Journal of Cardiothoracic and Vascular Anesthesia - Articles in Press

Assessment of Surgical Septal Myectomy by Real-Time 3-Dimensional Transesophageal Echocardiography - Corrected Proof

Mary S. Lee, Paul Stelzer, Robin Varghese, Gregory W. Fischer — 2010-02-08

HYPERTROPHIC CARDIOMYOPATHY (HCM) with dynamic left ventricular outflow tract obstruction (HCOM) was first described 50 years ago. Recent observational studies have confirmed that subaortic pressure gradients associated with this disease represent true impedance to left ventricular (LV) outflow and are responsible for symptoms and mortality. Surgical myectomy can reduce these gradients and provide long-term survival benefit similar to that observed in the general population.

One-Lung Ventilation Can Alter the Severity of Aortic Regurgitation - Corrected Proof

Prabhat Kumar Sinha, Satyajeet Misra, Thomas Koshy — 2010-02-08

Aortic regurgitation (AR) is mainly affected by changes in the systemic vascular resistance (SVR) and left ventricular (LV) diastolic pressures. There are no previous reports describing the effects of one-lung ventilation (OLV) on the magnitude of AR.

Difficult Management of Anticoagulation With Argatroban in a Patient Undergoing On-Pump Cardiac Surgery - Corrected Proof

2010-02-08

HEPARIN-INDUCED THROMBOCYTOPENIA (HIT), presenting as severe thrombocytopenia and possible vascular thrombosis resulting from platelet activation secondary to immune response to heparin-platelet factor 4 (PF4) complexes, is a critical concern in patients with this disorder and at risk of exposure to heparin. Patients with HIT requiring cardiopulmonary bypass (CPB) present complex issues regarding the choice of an alternative agent to heparin for anticoagulation during CPB. Alternative anticoagulants include lepirudin, bivalirudin, danaparoid, and argatroban. Argatroban seems to be a reasonable option, especially for patients with renal failure because it is metabolized and eliminated primarily via a hepatic route. Furthermore, its anticoagulant effect is spontaneously reversed within 2 to 4 hours because of its short elimination half-life (39-53 minutes), and its anticoagulant effect can be conveniently monitored with the activated coagulation time (ACT). Although several case reports described the successful management of anticoagulation with argatroban in on-pump cardiac surgery, the lack of an effective antidote may pose a significant problem. At present, reports describing the use of argatroban for adult on-pump cardiac surgery are quite limited in number. Therefore, there is no consensus regarding precautions necessary with the use of argatroban for CPB.

Cerebrospinal Fluid Drainage With Bivalirudin and rFactor VIIa for Thoracic Aortic Aneurysm Surgery Using Left Atrial–Femoral Artery Bypass - Corrected Proof

Caleb Ing, Jessica Spellman, Ervant Nishanian — 2010-02-08

WHEN HEPARIN-INDUCED thrombocytopenia is diagnosed, direct thrombin inhibitors can be used in cases requiring cardiopulmonary bypass. Spinal drains are routinely used in preventing spinal cord ischemia for thoracoabdominal aneurysm repairs. Spinal drains placed before starting heparin anticoagulation are safe and routinely used. The use of bivalirudin with a spinal drain for repair of a thoracoabdominal aneurysm in a patient with heparin-associated antibodies is reported. A good outcome was achieved by promoting coagulation with rFactor VIIa when ultrafiltration was not available to remove bivalirudin.

Cardiac Calendar—2010 to 2012 - Corrected Proof

George Silvay — 2010-02-08

Fifty-Seventh Annual Meeting, Association of University Anesthesiologists. Denver, Colorado. April 8-10, 2010. Contact: AUA, 520 North Northwest Highway, Park Ridge, IL 60068, e-mail: dionne@ASAhq.org.

Aortic Short-Axis View - Corrected Proof

2010-02-08

A 65-YEAR-OLD MAN presented to the authors' institution for the evaluation of progressive dyspnea and angina on exertion. On physical examination, his blood pressure was 160/90 mmHg with a heart rate of 90 beats/min. Cardiac auscultation revealed a grade 4 early diastolic murmur at the 2nd right intercostal space. The electrocardiogram showed sinus rhythm with left ventricular hypertrophy. Transthoracic echocardiography (TTE) revealed moderately severe aortic regurgitation, mild mitral regurgitation, thickened interventricular septum (15 mm), and concentric left ventricular hypertrophy with an ejection fraction of 53%. Furthermore, it showed a left ventricular end-diastolic dimension of 50 mm and an end-systolic dimension of 32 mm. A cardiac catheterization study showed triple-vessel coronary artery disease, and pressure data revealed the left ventricular pressure of 180/18 mmHg and aortic pressure of 180/70 mmHg. The patient was scheduled for aortic valve replacement with coronary artery bypass graft surgery. After the induction of anesthesia and endotracheal intubation, transesophageal echocardiography (TEE) revealed the image shown in . What is the diagnosis?

Transfemoral Catheter Thrombolysis and Use of Sildenafil in Acute Massive Pulmonary Embolism - Corrected Proof

2010-02-08

ACUTE PULMONARY EMBOLISM (PE) develops in approximately 630,000 people annually and contributes to 200,000 deaths annually. The prophylactic use of heparin, vitamin K antagonists, or compression stockings are standard care in hospitalized individuals and particularly important in surgical patients because they have an increased risk for deep venous thrombosis and pulmonary embolism. The mortality associated with massive PE is secondary to acute right-heart failure and circulatory shock. Estimated mortality in the post-thrombolytic era in patients with acute PE with hemodynamic instability is between 23% and 38%; approximately 90% of these deaths occur within 2 hours of the onset of symptoms. Acute right-heart failure together with poor filling of the left heart are indicative; this condition may rapidly lead to circulatory arrest.

Surgery for Pseudoaneurysm of the Ascending Aorta: Role of Intraoperative 2-Dimensional and Real-time 3-Dimensional Transesophageal Echocardiography - Corrected Proof

Shrinivas Gadhinglajkar, Rupa Sreedhar — 2010-02-08

Intraoperative 2-dimensional (2D) transesophageal echocardiography (TEE) is a useful monitoring tool during aortic surgery and has been found to alter the surgical course for patients undergoing ascending aortic aneurysm repair. Published reports suggest that real-time 3-dimensional TEE (RT-3D-TEE) is a valuable technology for the intraoperative assessment of left ventricular assist devices and left atrial myxomas. However, its utility during the surgical repair of an ascending aortic pseudoaneurysm is yet to be evaluated. A 55-year-old female patient weighing 58 kg was operated on for aortic valve replacement. She was incidentally detected to have an ascending aortic pseudoaneurysm 3 months after surgery on a routine chest x-ray. A chest computed tomography scan revealed a pseudoaneurysm of the ascending aorta measuring 13 cm in its transverse diameter, which was compressing the main pulmonary artery and the superior vena cava (SVC). Even though there was no evidence of tracheal compression on the computed tomography scan, the shape of the trachea was altered. The patient was subjected to surgical repair of the pseudoaneurysm on an emergency basis.

Severe Pulmonary Artery Hypertension Caused by Hypoglycemia After Cardiac Surgery - Corrected Proof

Gaganpal Singh, Sanjay Goel, Sanjay Majhi, Bishnu Panigrahi — 2010-02-05

The recent pro/con debate on tight glycemic control reviewed the literature, but consensus is still not clear. The institution of tight glycemic control has been shown to reduce morbidity and mortality after cardiac surgery in diabetic patients, but hypoglycemia is a potential risk of this therapy. In addition, the majority of these patients are on β-blockers and the presentation of hypoglycemic symptoms may vary among them. We present a case of severe pulmonary artery hypertension caused by hypoglycemia in a post–cardiac surgery patient receiving β-blocker therapy.

Pro and Con Ultrasound: Are We Missing the Larger Picture? - Corrected Proof

Catalin Ezaru, Andrew Murray, Todd Oravitz, James Ibinson, Michael Mangione — 2010-02-05

We read the pro and con debate with great interest, and the arguments presented by both sides appear compelling. Minimizing or eliminating complications associated with central venous catheterization (CVC) should be expected of every practitioner, regardless of training or experience level. Arterial injury caused by a large-bore catheter or dilator, albeit infrequent, can be a devastating complication of CVC.

A Category I Indication for Transesophageal Echocardiography - Corrected Proof

Muralidhar Kanchi — 2010-02-05

Mitral stenosis (MS) is not an uncommon condition presenting for interventional procedures as reviewed recently in the Journal. “Mitral valvuloplasty” is offered to these patients who have MS with a pliable valve. Percutaneous transvenous mitral commissurotomy (PTMC) is associated with a low risk of major complications and yields an excellent immediate and long-term outcome. In addition, PTMC is nontraumatic and efficacious in a subset of patients at high risk because of medical comorbidities. The increase in the mitral valve area is determined by morphologic and hemodynamic changes produced in the valve by PTMC. Wilkins et al examined a number of clinical hemodynamic and echocardiographic variables to predict success after PTMC; patients who have a splittability score of less than 9 had an optimal result after PTMC. However, a significant number of patients develop left atrial clots before presentation to a heart center. The main indication for transesophageal echocardiography for the assessment of MS is for the exclusion of left atrial thrombosis, which is a contraindication to PTMC. The author believes that performing transesophageal echocardiography is mandatory before a balloon mitral valvuloplasty to detect the presence of LA thrombi. Hence, it is strongly believed that a list of category I indications for transesophageal echocardiography should include patients with MS who are candidates for PTMC.

Coopdech Bronchial Blocker Is Useful in Abnormalities of the Tracheobronchial Tree - Corrected Proof

Roser Garcia-Guasch, Anna Flo, Pedro L. de Castro — 2010-02-01

We recently read the interesting study by Dumans-Nizard et al in the Journal, and would like to present our experience with bronchial blockers. The Coopdech endobronchial blocker (Smiths-Medical, Barcelona, Spain) has recently been introduced in Europe. A multiport adapter allows ventilation and introduction of both a fiberoptic bronchoscope and a bronchial blocker (). The distal end has an angle of 20°. We present a case in which an Arndt endobronchial blocker (William Cook Europe A/S, Bjaeverskov, Denmark) was abandoned, and a Coopdech was inserted uneventfully.

Complications with Laser-Lead Extraction - Corrected Proof

Emily H. Garmon, William E. Johnston — 2010-02-01

FIBROTIC SHEATHS often develop around implanted intracardiac leads and prevent removal by simple counter-traction. The excimer laser lead extraction system was approved in 1997 by the Food and Drug Administration as an alternative to open-chest removal of implantable endocardial leads when minimally invasive counter-traction techniques proved unsuccessful. With laser-lead extraction, a xenon chloride cool cutting laser sheath (with an absorption depth of 0.06 mm) is advanced over an existing lead under fluoroscopic visualization. Proteins and lipids absorb the energy and dissolve the fibrotic sheath surrounding the leads for extraction, leaving the surrounding tissue and other leads unharmed. Counter-traction is then applied to remove the lead. Since complete description of the procedure is outside the scope of this article, the reader is referred to Kennergren et al for an excellent review of the technical aspects of this procedure with illustrations.

Transthoracic Echocardiography for the Identification of Acute Aortic Regurgitation in the Intensive Care Unit - Corrected Proof

2010-02-01

An interesting case is presented in which transthoracic echocardiography provided serendipitous diagnostic information and aided in the diagnosis of acute aortic regurgitation in the setting of the intensive care unit (ICU). Specifically, a 67-year-old female patient underwent mitral valve replacement and then was admitted to the ICU for further monitoring. Six hours later, the patient was hemodynamically unstable with significant coagulation abnormalities. For this reason, FOCUS transthoracic cardiac ultrasound examination was used, which finally revealed significant aortic regurgitation with a pressure half-time (PHT) of 240 milliseconds (). These findings were absent in the preoperative transthoracic and intraoperative transesophageal echocardiographic examination, respectively; hence, acute aortic regurgitation was diagnosed, and the patient underwent another operation. Indeed, dysfunction of the noncoronary cusp was possibly induced by trauma of the aortic valve during mitral valve replacement. In our case, we considered that aortic valve dysfunction developed intraoperatively, and the anesthesiologist might have overlooked aortic regurgitation during routine transesophageal examination after cardiopulmonary bypass.

Finding Information by “Design”: Search Strategies for Cardiothoracic and Vascular Anesthesia Literature - Corrected Proof

Viji Kurup, Denise Hersey — 2010-01-28

CARDIOTHORACIC AND VASCULAR anesthesia is a dynamic field with a strong emphasis on evidence-based care. Efficient literature searching is an indispensable tool for medical practice, research, and education. The practice of evidence-based medicine requires the integration of the best available evidence with patient conditions and preferences to guide clinical practice every day. However, keeping up with the literature has become an increasingly difficult task for the busy practicing physician. The amount of medical information available has increased exponentially. It is estimated that the average physician uses 2 million pieces of information to practice medicine. There are 7 million pages of information added to the World Wide Web every day. “Information overload” is being recognized as a prevalent problem. In 1996, Waddington reported that information overload was leading to stress and tension within the work environment, resulting in longer working hours, loss of job satisfaction, decrease in social life, tiredness and illness, and a degradation in personal relationships. The report underscored the need to take information management seriously. This has led to a growing realization among the medical community of the importance of acquiring and teaching information management skills.

Response: Is It Reasonable To Discourage Propofol Use in Cardiac Surgery Patients Until Strong Evidence Is Provided? - Corrected Proof

Lukasz Krzych, Dariusz Szurlej, Andrzej Bochenek — 2010-01-25

We appreciate that our article was read by Landoni et al with such attention. In our article, we attempted to describe a rationale for propofol use in cardiac surgery. We aimed to summarize data from the literature regarding the influence of the agent on the cardiovascular system, vessels, and blood including the inflammatory response.

Any Rationale for Propofol Use in Cardiac Surgery? - Corrected Proof

Giovanni Landoni, Isotta Virzo, Elena Bignami, Alberto Zangrillo — 2010-01-25

We read with interest the article by Krzych et al regarding propofol use in cardiac surgery. We agree with the authors that propofol is widely used in cardiac surgery worldwide for the induction and maintenance of general anesthesia and for sedation in intensive care units. We disagree that there is any evidence-based rationale to support its use in cardiac surgery when patients' clinically relevant outcomes are considered.

Quantitative Imaging of Microcirculatory Response During Nitroglycerin-Induced Hypotension - Corrected Proof

2010-01-25

MORE THAN 20 YEARS AGO, Endrich et al investigated the effects of nitroglycerin (NTG)-induced hypotension on microcirculation in a hamster dorsal skin fold model using intravital microscopy, quantitative video image analysis, and a micropuncture system for the determination of microcirculatory pressure. The authors concluded that NTG dilated both arterioles and venules in the microvascular network during hypotension as shown by a decrease in the arteriolar-venular pressure gradient.

Assessing Agreement in Cardiac Output Monitoring Validation Studies - Corrected Proof

2010-01-25

We have read the meta-analysis by Mayer et al with interest. They should be congratulated for attempting to bring together a number of heterogenous studies into a single paper evaluating the accuracy and precision of the FloTrac/Vigileo System (Edwards Lifesciences, Irvine, CA) for monitoring cardiac output. We think that the article tries to address a very important issue, which is trying to take into consideration the results of several validation studies assessing the same device.

Response to Cecconi et al - Corrected Proof

Gerard R. Manecke — 2010-01-25

We would like to thank Dr Cecconi and his colleagues for their thoughtful, insightful comments. We agree wholeheartedly that consensus and consistency in terminology and study design must be established for validation studies. Furthermore, we regret any confusion we might have contributed by our reporting the “precision” in our previous articles. Indeed, in the Manecke study, “precision” refers to 1 standard deviation from the mean, whereas in the Mayer study “precision” refers to 2 standard deviations from the mean. We agree we should have clarified this.

Acute Lung Injury After Thoracic Surgery - Corrected Proof

Kenneth D. Eichenbaum, Steven M. Neustein — 2010-01-11

THORACIC SURGERY may be followed by pulmonary complications, such as atelectasis, pneumonia, and respiratory failure requiring ventilatory support. In recent years, the incidence of these complications has declined. Advances in perioperative management such as post-thoracotomy epidural analgesia and incentive spirometry may have contributed to a reduction of these complications. However, with an estimated 190,000 cases of acute lung injury annually in the United States accounting for 3.6 million hospital days, lung injury remains a major source of morbidity and mortality after lung resection.

Remifentanil Reduces the Release of Biochemical Markers of Myocardial Damage After Coronary Artery Bypass Surgery: A Randomized Trial - Corrected Proof

Gordon T.C. Wong, Zhiyong Huang, Shangyi Ji, Michael G. Irwin — 2010-01-08

Objective: Opioids, including remifentanil, have been demonstrated to confer cardiac protection against ischemia reperfusion injury in animals. This study evaluated whether remifentanil preconditioning is protective in first-time elective on-pump coronary artery bypass surgery patients receiving a standardized fentanyl (25 μg/kg in total) and propofol anesthetic.Design: A prospective, double blind, randomized, controlled study.Setting: University hospital; single institution.Participants: Forty patients scheduled for first-time elective, on-pump coronary artery bypass surgery for at least 3 diseased vessels.Interventions: Patients randomized to the remifentanil group (n = 20) received a 1 μg/kg bolus followed by a 0.5 μg/kg/min infusion for 30 minutes after induction but before sternotomy, while the control group (n = 20) received normal saline. Serial samples for measurement of creatine kinase (CK-MB), cardiac troponin I (cTnI), ischemia-modified albumin (IMA) and heart-type fatty-acid-binding protein (hFABP) were taken at baseline, prebypass, T = 10 minutes, 2, 6, 12, and 24 hours after cross-clamp release, to assess the degree of myocardial damage.Measurements and Main Results: Patients in the remifentanil group had lower levels of CK-MB from T = 2 hours to 24 hours, cTnI from T = 10 minutes to T = 12 hours, IMA from T = 10 minutes to T = 2 hours and h-FABP from T = 10 minutes to T = 12 hours (p < 0.05). The time to tracheal extubation was shorter in patients in the remifentanil group. The overall lengths of ICU and hospital stays were not different.Conclusions: The addition of remifentanil to the anesthesia regimen reduced the degree of myocardial damage. This incremental benefit may be attributable either to remifentanil itself or to an overall increased opioid dose, the latter may be necessary to trigger cardiac protection.

Intraoperative Pulmonary Tumor Embolism from Renal Cell Carcinoma and a Patent Foramen Ovale Detected by Transesophageal Echocardiography - Corrected Proof

2010-01-08

PULMONARY TUMOR EMBOLIZATION from renal cell carcinoma is a fatal complication during nephrectomy since it is associated with high perioperative mortality and cardiopulmonary morbidity. A persistent patent foramen ovale (PFO) is a heart defect that can be found in approximately one-fourth of the population and increases the risk for ischemic stroke and arterial embolization. A unique case of intraoperative pulmonary tumor embolism is described in a patient with a previously undiagnosed PFO, in whom intraoperative transesophageal echocardiography (TEE) led to fast diagnosis, successful surgical embolus removal and closure of the PFO.

Profound Effects of Cardiopulmonary Bypass Priming Solutions on the Fibrin Part of Clot Formation: An Ex Vivo Evaluation Using Rotation Thromboelastometry - Corrected Proof

2010-01-07

Objectives: Dilutional coagulopathy as a consequence of cardiopulmonary bypass (CPB) system priming may also be affected by the composition of the priming solution. The direct effects of distinct priming solutions on fibrinogen, one of the foremost limiting factors during dilutional coagulopathy, have been minimally evaluated. Therefore, the authors investigated whether hemodilution with different priming solutions distinctly affects the fibrinogen-mediated step in whole blood clot formation.Design: Prospective observational laboratory study.Setting: University hospital laboratory.Participants: Eight male healthy volunteers.Interventions: Blood samples diluted with gelatin-, albumin-, or hydroxyethyl starch (HES)-based priming solutions were ex-vivo evaluated for clot formation by rotational thromboelastometry.Measurements and Main Results: The intrinsic pathway (INTEM) coagulation time increased from 186 ± 19 seconds to 205 ± 16, 220 ± 17, and 223 ± 18 seconds after dilution with gelatin-, albumin-, or HES-containing prime solutions (all p < 0.05 v baseline). The extrinsic pathway (EXTEM) coagulation time was only minimally affected by hemodilution. Moreover, all 3 priming solutions significantly reduced the INTEM and EXTEM maximum clot firmness. The HES-containing priming solution induced the largest decrease in the maximum clot firmness attributed to fibrinogen, from 13 ± 1 mm (baseline) to 6 ± 1 mm (p < 0.01 v baseline).Conclusions: All studied priming solutions prolonged coagulation time and decreased clot formation, but the fibrinogen-limiting effect was the most profound for the HES-containing priming solution. These results suggest that the composition of priming solutions may distinctly affect blood clot formation, in particular with respect to the fibrinogen component in hemostasis.

Reply to Dr Valdivieso - Corrected Proof

Julie L. Huffmyer, Edward C. Nemergut — 2010-01-07

First of all, we would like to thank Dr Valdivieso for his interest in our work. In this study, we reviewed the perioperative records of 2,760 patients who underwent coronary artery bypass graft surgery over a 10-year period to evaluate the potential effect of preoperative statin administration on outcome. The preoperative variables we examined included age, sex, race, estimated GFR (eGFR), and statin administration. In our discussion, we acknowledged that many risk factors for acute renal failure (ARF) and renal replacement therapy including preoperative need for intra-aortic balloon pump, preoperative low ejection fraction, and diabetes mellitus were not consistently available in our database. We appreciate his comments and agree, as we stated in our article, that our interpretations are limited by the retrospective design of our study; however, the large sample size of our population (>2,700 patients) over a 10-year time span certainly limits the impact of these confounding variables.

Argatroban “Reversal” Is Caused by Nonphysiologic Stimulation of Coagulation Not Activated Factor VII - Corrected Proof

Kenichi A. Tanaka, Fania Szlam, Kaoru Koyama, Jerrold H. Levy — 2010-01-07

We read with interest the report on argatroban anticoagulation monitored by thromboelastography (TEG). The authors suggested that activated factor VII (FVIIa) might overcome argatroban anticoagulation based on the “normal” TEG tracing with dual activators (rapid TEG) kaolin and tissue factor (TF). However, there are several issues with this interpretation of which the readers should become aware. First, contact-activated tests (eg, partial thromboplastin time and activated coagulation time) are more sensitive to argatroban than the TF-activated test. The contact-activated pathway via FXIIa formation proceeds slowly until thrombin-mediated feedback activation of FV and FVIII occurs (A). Argatroban and other direct thrombin inhibitors reduce the propagation of thrombin generation by inhibiting the latter feedback mechanisms. Second, TF added to kaolin in rapid TEG is supraphysiologic; thus, it is not surprising to see some thrombin molecules escape argatroban inhibition. It is important to mention that platelets and fibrinogen can be rapidly activated when a relatively small amount of thrombin (10-20 nmol/L, peak thrombin >150 nmol/L) is available. A seemingly “normalized” TEG tracing does not represent the recovery of endogenous thrombin generation (B). Coagulopathy in the presence of argatroban is typically multifactorial because of different underlying conditions such as heparin-induced thrombocytopenia or low fibrinogen. We agree that TEG can be a useful diagnostic tool to evaluate the time course of hemostatic function, but results should be interpreted carefully because different activators and instruments yield different coagulant parameters. Because the procoagulant effects of FVIIa critically depend on TF, the clinical efficacy of FVIIa cannot be inferred simply from nonphysiologic activation of coagulation on rapid TEG.

Considerations About the Association Between Preoperative Statin Administration and Outcomes in Patients Undergoing CABG - Corrected Proof

Jose Ramon Perez-Valdivieso — 2010-01-07

In a recent article on patients undergoing coronary artery bypass graft surgery, Huffmyer et al concluded that preoperative statin administration resulted in a decreased incidence of postoperative mortality and need for hemodialysis. The authors should be praised for their efforts in this important area. However, this research raises several issues. First, authors should specify if more variables were included into the database apart from the ones stated in the article and moreover if they were studied in a univariate analysis. Otherwise, the readers can assume that not enough variables were analyzed to accurately assess the effect of statins on outcomes. Although the authors mention as an important limitation that some risk factors were not consistently included in the database, they are confident that the size of the population studied might have limited the impact of such bias. However, it remains unclear to me to what extent other variables may have influenced the outcomes. The practical effect is that few baseline characteristics are available to adjust in the performance of a multivariate analysis. In other words, clinical scores or some of their variables should have been included, such as Thakar or Mehta scores or the Euroscore for instance. In this way, patients could have been compared according to their risk profiles for acute kidney injury or mortality after cardiac surgery. At the same time, the readers could have been better informed about the characteristics in the study population and if the results given could be extrapolated to other cohorts of patients. Finally, I find the definition of acute renal failure in reference to the Acute Dialysis Quality Initiative Group to be inappropriate. The definition formulated by this group is broader and far more sensible than a mere decrease in the estimated glomerular filtration rate of >50%.

Speckle Tracking for the Intraoperative Assessment of Right Ventricular Function: A Feasibility Study - Corrected Proof

2010-01-07

Objectives: Speckle tracking is an ultrasound method that assesses B-mode features to measure tissue displacement and derive deformation parameters. The objective of this study was to assess the feasibility of using speckle tracking in the measurement of right ventricular (RV) longitudinal strain during cardiac surgery using transesophageal echocardiography (TEE).Design: This was a prospective, observational cohort study.Setting: A single university hospital setting.Participants: Twenty-one patients without valvular disease referred for coronary artery bypass graft surgery were studied.Interventions: None.Measurements and Main Results: After the induction of anesthesia and mechanical ventilation, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were used to obtain tricuspid annular plane systolic excursion (TAPSE), RV fractional area of change (FAC), and 2-dimensional strain analysis (speckle tracking) on 3 consecutive heart beats. There was a larger percentage of measurable segments achieved when using TEE. All segments could be analyzed per cardiac cycle in 73% of loops when using TEE and 38% when using TTE. The global strain value was similar using both methods (TEE: −20.4%, TTE: −20.1%). The TAPSE could be measured in only 52% of the segments using TTE and 100% using TEE. The FAC could be measured in 90.5% of the loops using TEE and in only 33.3% of the loops using TTE.Conclusions: Perioperative measurements of RV strain using TEE in ventilated patients is feasible. The success rate was higher using TEE in ventilated patients under anesthesia. Differences between the 2 methods were likely the result of differences in 2-dimensional image quality.

Effects of Single-Dose Gabapentin on Postoperative Pain and Morphine Consumption After Cardiac Surgery - Corrected Proof

2010-01-07

Objective: The purpose of this study was to evaluate the analgesic effect of single-dose preoperative gabapentin on postoperative pain and morphine consumption after cardiac surgery.Design: A randomized, double-blind, placebo-controlled, clinical study.Setting: A single university hospital.Participants: Sixty patients undergoing coronary artery bypass graft surgery.Interventions: Patients were randomly allocated into 2 groups preoperatively either to receive 600 mg of oral gabapentin (GABA) or placebo (PLA) 2 hours before the operation. After extubation, an anesthesiologist blinded to the groups recorded pain scores both at rest and with cough with a 10-point verbal rating scale and sedation scores at 2, 6, 12, 18, 24, and 48 hours. Cumulative morphine consumption and the incidence of side effects were recorded during the study period.Measurements and Main Results: The total morphine consumption was lower in the GABA group (6.7 ± 2.5 mg) than in the PLA group (15.5 ± 4.6 mg, p < 0.01). Pain scores at rest were significantly lower in the GABA group than in the PLA group throughout the study period (p < 0.05 in all measurement times). Pain scores at 2, 6, and 12 hours during coughing were significantly lower in the GABA group (p < 0.05). The number of oversedated patients was significantly higher in the GABA group at 2, 6, and 12 hours of study compared with PLA (p < 0.001 at 2 and 6 hours and p < 0.02 at 12 hours). The postoperative mechanical ventilation period was significantly prolonged in the GABA group (6.6 ± 1.2 hours) compared with the PLA group (5.5 ± 1 hours, p < 0.01). Nausea incidence was significantly lower in the GABA group (n = 9) than in the PLA group (n = 18, p = 0.02).Conclusions: Oral GABA at a dose of 600 mg given before cardiac surgery significantly reduced postoperative morphine consumption and postoperative pain both at rest and with cough.

Inhaled Nitroglycerin Versus Inhaled Milrinone in Children with Congenital Heart Disease Suffering from Pulmonary Artery Hypertension - Corrected Proof

2010-01-07

Objective: The aim of the present study was to compare the acute effects of inhaled milrinone and inhaled nitroglycerin on pulmonary and systemic hemodynamics in children with acyanotic congenital heart disease (left-to-right shunt) and pulmonary artery hypertension.Design: Randomized clinical trial.Setting: Catheterization laboratory of a tertiary care hospital.Participants: Thirty-five children below the age of 12 years who were suffering from acyanotic congenital heart disease with left-to-right intracardiac shunt and pulmonary artery hypertension (mean PA pressure > 30 mmHg).Intervention: Right-heart catheterization was done using an end-hole balloon wedge pressure catheter. Baseline pulmonary and systemic hemodynamic parameters were recorded for all patients while breathing room air. All patients then underwent pulmonary vasodilator testing with 100% oxygen. Following this, patients were randomized into two groups and received either inhaled milrinone (group M, n = 18) or inhaled nitroglycerin (group N, n = 17) in a 50% air-oxygen mixture. Oximetry data were used to calculate systemic and pulmonary cardiac output based on Fick's principle.Results: Systolic, diastolic, and mean pulmonary artery pressures decreased significantly in both the groups after drug nebulization, while there were no significant changes in systemic pressures. The percentage decrease from baseline in systolic (5.2% v 8.6%, p = 0.43), diastolic (19.5% v 16.8%, p = 0.19) and mean (14.9% v14.5%, p = 0.29) pulmonary artery pressures were comparable in both groups. The pulmonary vascular resistance index (PVRI) decreased from 9.0 ± 3.9 to 2.9 ± 1.7 Wood Units (WU)/m2 in group M (p < 0.001) and from 8.6 ± 3.8 to 3.2 ± 3.3 WU/m2 in group N (p < 0.001). The fall in pulmonary artery pressures after drug nebulization in both groups was comparable to the fall seen with 100% oxygen.Conclusion: Both milrinone and nitroglycerin when given via the inhaled route significantly decrease systolic, diastolic and mean pulmonary artery pressures as well as PVRI without significant effects on systemic hemodynamics. Both the drugs given via inhaled route therefore can offer a good therapeutic choice and can help decrease the high inspired oxygen concentrations needed to treat pulmonary artery hypertensive episodes in perioperative settings.

Percutaneous Left Ventricular Assist Devices: Clinical Uses, Future Applications, and Anesthetic Considerations - Corrected Proof

Juan N. Pulido, Soon J. Park, Charanjit S. Rihal — 2010-01-07

THE EVOLUTION OF cardiovascular medicine has been dictated by the prevalence and high mortality of cardiovascular disease. The past 30 years have yielded an exponential increase in both knowledge and technologic progress in this field, from preventive cardiology and the movement toward gene therapy, to complex interventional therapeutics expanding the frontiers of minimally invasive procedures performed in the catheterization laboratory. These include high-risk percutaneous coronary interventions (PCIs) requiring temporary circulatory support and valvular interventions (percutaneous aortic valve replacement, mitral valvuloplasty).

The Effect of the Suspension of the License for Aprotinin on the Care of Patients Undergoing Cardiac Surgery: A Survey of Cardiac Anesthesiologists' and Surgeons' Opinions in the United Kingdom - Corrected Proof

Victoria McMullan, R. Peter Alston — 2010-01-07

Objective: The primary aim was to poll the opinions of cardiac anesthesiologists and surgeons as to the effect of the suspension of the license for aprotinin on patients undergoing cardiac surgery.Design: A mailed questionnaire.Setting: United Kingdom.Participants: Members of the Association of Cardiothoracic Anaesthetists and the Society for Cardiothoracic Surgery in Great Britain and Ireland with a UK address.Interventions: A structured questionnaire.Measurements and Main Results: Of the 546 dispatched surveys, 285 (52%) were returned. While the majority of respondents (61%) felt it had not had any effect, 29% of respondents felt the suspension of the license for aprotinin had had a detrimental effect on patient care and 2% an extremely detrimental effect. Eight percent of respondents reported a beneficial effect. Since license suspension, the reported use of aprotinin had declined and tranexamic acid use had risen. The majority of respondents reported no change in the use of packed red cells (66%), blood products (53%), mechanical cell salvage (84%), factor VIIa (79%), or frequency of reopening for bleeding (65%). Respectively, 32%, 45%, 24%, and 20% of respondents reported a perceived increased use of these products, and 30% reported an increased frequency of reopening for bleeding. Apart from knowledge regarding local aprotinin stock, there was no significant difference in opinions between surgeons and anesthesiologists.Conclusions: While the majority of respondents felt that the suspension of the license for aprotinin had no effect, almost a third felt it had impacted negatively on the care of patients undergoing cardiac surgery.

High-Frequency Jet Ventilation as an Alternative Method Compared to Conventional One-Lung Ventilation Using Double-Lumen Tubes: A Study of 40 Patients Undergoing Minimally Invasive Coronary Artery Bypass Graft Surgery - Corrected Proof

2010-01-07

Objective: To optimize the conditions for the surgeon during minimally invasive direct coronary artery bypass (MIDCAB) and totally endoscopic coronary artery bypass (TECAB) procedures, one-lung ventilation (OLV) is required using double-lumen tubes (DLT). This prospective study was designed to compare high-frequency jet ventilation (HFJV) of both lungs with the conventional method of OLV via DLT.Design: Prospective, randomized, clinical study.Setting: University-affiliated heart center.Participants: Forty patients with coronary artery disease and scheduled for elective MIDCAB or TECAB procedures were equally randomized into a DLT and an HFJV-group.Interventions: In the DLT group, OLV of the right lung was performed throughout the surgical procedure. In the HFJV group, patients received a conventional single-lumen endotracheal tube and both lungs were ventilated using HFJV.Measurements: Hemodynamic, oxygenation and ventilation parameters were measured at the beginning of the operation, then 5, 15, 30, and 60 minutes after OLV/HFJV, as well as immediately before transfer to the ICU.Main Results: Regarding the view of the surgical field, surgeons' comfort did not differ between methods. The intraoperative PaO2 was significantly higher in the HFJV group compared with the DLTs group at 5 (336.8 ± 123.3 v 228.6 ± 124.0; p = 0.009) and 15 minutes (301.7 ± 133.9 v 192.6 ± 92.8; p = 0.012). The PaCO2 was significantly higher in the HFJV groups after 5 minutes and persisted through 60 minutes of ventilation. The peak inspiratory pressure was significantly lower during HFJV (10.0 ± 2.8 mbar v 32.1 ± 5.9 mbar).Conclusions: HFJV in MIDCAB or TECAB procedures appears to be a feasible alternative to OLV using a DLT, although study in a larger population is required.

Association of the 98T ELAM-1 Polymorphism with Increased Bleeding After Cardiac Surgery - Corrected Proof

2010-01-07

Objective: Hemorrhage continues to be a major problem after cardiac surgery despite the routine use of antifibrinolytic drugs, with striking inter-patient variability poorly explained by already known risk factors. The authors tested the hypothesis that genetic polymorphisms of inflammatory mediators and cellular adhesion molecules are associated with bleeding after cardiac surgery.Design: Prospective, observational study.Setting: Single, tertiary referral university heart center.Participants: Adult patients undergoing aortocoronary surgery with cardiopulmonary bypass.Interventions: Patients (n = 759) had 10 mL of blood drawn preoperatively and genomic DNA isolated then genotyped for 17 polymorphisms in 7 candidate genes: tumor necrosis factor, interleukins 1β and 6, interleukin 1 receptor antagonist, intercellular adhesion molecule-1 (ICAM-1), P-selectin and endothelial leucocyte adhesion molecule-1 (E-selectin). Multivariate analyses were used to relate clinical and genetic factors to bleeding and transfusion.Measurements and Main Results: The 98G/T polymorphism of the E-selectin gene was independently associated with bleeding after cardiac surgery (p = 0.002), after adjusting for significant clinical predictors (patient size and baseline hemoglobin concentration). There was a gene dose effect according to the number of minor alleles in the genotype; carriers of the minor allele bled 17% (GT) and 54% (TT) more than wild type (GG) genotypes, respectively (p = 0.01). Carriers of the minor allele also had longer activated partial thromboplastin times (p = 0.0023) and increased fresh frozen plasma transfusion (p = 0.03) compared with wild type.Conclusions: The authors found a dose-related association between the 98T E-selectin polymorphism and bleeding after cardiac surgery, independent of and additive to standard clinical risk factors.

Guidewire Entrapment in a Tricuspid Valve Apparatus - Corrected Proof

2009-12-28

Percutaneous insertion of central venous catheters is routine in clinical practice. The authors report a case of an entrapped guidewire in a tricuspid valve apparatus during the insertion of a double-lumen dialysis catheter in a 45-year-old woman with chronic renal failure. Many anesthesiologists are not aware of the possibility of entangling the guidewire in the tricuspid valve apparatus, and excessive force during attempted removal can have disastrous consequences.

Epidural Anesthesia for Cesarean Section in a Patient With Severe Mitral Stenosis and Pulmonary Hypertension - Corrected Proof

2009-12-28

Mitral stenosis (MS) is the most prevalent clinically significant cardiac disease in pregnant women. It is considered severe when the mitral valve area is 1 cm2 or less, and maternal mortality rate may reach 15% if MS is accompanied by symptomatic pulmonary hypertension.

Iatrogenic Oropharyngeal Injury and Hemorrhage Requiring Blood Transfusions During Insertion of Transesophageal Echocardiographic Probes in Patients Undergoing Cardiac Surgery - Corrected Proof

Murali Chakravarthy — 2009-12-28

Complications such as oromucosal injury, perforation of the esophagus, perforation of the stomach, and death have been attributed to the insertion of a transesophageal echocardiography (TEE) probe. However, after an audit of 7,200 patients, it was suggested that TEE is a safe mode of investigation. Additionally, intraoperative TEE influenced cardiac surgical decisions in more than 9% of 12,000 patients, with the greatest observed impact in patients undergoing combined coronary artery bypass graft surgery and valve procedures. Based on the reported morbidities and mortalities associated with the use of a TEE probe, it is difficult to make an observation on the risk-benefit analysis of intraoperative TEE. Despite these claimed unquestionable benefits, Piercy et al recently recommended that “TEE use in cardiac surgery should be evaluated in the light of practice guidelines and morbidity and mortality data and not considered routine” after encountering 3 deaths among other morbidities in their analysis of data collected over 2 years. It is now clear that despite several claimed benefits, caution has to be exercised when a TEE probe is inserted. We report 2 cases of iatrogenic oropharyngeal injury after TEE probe insertion. Unanticipated difficulty was encountered in intubation of the first patient who developed hemorrhage requiring otolaryngologic intervention and blood transfusion. The second patient required insertion of a TEE probe with compromised exposure to the oral cavity (caused by the metal frame used routinely at our center) after the induction of general anesthesia and the commencement of surgery. The probe was maneuvered under the metal frame. The TEE probe caused injury to the posterior pharyngeal wall, resulting in hemorrhage requiring blood transfusion.

Failure of Double-Lumen Tube Cuff Deflation on the Cuff Leak Test - Corrected Proof

Koichi Nakazawa, Megumi Ohtaha, Koshi Makita — 2009-12-28

Difficulty in removing air from a cuff is usually caused by valve failure or damage to or kinking of the tubing connecting the pilot balloon to the cuff. We experienced another mechanism of cuff deflation failure while performing the cuff leak test.

Anesthesia for Combined Cardiac Surgery and Liver Transplant - Corrected Proof

2009-12-28

Objective: To describe aspects of anesthesia for combined cardiac surgery and orthotopic liver transplant (OLT).Design: Retrospective case series.Setting: Hospital with cardiac surgery and liver transplant programs.Participants: Nine patients between September 1998 and July 2006.Intervention: Combined cardiac surgery and OLT.Measurement and Main Results: Demographic and outcome data were recorded for each patient. Multiple intraoperative parameters were collected at baseline, after induction of anesthesia, after cardiac surgery, and after OLT. Five patients underwent combined OLT and coronary artery bypass graft (CABG) surgery. Four patients underwent combined OLT and aortic valve replacement (AVR) to relieve aortic stenosis. One of these 4 patients also had a saphenous vein graft to the left anterior descending artery. The CABG/OLT patients had hypertension, diabetes, or both, and multiple coronary arteries were affected although ejection fraction was preserved. The 1 death in this group was unrelated to a coronary event. The AVR/OLT patients had aortic stenosis that met American Heart Association guidelines for AVR. One death, within 24 hours of surgery, was associated with severe pulmonary artery hypertension. The median transfusion volumes were 12 units of packed red blood cells, 22 units of fresh frozen plasma, and 30 units of platelets. Three of the 9 patients required renal replacement therapy postoperatively. The median duration of intubation was 2 days, and length of stay in the intensive care unit was 5.5 days.Conclusion: Combined cardiac and OLT surgery is complex and serious morbidity occurs, but successful outcomes are attainable.

Milrinone Improves Diastolic Function in Coronary Artery Bypass Surgery as Assessed by Acoustic Quantification and Peak Filling Rate: A Prospective Randomized Study - Corrected Proof

Birger Axelsson, Mikael Arbeus, Anders Magnuson, Jan Hultman — 2009-12-18

Objective: To compare the effects of a bolus dose of milrinone, 50 μg/kg, to placebo on diastolic function (active relaxation) in patients undergoing on-pump coronary artery bypass grafting (CABG).Design: Prospective, randomized, double-blind, placebo-controlled study.Setting: University hospital.Participants: Twenty-four patients with stable angina and left ventricular ejection fraction >30%, scheduled for elective CABG using cardiopulmonary bypass (CPB), were included.Intervention: Patients were randomized to receive either 50 μg/kg of milrinone (n = 12) or placebo (n = 12) after aortic declamping.Measurements and Main Results: The diastolic function of the left ventricle (LV) was measured as peak filling rate (dA/dt [maximal diastolic area change over time]) with transesophageal echocardiography (TEE) using acoustic quantification (AQ) before CPB and 10 minutes after termination of CPB. The normalized peak filling rate (dA/dt)/EDA was also calculated. Active relaxation was statistically significantly increased in the milrinone group compared with the placebo group after CPB.Conclusion: Patients undergoing CABG surgery and treated with milrinone after aortic declamping had better diastolic function following cardiopulmonary bypass.

Arterial Pressure Variation and Goal-Directed Fluid Therapy - Corrected Proof

Maxime Cannesson — 2009-12-18

FLUID MANAGEMENT AND OPTIMIZATION are daily problems in anesthesiology and in the critical care setting. Hemodynamic management is related to the optimization of oxygen delivery to the tissues and has been shown to be able to improve postoperative outcome and to decrease the cost of surgery. Schematically, in the operating room, the anesthesiologist and his/her patients have to deal with 2 distinct risks: hypovolemia on one side and hypervolemia on the other side. Both risks potentially can lead to a decrease in oxygen delivery to the tissues and to an increase in postoperative morbidity (). However, despite evidence showing that organ perfusion requires 2 physiologic objectives, adequate perfusion pressure in order to force blood into the capillaries of all organs and adequate cardiac output to deliver oxygen and substrates and to remove carbon dioxide and other metabolic products, and despite data showing the impact of cardiac output optimization on postoperative outcome, cardiac output monitoring rarely is used in the daily anesthesiology practice; clinicians still rely on clinical judgment, blood loss estimates, and the vague concept of third-space losses.

Unexpected Air in the Left Ventricle after Aortic Cannulation in Two Patients with Severe Aortic Insufficiency: Possible Mechanisms and Clinical Implications - Corrected Proof

Satyajeet Misra, Shrinivas Gadhinglajkar — 2009-12-14

Air bubbles are commonly seen in the heart on echocardiography after cardiac surgery and may lead to systemic air embolism. The morbidity and mortality potential of air embolism to the coronary and cerebral circulation are described and may affect the surgical outcome. Air embolism has been described both during initiation as well as termination of cardiopulmonary bypass (CPB).

Pulmonary Artery Catheter Use With Left-Sided Active Endocarditis: Deal or No Deal? - Corrected Proof

Fellery de Lange, Donald D. Glower, Mark Stafford Smith — 2009-12-14

Whenever the use of a pulmonary artery (PA) catheter is contemplated, it is always a matter of good clinical judgment and weighing risks and benefits. It has come to our attention that practitioners vary in their opinion on the safety of using a PA catheter in the management of patients with active left-sided endocarditis undergoing valve repair/replacement. We present the pros and cons and our experience on this topic.

Congenital Pleuropericardial Fistula Complicating Awake Cardiac Surgery - Corrected Proof

Murali Chakravarthy, Sona Mitra, Veerappa Muralimanohar, Vivek Jawali — 2009-12-14

Conducting awake cardiac surgery using thoracic epidural anesthesia (TEA) has been reported. Off-pump coronary artery surgeries, on-pump cardiac surgeries, and thoracic surgeries have been conducted successfully by using TEA (without endotracheal general anesthesia) at the authors' institute. Several other authors have reported conducting similar surgeries and have commented about the benefits of maintaining the pleural integrity during spontaneous ventilation during such surgeries. The occurrence of pneumothorax has been cited as one of the most important etiologies of failed awake surgeries. The modes of management of inadvertent pneumothorax include repairing the pleural breach, inserting intercostal drains connected to negative pressure, continuing the surgery while accepting the pneumothorax, or extending the opening in the pleura further to intentionally collapse the lung (so that the mediastinal movements do not disturb the operating surgeon) and applying fibrin glue on the pleural opening. The occurrence of congenital pleura pericardial fistula in a patient undergoing awake surgery may be rare, and such an anomaly may have adverse outcome during awake surgeries. We report a case causing difficulties in performing awake surgery because of pneumothorax that resulted after opening the pericardium.

Cardiac Football or Cause of Severe Tricuspid Regurgitation? - Corrected Proof

Edward D. Schiller, M. Ansar Maqsood, Paul S. Pagel — 2009-12-14

A 77-YEAR-OLD, 175-cm, 71-kg man was admitted to the authors' institution for evaluation of progressive dyspnea on exertion and reduced exercise tolerance of 2 years duration. His symptoms occasionally were accompanied by chest pressure without radiation and were relieved consistently with rest. The patient also described intermittent paroxysmal nocturnal dyspnea and recent lower-extremity swelling, but he denied orthopnea, diaphoresis, syncope, and palpitations. The patient had undergone 2-vessel coronary artery bypass graft surgery and an aortic valve replacement with a Carpentier-Edwards bioprosthetic valve (Edwards Life Sciences, Irvine, CA) for aortic insufficiency 24 years before the current admission. The patient's past medical history also was notable for chronic atrial fibrillation (for which he received digoxin and warfarin), well-controlled essential hypertension (treated with carvedilol, lisinopril, and furosemide), and hyperlipidemia (treated with simvastatin). The physical examination revealed a harsh grade III of VI crescendo-decrescendo systolic murmur best heard at the 4th left intercostal space that radiated to the left axilla. A second, lower-pitched holosystolic murmur (grade II of VI) was noted at the 2nd right intercostal space. A grade II of VI early diastolic murmur also was heard at the left ventricular apex. Auscultation of the lungs indicated bilateral basilar rales. There was jugular venous distention present, and lower-extremity pitting edema was observed, but hepatojugular reflux was not elicited. Transesophageal echocardiography (TEE) was performed as part of the evaluation. The leaflets of the bioprosthesis were thickened, calcified, and sclerotic (not shown). Moderate aortic stenosis (peak gradient of 37 mmHg, area of 1.05 cm2) and severe aortic insufficiency were present. The mitral valve leaflets also were calcified and showed reduced mobility concomitant with mild stenosis (area of 1.9 cm2) and severe regurgitation (not shown). The TEE examination further revealed the images shown in through . What is the diagnosis? What is the mechanism responsible for the echocardiographic findings?

Electronic Storage of Echocardiographic Images: From Clips to Bits - Corrected Proof

Ronald A. Kahn — 2009-12-14

WHILE THE DEVELOPMENT and implementation of echocardiography have advanced rapidly over the last few decades, the storage of these images also has evolved substantially. Early images were stored using static photographic techniques, which limited the representation of dynamic images. With the increased availability of video technology, videocassette recording (VCR) became the prevalent method of image storage. However, this technology is limited by its sequential nature (limiting random access of images both within as well as among studies), physical storage requirements, and propensity for degradation of images over time. The increased affordability of both digital computing hardware and software has allowed the digital storage of echocardiographic images. In this review, the advantages of digital storage of images, the validation of digital storage in the interpretation of echocardiographic examinations, the concepts and language of echocardiographic image storage, and the necessary components for the establishment and operation of a digital echocardiographic storage system are discussed. This review is meant to provide the clinician with the basic concepts and terminology for effective communication with both potential vendors and members of his/her information technology department during the acquisition, development, and operation of a digital storage solution; it is not meant to be a comprehensive review of the subject.

Different Anesthetic Techniques Associated with Different Incidences of Chronic Post-thoracotomy Pain: Low-Dose Remifentanil Plus Presurgical Epidural Analgesia is Preferable to High-Dose Remifentanil with Postsurgical Epidural Analgesia - Corrected Proof

2009-12-14

Objective: To investigate the relationships between 2 anesthetic techniques, or the extent of allodynia around the surgical wound, and the occurrence of chronic post-thoracotomy pain.Design: Prospective, randomized study.Setting: A single-institution, university hospital.Participants: Thirty-eight patients who underwent elective thoracotomy under general anesthesia.Interventions: High-dose remifentanil (average effect-site concentration 5.61 ± 0.84 ng/mL) with epidural analgesia started and at the end of surgery or low-dose remifentanil (average effect site concentration 1.99 ± 0.02 ng/mL) with epidural analgesia with 0.5% ropivacaine started at the beginning of anesthesia.Measurements and Main Results: Pain intensity and the extent of allodynia around the wound were measured during the hospital stay. The presence and intensity of residual pain were assessed 1, 3, and 6 months after surgery and at the end of the study (6-13 months, average 9 months). A DN4 neuropathic pain diagnostic questionnaire was conducted at the same times. In the high-dose group, the area with allodynia was three times larger than the area in the low-dose group. The increased allodynia was associated with a higher incidence of chronic pain (RR: 2.7-4.2) 3 and 6 months after surgery and at the end of the study (median follow-up: 9.5 months).Conclusions: High-dose remifentanil (0.14-0.26 μg/kg/min) without epidural analgesia during surgery is associated with a large area of allodynia around the wound. These patients develop a much higher incidence of chronic pain than those receiving low-dose remifentanil with epidural analgesia during surgery.

A New Plasma-Adapted Hydroxyethyl Starch Preparation: In Vitro Coagulation Studies - Corrected Proof

Joachim Boldt, Andinet Mengistu — 2009-12-11

Objective: Preparing hydroxyethyl starch (HES) in a plasma-adapted solution is supposed to improve safety with regard to coagulation. The influence of a new plasma-adapted HES preparation on coagulation was studied.Design: Operator-blinded, randomized study.Setting: Laboratory in vitro study.Participants: Fifteen healthy young men scheduled for blood donation.Interventions: Blood was diluted by 10%, 30%, and 50% using either a plasma-adapted or nonplasma-adapted (prepared in saline solution) potato-derived 6% HES 130/0.42. Only the composition of the solvent of the 2 HES preparations was different.Measurements and Main Results: Rotation thromboelastometry (ROTEM; Pentapharm, Munich, Germany) was used to assess changes in coagulation; whole blood aggregometry with 3 inducers was used to assess effects of dilution with HES on platelet function. Clotting time (CT) and clot formation time were significantly prolonged by 30% and 50% dilution, showing significantly longer times in the non–plasma-adapted than in the plasma-adapted HES group (eg, intrinsic CT at the 30% dilution level: plasma-adapted HES 228 ± 26 seconds [within normal range] v 269 ± 29 seconds in the nonplasma-adapted HES group). Clot strengthening and clot firmness were significantly reduced by the non–plasma-adapted HES at the 30% dilution level. Platelet aggregation was significantly more reduced by the non–plasma-adapted HES at the 30% and 50% dilution levels.Conclusions: Dilution with the nonplasma-adapted HES 130/0.42 was associated with more negative effects on thromboelastometry and platelet aggregation than the same HES 130/0.4 dissolved in a plasma-adapted solution. The benefits of using a plasma-adapted modern HES preparation on blood loss and use of blood/blood products in cardiac surgery need to be studied.

Epidural Analgesia Improves Outcome in Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials - Corrected Proof

2009-12-11

Objective: The authors conducted a review of randomized studies to determine whether there were any advantages for clinically relevant outcomes by adding epidural analgesia in patients undergoing cardiac surgery under general anesthesia.Design: Meta-analysis.Setting: Hospitals.Participants: A total of 2366 patients from 33 randomized trials.Interventions: None.Measurements and Main Results: Data sources and study selection: PubMed, BioMedCentral, CENTRAL, EMBASE, Cochrane Central Register of Controlled Trials, and conference proceedings were searched (updated January 2008) for randomized trials that compared general anesthesia with an anesthetic plan including general anesthesia and epidural analgesia in cardiac surgery. Two independent reviewers appraised study quality, with divergences resolved by consensus. Overall analysis showed that epidural analgesia reduced the risk of the composite endpoint mortality and myocardial infarction (30/1125 [2.7%] in the epidural group v 64/1241 [5.2%] in the control arm, odds ratio [OR] = 0.61 [0.40-0.95], p = 0.03 number needed to treat [NNT] = 40), the risk of acute renal failure (35/590 [5.9%] in the epidural group v 54/618 [8.7%] in the control arm, OR = 0.56 [0.34-0.93], p = 0.02, NNT = 36), and the time of mechanical ventilation (weighted mean differences = −2.48 hours [−2.64, −2.32], p < 0.001).Conclusions: This analysis suggested that epidural analgesia on top of general anesthesia reduced the incidence of perioperative acute renal failure, the time on mechanical ventilation, and the composite endpoint mortality and myocardial infarction in patients undergoing cardiac surgery.

Increased Alveolar Damage After Mechanical Ventilation in a Porcine Model of Thoracic Surgery - Corrected Proof

2009-12-11

Objective: Mechanical stress during one-lung ventilation (OLV) results in lung injury. This study compared the effects of mechanical ventilation, OLV, and surgical manipulation on diffuse alveolar damage (DAD) after application of different anesthetic regimens.Design: Prospective, randomized, controlled, blinded animal experiment.Setting: University hospital.Objects: Twenty-one piglets.Interventions: Animals (27.5 kg) were randomized into 4 groups: spontaneous breathing (SB, n = 3), two-lung ventilation (TLV, n = 6), OLV during desflurane (n = 6), and propofol anesthesia (n = 6). SB pigs were killed after the induction of anesthesia. Lung tissue samples were analyzed to obtain reference values for alveolar damage. TLV pigs underwent standard TLV (tidal volumes [VT] = 10 mL/kg, FIO2 = 0.40, positive end-expiratory pressure = 5 cmH2O). In OLV pigs, after lung separation by a bronchial blocker, OLV (VT = 10 mL/kg) and thoracic surgery were performed. After the procedure, the pigs were killed. Lung tissue samples were harvested for histologic examination. Lung injury was quantified by DAD score; sequestration of leukocytes was assessed by the recruitment of CD45+ cells into the lungs.Main Results: TLV resulted in increased DAD scores in both lungs (TLV v SB: 6.9 v 2.7, p < 0.05); the number of CD45+ cells was not increased (TLV v SB: 8.7 v 5.0 cells per view). OLV and surgical manipulation increased DAD and leukocyte sequestration without differences between the ventilated and manipulated lungs. Leukocyte recruitment was not differently affected by the anesthetic regimen (propofol v desflurane: CD45+ cells per view: 13.5 v 11.3).Conclusions: TLV resulted in increased DAD scores in the lungs as compared with SB. OLV and thoracic surgery further increased lung injury and leukocyte recruitment independently of the administration of propofol or desflurane anesthesia.