Anestesia y reanimación cardiovascular

Ulus Travma Acil Cerrahi Derg. 2022 Nov;28(11):1563-1569. doi: 10.14744/tjtes.2022.92672.

ABSTRACT

BACKGROUND: Anesthesia management of pheochromocytoma excision surgery is associated with severe hemodynamic fluctuations. The objective of this study is to compare the number of hypertensive crisis requiring sodium nitroprusside (SNP) administration between the groups treated with magnesium (Mg)-dexmedetomidine (Dex) and conventional group in pheochromocytoma.

METHODS: This retrospective cohort study included patients who underwent pheochromocytoma surgery between 2011 and 2020. Patients were examined into two groups: 1-Conventional group (GC) included patients who were operated between 2011 and 2015 under standard anesthesia care and who did not receive perioperative additional medication. 2- Mg-Dex therapy group (GMD) comprised the patients who were operated between 2015 and 2020 and who had received 300 mg Mg per oral daily 1 week before the surgery and Mg-Dex infusion intraoperatively. Blood pressure, heart rate (HR), and SNP requirement were recorded throughout surgery as well as demographics and operative data. Hypertensive crisis was defined as systolic blood pressure (SBP) >180 mmHg, and tachycardia was defined as HR >110 bpm.

RESULTS: A total of 78 patients' data were analyzed from 108 patients' documentary. (38 in GC, 40 in GMD) SNP requirement was significantly higher in GC (39.5%) comparing GMD (7.5%) (p=0.001). SBPs during tumor manipulation period were statistically higher in GC than in GMD at 10th, 15th, 20th, 25th, 30th, and 35th min. HR values were significantly higher in GC compared to GMD at 10th and 15th min of tumor manipulation period (p<0.05).

CONCLUSION: Combination of Mg-Dex seems to be an alternative therapy for reducing vasodilator requirement in perioperative management of pheochromocytoma.

PMID:36282168 | DOI:10.14744/tjtes.2022.92672

JTCVS Tech. 2022 Aug 7;15:136-143. doi: 10.1016/j.xjtc.2022.07.018. eCollection 2022 Oct.

ABSTRACT

OBJECTIVES: To determine whether hearts reanimated with normothermic regional perfusion (NRP) have clinically detectable changes in function using echocardiography comparing the prearrest and post-NRP imaging. As heart transplantation from donation after circulatory death (DCD) continues to increase, preliminary results suggest outcomes comparable with donation after brain death. It is unknown whether the obligatory period of warm ischemia experienced during DCD withdrawal process causes immediate changes in cardiac allograft function following in situ reanimation.

METHODS: We retrospectively reviewed and compared predonation with postreanimation echocardiographic findings in all DCD donors at our institution from January to October 2021. All DCD donor organs were reanimated with in situ thoracoabdominal NRP after circulatory death. Echocardiographic assessment included (1) 2-dimensional and speckle-tracking measures of chamber size and function; (2) ejection fraction; (3) fractional area change; and (4) global longitudinal strain.

RESULTS: Altogether, 4 DCD heart donations were performed during the study period. Basic demographics and withdrawal ischemic time periods are reported. There were no changes in left ventricular ejection fraction and right ventricular fractional area change when comparing the predonation and the postreanimation echocardiogram. There was a minimal, nonstatistically significant decrease in left ventricular global longitudinal strain and right ventricular free-wall systolic strain in 3 of the 4 donors following reanimation.

CONCLUSIONS: DCD cardiac allografts reanimated with NRP demonstrated no change in echocardiographic parameters used for a standard predonation donor heart evaluation. Findings suggest cardiac function of DCD allografts reanimated with thoracoabdominal NRP is not adversely impacted by limited period of warm ischemia following circulatory arrest.

PMID:36276687 | PMC:PMC9579788 | DOI:10.1016/j.xjtc.2022.07.018

Lancet Respir Med. 2022 Oct 11:S2213-2600(22)00353-8. doi: 10.1016/S2213-2600(22)00353-8. Online ahead of print.

ABSTRACT

BACKGROUND: In patients receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO) packed red blood cell (PRBC) transfusion thresholds are usually higher than in other patients who are critically ill. Available guidelines suggest a restrictive approach, but do not provide specific recommendations on the topic. The main aim of this study was, in a short timeframe, to describe the actual values of haemoglobin and the rate and the thresholds for transfusion of PRBC during VV ECMO.

METHODS: PROTECMO was a multicentre, prospective, cohort study done in 41 ECMO centres in Europe, North America, Asia, and Australia. Consecutive adult patients with acute respiratory distress syndrome (ARDS) who were receiving VV ECMO were eligible for inclusion. Patients younger than 18 years, those who were not able to provide informed consent when required, and patients with an ECMO stay of less than 24 h were excluded. Our main aim was to monitor the daily haemoglobin concentration and the value at the point of PRBC transfusion, as well as the rate of transfusions. The practice in different centres was stratified by continent location and case volume per year. Adjusted estimates were calculated using marginal structural models with inverse probability weighting, accounting for baseline and time varying confounding.

FINDINGS: Between Dec 1, 2018, and Feb 22, 2021, 604 patients were enrolled (431 [71%] men, 173 [29%] women; mean age 50 years [SD 13·6]; and mean haemoglobin concentration at cannulation 10·9 g/dL [2·4]). Over 7944 ECMO days, mean haemoglobin concentration was 9·1 g/dL (1·2), with lower concentrations in North America and high-volume centres. PRBC were transfused on 2432 (31%) of days on ECMO, and 504 (83%) patients received at least one PRBC unit. Overall, mean pretransfusion haemoglobin concentration was 8·1 g/dL (1·1), but varied according to the clinical rationale for transfusion. In a time-dependent Cox model, haemoglobin concentration of less than 7 g/dL was consistently associated with higher risk of death in the intensive care unit compared with other higher haemoglobin concentrations (hazard ratio [HR] 2·99 [95% CI 1·95-4·60]); PRBC transfusion was associated with lower risk of death only when transfused when haemoglobin concentration was less than 7 g/dL (HR 0·15 [0·03-0·74]), although no significant effect in reducing mortality was reported for transfusions for other haemoglobin classes (7·0-7·9 g/dL, 8·0-9·9 g/dL, or higher than 10 g/dL).

INTERPRETATION: During VV ECMO, there was no universally accepted threshold for transfusion, but PRBC transfusion was invariably associated with lower mortality only when done with haemoglobin concentration of less than 7 g/dL.

FUNDING: Extracorporeal Life Support Organization.

PMID:36240836 | DOI:10.1016/S2213-2600(22)00353-8

Pediatr Int. 2022 Jan;64(1):e15270. doi: 10.1111/ped.15270.

ABSTRACT

BACKGROUND: We aimed to compare the frequency of acute kidney injury (AKI) and its effects on mortality and morbidity with different classification systems in pediatric patients who had surgery under cardiopulmonary bypass for congenital heart disease.

METHODS: This study included children younger than 18 years old who were followed up in the pediatric cardiac intensive care unit between September 1 and December 1, 2020, after congenital heart surgery with cardiopulmonary bypass. Each case was categorized postoperatively in terms of AKI using Pediatric-Modified Risk, Injury, Failure, Loss, and End-Stage (pRIFLE), Acute Kidney Injury Network (AKIN), and Kidney Disease: Improving Global Outcomes (KDIGO). Hospital mortality (developed within the first 30 days postoperatively) and morbidity (longer than 7 days intensive care unit stay) were compared by three model classes. Results were evaluated statistically.

RESULTS: One hundred patients were included in the study. The median age was 3 months (1 day-180 months). Acute kidney injury was diagnosed in 49% of the cases according to the pRIFLE classification. It was diagnosed in 31% of the patients by AKIN classification. It was diagnosed in 41% of the patients with the KDIGO criteria. Morbidity was observed in 25% (n = 25) of all cases. The morbidity predictor was 0.800 for pRIFLE, 0.747 for AKIN and 0.853 for KDIGO by receiver operating characteristics analysis. All three categories predicted morbidity significantly (P < 0.001). Mortality was 10% (n = 10) for all groups. The mortality predictor was 0.783 for pRIFLE, 0.717 for AKIN and 0.794 for KDIGO by receiver operating characteristics analysis, and all three categories predicted mortality significantly (P < 0.001).

CONCLUSIONS: Regardless of the three methods used, AKI was commonly detected in pediatric patients undergoing congenital heart surgery. pRIFLE classification diagnosed more patients with AKI than AKIN and KDIGO. The KDIGO and pRIFLE classifications were better in predicting hospital mortality.

PMID:36239168 | DOI:10.1111/ped.15270

Ann Cardiothorac Surg. 2022 Sep;11(5):533-537. doi: 10.21037/acs-2022-rmvs-11.

ABSTRACT

BACKGROUND: This study evaluates the clinical outcome of patients with robotic mitral valve replacement (MVR).

METHODS: Between January 2010 and April 2022, 117 consecutive patients underwent robotic MVR with or without additional cardiac procedures. All procedures were completed by a single surgical team with Da Vinci Robotic Systems. Perioperative variables and early clinical outcomes were recorded.

RESULTS: Mean age and EuroScore II of the patients were 57.1±12.9 and 5.1±5.7, respectively. Isolated MVR was performed in 55 (47.0%) patients and combined cardiac procedures were performed in 62 (53.0%) patients. Additional procedures included: ablation for atrial fibrillation, tricuspid valve replacement, tricuspid valve repair, left atrial appendix ligation, patent foramen ovale closure, left atrial thrombectomy and septal myectomy for hypertrophic obstructive cardiomyopathy. Mean cardiopulmonary bypass time and cross clamp time were 143±54 and 93±37 minutes, respectively. Mean intensive care unit stay time was 26.5±26.0 hours. Postoperative stroke was observed in one (0.9%) patient and new onset renal failure was observed in two (1.7%) patients. Perioperative and postoperative early mortality was observed in three (2.6%) patients, which was lower than expected.

CONCLUSIONS: Robotic MVR is feasible and can be performed with good early postoperative outcomes. A majority of the patients require additional cardiac procedures.

PMID:36237592 | PMC:PMC9551377 | DOI:10.21037/acs-2022-rmvs-11

J Clin Med. 2022 Sep 23;11(19):5585. doi: 10.3390/jcm11195585.

ABSTRACT

BACKGROUND: Intraoperative hypotension is common in patients having non-cardiac surgery and associated with postoperative acute myocardial injury, acute kidney injury, and mortality. Avoiding intraoperative hypotension is a complex task for anesthesiologists. Using artificial intelligence to predict hypotension from clinical and hemodynamic data is an innovative and intriguing approach. The AcumenTM Hypotension Prediction Index (HPI) software (Edwards Lifesciences; Irvine, CA, USA) was developed using artificial intelligence-specifically machine learning-and predicts hypotension from blood pressure waveform features. We aimed to describe the incidence, duration, severity, and causes of intraoperative hypotension when using HPI monitoring in patients having elective major non-cardiac surgery.

METHODS: We built up a European, multicenter, prospective, observational registry including at least 700 evaluable patients from five European countries. The registry includes consenting adults (≥18 years) who were scheduled for elective major non-cardiac surgery under general anesthesia that was expected to last at least 120 min and in whom arterial catheter placement and HPI monitoring was planned. The major objectives are to quantify and characterize intraoperative hypotension (defined as a mean arterial pressure [MAP] &lt; 65 mmHg) when using HPI monitoring. This includes the time-weighted average (TWA) MAP &lt; 65 mmHg, area under a MAP of 65 mmHg, the number of episodes of a MAP &lt; 65 mmHg, the proportion of patients with at least one episode (1 min or more) of a MAP &lt; 65 mmHg, and the absolute maximum decrease below a MAP of 65 mmHg. In addition, we will assess causes of intraoperative hypotension and investigate associations between intraoperative hypotension and postoperative outcomes.

DISCUSSION: There are only sparse data on the effect of using HPI monitoring on intraoperative hypotension in patients having elective major non-cardiac surgery. Therefore, we built up a European, multicenter, prospective, observational registry to describe the incidence, duration, severity, and causes of intraoperative hypotension when using HPI monitoring in patients having elective major non-cardiac surgery.

PMID:36233455 | PMC:PMC9571548 | DOI:10.3390/jcm11195585

Paediatr Anaesth. 2023 Jan;33(1):52-58. doi: 10.1111/pan.14561. Epub 2022 Oct 17.

ABSTRACT

INTRODUCTION: The Plethysmographic Variability Index can be measured by both finger and forehead probes. Vasoconstriction may jeopardize the reliability of finger PVI measurements in pediatric patients undergoing surgery. However, forehead vasculature exhibits more marked resistance to alterations in the vasomotor tonus.

OBJECTIVE: Our aim was to compare the Plethysmographic Variability Index measured via finger or forehead probes in mechanically ventilated pediatric surgery patients in terms of their ability to predict fluid responsiveness as well as to determine the best cut-off values for these two measurements.

MATERIALS AND METHODS: A total of 50 pediatric patients undergoing minor elective surgery were included after provision of parental consent and ethics committee approval. Perfusion index measured at the finger or forehead and Plethysmographic Variability Index monitoring comprised the primary assessments. Hemodynamic parameters monitored included perfusion index, Plethysmographic Variability Index, and cardiac output. A ≥ 15% increase in cardiac output following passive leg raise maneuver was considered to show fluid responsiveness. Two groups were defined based on fluid responsiveness: Group R (responsive) and Group NR (non-responsive). Student's t-test, Mann-Whitney U test, DeLong test, and ROC were used for statistical analysis.

RESULTS: The area under curve for finger and forehead Plethysmographic Variability Index prior to passive leg raise maneuver were 0.699 (p = .011) and 0.847 (p < .001), respectively. The sensitivity for finger and forehead measurements at a cut-off value of ≤14% was 92.9% and 96.4%, and 45.4% and 72.7%, respectively.

CONCLUSION: Although forehead and finger Plethysmographic Variability Index monitoring were similarly sensitive in predicting fluid responsiveness in pediatric surgical patients, the former method provided higher specificity. The best cut-off value for PVI measurements with forehead and finger probes was found to be 14%.

PMID:36168810 | DOI:10.1111/pan.14561

Turk Gogus Kalp Damar Cerrahisi Derg. 2022 Apr 27;30(2):160-166. doi: 10.5606/tgkdc.dergisi.2022.23347. eCollection 2022 Apr.

ABSTRACT

BACKGROUND: This study aims to investigate the effect of cardiopulmonary bypass on antibody titers in patients vaccinated against the severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) undergoing cardiac surgery with cardiopulmonary bypass.

METHODS: Between October 2021 and October 2022, a total of 70 patients (44 males, 26 females; mean age 59.9±10.3; range, 26 to 79 years) who completed their recommended COVID-19 vaccinations and underwent elective cardiac surgery with cardiopulmonary bypass were prospectively included. Serum samples for antibody titer measurements were taken at anesthesia induction and the end of cardiopulmonary bypass after decannulation. The SARS-CoV-2 total immunoglobulin antibodies against N-protein were measured. The antibody titer measurements at anesthesia induction and at the end of cardiopulmonary bypass were compared in all patients.

RESULTS: The median levels after cardiopulmonary bypass were lower than the preoperative levels (1,739.0 vs. 857.0, respectively; p<0.001). There was a drop of 40.0% (21.2%-62.6%) in the antibody titers among all patients. The decrease in antibody titers was consistent regardless of the number of vaccine doses or whether the last dose was received within the last three months. Among the studied factors, no parameter was significantly associated with a lesser or higher decrease in antibody titers.

CONCLUSION: Cardiac surgery with cardiopulmonary bypass causes a decrease in SARS-CoV-2 antibody titers at the end of cardiopulmonary bypass. Revaccination after cardiac operations may be considered in this patient group that is highly vulnerable due to their comorbidities and lowered antibody levels.

PMID:36168572 | PMC:PMC9473596 | DOI:10.5606/tgkdc.dergisi.2022.23347

BMC Anesthesiol. 2022 Sep 16;22(1):295. doi: 10.1186/s12871-022-01832-0.

ABSTRACT

BACKGROUND: We aimed to compare the effectiveness of bilateral erector spinae plane (ESP) block and superficial parasternal intercostal plane (S-PIP) + ESP block in acute post-sternotomy pain following cardiac surgery.

METHODS: Forty-seven patients aged between 18 and 80 years of age with American Society of Anesthesiologists class II-III due to undergo median sternotomy for cardiac surgery were included in this prospective, randomized, double-blinded study. Following randomization into two groups, one group received bilateral ultrasound-guided ESP and the other S-PIP plus ESP block. Morphine consumption within the first 24 h after surgery was the primary outcome of the study while NRS scores at rest, NRS scores when coughing, time taken until extubation, use of rescue analgesic, presence of nausea/vomiting, length of hospital and intensive care unit (ICU) stay, and patient satisfaction were secondary outcome measures.

RESULTS: Morphine use up to 24 h following surgery was statistically significantly different between the ESP block and ESP + S-PIP block groups (18.63 ± 6.60 [15.84-21.41] mg/24 h vs 14.41 ± 5.38 [12.08-16.74] mg/24 h, p = 0.021). The ESP + S-PIP block group had considerably reduced pain scores compared to the ESP block group across all time points. Rescue analgesics were required in 21 (87.5%) patients in the ESP block group and seven (30.4%) in the ESP + S-PIP group (p < 0.001). PONV, length of stay in the ICU and hospital, and time to extubation were similar between groups.

CONCLUSIONS: In open cardiac surgery, the combination of ESP and S-PIP blocks lowers pain scores and postoperative morphine requirement of patients.

TRIAL REGISTRATION: Clinicaltrials Registration No: NCT05191953, Registration Date: 14/01/2022.

PMID:36114466 | PMC:PMC9479438 | DOI:10.1186/s12871-022-01832-0

Intensive Care Med. 2022 Nov;48(11):1513-1524. doi: 10.1007/s00134-022-06821-y. Epub 2022 Sep 16.

ABSTRACT

PURPOSE: The aim of this study was to perform a systematic review and meta-analysis to investigate the incidence rate of cardiac arrest and severe complications occurring under non-invasive ventilation (NIV).

METHODS: We performed a systematic review and meta-analysis of studies between 1981 and 2020 that enrolled adults in whom NIV was used to treat acute respiratory failure (ARF). We generated the pooled incidence and confidence interval (95% CI) of NIV-related cardiac arrest per patient (primary outcome) and performed a meta-regression to assess the association with study characteristics. We also generated the pooled incidences of NIV failure and hospital mortality.

RESULTS: Three hundred and eight studies included a total of 7,601,148 participants with 36,326 patients under NIV (8187 in 138 randomized controlled trials, 9783 in 99 prospective observational studies, and 18,356 in 71 retrospective studies). Only 19 (6%) of the analyzed studies reported the rate of NIV-related cardiac arrest. Forty-nine cardiac arrests were reported. The pooled incidence was 0.01% (95% CI 0.00-0.02, I2 = 0% (0-15)). NIV failure was reported in 4371 patients, with a pooled incidence of 11.1% (95% CI 9.0-13.3). After meta-regression, NIV failure and the study period (before 2010) were significantly associated with NIV-related cardiac arrest. The hospital mortality pooled incidence was 6.0% (95% CI 4.4-7.9).

CONCLUSION: Cardiac arrest related to NIV occurred in one per 10,000 patients under NIV for ARF treatment. NIV-related cardiac arrest was associated with NIV failure.

PMID:36112157 | PMC:PMC9483519 | DOI:10.1007/s00134-022-06821-y

Medicine (Baltimore). 2022 Sep 2;101(35):e30290. doi: 10.1097/MD.0000000000030290.

ABSTRACT

AIM: To determine effect of ultrasound-guided serratus anterior plane block (SAPB) on intraoperative opioid consumption in patients undergoing oncoplastic breast surgery under general anesthesia.

METHODS: This study was conducted as a prospective, randomized controlled trial. Forty-four patients enrolled, aged 18 to 75 years with American Society of Anesthesiologists physical status I to III, undergoing elective oncoplastic breast surgery. Patients were randomly allocated to receive SAPB with 20 mL of 0.25% bupivacaine + general anesthesia (group SAPB) or only general anesthesia (group control). The primary outcome was assessing the effect of SAPB on intraoperative remifentanil consumption. Patients were assessed for emergence time, hemodynamic parameters, doses of rescue drugs used to control hemodynamic parameters, and duration of stay in the recovery room.

RESULTS: Preoperative SAPB with 0.25% bupivacaine reduced intraoperative opioid consumption (851.2 ± 423.5 vs 1409.7 ± 756.1 µg, P = .019). Emergence time was significantly shorter in group SAPB (6.19 ± 1.90 minutes) compared to group control (9.50 ± 2.39 minutes; P < .001). There were no significant differences in the doses of rescue drugs used for systolic blood pressure and heart rate between the groups.

CONCLUSIONS: Preoperative SAPB with bupivacaine reduced intraoperative opioid consumption and shortened emergence time and duration of stay in the recovery unit, and hemodynamic stability was maintained without block-related complications.

PMID:36107549 | PMC:PMC9439800 | DOI:10.1097/MD.0000000000030290

J Cardiothorac Vasc Anesth. 2022 Dec;36(12):4333-4340. doi: 10.1053/j.jvca.2022.08.002. Epub 2022 Aug 12.

ABSTRACT

OBJECTIVE: This study evaluated the effects of serratus anterior plane block (SPB) and its combination with transverse thoracic muscle plane block (TTPB) on analgesia, opioid consumption, incentive spirometry performance, and patient comfort.

DESIGN: A prospective, observational study.

SETTING: A university hospital.

PARTICIPANTS: Adult patients scheduled for elective cardiac surgery with cardiopulmonary bypass.

INTERVENTIONS: Patients who received intravenous patient-controlled analgesia only were labeled as the control group. Patients who received additional SPB were labeled as the SPB group, and patients who received additional SPB and TTPB were labeled as the SPB+TTPB group. The visual analog scores for pain (VAS), time to first analgesic requirement, total tramadol requirement, incentive spirometry values, and patient comfort indices were recorded during the first 36 postoperative hours.

MEASUREMENTS AND MAIN RESULTS: From October 2020 to October 2021, data from 95 patients were analyzed. The VAS score was lower in the SPB+TTPB group at 0, 14, and 18 hours (p < 0.001, p = 0.028, p = 0.047, respectively). Time to first analgesic was longer in the SPB+TTPB group (8 hours v 0-2 hours, p = 0.001). Total tramadol consumption was similar among groups. Incentive spirometer performance was superior in the SPB+TTPB group (p < 0.001). The SPB group had similar success at 0, 14, and 18 hours.

CONCLUSION: Although pain scores and opioid consumption were similar, the addition of TTPB to SPB improved pain scores during patient mobilization and incentive spirometry capacity.

PMID:36100497 | DOI:10.1053/j.jvca.2022.08.002