypass (CPB) improves venous drainage via small cannulae. Complications specific to VAVD are important to anticipate and recognize. A case of air lock and air embolus upon initiation of CPB caused by overpressurization of the venous catheter is described. A description of indications and potential complications of VAVD is presented.

Prone Ventilation in the Management of Infants With Acute Respiratory Distress Syndrome After Complex Cardiac Surgery

2011-07-04

ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) after systemic infection is a known complication after congenital heart surgery. This can result in life-threatening hypoxemia in some critically ill infants. This complication assumes special clinical relevance after cardiac surgery because it leads to an imbalance among the available oxygen, impaired myocardial function, and increased oxygen requirements. Traditional ventilation techniques have been implicated in worsening lung injury. Prone ventilation is emerging as a promising adjuvant to lung-protective ventilatory strategies in ARDS in both the adult and pediatric populations. There is a paucity of literature on the use of prone ventilation in pediatric cardiac surgery. By presenting this case series, the authors want to convey the efficacy of prone ventilation in infants with severe refractory hypoxemia after systemic infection and ARDS after complex congenital heart surgery.

Simulation in Echocardiography: An Ever-Expanding Frontier

Omair Shakil, Feroze Mahmood, Robina Matyal — 2012-03-12

INNOVATIONS IN TECHNOLOGY have made it possible to create “virtual reality circumstances” of specific scenarios to refine training and education. Because of its virtual nature, ie, no consequences of failure and no risk to a patient, simulation-based education has become an integral component of medical training. Simulation technology traditionally has been used as a “situational” teaching tool to facilitate multidisciplinary team building, communication, and complex decision making. The development of “phantom models” has broadened the scope of simulation as a teaching adjunct to improve skills in performing procedures (regional anesthesia, central venous access, and laparoscopic surgery). The art of image acquisition during echocardiography is another such discipline that requires a complex interaction between an operator, the equipment, and a subject. The cognitive component of proficiency in echocardiography consists of a theoretical understanding of cardiac anatomy, physiology, and the echocardiographic image display through specific “echo windows.” The manual dexterity component requires repetitive, mentored, hands-on experience to acquire interpretable standardized images reliably. The multifaceted skill sets required to gain expertise in echocardiography further require a clinical context for their application. Such dedicated clinical training is available to anesthesia residents as an elective during their “core” residency or as a part of an accredited cardiac anesthesia fellowship.

State-of-the-Art Mechanical Ventilation

2011-05-23

THE CONCEPT OF artificial respiration was first recognized in the 16th century by Vesalius. However, it was not until the 20th century that mechanical ventilation became a widely used therapeutic modality. Bjorn Ibsen successfully applied positive-pressure ventilation to a population of patients with polio-induced respiratory paralysis during the 1952 Copenhagen outbreak, reducing their overall mortality from around 85% in July 1952 to 15% in March the following year. This intervention is now seen as the birth of modern mechanical ventilation as a method to manage acute respiratory failure, and the intervention also heralded the development of the modern intensive care unit (ICU).

A Method for Automating 3-Dimensional Proximal Isovelocity Surface Area Measurement

2012-02-13

Objective: The proximal isovelocity surface area (PISA) is used for the echocardiographic quantification of effective orifice areas in valvular stenosis and regurgitation. Typically measured in 2 dimensions, the PISA relies on the geometric assumption that the shape of flow convergence is a hemisphere and that the orifice is a single circular point. Neither assumption is true. The objective was to develop a method for automating the measurement of the PISA in 3 dimensions and to illuminate the actual shape of the flow convergence pattern and how it changes over time. Design: Retrospective, single-case study. Setting: Major urban hospital. Participants: This study was based on a single patient undergoing mitral valve replacement. Interventions: No additional interventions were performed in the patient. Results: The effective orifice areas calculated from the serial hemispheric, hemi-elliptic, and 3-dimensional (3D) PISAs during diastole were compared with the corresponding planimetric anatomic mitral orifice area. The effective orifice areas based on the manual and automated measurements of 3D PISAs more closely approximated the anatomic orifice than the effective orifice areas calculated using hemispheric or hemi-elliptic PISAs. Conclusions: An automated analysis of 3D color Doppler data is feasible and allows a direct and accurate measurement of a 3D PISA, thus avoiding reliance on simplistic geometric assumptions. The dynamic aspect of cardiac orifices also must be considered in orifice analysis.

CASE 3—2012: Iatrogenic Circumflex Artery Injury During Minimally Invasive Mitral Valve Surgery

Jennifer Banayan, Richa Dhawan, William J. Vernick, Patrick M. McCarthy — 2012-03-30

IATROGENIC CIRCUMFLEX ARTERY INJURY during mitral valve surgery rarely has been reported. Although a handful of case reports can be found in the literature, no large case series identifying risk factors to assess those patients at highest risk for this potentially catastrophic complication exist. A few commentaries suggest that specific coronary anatomy dominance may predict risk, yet others disagree. Some researchers specifically have studied patients undergoing minimally invasive mitral valve surgeries, whereas others reported on patients undergoing conventional sternotomies. One investigator assessed the risk between repairing versus replacing the valve. However, no consensus exists regarding who is at an increased risk. The authors report two such cases at their institution, discuss the literature, and present unique risk factors for this potentially deadly complication.

Case 4—2012: Intrathoracic Fire During Coronary Artery Bypass Graft Surgery

D. Wesley Hudson, Orin F. Guidry, James H. Abernathy, Jan Ehrenwerth — 2012-03-26

OPERATING ROOM FIRES have been attracting increasing attention over the last several years with advisory publications from the Joint Commission, the Emergency Care Research Institute (ECRI) and the American Society of Anesthesiologists. The Anesthesia Patient Safety Foundation (APSF) recently published a video addressing many of these concerns as well.

Severe Tricuspid Valve Regurgitation: A Case for Laminar Flow

2012-03-05

For further information and follow-up discussion of the E-Challenge, please go to:

Going With the Flow: The Dilemma of a Laminar Jet

Madhav Swaminathan, Feroze Mahmood — 2012-03-12

To comment on this case and the clinical decisions made, please go to:

Perioperative Management of Pheochromocytoma: Focus on Magnesium, Clevidipine, and Vasopressin

Michael S. Lord, John G.T. Augoustides — 2012-02-24

The perioperative management of pheochromocytomas requires meticulous anesthetic care. There has been considerable progress in its management, recently 3 agents that may be particularly advantageous to the anesthetic team have been identified. Magnesium sulfate is readily available, cheap, safe, and effective for hemodynamic control before tumor resection. It has demonstrated efficacy in adults, children, and in rarer scenarios, such as pheochromocytoma resection in pregnancy and in pheochromocytoma crises. Although only recently entering clinical practice, clevidipine exhibits a pharmacologic profile of great interest, showing efficacy in the management of hypertensive crisis and providing rapid titration and precise hemodynamic control. Its application in the perioperative management of pheochromocytoma before tumor resection recently has been described and likely will expand in the near future. Vasopressin has demonstrated utility in the management of catecholamine-resistant shock after tumor resection. A familiarity with these 3 agents offers anesthesia providers further effective pharmacologic options for managing the hemodynamic challenges inherent to this population before and after tumor resection.

Persistent Chest Pain in a Polysubstance Abuser: An Unusual Consequence

Laurie A. Radojevich, Paul S. Pagel — 2011-01-13

A 30-YEAR-OLD, 93-kg, 191-cm man with a history of active polysubstance abuse (cocaine, marijuana, and alcohol) and posttraumatic stress disorder presented to the authors' institution with severe, sharp sternal chest pain radiating to the left chest. The patient reported that he had been involved in a physical altercation related to an illicit drug purchase a few weeks before the current evaluation during which 2 assailants repeatedly punched and kicked him in the chest. He was assessed on 2 previous occasions in a local community hospital emergency department. The patient was treated conservatively with oxycodone for contusions after a chest radiograph failed to demonstrate rib fractures. Despite this approach, the patient's pain became progressively worse during the week before the current evaluation. He reported severe pain during voluntary deep inspiration and when he attempted to lift his arms over his head. The patient denied fever, chills, cough, hemoptysis, dyspnea at rest or during mild exertion, orthopnea, and paroxysmal nocturnal dyspnea. The physical examination revealed tenderness to palpation along the upper left border of the sternum, the adjacent proximal ribs, and the chest wall. The patient described being kicked in these locations during the assault. The remainder of the physical examination was noncontributory. Pulse oximetry indicated an arterial oxygen saturation of 100% with the patient breathing room air. Posterior-anterior and lateral chest radiographs showed an absence of pulmonary consolidation and effusion, a normal cardiac silhouette without a widened mediastinum, and no evidence of rib fractures or pneumothorax (). A thoracic computed tomography (CT) study without angiographic contrast was performed (). What is the diagnosis?

Sudden Onset of Atrial Flutter During Continuous Venovenous Hemodialysis

2011-01-13

A 56-YEAR-OLD MAN was admitted to the authors' intensive care unit with an exacerbation of congestive heart failure concomitant with hypotension (80/49 mmHg) and hyperkalemia (6.2 mmol/L). The patient had end-stage cardiomyopathy and hemodialysis-dependent renal failure resulting from chronic human immunodeficiency virus infection. Transthoracic echocardiography revealed biventricular failure with an ejection fraction of 15%. A chest radiograph showed cardiomegaly and pulmonary edema. A 12-lead electrocardiogram (ECG) showed normal sinus rhythm and nonspecific T-wave changes in the lateral leads. Inotropic support (intravenous infusions of dobutamine and dopamine) was begun to support the patient's arterial blood pressure, and continuous venovenous hemodialysis (CVVHD) was initiated for the treatment of hyperkalemia. Approximately 1 hour after CVVHD was begun, the intensive care unit nurse reported the presence of new-onset atrial flutter to the resident on call. A new 12-lead ECG was consistent with this diagnosis (). Clinical symptoms were absent as a result of the arrhythmia, and the physical signs, including heart rate (86 beats/min) and arterial blood pressure (100/65 mmHg), essentially were unchanged. In response to this apparent medication-related atrial flutter, the intravenous infusion of dobutamine was discontinued and the infusion rate of dopamine was reduced. CVVHD of intravascular volume also was decreased to maintain normal arterial blood pressure. These interventions did not affect the atrial arrhythmia. No other drug therapy was begun to treat the arrhythmia, and cardioversion was not considered because the patient's heart rate and arterial blood pressure were stable. What is the etiology of the new-onset atrial flutter?

Device Closure of an Atrial Septal Defect: An Unexpected Stumbling Block

Eapen Thomas, Salim Nasser Al-Maskari, Madan Mohan Maddali, Md Shamsuz Zoha — 2011-02-14

A 7-YEAR-OLD, 23-kg, 130-cm girl was admitted to the authors' institution for a device closure of an atrial septal defect (ASD). She had her initial outpatient clinic review when she was 1 year old for the evaluation of a small apical muscular ventricular septal defect (VSD) and an ASD. There were 3 subsequent clinic visits. These reviews showed that the VSD had closed spontaneously, but the ASD remained patent. She complained of lethargy and decreased exercise tolerance during her most recent clinic visit. The arterial oxygen saturation measured by pulse oximetry was 98% on room air. There was a grade 2/6 ejection systolic murmur along the left upper sternal border in the second intercostal space. A transthoracic echocardiogram revealed a fossa ovalis ASD measuring about 8 mm in dimension with adequate rims and mild right atrial and right ventricular dilatation. An unusual echodense structure also was noticed in the right atrium, distinct from the atrial septum, and it was decided to evaluate this in detail with a transesophageal echocardiogram (TEE). The child subsequently was taken to the cardiac catheterization laboratory for both TEE assessment and device closure of the ASD. After anesthetic induction and endotracheal intubation, a TEE was performed. The images shown in were obtained. What is the diagnosis?

Cardiac Calendar—2012 TO 2013

George Silvay — 2012-03-30

Second International Congress, Anesthesia for Seniors. Prague, Czech Republic. June 7-9, 2012. Contact: www.anesthesiaforseniors2012.cz. Euroanaesthesia 2012. Paris, France. June 9-12, 2012. Contact: info@euroanaesthesia.org.

Timing Is Everything

Andreas Edel, Sascha Tafelski, Irit Nachtigall, Claudia Spies — 2012-03-26

With great interest, we read the cohort study of Stransky et al focusing on hypoactive delirium in cardiosurgical patients. Of 467 patients, 54 (11.6%) developed early-onset delirium on days 1 through 3 after surgery. In their extensive statistical analyses, the authors identified diuretic premedication, among others, as an independent risk factor for hypoactive delirium. The hypoactive form is known to be routinely underreported compared with the mixed delirium variant. A standardized and repetitive evaluation of changes in patients' consciousness and cognition is necessary for its diagnosis. There are validated tools to support the diagnosing process including the Confusion Assessment Method for the Intensive Care Unit and the Intensive Care Delirium Checklist, as used in Stransky et al's study. Unfortunately, the authors did not report on the definite number of scorings per day that were assessed to identify delirium. Because of the fluctuating character of the disease, repetitive scoring should be performed with regard to the risk factors for delirium (eg, infections, withdrawal, hypoxia, or metabolic derangements) every 8 hours to exclude potential underdiagnosing. For the Confusion Assessment Method for the Intensive Care Unit screening, excellent specificity but limited sensitivity of 86% are reported, and identifying delirium based on this score might cause further risk of selection bias. Similar results were found for the Intensive Care Delirium Checklist, with 89% sensitivity and 57% specificity, respectively. Contrary to the findings of Stransky et al, the most common delirium in the intensive care unit is reported to be the mixed form; the hypoactive variant is seen in about 45% and the hyperactive form in only 2%. If the study protocol included a once-daily delirium measurement over the first 3 postoperative days, there may have been more patients with mixed delirium because the clinical syndrome changes over time. Thus, the results of the study by Stransky et al also might be transferable to populations with other delirium forms, which would help to lower delirium rates and prevent sequelae.

Response to Edel et al

Benedikt Trabold, Bernhard M. Graf — 2012-03-26

We would like to thank Dr Edel et al for the comments regarding our article and the editors of the Journal of Cardiothoracic and Vascular Anesthesia for the opportunity to respond to those comments. The aim of our study was to evaluate the incidence of the 3 subtypes of postoperative delirium in patients who have undergone cardiac surgery. The reasons for using the Intensive Care Delirium Screening Checklist are described in the discussion section of our article. Patients were evaluated once daily for delirium using the Intensive Care Delirium Screening Checklist and the Richmond Agitation-Sedation Scale.

Role of Ketamine in the Management of Pulmonary Hypertension and Right Ventricular Failure

Bryan G. Maxwell, Ethan Jackson — 2012-02-24

We read with interest the excellent review by Strumpher and Jacobsohn of pulmonary hypertension and right ventricular dysfunction. However, we take issue with the authors' statement during their discussion of the management of right ventricular failure that “ketamine … increase[s] [pulmonary vascular resistance] PVR and should be avoided.” We believe it is an overly negative and simplistic assessment of the role of ketamine in this context, and that it would lead readers to dismiss an agent that has significant potential benefits in this setting.

Response to Drs Maxwell and Jackson

Johann Strumpher, Eric Jacobsohn — 2012-02-24

We appreciate the comments Drs Maxwell and Jackson on the use of ketamine as a coinduction and/or coanalgesic agent in patients with pulmonary hypertension. We agree that earlier studies mostly were conducted on spontaneously breathing patients in whom alterations in oxygenation and ventilation could have accounted for observed increases in pulmonary vascular resistance (PVR). However, Gooding et al and Spotoft et al showed significant increases in PVR after ketamine administration in spontaneously breathing patients without significant changes in PaO2 and PaCO2. Likewise, in a cardiac catheterization study of 20 spontaneously breathing children with congenital heart disease, Morray et al found no significant alterations in PaO2 and PaCO2 after the administration of ketamine, but they did show “statistically significant but clinically minor” increases in heart rate, the mean pulmonary artery pressure, and the ratio between pulmonary and systemic vascular resistance.

The Effects of Gabapentin on Acute and Chronic Postoperative Pain After Coronary Artery Bypass Graft Surgery

Juan Graterol, S.P.K. Linter — 2012-02-24

We read with interest the article by Ucak et al on the effects of gabapentin on acute and chronic postoperative pain after coronary artery bypass graft surgery; however, there are some points that deserve comment.

Response to Drs Graterol and Linter

2012-02-24

We would like to thank Drs Graterol and Linter for their suggestions on our study about the effects of gabapentin on postoperative pain after cardiac surgery. As stated in the Methods section of our study, all patients had 50 mg of oral tramadol hydrochloride every 12 hours and 500 mg of paracetamol (acetaminophen) every 8 hours for the 1st and 2nd postoperative days. During this period, 1 mg/kg of intravenous tramadol was delivered as the rescue medication if the visual analog scale score was above 4.

Use of Near-Infrared Spectroscopy in Combination With Monitoring of External Jugular Vein Pressure for Early Detection of Cerebral Ischemia by Unintentional Superior Vena Cava Obstruction

Ryoko Ito, Koichi Takita, Kazuyuki Mizunoya, Atsunori Kida, Yuji Morimoto — 2012-03-05

In the resection of tumors infiltrating near the superior vena cava (SVC), the SVC can be occluded unintentionally by surgical manipulations. Because an SVC obstruction results in cerebral ischemia and >45 minutes of an SVC occlusion cannot be tolerated in humans, the lack of awareness of an SVC obstruction can lead to serious neurologic complications. The monitoring of pressure in the external or internal jugular vein is a sensitive indicator of an SVC obstruction. However, it is difficult to know the critical level that indicates impaired cerebral perfusion in patients. Near-infrared spectroscopy (NIRS) is used clinically to detect cerebral ischemia. Although NIRS has been shown to detect venous cannula occlusion during cardiopulmonary bypass in an animal study, its efficacy for the early detection of cerebral ischemia associated with an SVC obstruction in clinical settings has not been reported.

What Is the Optimal Practice of Analgesia for Post-thoracotomy Pain?

Yong Xin Liang, Li Jiang Sun, Hai Chen Chu — 2012-03-05

We read with interest the recent article by Grider et al in which they studied 75 consecutive patients presenting for thoracotomy with thoracic epidural analgesia (TEA) or continuous paravertebral infusion (CPI) and found that TEA with bupivacaine and hydromorphone may provide enhanced analgesia over TEA or CPI with bupivacaine alone. CPI is comparable with TEA, the current gold standard, and has very few side effects. However, what is the optimal practice of analgesia for post-thoracotomy pain?

Response to Drs Liang, Sun, and Chu

Jay S. Grider, Paul A. Sloan — 2012-03-05

We appreciate the interest of Drs Liang et al in the important topic of postoperative analgesia for patients undergoing thoracotomy. Despite numerous clinical studies, controversies remain as to the best analgesic technique and regimen. The following question raised by Drs Liang et al appears to generate considerable controversy: “What is the optimal mode of analgesia for thoracotomy?”

Ultrasound-Guided Cannulation of Radial Artery With Anatomic Variation

Gökhan İnangil, Süleyman Deniz, Hüseyin Şen — 2012-02-24

Arterial cannulation usually is performed to allow continuous blood pressure monitoring and frequent arterial blood sampling. Approximately 8 million and 2.5 million arterial catheters are placed yearly in the United States and Europe, respectively. Relative contraindications to the procedure include bleeding abnormalities and peripheral vascular disease. The reported complications include catheter-related sepsis in 4%, thrombosis in 38%, and peripheral embolization in 28% of the cases. The consistent anatomic accessibility, the ease of cannulation, and the low rate of complications make the radial artery the preferred site for arterial cannulation. However, problems do occur.

Journal of Cardiothoracic and Vascular Anesthesia

Masthead

Editorial Board

Contents

Articles to Appear in Future Issues

Guide for Authors

EACTA Meeting - EACTA Echo 2012

EACTA Meeting - Barcelona 2013

Emergent Echocardiography in Noncardiac Surgical Patients

Use of Rapid “Rescue” Perioperative Echocardiography to Improve Outcomes After Hemodynamic Instability in Noncardiac Surgical Patients

Intraoperative Changes in Regional Wall Motion: Can Postoperative Coronary Artery Bypass Graft Failure Be Predicted?

Cardiopulmonary Bypass Transiently Inhibits Intraventricular Vortex Ring Formation in Patients Undergoing Coronary Artery Bypass Graft Surgery

Respiratory Variations of R-Wave Amplitude in Lead II Are Correlated With Stroke Volume Variations Evaluated by Transesophageal Doppler Echocardiography

Pulse Pressure Variation Predicts Fluid Responsiveness in Elderly Patients After Coronary Artery Bypass Graft Surgery

Impact of Patients' Positions on the Incidence of Arrhythmias During Pulmonary Artery Catheterization

Volatile Anesthetics Reduce Biochemical Markers of Brain Injury and Brain Magnesium Disorders in Patients Undergoing Coronary Artery Bypass Graft Surgery

Morphine Reduces the Threshold of Remote Ischemic Preconditioning Against Myocardial Ischemia and Reperfusion Injury in Rats: The Role of Opioid Receptors

Fenoldopam and Acute Renal Failure in Cardiac Surgery: A Meta-Analysis of Randomized Placebo-Controlled Trials

Vascular Surgery Patients Prescribed Preoperative β-Blockers Experienced a Decrease in the Maximal Heart Rate Observed During Induction of General Anesthesia

Socioeconomic Position Is Not Associated With 30-Day or 1-Year Mortality in Demographically Diverse Vascular Surgery Patients

Characterization of Pulmonary and Systemic Inflammatory Responses Produced by Lung Re-expansion After One-Lung Ventilation

Anesthetic Management of Patients Undergoing Pulmonary Vein Isolation for Treatment of Atrial Fibrillation Using High-Frequency Jet Ventilation

Parasternal Intercostal Block With Ropivacaine for Postoperative Analgesia in Pediatric Patients Undergoing Cardiac Surgery: A Double-Blind, Randomized, Controlled Study

Postoperative Respiratory Failure After Cardiac Surgery: Use of Noninvasive Ventilation

The Effect of Different Lung-Protective Strategies in Patients During Cardiopulmonary Bypass: A Meta-Analysis and Semiquantitative Review of Randomized Trials

Magic Bullets in Cardiac Anesthesia and Intensive Care

Transesophageal Echocardiography in the Management of Right Ventricular Bullet Embolization From the Left Brachiocephalic Vein

Do Not Blame the Arterial Catheter: A Case Report of Intraoperative Acute Leriche Syndrome

Use of Venovenous Extracorporeal Membrane Oxygenation Under Regional Anesthesia for a High-Risk Rigid Bronchoscopy

Air Lock and Embolism Upon Attempted Initiation of Cardiopulmonary Bypass While Using Vacuum-Assisted Venous Drainage

Prone Ventilation in the Management of Infants With Acute Respiratory Distress Syndrome After Complex Cardiac Surgery

Simulation in Echocardiography: An Ever-Expanding Frontier

State-of-the-Art Mechanical Ventilation

A Method for Automating 3-Dimensional Proximal Isovelocity Surface Area Measurement

CASE 3—2012: Iatrogenic Circumflex Artery Injury During Minimally Invasive Mitral Valve Surgery

Case 4—2012: Intrathoracic Fire During Coronary Artery Bypass Graft Surgery

Severe Tricuspid Valve Regurgitation: A Case for Laminar Flow

Going With the Flow: The Dilemma of a Laminar Jet

Perioperative Management of Pheochromocytoma: Focus on Magnesium, Clevidipine, and Vasopressin

Persistent Chest Pain in a Polysubstance Abuser: An Unusual Consequence

Sudden Onset of Atrial Flutter During Continuous Venovenous Hemodialysis

Device Closure of an Atrial Septal Defect: An Unexpected Stumbling Block

Cardiac Calendar—2012 TO 2013

Timing Is Everything

Response to Edel et al

Role of Ketamine in the Management of Pulmonary Hypertension and Right Ventricular Failure

Response to Drs Maxwell and Jackson

The Effects of Gabapentin on Acute and Chronic Postoperative Pain After Coronary Artery Bypass Graft Surgery

Response to Drs Graterol and Linter

Use of Near-Infrared Spectroscopy in Combination With Monitoring of External Jugular Vein Pressure for Early Detection of Cerebral Ischemia by Unintentional Superior Vena Cava Obstruction

What Is the Optimal Practice of Analgesia for Post-thoracotomy Pain?

Response to Drs Liang, Sun, and Chu

Ultrasound-Guided Cannulation of Radial Artery With Anatomic Variation