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BACKGROUND: Andexanet alfa, an anti-Xa inhibitor antagonist, induces heparin resistance. Here, we report a case of successful management of cardiopulmonary bypass with andexanet alfa-induced heparin resistance using nafamostat mesylate. CASE PRESENTATION: An 84-year-old female, with Stanford type A acute aortic dissection, underwent an emergency surgery for total aortic arch replacement. Andexanet alfa 400 mg was administered preoperatively to antagonize edoxaban, an oral Xa inhibitor. Heparin 300 IU/kg was administered before cardiopulmonary bypass, and the activated clotting time (ACT) was 291 s. The ACT was 361 s after another administration of heparin 200 IU/kg. According to our routine therapy for heparin resistance, an initial dose of nafamostat mesylate 10 mg was administered intravenously, followed by a continuous infusion of 20-30 mg/h. The ACT was prolonged to 500 s, and cardiopulmonary bypass was successfully established thereafter. CONCLUSIONS: This case report presents the successful management of cardiopulmonary bypass with andexanet alfa-induced heparin resistance using nafamostat mesilate. This report presents the successful management of cardiopulmonary bypass with andexanet alfa-induced heparin resistance using nafamostat mesilate.
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BACKGROUND: The importance of patient blood management is increasingly recognized in surgery patients. This study aimed to examine the effect of perioperative restrictive blood transfusion on 1-year mortality and blood transfusion rate in open abdominal surgery. METHODS: We retrospectively studied 452 consecutive patients who underwent open abdominal surgery before (liberal group: 233 patients) and after (restrictive group: 219 patients) implementing intraoperative restrictive transfusion of red blood cell. The trigger levels of hemoglobin were less than 9-10 g/dL in the liberal group and less than 7-8 g/dL in the restrictive group. All-cause mortality at 1-year as the primary outcome and the transfusion rate of any allogeneic blood products as secondary outcome were compared between the liberal group and the restrictive group by the propensity-score matching. RESULTS: Among a total of 452 patients (69 ± 11 yr., 70.5 % men), overall mortality at 1 year was 8.4 % and the proportion of patients who received any allogeneic blood products was 19.6 %. Compared with 155 propensity-score matched patients of the liberal group, 155 matched patients of the restrictive group had significantly lower 1-year mortality (4 [2.5 %] versus 18 [11.6 %], p = 0.003, percent absolute risk reduction [%ARR]; 9.0, 95 % confidential interval [CI], 3.1-14.7) and had significantly lower proportion of patients who received any allogeneic blood products (21 [13.5 %] versus 41 [26.4 %], p = 0.006, %ARR; 12.9, 95 % CI, 3.9-21.5). CONCLUSIONS: The results of this study indicate that intraoperative restrictive blood transfusion reduces 1-year mortality and the transfusion rate of allogeneic blood products.
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Transfusão de Eritrócitos , Hemoglobinas , Feminino , Humanos , Masculino , Transfusão de Sangue , Estudos de Coortes , Hemoglobinas/análise , Pontuação de Propensão , Estudos RetrospectivosRESUMO
PURPOSE: This study aimed to examine the effect of fibrinogen replacement therapy with cryoprecipitate or fibrinogen concentrate on bleeding outcomes and 1-year mortality in patients undergoing thoracic aortic surgery. METHODS: We retrospectively studied 439 consecutive patients who underwent thoracic aortic surgery with cardiopulmonary bypass between January 1st, 2010 and December 31st, 2019 and identified patients who received cryoprecipitate or fibrinogen concentrate (the fibrinogen replacement group) and those who did not (the control group). Multivariate analyses were performed to examine the associations of fibrinogen replacement therapy with perioperative major bleeding (i.e., excessive hemorrhage or blood transfusion), re-exploration for bleeding, and 1-year mortality. RESULTS: There were 285 patients in the fibrinogen replacement group who received 2.2 ± 1.0 g of concentrated fibrinogen amount and 154 patients in the control group. The incidence of major bleeding in the fibrinogen replacement group was less than that in the control group in patients with fibrinogen level < 150 mg/dL during cardiopulmonary bypass (49.7% versus 74.6%, p = 0.0007, multivariate odds ratio; 0.33, 95% confidence intervals; 0.12-0.91, p = 0.03), but not in patients with fibrinogen level ≥ 150 mg/dL (25.0% versus 29.6%, p = 0.51). No significant difference was found in re-exploration for bleeding (1.0% versus 1.3%, p = 1.00) or 1-year mortality (10.4% versus 5.3%, multivariate Cox proportional-hazard ratio; 1.03, 95% confidence intervals; 0.82-1.31, p = 0.74) between the fibrinogen replacement group and the control group. CONCLUSIONS: The results of this study indicate that 2-3 g of fibrinogen replacement reduces the incidence of major bleeding in patients with hypofibrinogenemia during cardiopulmonary bypass in thoracic aortic surgery.
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Fibrinogênio , Hemostáticos , Humanos , Estudos Retrospectivos , Ponte Cardiopulmonar/efeitos adversos , Perda Sanguínea CirúrgicaRESUMO
The clinical importance of viscoelastic testing in patient blood management when performing cardiovascular surgery is increasing. We aimed to examine the effect of a blood transfusion protocol including an assessment of fibrin-based rotational thromboelastometry on transfusion volume, mortality, and bleeding complications in patients undergoing cardiac or thoracic aortic surgery. We retrospectively studied a cohort of 376 consecutive patients who underwent cardiopulmonary bypass before (control group: 150 cardiac and 35 thoracic aortic surgeries) and after (assessment group: 154 cardiac and 37 thoracic aortic surgeries) introducing the fibrin polymerization assessment with thromboelastometry in the blood transfusion protocol. The transfusion volume and clinical outcomes were compared between the control and assessment groups, and the standardized (mean) difference (S[M]D) was calculated as an indicator of statistical effect size. Compared with the control group, the assessment group had a lower total blood transfusion volume (mL) in cardiac (2720 ± 1282 vs. 2034 ± 1330, p < 0.0001, [SMD] = 0.68) and thoracic aortic surgeries (5236 ± 2732 vs. 3714 ± 1768, p < 0.0001, SMD = 0.67). The 1-year mortality rates were 1.9 % and 2.7 % in cardiac and thoracic aortic surgeries, respectively. Significant differences were not observed in the 1-year mortality (3.2 % vs. 1.0 %, p = 0.16, relative risk [RR] = 0.32 with 95 % confidence intervals [CI] = 0.06-1.57, SD = 0.15), re-exploration for bleeding (4.8 % vs. 2.6 %, p = 0.28, RR = 0.53 with 95 % CI = 0.18-1.57, SD = 0.12), and major bleeding (17.3 % vs. 13.0 %, p = 0.31, RR = 0.75 with 95 % CI = 0.46-1.22, SD = 0.12) rates between the control and assessment groups. The assessment of fibrin polymerization with thromboelastometry using the blood transfusion protocol reduced the blood transfusion volume in cardiovascular surgery.
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Transfusão de Sangue/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Fibrina/metabolismo , Tromboelastografia/métodos , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Resultado do TratamentoRESUMO
BACKGROUND: Monitoring of decrease in fibrinogen levels with surgical blood loss is crucial for timely transfusion of fresh frozen plasma (FFP) to avoid coagulopathic bleeding. Here, we validated a simulation model to predict hemorrhagic reductions in fibrinogen levels during major noncardiac surgery. METHODS: We retrospectively performed exponential regression analysis of intraoperative blood loss and fibrinogen levels to develop a simulation model in the initial 50 patients and applied the model to another 59 patients to compare the measured and simulated fibrinogen levels. We examined the relationship between FFP transfusion and the measured fibrinogen levels or blood loss. The fibrinogen trigger level of FFP transfusion was below 130 mg/dL, although the decision of a perioperative blood transfusion was at the discretion of the anesthesiologists and surgeons. RESULTS: Application of the simulation model based on the initial 50 patients to another 59 patients showed no difference between the measured and estimated fibrinogen levels (189 ± 61 versus 186 ± 62, P = 0.60, mean difference: -2.28, limits of agreement: -69.42 to 64.84). The estimated fibrinogen level (mg/dL) = preoperative fibrinogen × exp (-1.90 × [blood loss/estimated circulation volume]), in which the estimated circulation volume = (70 [mL/kg] × body weight [kg]). FFP transfusion was significantly related to the measured fibrinogen level (cutoff: 145; 95% confidence intervals: 124-168; P = 0.0003) but not blood loss (P = 0.12). CONCLUSIONS: Fibrinogen level simulation predicted a hemorrhagic fibrinogen decline, thereby guiding FFP transfusion during active surgical bleeding. Further studies on the usefulness of fibrinogen level simulation are warranted.
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Perda Sanguínea Cirúrgica , Transfusão de Sangue , Fibrinogênio/metabolismo , Hemorragia/metabolismo , Modelos Biológicos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Renal function tends to deteriorate in a hyperchloremic acidifying environment, which is reflected by a decrease in the difference between sodium and chloride. OBJECTIVES: To examine the effect of furosemide administered under hyperchloremic acidosis on intraoperative oliguria and acute kidney injury in patients with preoperatively normal renal function. METHODS: In patients undergoing abdominal or orthopedic surgeries (April 2010-November 2018), we retrospectively identified patients who preoperatively had a normal renal function but experienced intraoperative oliguria under hyperchloremic acidosis (a sodium-chloride difference < 30 mEq/L) without dehydration. We compared the perioperative urine output and the incidence of postoperative acute kidney injury between patients who intraoperatively received an initial dose of 5 mg of furosemide (the furosemide group) and patients who did not intraoperatively receive furosemide (the control group). RESULTS: We identified 62 patients in the furosemide group and 48 patients in the control group. The furosemide group intraoperatively received 0.11 ± 0.06 mg/kg of furosemide (range 0.06-0.39 mg/kg). Compared to the control group, the furosemide group had greater urine output (mL/kg/h) in the operating room (1.1 ± 0.7 vs. 0.3 ± 0.1, p < 0.01) and on postoperative day 1 (1.2 ± 0.5 vs. 1.1 ± 0.4, p = 0.02). The incidence of postoperative acute kidney injury was lesser in the furosemide group than that in the control group (8.0 vs. 27.0%, p < 0.01; multivariate OR 0.18; 95% CI 0.05-0.61; p < 0.01). CONCLUSIONS: In surgery patients under hyperchloremic acidosis, furosemide (0.1 mg/kg) resolved intraoperative oliguria and reduced the incidence of postoperative acute kidney injury.
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Acidose , Injúria Renal Aguda/tratamento farmacológico , Cloro/sangue , Diuréticos/uso terapêutico , Furosemida/uso terapêutico , Oligúria/tratamento farmacológico , Humanos , Período IntraoperatórioRESUMO
In addition to cutaneous, gastrointestinal, hemodynamic, and respiratory symptoms, allergic reactions can induce an acute coronary syndrome in normal or atheromatous coronary arteries and can cause coronary stent thrombosis. Here, we report a case of coronary stent thrombosis due to allergic acute coronary syndrome during anaphylaxis induced by sugammadex in a female patient undergoing general anesthesia. She was emergently treated with percutaneous transluminal coronary balloon angioplasty with catecholamine, vasodilator, and intraaortic balloon support. Knowledge of perioperative allergy-triggered acute coronary syndrome is crucial for prompt and appropriate treatment.
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Síndrome Coronariana Aguda/terapia , Trombose Coronária/terapia , Sugammadex/efeitos adversos , Síndrome Coronariana Aguda/induzido quimicamente , Idoso , Anestesia Geral/efeitos adversos , Angioplastia Coronária com Balão , Catecolaminas/uso terapêutico , Colectomia , Neoplasias do Colo/cirurgia , Trombose Coronária/induzido quimicamente , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Resultado do TratamentoRESUMO
AIM: Hyperchloremic acidosis may have an important role as a precursor of acute kidney injury (AKI) in the hyperchloremic environment induced by chloride-rich fluids, but this remains unclear. We tested the hypothesis that hyperchloremic acidosis assessed by the Stewart approach is associated with postoperative AKI. METHODS: A historical cohort study was conducted in adult patients who had normal renal function preoperatively and required admission to the intensive care unit after elective abdominal surgery. The Risk, Injury, Failure, Loss of kidney function, End stage kidney disease (RIFLE) classification was used for definition of AKI. RESULTS: Of 206 patients (144 male, 69.9%) included in the study, 42 (20.4%) had postoperative AKI (AKI group) and 164 (79.6%) did not (non-AKI group). Base excess-chloride (BE-Cl) and strong ion difference (SID, approximated as Na-Cl) decreased, and the chloride level on postoperative day 1 increased compared with preoperative values in both groups (P < 0.05). In the AKI group, BE-Cl and SID were lower, and chloride was higher than in the non-AKI group (P < 0.05). The intraoperative load of chloride ions in fluids increased the risk of postoperative AKI (P < 0.01). In multivariate logistic regression analysis, postoperative BE-Cl < -7 mEq/L (i.e. SID <31 mEq/L) was an independent risk factor for AKI (odds ratio; 2.8, 95% CI; 1.2-6.4, P = 0.01). In the AKI group, stays in the intensive care unit and in hospital were longer than those in the non-AKI group (P < 0.05). CONCLUSION: Hyperchloremic acidosis is associated with postoperative AKI, and this may be attenuated by reducing the intraoperative chloride load.
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Abdome/cirurgia , Equilíbrio Ácido-Base , Acidose/etiologia , Injúria Renal Aguda/etiologia , Cloretos/sangue , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Hidratação/efeitos adversos , Acidose/sangue , Acidose/diagnóstico , Acidose/fisiopatologia , Injúria Renal Aguda/sangue , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/fisiopatologia , Idoso , Biomarcadores/sangue , Distribuição de Qui-Quadrado , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Fibrinogen replacement therapy con- tributes to effective hemostasis and saving blood trans- fusions in critical hemorrhage. We retrospectively studied the efficacy and indication for cryoprecipitate or fibrinogen concentrate in thoracic aortic surgery. METHODS: In 169 patients undergoing thoracic aortic surgery, 92 (54.4%) patients received dryoprecipitate or fibrinogen concentrate and 77 (45.6%) patients did not We compared them with regard to postoperative bleeding and perioperative blood transfusion. We deter- mined the effective dose of the fibrinogen in cryopre- cipitate or fibrinogen concentrate for increasing the fibrinogen level. RESULTS: The cutoff value of the fibrinogen level at the end of cardiopulmonary bypass between both groups was 100 mg · dl⻹. For a fibrinogen level less than 130 mg · dl⻹ during cardiopulmonary bypass, the patients who received cryoprecipitate or fibrinogen concentrate had less postoperative bleeding (P<0.01) and fewer transfusions of total blood, fresh frozen plasma, and platelet concentrates (P<0.05). The effec- tive dose 50 of fibrinogen amount was 0.031-0.051 g - kg⻹. CONCLUSIONS: The fibrinogen amount of 2-3 g (per 50-70 kg in body weight) in cryoprecipitate or fibrino- gen concentrate effectively reduces postoperative bleeding and perioperative blood transfusions when a fibrinogen level is less than 100-130 mg · dl⻹ during cardiopulmonary bypass.
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Fibrinogênio/uso terapêutico , Procedimentos Cirúrgicos Torácicos , Idoso , Idoso de 80 Anos ou mais , Aorta , Transfusão de Sangue , Ponte Cardiopulmonar , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória , Estudos RetrospectivosRESUMO
BACKGROUND: Fibrinogen replacement therapy is effective for attaining perioperative hemostasis in critical bleeding due to acquired hypofibrinogenemia. By simulating the fibrinogen level and fibrin polymerization, we compared the effect of fibrinogen replacement therapy using cryoprecipitate or fibrinogen concentrate versus the effect of fresh frozen plasma. METHODS: We simulated the plasma concentration of fibrinogen during fibrinogen replacement therapy in a model of cardiopulmonary bypass (CPB) and intensive care unit (ICU). We estimated fibrin polymerization (FIBTEM A10, thromboelastometry) by the simulated fibrinogen level, and compared this value with the fibrinogen level and FIBTEM in clinical patients. RESULTS: In the simulation model of CPB and ICU, cryoprecipitate and fibrinogen concentrate both effectively restored the fibrinogen level and FIBTEM, compared to fresh frozen plasma. In clinical patients, the simulated values of the fibrinogen level and FIBTEM after administering the fibrinogen concentrate were similar to the measured values. CONCLUSIONS: In the simulation model, which combines the fibrinogen level and fibrin polymerization, cryoprecipitate and fibrinogen concentrate effectively normalize the fibrinogen level and fibrin polymerization, compared to fresh frozen plasma. The fibrinogen concentrate also demonstrated efficacy in treating hypofibrinogenemia in clinical patients. The combined simulation model is useful in assessing the efficacy of fibrinogen replacement therapy by cryoprecipitate or by fibrinogen concentrate.
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Fibrina/administração & dosagem , Fibrinogênio/administração & dosagem , Ponte Cardiopulmonar , Hemostasia , Humanos , Unidades de Terapia Intensiva , Plasma , PolimerizaçãoRESUMO
Fibrinogen and fibrin formation have a key role in perioperative hemostasis. The aim of this study is to examine the association of postoperative hemostasis with a combined evaluation of the fibrinogen level and fibrin polymerization in cardiac surgery. We retrospectively classified 215 consecutive cardiac surgery patients into 4 groups (Fuji-san classification) that were divided by fibrinogen level <150 mg/dL (ie, hypofibrinogenemia) and fibrinogen thromboelastometry value at 10 minutes with rotational thromboelastometry <6 mm (ie, low fibrin polymerization) at the warming of cardiopulmonary bypass. Four groups resulted; group I, the acceptable range (n = 85); group II, only hypofibrinogenemia (<150 mg/dL, ≥6 mm, n = 63); group III, hypofibrinogenemia and low fibrin polymerization (<150 mg/dL, <6 mm, n = 60); and group IV, only low fibrin polymerization (≥150 mg/dL, <6 mm, n = 7). The risk of chest tube drainage volume greater than 500 mL within the first 24 hours after surgery (with group I as the reference) was increased in group II (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.5-7.4; P < .01) and group III (OR, 8.5; 95% CI, 3.5-21.7; P < .01), and the risk greater than 1000 mL (with group I as the reference) was increased in group III (OR, 4.0; 95% CI, 1.1-17.3; P = .03) and group IV (OR, 23.1; 95% CI, 3.2-201.0; P < .01). Intraoperative blood transfusions were decreased by 24.5%, after stratifying the starting amount of fresh frozen plasma by the 4-group classification in the recent consecutive 65 (30.2%) patients (P < .01). The 4-group classification is associated with postoperative bleeding and may improve the quality of perioperative blood transfusion in cardiac surgery.
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Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Fibrina/metabolismo , Fibrinogênio/metabolismo , Hemostasia/fisiologia , Hemorragia Pós-Operatória/etiologia , Tromboelastografia/métodos , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polimerização , Estudos Prospectivos , Estudos RetrospectivosRESUMO
Vocal cord paralysis after tracheal intubation is rare. It causes severe hoarseness and aspiration, and delays recovery and discharge. Arytenoid cartilage dislocation and recurrent nerve paralysis are main causes of vocal cord paralysis. Physical stimulation of the tracheal tube as well as patient and surgical characteristics also contribute. Vocal cord paralysis occurs in 1 (0.07%) of 1,500 general surgery patients and on the left side in 70% of cases. It is associated with surgery/anesthesia time (two-fold, 3-6 hours; 15-fold, over 6 hours), age (three-fold, over 50 years), and diabetes mellitus or hypertension (two-fold). Symptoms resolve in 2-3 months. In adult cardiovascular surgery, vocal cord paralysis occurs in 1 (0.7-2%) of 50-100 cardiac surgery patients and 1 (8.6-32%) of 3-10 thoracic aortic surgery patients. In pediatric cardiac surgery, vocal cord paralysis occurs in 1 (0.1-0.5%) of 200-1,000 patients. We classified the severity of vocal cord paralysis as I, severe hoarseness; II, aspiration or dysphagia; and III, bilateral vocal cord paralysis, aspiration pneumonia, or the need for tracheal re-intubation or tracheotomy. We discuss the importance of informed consent for the patient and family.
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Intubação Intratraqueal/efeitos adversos , Paralisia das Pregas Vocais/etiologia , Doenças Cardiovasculares/cirurgia , Humanos , Prognóstico , Medição de Risco , Índice de Gravidade de DoençaRESUMO
OBJECTIVE: To examine the characteristics of postoperative fentanyl effect-site concentrations during intravenous analgesia in patients requiring or not requiring a fentanyl bolus and in patients with or without postoperative nausea and vomiting (PONV). DESIGN: Retrospective observational study. SETTING: University-affiliated general hospital. PATIENTS: Sixty patients who underwent posterior lumbar spine fusion. MAIN OUTCOME MEASURES: The authors simulated the fentanyl effect-site concentration for 48 postoperative hours and compared it between patients who did and did not require a fentanyl bolus and between patients who did and did not experience PONV. RESULTS: At the end of anesthesia, the fentanyl effect-site concentration was similar between 37 (61.7 percent) patients requiring and 23 (38.3 percent) patients not requiring a postoperative fentanyl bolus (p=0.97). Within the first 12 postoperative hours, the concentration decreased in both groups (p < 0.01). The fentanyl effect-site concentration was higher in patients requiring a postoperative fentanyl bolus (within 12 hours, 1.4 ± 0.32 ng/mL vs 0.89 ± 0.35 ng/mL; between 12 and 48 hours, 0.94 ± 0.19 ng/mL vs 0.57 ± 0.09 ng/mL) (p < 0.05). PONV occurred in 22 (36.6 percent) patients, but more so in women (68.2 percent; p < 0.01); PONV was similar between patients requiring and not requiring a fentanyl bolus (p=0.78). Between the 12th and 48th postoperative hours, fentanyl effect-site concentrations were higher in patients with PONV (0.61 ± 0.10 ng/mL vs 0.57 ± 0.10 ng/mL, p=0.03). CONCLUSIONS: Patients needing a postoperative fentanyl bolus require a higher fentanyl effect-site concentration possibly because of individual variations, and PONV depends on the postoperative fentanyl effect-site concentration.
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Analgésicos Opioides/uso terapêutico , Fentanila/uso terapêutico , Vértebras Lombares/cirurgia , Dor Pós-Operatória/tratamento farmacológico , Fusão Vertebral , Idoso , Feminino , Fentanila/administração & dosagem , Fentanila/sangue , Humanos , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Náusea e Vômito Pós-Operatórios/epidemiologia , Náusea e Vômito Pós-Operatórios/prevenção & controle , Estudos RetrospectivosRESUMO
Two patients underwent resection of renal malignant tumors involving vena cava. Such tumors occasionally extend to the inferior vena cava with tumor thrombus and invasion to the lymph nodes and adjacent organs. Perioperative management of patients with these tumors is difficult because of the risk of pulmonary embolism and massive bleeding, and requires appropriate cooperation among the surgical team. In case 1, a 56-year-old man, renal cell carcinoma with tumor thrombus had extended into the intrahepatic vena cava. It was resected after isolating the liver from vena cava and incising the cross-clamped inferior vena cava without extracorporeal circulation or blood transfusion. A prosthetic graft replaced the inferior vena cava. In case 2, a 64-year-old woman, renal pelvis cancer adhered to the inferior vena cava and the mesentery with enlarged lymph nodes. It was separated from the inferior vena cava and removed with the ascending colon. The patient received a blood transfusion of approximately 2,000ml. Cardiomyopathy associated with a left ventricular outflow tract pressure gradient of 100mmHg required perioperative management. After surgery, both patients underwent controlled ventilation in the intensive care unit. After recovery, they were discharged without complications. We discuss perioperative management, with regard to the level of the tumor extension and perioperative complications.
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Carcinoma de Células Renais/cirurgia , Neoplasias Renais/cirurgia , Assistência Perioperatória/métodos , Veia Cava Inferior/patologia , Carcinoma de Células Renais/patologia , Feminino , Humanos , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Células Neoplásicas Circulantes/patologiaRESUMO
OBJECTIVE: Nafamostat mesilate, a short-acting protease inhibitor, treats heparin resistance during cardiopulmonary bypass. This study tested whether nafamostat mesilate is associated with perioperative ischemic stroke. DESIGN: A retrospective observational study. PARTICIPANTS: A total of 870 adult cardiac surgery patients. INTERVENTION: The authors retrospectively identified the patients who received nafamostat mesilate and who suffered symptomatic ischemic stroke within 30 postoperative days. MEASUREMENTS AND MAIN RESULTS: The authors evaluated perioperative patient characteristics in association with perioperative ischemic stroke and death. The patients were identified as heparin resistant if they had an activated coagulation time of <480 seconds after the administration of heparin at 400 to 500 U/kg. Heparin-resistant patients received a 10- to 20-mg bolus plus 25 to 50 mg/h of nafamostat mesilate and heparin at 100 U/kg intravenously every 1.5 to 2.0 hours to maintain an activated coagulation time over 480 seconds. Of the 870 patients, 11 (1.3%) suffered a perioperative ischemic stroke. Of the 190 (21.8%) patients who received nafamostat mesilate, 1 (0.5%) suffered ischemic stroke compared with 10 (1.5%) in 680 patients without nafamostat mesilate (Fisher exact test; p = 0.47; regression analysis; odds ratio, 0.35; 95% confidence interval, 0.45-2.8; p = 0.32); 3 (1.6%) patients with nafamostat mesilate died postoperatively within 30 days compared with 11 (1.6%) without nafamostat mesilate (Fisher exact test; p > 0.99, regression analysis; odds ratio, 0.98; 95% confidence interval, 0.27-3.5; p = 0.97). CONCLUSIONS: No evidence was found that nafamostat mesilate was associated with perioperative ischemic stroke in heparin-resistant patients undergoing cardiac surgery with cardiopulmonary bypass.
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Isquemia Encefálica/epidemiologia , Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Resistência a Medicamentos/efeitos dos fármacos , Guanidinas/uso terapêutico , Acidente Vascular Cerebral/epidemiologia , Idoso , Benzamidinas , Isquemia Encefálica/induzido quimicamente , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Estudos de Coortes , Resistência a Medicamentos/fisiologia , Feminino , Guanidinas/efeitos adversos , Heparina , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/efeitos adversos , Inibidores de Proteases/efeitos adversos , Inibidores de Proteases/uso terapêutico , Estudos Retrospectivos , Acidente Vascular Cerebral/induzido quimicamente , Resultado do TratamentoRESUMO
Perioperative ischemic stroke occurs in approximately 0.08-0.7% of patients after non-cardiovascular surgery and confers a significant risk of morbidity and mortality. The mortality rate of this major complication is similar in non-cardiovascular and cardiovascular surgery. Its incidence appears to be similar in Japan, Europe, and the United States. Perioperative physicians should be aware of the pathophysiology and predictors of ischemic stroke, and the anti-thrombotic strategies to prevent it. The main causes of perioperative ischemic stroke include cerebral atherothrombosis; lacuna stroke; cardiac thrombi due to atrial fibrillation; dehydration; hypotension; and perioperative systemic hypercoagulability. Perioperative management includes detailed informed consent regarding potential stroke risks, counseling, careful surgical treatment decisions, and identification of the high-risk patient for perioperative antithrombotic strategies. The 2009 Japanese guidelines for the management of stroke recommend using the appropriate intravenous infusions to avoid dehydration and consideration of anticoagulation in the patients who are at high risk for thrombosis and embolism while antithrombotic agents are discontinued. Understanding how to prevent perioperative ischemic stroke remains a challenge. In this article, we review the incidence, timing of the occurrence, mortality, risk factors, and pathophysiology of perioperative ischemic stroke in the non-cardiovascular surgery patient.
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Isquemia Encefálica/fisiopatologia , Complicações Intraoperatórias/fisiopatologia , Complicações Pós-Operatórias/fisiopatologia , Acidente Vascular Cerebral/fisiopatologia , Procedimentos Cirúrgicos Operatórios , Adolescente , Adulto , Idoso , Coagulação Sanguínea/fisiologia , Isquemia Encefálica/etiologia , Isquemia Encefálica/mortalidade , Feminino , Humanos , Complicações Intraoperatórias/mortalidade , Masculino , Pessoa de Meia-Idade , Consumo de Oxigênio , Assistência Perioperatória , Complicações Pós-Operatórias/mortalidade , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Adulto JovemRESUMO
OBJECTIVE: Aprotinin, once used to reduce allogeneic blood product transfusion during cardiac surgery, was withdrawn from the market in late 2007 over concerns of causing increased mortality. This study was undertaken to determine what, if any, the impact of changing antifibrinolytic agents (from aprotinin to tranexamic acid) for deep hypothermic circulatory arrest cases would have on blood bank resource utilization. DESIGN: This a retrospective review. SETTING: All cases were performed at a single university hospital. PARTICIPANTS: All patients underwent cardiac surgical procedures requiring deep hypothermic circulatory arrest performed by a single cardiac surgeon between January 2006 and November 2008. INTERVENTION: All patients prior to November 15, 2007 received aprotinin as antifibrinolytic therapy, while those after that date received tranexamic acid for antifibrinolytic therapy. MEASUREMENTS AND MAIN RESULTS: Blood transfusion data and recombinant factor VIIa use during the pre- and immediate postoperative period was collected for all patients during the study time period. There were no significant differences between the aprotinin (n = 82) and tranexamic acid (n = 78) groups with regard to baseline coagulation status or operative characteristics. Patients treated with tranexamic acid required more fresh frozen plasma (2.5 units, p < 0.001), platelets (0.5 units, p < 0.01), and cryoprecipitate (25 units, p < 0.001), and had a higher incidence of recombinant factor VIIa use (34.6% v 12.2%, p < 0.01) compared with patients in the aprotinin group. CONCLUSIONS: Patients treated with tranexamic acid required more clotting factors than the control group receiving aprotinin.
Assuntos
Antifibrinolíticos/uso terapêutico , Aprotinina/uso terapêutico , Transfusão de Sangue/estatística & dados numéricos , Procedimentos Cirúrgicos Cardíacos , Parada Circulatória Induzida por Hipotermia Profunda , Fator VIIa/uso terapêutico , Ácido Tranexâmico/uso terapêutico , Idoso , Anticoagulantes/uso terapêutico , Aorta/cirurgia , Aorta Torácica/cirurgia , Biomarcadores , Contagem de Células Sanguíneas , Transfusão de Sangue/economia , Procedimentos Cirúrgicos Cardíacos/economia , Ponte Cardiopulmonar , Parada Circulatória Induzida por Hipotermia Profunda/economia , Estudos de Coortes , Feminino , Hemostasia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Proteínas Recombinantes/uso terapêutico , Estudos RetrospectivosRESUMO
Cold agglutinin (CA) reacts reversibly with red blood cells at a low temperature and may cause thromboembolism of various organs. Therefore, special consideration is required in patients with cold agglutinin disease (CAD) undergoing cardiovascular surgery requiring hypothermia. Case 1: A 71-year-old man with elevated CA was scheduled to undergo total aortic arch replacement. Preoperatively, the patient received double filtration plasmapheresis to reduce CAs. The operation was performed at a higher temperature than the patient's thermal amplitude (TA) of 30 degrees C. Case 2: A 72-year-old man with CAD underwent a coronary artery bypass grafting. The patient's TA was 32 degrees C. The operation was performed on the beating heart with normothermic cardiopulmonary bypass. We performed an agglutination test at the temperature of 24 degrees C using the blood sample from the cardiopulmonary bypass circuit and no signs of agglutination were found. In both cases, no symptom of microembolism due to cold agglutination was recognized. This may indicate the possibility that the clinical risk is smaller than the risk recognized in vitro analysis. However, no safety standards for perioperative management of patients with CA are clearly established. Generally, it is more important to figure out the TA and to prevent the low-temperature exposure below the TA. In cases of normothermic procedures, further consideration for cerebral and myocardial protection is important.
Assuntos
Anemia Hemolítica Autoimune/complicações , Angina Pectoris/complicações , Angina Pectoris/cirurgia , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Ponte Cardiopulmonar , Ponte de Artéria Coronária , Assistência Perioperatória , Plasmaferese , Idoso , Aorta Torácica/cirurgia , Humanos , Hipotermia Induzida , MasculinoRESUMO
BACKGROUND: Vocal cord paralysis (VCP) after cardiovascular surgery can affect the postoperative outcome. The aim of the present study was to clarify the incidence of VCP after cardiovascular surgery and the relationship between the surgery characteristics and the risk of VCP. METHODS: A total of 987 consecutive patients who underwent cardiovascular surgery (cardiac, n = 895; aortic, n = 92) were enrolled. We retrospectively assessed the incidence and the risk of VCP according to the length and types of surgery and the details of each VCP case and compared them between the aortic and the nonaortic group. RESULTS: Twenty-three patients (2.3%: cardiac, n =15; aortic, n = 8) were expertly diagnosed with VCP (left, n = 19; right, n = 2; bilateral, n = 2). In the multivariate analysis, the risk for VCP increased with the duration of the operation (odds ratio [OR], 4.4, 95% confidence interval [CI] 1.7 to 11.4), and aortic procedures (OR, 5.6, CI 2.3 to 13.5) exhibited higher risk compared with coronary artery bypass grafting. Among the VCP cases, the incidence of poor outcomes (ie, bilateral VCP, repeated airway treatment, death within 6 months) was significantly higher in the aortic group (p = 0.016). All patients that were intubated for longer than 100 hours exhibited poor outcomes. CONCLUSIONS: Aortic procedures and prolonged operation increase the risk of VCP. Severe VCP tended to be associated with aortic surgery and intubation for more than 100 hours.
Assuntos
Procedimentos Cirúrgicos Cardiovasculares/efeitos adversos , Paralisia das Pregas Vocais/epidemiologia , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Incidência , Japão , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Paralisia das Pregas Vocais/etiologiaRESUMO
Tuberous sclerosis (Bourneville-Pringle disease) is a rare disease with a triad of mental retardation, epilepsy, and facial spot. Management of the patients with tuberous sclerosis under general anesthesia has been previously reported. However, there are few case reports about management under general anesthesia of a pediatric patient with tuberous sclerosis with frequent epileptic seizure. Here, we report a case of a pediatric patient with tuberous sclerosis and frequent epileptic seizure who underwent intensive dental treatment under general anesthesia with careful management of epilepsy. The patient was discharged on the day of surgery without any complications. In this case report, we discussed the appropriate assessment of the complications of tuberous sclerosis; such as, of central nervous, circulatory, respiratory, endocrine, and urinary systems including the management of general anesthesia.