Anestesia y reanimación cardiovascular

J Cardiothorac Vasc Anesth. 2025 Jul;39(7):1763-1773. doi: 10.1053/j.jvca.2025.03.023. Epub 2025 Mar 15.

ABSTRACT

OBJECTIVES: To evaluate the utility of high-sensitivity cardiac troponin (hs-cTn) monitoring in thoracic surgery to predict severe postoperative complications (sPOCs) according to the Clavien-Dindo classification.

DESIGN: Retrospective, observational cohort study.

SETTING: Tertiary-level hospital involving multiple departments.

PARTICIPANTS: A total of 220 patients who underwent lung resection surgery between November 2018 and October 2021, with preoperative and postoperative troponin measurements.

INTERVENTIONS: hs-cTnI levels (Abbott Alinity) were measured before surgery and within the first 24 hours postoperatively. Myocardial injury (MI) was defined as hs-cTnI greater than 26.2 ng/L postoperatively. In addition, the impact of a postoperative cTnI elevation greater than 20% or a preoperative value below 1.6 ng/L on the occurrence of sPOCs is analyzed. Postoperative complications were recorded for the first 30 days and classified using the Clavien-Dindo classification.

MAIN MEASUREMENTS AND RESULTS: Patients with sPOCs had higher pre- and postoperative hs-cTnI levels compared to those without complications. Patients with MI had a higher incidence of POCs than those without MI. Additionally, undetectable preoperative hs-cTnI levels were associated with better survival.

CONCLUSIONS: Perioperative troponin elevation is associated with worse short-term postoperative outcomes, including a higher incidence of sPOCs and prolonged hospital stays. Preoperative hs-cTnI levels correlate with preoperative morbidity (frailty) in patients.

PMID:40189451 | DOI:10.1053/j.jvca.2025.03.023

J Crit Care. 2025 Aug;88:155076. doi: 10.1016/j.jcrc.2025.155076. Epub 2025 Apr 3.

ABSTRACT

BACKGROUND AND HYPOTHESIS: Up to 14 % of critically ill patients receive renal replacement therapy (RRT) during their ICU stay and are treated with intermittent hemodialysis (IHD) or one of the continuous renal replacement therapy (CRRT) techniques. The choice of a modality (IHD or CRRT) and technique (continuuous veno-venous -hemodialysis (CVVHD), -hemofiltration (CVVH), or - hemodiafiltration (CVVHDF)), and the way it is delivered, may have an impact on outcomes but only few studies addressed this question. We aimed to survey the availability, settings, and clinicians' preferences regarding RRT modalities and techniques in critically ill patients.

METHODS: Between July 2021 and March 2022, we conducted an open online worldwide survey targeting ICU clinicians and consisting of 31 questions.

RESULTS: Among the 1174 participants from 73 countries, 94 % indicated their ability to initiate RRT at any time. CRRT was more widely available than IHD (97 % vs 85 %). CVVHDF was the most frequently used CRRT technique (59 %), followed by CVVHD (26 %) and CVVH (16 %). Most participants (70 %) reported having access to at least two CRRT techniques in their unit. Preference for IHD or CRRT varied greatly, depending on the clinical situation. Among CRRT techniques, CVVHD was preferred for removal of small-sized molecules, better hemofilter lifespan and reduced nursing workload. The preferential indications for CVVH included septic shock, removal of middle-sized molecules and fluid overload. The technical settings for CVVH and CVVHDF were very heterogeneous.

CONCLUSION: This international survey underscores the large diversity in RRT practices wordlwide, as well as heterogeneity in beliefs and preferences among intensivists. These data highlight the need for robust comparative trials to identify the optimal RRT modality and technique to improve outcomes in specific clinical situations.

PMID:40179459 | DOI:10.1016/j.jcrc.2025.155076

Circ Heart Fail. 2025 May;18(5):e012399. doi: 10.1161/CIRCHEARTFAILURE.124.012399. Epub 2025 Apr 3.

NO ABSTRACT

PMID:40177751 | DOI:10.1161/CIRCHEARTFAILURE.124.012399

Crit Care. 2025 Mar 31;29(1):140. doi: 10.1186/s13054-025-05350-6.

ABSTRACT

BACKGROUND: During the weaning process, the transition from positive to negative pressure ventilation may induce cardiac dysfunction, which may lead to pulmonary oedema. The incidence of weaning-induced pulmonary oedema (WIPO) is poorly documented and shows huge variations. Our study aims to investigate the incidence and risk factors for WIPO during weaning from mechanical ventilation in general critically ill patients.

METHODS: This multicentre study was conducted in France, Italy, and India. Adult critically ill patients receiving invasive ventilation were included once a spontaneous breathing trial (SBT) was performed. The SBT technique could be either T-piece or pressure support mode with (PSV-PEEP) or without positive end expiratory pressure (PEEP) (PSV-ZEEP). A consensual diagnosis of WIPO was made a posteriori by five experts who analysed changes observed during the SBT that were retrospectively recorded.

RESULTS: From July 2019 to February 2021, 634 SBTs were performed in 500 patients from 13 ICUs. Weaning success occurred in 417 patients (66%) and weaning failure in 217 (34%). Weaning was short in 414 (83%) of SBTs, difficult in 47 (9%) SBTs, and prolonged in 39 (8%) SBTs. WIPO was diagnosed in 79 (12%) cases, which accounted for 36% of the 217 weaning failures. WIPO occurred in 54/358 (15%) of T-piece SBT, in 7/84 (8%) of PSV-PEEP SBT (p = 0.072 vs. T-piece), and in 18/192 (9%) of PSV-ZEEP SBT (p = 0.002 vs. T-piece). In multilevel logistic regression analysis including 202 weaning failures from 149 different patients, COPD, and previous cardiomyopathy were identified as independent risk factors associated with WIPO.

CONCLUSION: In general ICU patients, WIPO accounts for 36% of weaning failure cases. Previous heart disease and COPD are two independent risk factors for developing WIPO during the weaning process.

CLINICALTRIALS: gov identifier (retrospectively registered on 2022-03-31): NCT05318261.

PMID:40165223 | PMC:PMC11956494 | DOI:10.1186/s13054-025-05350-6

BMC Anesthesiol. 2025 Mar 31;25(1):142. doi: 10.1186/s12871-025-03022-0.

ABSTRACT

BACKGROUNDS: The benefit of fiberoptic bronchoscopy (FOB) guidance during percutaneous dilatational tracheostomy (PDT) remains unclear. We aimed to compare PDT performed with and without FOB guidance in terms of procedure duration, number of attempts, and perioperative complications.

METHODS: A total of 103 patients were divided into two groups, and the PDT procedure was performed either with or without FOB guidance. The primary outcome of our study was the duration of the tracheostomy procedure (PDT procedure time) and the number of attempts. The secondary outcome was the major/minor complications that might develop during and after tracheostomy.

RESULTS: The mean PDT procedure time was 8 (4-14) minutes in the FOB (-) group and 7 (3-14) minutes in the FOB (+) group, with no statistically significant difference between them (p = 0.081). The mean number of PDT attempts was the same in both the FOB (-) and FOB (+) groups, 1 (1-3) (p = 0.079). Hypoxemia/desaturation occurred in 1 (2%) patient in the FOB (-) group and in 1 (1.9%) patient in the FOB (+) group (p = 0.748). Cardiac arrhythmia occurred in 2 (3.9%) patients in the FOB (-) group and in 2 (3.8%) patients in the FOB (+) group (p = 0.684). No cases of pneumothorax or pneumomediastinum were observed in either group (p > 0.999).

CONCLUSION: No difference was found between the two groups in terms of procedure duration, number of attempts, and perioperative complications when performing PDT in the intensive care unit with or without fiberoptic bronchoscopy guidance. PDT can be performed effectively and safely in critically ill patients using a standardized approach by an experienced team, with or without bronchoscopy guidance. However, further investigation and advanced studies are needed to evaluate both methods in more detail.

TRIAL REGISTRATION: Retrospectively registered. Clinical trial number was not applicable.

PMID:40165086 | PMC:PMC11956419 | DOI:10.1186/s12871-025-03022-0

Turk J Anaesthesiol Reanim. 2025 May 30;53(3):87-97. doi: 10.4274/TJAR.2025.251925. Epub 2025 Mar 27.

ABSTRACT

Standard monitoring guidelines by the American Society of Anesthesiologists and European Society of Anaesthesiology and Intensive Care have not been updated for over a decade, despite rapid advancements in monitoring technology and the growing complexity of surgical patients. Traditional parameters such as blood pressure and pulse oximetry often fail to detect critical intraoperative conditions, emphasizing the need for comprehensive hemodynamic assessment. This review, the first of a two-part series, explores the fundamental elements of hemodynamics, including cardiac output, stroke volume, blood pressure, and oxygen delivery, with a focus on their physiological basis, clinical significance, and perioperative applications. This article provides a detailed foundation for understanding hemodynamic monitoring, setting the stage for the second article, which addresses advanced monitoring tools and their applications in contemporary anaesthesia practice.

PMID:40150830 | PMC:PMC12123657 | DOI:10.4274/TJAR.2025.251925

J Clin Med. 2025 Mar 13;14(6):1957. doi: 10.3390/jcm14061957.

ABSTRACT

Background: In this study, we present our early and mid-term results using two different types of handmade polytetrafluoroethylene (PTFE) valved conduits in patients who require right ventricular outflow reconstruction. Methods: Between March 2021 and May 2024, 72 patients (30 males and 42 females; median age: 69 (IQR: 26-123) months) who underwent implantation of a handmade bicuspid or tricuspid valve PTFE conduit for right ventricular outflow reconstruction were retrospectively analyzed. Preoperative, postoperative, and follow-up echocardiograms were also evaluated. Results: The first postoperative echocardiography revealed that 11 (36.7%) patients had mild regurgitation, and 3 (10%) patients had moderate regurgitation in the bicuspid group initially, while only 7 (16.7%) of the patients in the tricuspid group had mild regurgitation (p = 0.004). None of the patients required reintervention in the early postoperative period because of conduit dysfunction. In the mid-term follow-up, the mean follow-up duration was 22.4 ± 11 months. PTFE-valved conduit dysfunction was observed in three patients in the bicuspid group, while no dysfunction was observed in the tricuspid group (p = 0.049). Even if the median peak gradient was found to be slightly higher in the tricuspid group [15 (IQR: 0-25) vs. 0 (IQR: 0-15)] (p = 0.032), no conduit dysfunction was reported during follow-up. Kaplan-Meier analysis demonstrated that the tricuspid conduit group maintained 100% freedom from dysfunction during the 24-month follow-up period. In contrast, the bicuspid group had rates of 90%, 87%, and 83% at 6, 12, and 24 months, respectively (log-rank p = 0.016). Conclusions: The ePTFE valved conduits provide significant advantages in terms of durability, biocompatibility, cost-effectiveness, and hemodynamic performance for right ventricular outflow tract reconstruction in pediatric cardiac surgery. The findings of our study suggest that tricuspid valve design offers better potential for preventing conduit dysfunction.

PMID:40142765 | PMC:PMC11942932 | DOI:10.3390/jcm14061957

Turk Gogus Kalp Damar Cerrahisi Derg. 2025 Jan 31;33(1):27-35. doi: 10.5606/tgkdc.dergisi.2025.26627. eCollection 2025 Jan.

ABSTRACT

BACKGROUND: This study aimed to investigate the effect of operative and postoperative parameters on late-onset hyperlactatemia (LOHL) after cardiac surgery in the pediatric patient population.

METHODS: One hundred fifty-nine ventricular septal defect patients (77 males, 82 females; mean age: 8.0±8.6 years; range, 1 to 48 years) were retrospectively examined between August 2020 and February 2023. Patients with the highest lactate value measured between 6 to 12 h postoperatively <3 mmol/L were defined as Group 1, and those with lactate values ≥3 mmol/L (LOHL) were included in Group 2.

RESULTS: Cardiopulmonary bypass (CPB) time, aortic cross-clamp time, and CPB flow did not differ between groups (p=0.916, p=0.729, and p=0.699, respectively). The difference between partial oxygen pressure (PaO2) in the first blood gas obtained after CPB was statistically significant (p=0.017). The lactate level measured in the first arterial blood gas obtained after CPB was 1.74±0.61 mmol/L in Group 1 and 3.01±1.63 mmol/L in Group 2 (p<0.001). The PaO2 in the arterial blood gas measured at 6 h postoperatively was 129.22±61.20 mmHg in Group 1 and 156.07±64.49 mmHg in Group 2 (p=0.046).

CONCLUSION: The development of hyperlactatemia due to ischemia in the early post-CPB period may affect the development of LOHL. Microcirculatory changes at the tissue level may play a role in the etiology of LOHL.

PMID:40135081 | PMC:PMC11931366 | DOI:10.5606/tgkdc.dergisi.2025.26627

JAMA Netw Open. 2025 Mar 3;8(3):e251714. doi: 10.1001/jamanetworkopen.2025.1714.

ABSTRACT

IMPORTANCE: Understanding the relationship between patients' clinical characteristics and outcomes is fundamental to medicine. When critically ill patients die after withdrawal of life-sustaining therapy (WLST), the inability to observe the potential for recovery with continued aggressive care could bias future clinical decisions and research.

OBJECTIVE: To quantify the frequency with which experts consider patients who died after WLST following resuscitated cardiac arrest to have had recovery potential if life-sustaining therapy had been continued.

DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study included comatose adult patients (aged ≥18 years) treated following resuscitation from cardiac arrest at a single academic medical center between January 1, 2010, and July 31, 2022. Patients with advanced directives limiting critical care or who experienced cardiac arrest of traumatic or neurologic etiology were excluded. An international cohort of experts in post-arrest care based on clinical experience and academic productivity was identified. Experts reviewed the cases between August 24, 2022, and February 11, 2024.

EXPOSURE: Patients who died after WLST.

MAIN OUTCOME AND MEASURES: Three or more experts independently estimated recovery potential for each patient had life-sustaining treatment been continued, using a 7-point numerical ordinal scale. In the primary analysis, which involved the patient cases with death after WLST, a 1% or greater estimated recovery potential was considered to be clinically meaningful. In secondary analyses, thresholds of 5% and 10% estimated recovery probability were explored.

RESULTS: A total of 2391 patients (median [IQR] age, 59 [48-69] years; 1455 men [60.9%]) were included, of whom 714 (29.9%) survived to discharge. Cases of uncertain outcome (1431 patients [59.8%]) in which WLST preceded death were reviewed by 38 experts who rendered 4381 estimates of recovery potential. In 518 cases (36.2%; 95% CI, 33.7%-38.7%), all experts believed that recovery potential was less than 1% if life-sustaining therapies had been continued. In the remaining 913 cases (63.8%; 95% CI, 61.3%-66.3%), at least 1 expert believed that recovery potential was at least 1%. In 227 cases (15.9%; 95% CI, 14.0%-17.9%), all experts agreed that recovery potential was at least 1%, and in 686 cases (47.9%; 95% CI, 45.3%-50.6%), expert estimates differed at this threshold.

CONCLUSIONS AND RELEVANCE: In this cohort study of comatose patients resuscitated from cardiac arrest, most who died after WLST were considered by experts to have had recovery potential. These findings suggest that novel solutions to avoiding deaths based on biased prognostication or incomplete information are needed.

PMID:40131275 | PMC:PMC11937936 | DOI:10.1001/jamanetworkopen.2025.1714

Med Sci Monit. 2025 Mar 23;31:e947462. doi: 10.12659/MSM.947462.

ABSTRACT

BACKGROUND Acute renal failure (ARF) is a critical complication following open-heart surgery, significantly impacting morbidity and mortality. This study aimed to evaluate the association between intraoperative renal near-infrared spectroscopy (NIRS) findings and postoperative ARF in 357 patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). MATERIAL AND METHODS This prospective study included 357 patients undergoing open-heart surgery with CPB. ARF diagnosis was based on KDIGO criteria. NIRS sensors were placed bilaterally at the T12/L2 level under ultrasound guidance, and renal oxygenation (rSO2) values were continuously monitored intraoperatively. Patients were categorized into ARF and non-ARF groups for comparative analysis. RESULTS ARF developed in 12.3% (n=44) of patients. ARF patients were older (p=0.024) and had longer surgery (p<0.001), CPB (p=0.004), and aortic cross-clamping durations (p=0.013). They required more blood products (p<0.001) and intra-aortic balloon pump support (p=0.027). Intensive care unit stays were significantly longer in ARF patients (p=0.036). NIRS analysis showed significant rSO2 reductions in ARF patients. Time spent with rSO2 below 80%, 70%, and 60% was a strong predictor of ARF. Receiver operating characteristic (ROC) analyses demonstrated that time exceeding 30 minutes below the 60% threshold predicted ARF with 96.5% specificity and 86.4% sensitivity. CONCLUSIONS Intraoperative NIRS monitoring is crucial for detecting renal perfusion abnormalities during high-risk surgeries. Declines below 80%, 70%, and 60% thresholds strongly predict ARF. Timely interventions, such as fluid resuscitation and hemodynamic support, can mitigate risks. ARF patients require intensive postoperative monitoring due to prolonged ICU stays and complications.

PMID:40121520 | PMC:PMC11948832 | DOI:10.12659/MSM.947462

BMC Anesthesiol. 2025 Mar 22;25(1):138. doi: 10.1186/s12871-025-03007-z.

ABSTRACT

INTRODUCTION: Caudal epidural block is a widely performed procedure for postoperative pain control of pediatric patients. As the local anesthetic acts by spreading cranially after caudal block, it may lead to several effects on the cerebrospinal fluid and intracranial region.

METHOD: Children aged 1-7, ASA I-II were included in this study. The patient population was assigned into two groups as the Caudal Block Group (Group CB) and the Control Group (Group C) Caudal block with 0.25% bupivacaine 1 ml/kg was performed on patients in Group CB. Optic nerve sheath diameter was measured at the following timeline: T0: Following laryngeal mask placement, T1: Following caudal block. T15:15. min, T30:30. min. Heart rate, non-invasive blood pressure, SpO2 and PCO2 values were also recorded at every time point.

RESULTS: There was no significant difference between two groups considering demographic data, intraoperative hemodynamic parameters, intraoperative SpO2 and PCO2 values. While optic nerve sheath diameter findings were not significantly different between the groups at T0 and T1 points(P > 0.05), the measurements at T15(4.18 ± 0.56 for Group C and 4.62 ± 0.47 for Group CB, P = 0.006) and T30(4.20 ± 0.53 for Group C and 4.76 ± 0.52 for Group CB) were statistically higher in the Caudal Group.

CONCLUSION: Evaluation of optic nerve sheath diameter has high diagnostic precision for detecting increased intracranial pressure in children. The findings in this study display that local anesthetic applied for caudal block in pediatric surgeries spread cranially resulting in an increase in the intracranial pressure and optic nerve sheath diameter. However, this increase does not cause intraoperative hemodynamic changes.

PMID:40119299 | PMC:PMC11929278 | DOI:10.1186/s12871-025-03007-z

Turk J Anaesthesiol Reanim. 2025 Mar 21;53(2):53-61. doi: 10.4274/TJAR.2025.241830.

ABSTRACT

OBJECTIVE: To evaluate the cardiopulmonary effect during prone position (PP) on right ventricular (RV) recovery in coronavirus disease-2019 related acute respiratory distress syndrome (C-ARDS) through transesophageal echocardiography (TEE).

METHODS: This prospective study included 30 moderate-to-severe C-ARDS patients who were treated with PP in the first 48 h of invasive mechanical ventilation support. It was evaluated with TEE three times: before PP (T0f), the first hour of PP (T1), and the first hour of returning to the supine position (T0 + 24 h) (T2) after 23 hours of PP treatment. RV end-diastolic area/left ventricular (LV) end-diastolic area (RVEDA/LVEDA), tricuspid annular plane systolic excursion (TAPSE) and LV end-systolic eccentricity index were preferred RV evaluations as primary outcomes. Pulmonary effects of PP were evaluated as a secondary outcome, including PaO2/FiO2, driving pressure (dP), static compliance (Cstat), mechanical ventilation parameters, and their association with 28-day survival. Tissue DO2 was examined as a secondary outcome, and it was calculated using the measured cardiac output through TEE.

RESULTS: With the cardiopulmonary effect of PP, the decrease in RVEDA/LVEDA, the increase in TAPSE, PaO2/FiO2, and Cstat, and the decrease in dP were statistically significant (P < 0.05). The Cstat value associated with 28-day survival showed decreased mortality for each unit increase. The Cstat cut-off value, which was statistically significant for survival, was 37.

CONCLUSION: PP can improve RV recovery and oxygenation, but it isn't always accompanied by increased survival. An increase in the Cstat may improve survival without the development of RV dysfunction while maintaining heart-lung interaction.

PMID:40116456 | PMC:PMC11931261 | DOI:10.4274/TJAR.2025.241830

BMC Anesthesiol. 2025 Mar 20;25(1):133. doi: 10.1186/s12871-025-03004-2.

ABSTRACT

BACKGROUND: Postoperative sore throat (POST) is a common complication following endotracheal intubation after general anesthesia. This study aimed to examine the effect of administering lidocaine via the Trachospray device on POST severity and to assess its impact on hemodynamic responses (heart rate and blood pressure) during tracheal intubation.

METHODS: In a double-blind, randomized controlled trial was conducted, approved by the local ethics committee and registered on ClinicalTrials.gov. 100 patients aged 18-65 undergoing elective laparoscopic cholecystectomy and classified as ASA I-III were randomly divided into two groups. Group T received 10% lidocaine through Trachospray before intubation, while Group S was given distilled water. POST severity was evaluated at 2, 6, 12, and 24 h postoperatively. POST was evaluated on a 4-point scale, with scores of 0 (none) to 3 (severe).

RESULTS: Group T showed significantly lower POST severity and incidence at all time points compared to Group S (p = 0.001; p < 0.05). Additionally, hemodynamic responses (heart rate and blood pressure) were significantly lower in Group T following intubation (heart rate, p = 0.015; systolic blood pressure, p = 0.006; diastolic blood pressure, p = 0.010).

CONCLUSION: The use of 10% lidocaine via Trachospray before endotracheal intubation effectively decreases POST severity and incidence as well as the hemodynamic response to intubation, highlighting its potential to improve patient outcomes in the postoperative period.

PMID:40114047 | PMC:PMC11924844 | DOI:10.1186/s12871-025-03004-2

Pain Res Manag. 2025 Mar 12;2025:9187270. doi: 10.1155/prm/9187270. eCollection 2025.

ABSTRACT

Background: This study was designed to compare the effectiveness of the transversus abdominis plane (TAP) block with the addition of morphine to bupivacaine and the TAP block with bupivacaine plus intramuscular (IM) morphine. The aim of the study was to evaluate the effect of morphine administered with the TAP block on postoperative opioid consumption and pain scores and, secondarily, to determine whether the effect was systemic or local. Methods: This prospective, double-blind, randomized controlled trial included 52 patients. In the IM group, morphine at a dose of 0.1 mg/kg based on ideal body weight (IBW) was administered IM. In addition, a bilateral TAP block was performed under ultrasound guidance using a total of 40 mL of 0.25% bupivacaine, with 20 mL injected on each side. In the TAP group, an ultrasound-guided TAP block, including a total of 40 mL of 0.25% bupivacaine and 0.1 mg/kg morphine according to the IBW of patients, was administered bilaterally. Results: Total morphine consumption 24 h was 19.08 + 11.35 in the IM group and 11.81 + 7.02 in the TAP group, with an estimated difference in means of 7.2 (95% CI: 2.0, 12.5; p=0.008). The morphine consumption after 6, 12, and 24 h was lower in the TAP group than in the IM group (p=0.033, p=0.003, and p=0.008, respectively). The VAS scores at rest and during movement did not differ between the two groups. The total 24-h ondansetron consumption was higher in the IM group (p=0.046). The postoperative heart rates, blood pressure, and peripheral oxygen saturation at 0, 1, 6, 12, and 24 h did not differ significantly between the groups. Conclusions: The addition of morphine to the TAP block may be an effective method for postoperative analgesia in gynecologic surgery and may not increase systemic side effects, due to the possible local effects of morphine administered interfacial. Trial Registration: ClinicalTrials.gov identifier: NCT05420337.

PMID:40109499 | PMC:PMC11922606 | DOI:10.1155/prm/9187270

Ann Intensive Care. 2025 Mar 19;15(1):32. doi: 10.1186/s13613-025-01458-8.

ABSTRACT

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) offers an immediate and effective mechanical cardio-circulatory support for critically ill patients with refractory cardiogenic shock or selected refractory cardiac arrest. As fluid therapy is routinely performed as a component of initial hemodynamic resuscitation of ECMO supported patients, this narrative review intends to summarize the rationale and the evidence on the fluid resuscitation strategy in terms of fluid type and dosing, the impact of fluid balance on outcomes and fluid responsiveness assessment in VA-ECMO patients. Several observational studies have shown a deleterious impact of positive fluid balance on survival and renal outcomes. With regard to the type of crystalloids, further studies are needed to evaluate the safety and efficacy of saline versus balanced solutions in terms of hemodynamic stability, renal outcomes and survival in VA-ECMO setting. The place and the impact of albumin replacement, as a second-line option, should be investigated. During VA-ECMO run, the fluid management approach could be divided into four phases: rescue or salvage, optimization, stabilization, and evacuation or de-escalation. Echocardiographic assessment of stroke volume changes following a fluid challenge or provocative tests is the most used tool in clinical practice to predict fluid responsiveness. This review underscores the need for high-quality evidence regarding the optimal fluid strategy and the choice of fluid type in ECMO supported patients. Pending specific data, fluid therapy needs to be personalized and guided by dynamic hemodynamic approach coupled to close monitoring of daily weight and fluid balance in order to provide adequate ECMO flow and tissue perfusion while avoiding harmful effects of fluid overload.

PMID:40106084 | PMC:PMC11923310 | DOI:10.1186/s13613-025-01458-8

Braz J Cardiovasc Surg. 2025 Mar 18;40(2):e20220468. doi: 10.21470/1678-9741-2022-0468.

ABSTRACT

A 58-year-old man, who has undergone ascending aorta replacement, started to complain of pain in the lower limbs, shortness of breath, and progressive fatigue a few months after surgery. Transthoracic and transesophageal Doppler echocardiographies revealed a diseased bicuspid aortic valve and a subocclusive mass in the ascending aorta. Thoracic computed tomography angiography confirmed the presence of a subocclusive mass, pseudoaneurysm formation, and a distorted shape of the Dacron® graft. The patient underwent urgent surgery to remove the mass, which appeared to be a thrombus, and aortic valve and ascending aorta replacement. Kinking of vascular graft has been reported including surgical techniques to correct the excessive length to avoid gradients and guarantee laminar flow. When kinking is severe, high gradients and hemolysis can be detected. However, thrombus formation in the ascending aorta segment is less likely, due to the high blood velocity flow. Therefore, several concurrent causes should be considered. In this case, the most probable explanation for thrombus formation was kinking of a too long Dacron® graft, combined with extrinsic compression effect of the graft by the pseudoaneurysm at the anastomosis site and anomalous flow directed from the diseased bicuspid aortic valve. Various grades of Dacron® graft kinking might occur following ascending aorta replacement and undiagnosed at follow-up especially if resulting in mild symptoms, thus, careful visual and echocardiography evaluation should be done at the end of surgery. Finally, distorted Dacron® graft might trigger thrombus formation when inflammation and coagulation processes are set off during bacteria or viral infection.

PMID:40101116 | PMC:PMC11921935 | DOI:10.21470/1678-9741-2022-0468

Medicine (Baltimore). 2025 Mar 14;104(11):e41934. doi: 10.1097/MD.0000000000041934.

ABSTRACT

Increased intra-abdominal pressure during laparoscopic surgery, anesthesia, patient position, and neuroendocrine response may increase the risk of arrhythmia. This study aimed to investigate the perioperative changes in the frontal QRS-T angle in patients undergoing laparoscopic cholecystectomy under general anesthesia. Therefore, electrophysiological parameters at different stages of laparoscopic cholecystectomy were studied using the frontal QRS-T angle and the risk of arrhythmia susceptibility was investigated. This prospective observational study included 48 patients aged 23 to 65 years with an American Society of Anesthesiologists score of 1 to 3 who underwent laparoscopic cholecystectomy in the operating room of Gaziosmanpaşa University Research and Application Hospital. Electrocardiographic recordings were obtained immediately before surgery, immediately before and after intra-abdominal carbon dioxide insufflation, 2 minutes after reverse Trendelenburg, immediately after extubation, and 2 hours postoperatively, and the frontal plane QRS-T angle, QT and QTc interval were studied. Rhythm disturbances, bleeding and complications were recorded. The frontal QRS-T angle, QT and QTc interval were significantly increased with intra-abdominal hypertension (IAH) compared to baseline (P < .001, P < .001, P < .001, respectively). Similarly, frontal QRS-T angle, QT, and QTc interval increased significantly with reverse Trendelenburg position compared to baseline (P < .001, P < .001, P < .001, respectively). The frontal QRS-T angle, which increased with IAH and the reverse Trendelenburg position, significantly decreased immediately after the patient woke up (P < .001). Heart rate and mean arterial pressure increased significantly with IAH compared to those just before carbon dioxide insufflation (P = .03, P < .001, respectively). The present study found that IAH induction and reverse Trendelenburg positioning increased the frontal QRS-T angle, QT, and QTc interval in patients undergoing laparoscopic cholecystectomy. These prolonged values may cause serious arrhythmias, particularly in patients with cardiac disease. Therefore, it is very important for anesthetists to be aware of electrocardiographic changes such as arrhythmias in patients undergoing laparoscopic cholecystectomy.

PMID:40101078 | PMC:PMC11922400 | DOI:10.1097/MD.0000000000041934