RESUMEN
OBJECTIVES: This study evaluated whether the postoperative pulmonary artery pulsatility index (PAPi) is associated with postoperative right ventricular dysfunction after durable left ventricular assist device (LVAD) implantation. DESIGN: Single-center retrospective observational cohort study. SETTING: The University of Kansas Medical Center, a tertiary-care academic medical center. PARTICIPANTS: Sixty-seven adult patients who underwent durable LVAD implantation between 2017 and 2019. INTERVENTIONS: All patients underwent open cardiac surgery with cardiopulmonary bypass under general anesthesia with pulmonary artery catheter insertion. MEASUREMENTS AND MAIN RESULTS: Clinical and hemodynamic data were collected before and after surgery. The Michigan right ventricular failure risk score and the European Registry for Patients with Mechanical Circulatory Support score were calculated for each patient. The primary outcome was right ventricular failure, defined as a composite of right ventricular mechanical circulatory support, inhaled pulmonary vasodilator therapy for 48 hours or greater, or inotrope use for 14 days or greater or at discharge. Thirty percent of this cohort (n = 20) met the primary outcome. Preoperative transpulmonary gradient (odds ratio [OR] 1.15, 95% CI 1.02-1.28), cardiac index (OR 0.83, 95% CI 0.71-0.98), and postoperative PAPi (OR 0.85, 95% CI 0.75-0.97) were the only hemodynamic variables associated with the primary outcome. The addition of postoperative PAPi was associated with improvement in the predictive model performance of the Michigan score (area under the receiver operating characteristic curve 0.73 v 0.56, p = 0.03). An optimal cutoff point for postoperative PAPi of 1.56 was found. CONCLUSIONS: The inclusion of postoperative PAPi offers more robust predictive power for right ventricular failure in patients undergoing durable LVAD implantation, compared with the use of existing risk scores alone.
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Insuficiencia Cardíaca , Corazón Auxiliar , Procedimientos Quirúrgicos Torácicos , Disfunción Ventricular Derecha , Adulto , Humanos , Estudios Retrospectivos , Arteria Pulmonar/diagnóstico por imagen , Corazón Auxiliar/efectos adversos , Factores de Riesgo , Insuficiencia Cardíaca/cirugía , Disfunción Ventricular Derecha/diagnóstico por imagen , Disfunción Ventricular Derecha/etiologíaRESUMEN
While considerable literature exists with respect to clinical aspects of critical care anesthesiology (CCA) practice, few publications have focused on how anesthesiology-based critical care practices are organized and the challenges associated with the administration and management of anesthesiology critical care units. Currently, numerous challenges are affecting the sustainability of CCA practice, including decreased applications to fellowship positions and decreased reimbursement for critical care work. This review describes what is known about the subspecialty of CCA and leverages the experience of administrative leaders in adult critical care anesthesiologists in the United States to describe potential solutions.
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Anestesiología , Consenso , Cuidados Críticos , Humanos , Cuidados Críticos/normas , Estados Unidos , Anestesiólogos/normasRESUMEN
OBJECTIVES: The decision algorithm for managing patients in cardiogenic shock depends on cardiac index (CI) estimates. Cardiac index estimation via thermodilution (CI-TD) using a pulmonary artery catheter is used commonly for obtaining CI in these patients. Minimally invasive methods of estimating CI, such as multibeat analysis (CI-MBA), may be an alternative in this population. DESIGN: A prospective, observational study. SETTING: Cardiac intensive care unit. PARTICIPANTS: Twenty-two subjects in cardiogenic shock provided 101 paired CI measurements. INTERVENTIONS: Measurements were obtained concomitantly by intermittent CI-TD and CI-MBA (Argos Cardiac Output Monitor; Retia Medical, Valhalla, NY). For each CI-TD, CI-MBA estimates were averaged over 1 minute to provide paired values. Bland-Altman and 4-quadrant analyses were performed by plotting changes between successive CI measurements (ΔCI) from each of the 2 methods. Concordance was calculated as a percentage using ΔCI data points from the 2 methods, outside an exclusion zone of 15%. MEASUREMENTS AND MAIN RESULTS: The correlation coefficient between CI-MBA and CI-TD was 0.78 across patients. Mean CI-TD was 2.19 ± 0.46 L/min/m2 and mean CI-MBA was 2.38 ± 0.59 L/min/m2. The mean difference between CI-MBA and CI-TD (bias ± SD) was 0.20 ± 0.47 L/min/m2, and the limits of agreement were -0.72 to 1.11 L/min/m2. The percentage error was 40.0%. The concordance rate was 94%. A secondary analysis of a subgroup of patients during periods of arrhythmia demonstrated a similar accuracy of performance of CI-MBA. CONCLUSIONS: Cardiac index-MBA is not interchangeable with CI-TD. However, CI-MBA provides reasonable correlation and clinically acceptable trending ability compared with CI-TD. Cardiac output-MBA may be useful in trending changes in CI in patients with cardiogenic shock, especially in those whose pulmonary artery catheterization placement carries a high risk or is unobtainable.
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Cateterismo de Swan-Ganz , Choque Cardiogénico , Humanos , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/terapia , Reproducibilidad de los Resultados , Gasto Cardíaco , Puente de Arteria Coronaria , Termodilución/métodosRESUMEN
OBJECTIVE: Recombinant factor VII (rFVIIa) is used to treat cardiac surgical bleeding in an off-label manner. However, optimal dosing and timing of administration to provide efficacious yet safe outcomes remain unknown. DESIGN: Retrospective, observational study. SETTING: Tertiary care academic center. PARTICIPANTS: Cardiac surgical patients (Nâ¯=â¯214) who received low-dose rFVIIa for cardiac surgical bleeding. INTERVENTIONS: Patients were allocated into one of three groups based on timing of rFVIIa administration during the course of bleeding resuscitation based on the number of hemostatic products given before rFVIIa administration: group oneâ¯=â¯≤one products (nâ¯=â¯82); group twoâ¯=â¯two-to-four products (nâ¯=â¯73); and group three=â¯≥five products (nâ¯=â¯59). MEASUREMENTS AND MAIN RESULTS: Patients who received low-dose rFVIIa later in the course of bleeding resuscitation (group three) had longer intensive care unit stays (pâ¯=â¯0.014) and increased incidence of postoperative renal failure when compared with group one (pâ¯=â¯0.039). Total transfusions were lowest in patients who received rFVIIa early in the course of resuscitation (group one) (median, two [interquartile range (IQR), 1-4.75]) and highest in group three (median, 11 [IQR, 8-14]; p < 0.001). Subsequent blood product transfusions after rFVIIa administration were highest in group two (pâ¯=â¯0.003); however, the median for all three groups was two products. There were no differences in thrombosis, reexplorations, or mortality in any of the groups. CONCLUSIONS: This study identified no differences in adverse outcomes based on timing of administration of low-dose rFVIIa for cardiac surgical bleeding defined by stage of resuscitation, but the benefits of early administration remain unclear.
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Procedimientos Quirúrgicos Cardíacos , Factor VIIa , Pérdida de Sangre Quirúrgica , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Humanos , Tiempo de Internación , Hemorragia Posoperatoria/epidemiología , Hemorragia Posoperatoria/terapia , Proteínas Recombinantes , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Heart disease is the leading cause of death in men and women in the United States. During the past several decades, research into the role of specific intracellular mediators, called exosomes, has advanced the understanding of molecular cardioprotection. Exosomes and the micro-RNAs within them may be potential targets for the development of genetically engineered or biosimilar medications for patients in heart failure or with ischemic cardiac disease. This review discusses anesthetic implications of exosome production and the future micro-RNA applications for cardioprotection.
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Exosomas , Humanos , MasculinoRESUMEN
As treatments for hematologic malignancies continue to advance, many patients with active disease and many more in remission will present for cardiac surgical procedures. Radiation and chemotherapeutic therapies for hematologic malignancies often result in cardiopulmonary injury. Evidence demonstrates that patients with hematologic malignancies undergoing cardiac surgery are at risk for perioperative adverse events, including bleeding, clotting, infection, and immunomodulation. However, short- and long-term mortality has been found to be acceptable. This review will distinguish the important points of characterizing, understanding, and managing hematologic malignancies in the cardiac surgical patient.
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Procedimientos Quirúrgicos Cardíacos , Neoplasias Hematológicas , Adulto , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Neoplasias Hematológicas/terapia , Hemorragia , HumanosRESUMEN
Miniaturized transesophageal echocardiography has become more common in cardiac intensive care units. There are potential benefits to this mode of technology, many of which have been described in the literature. However, image acquisition and quality have been cited as being less optimal when compared to traditional transesophageal echocardiography. This review will discuss the current options available for miniaturized transesophageal echocardiography along with a literature review of this emerging assessment modality.
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Ecocardiografía Transesofágica/instrumentación , Unidades de Cuidados Intensivos , Sistemas de Atención de Punto , Diseño de Equipo , Humanos , MiniaturizaciónAsunto(s)
Procedimientos Quirúrgicos Cardíacos , Factor VIIa , Humanos , Factor VIIa/uso terapéutico , Uso Fuera de lo Indicado , Pérdida de Sangre Quirúrgica/prevención & control , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Proteínas Recombinantes/uso terapéutico , Hemorragia Posoperatoria/tratamiento farmacológico , Estudios RetrospectivosRESUMEN
OBJECTIVE: This prospective observational study was undertaken to evaluate the utility of a miniature transesophageal echocardiography probe (ImaCor hemodynamic [hTEE]) in the management of hemodynamically unstable intensive care unit patients with and without various forms of mechanical circulatory support. DESIGN: A prospective observational study. SETTING: A single tertiary care cardiothoracic and surgical intensive care unit. PARTICIPANTS: Fifty-three cardiothoracic and surgical intensive care unit patients undergoing miniature transesophageal echocardiography examinations. All patients had hemodynamic instability as defined by necessity of mechanical circulatory support (MCS) devices or vasoactive medications. INTERVENTIONS: From April 2012 to February 2014, 53 hemodynamically unstable intensive care unit patients received an examination with the miniature transesophageal echocardiography probe when deemed necessary by the intensivist for rapid and/or ongoing transesophageal echocardiographic examinations. Twenty-eight of the examinations were performed in patients with MCS devices (53%). The remainder of examinations (n = 25, 47%) were performed in patients after other cardiothoracic surgery or noncardiac surgery with cardiac complications. MEASUREMENTS AND MAIN RESULTS: The measured endpoint was determination of usefulness of management guidance due to the miniature transesophageal echocardiographic examination as assessed by the intensivist caring for the patient. The incidence of hTEE imaging provoking a change in management also was recorded. Overall, of the 53 examinations, 77% (n = 41) provided useful information to the management. Of the 25 examinations in patients without MCS, 92% (n = 23) of the examinations were useful in guiding management. Among the 28 examinations in patients with MCS devices, 64% (n = 18) of examinations were useful in guiding management (odds ratio = 0.156; 95% confidence interval, 0.015-0.899; p = 0.022). Eight of the 53 examinations (15%) were deemed to have "poor image quality" by the echocardiographer. Age, sex, and body mass index did not significantly affect the usefulness of the hTEE examinations. CONCLUSION: Examination of a heterogeneous hemodynamically unstable intensive care population with a miniature transesophageal echocardiography probe provided useful information beyond standard intensive care unit monitoring data, which influenced post-hTEE medical decision making. The examinations were more useful in patients without MCS devices than in those with MCS. Of the patients with MCS, patients with durable ventricular assist devices had the lowest rate of useful examinations.
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Ecocardiografía Transesofágica/instrumentación , Hemodinámica , Unidades de Cuidados Intensivos , Toma de Decisiones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
OBJECTIVE: The optimal timing of extubation following cardiac surgery is currently unknown. Protocols implemented in order to achieve a rapid extubation may achieve this goal, but not prove beneficial in terms of outcomes. DESIGN: A prospective clinical trial. SETTING: Tertiary care cardiac surgical intensive care unit. PARTICIPANTS: Adult cardiac surgical patients. INTERVENTIONS: Implementation of an 8-tier multidisciplinary rapid weaning protocol. MEASUREMENTS AND MAIN RESULTS: Ventilator times 6 months prior to and 6 months after implementation of the protocol were measured. Outcomes associated with ventilator times were measured by dividing the patients into tertiles (<6 hours, 6-12 hours, >12 hours). Primary outcomes were intensive care unit (ICU) and hospital length of stay. Secondary outcomes included mortality at 30 days and other major morbidities. In all, 459 patients were included in the study. With implementation of the protocol, median ventilation times decreased from 7.4 hours (interquartile range, IQR = 3rd quartile - 1st quartil e= 6.72 hours) to 5.73 hours (IQR = 5.51 hours) (p < 0.0001). However, median ICU length of stay in patients who achieved extubation within 6 hours increased to 49.45 hours (IQR = 44.4) from 40.3 (IQR = 25.6) (p = 0.0017). Median hospital length of stay was not significantly changed due to the protocol in any ventilation tertile (p = 0.650). CONCLUSIONS: Decreasing intubation times to <6 hours in postsurgical cardiac patients is obtainable with implementation of a multidisciplinary rapid weaning protocol. However, patients extubated within 6 hours had increased ICU length of stay and no difference in hospital length of stay with this intervention.
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Extubación Traqueal/métodos , Procedimientos Quirúrgicos Cardíacos/métodos , Unidades de Cuidados Intensivos , Tiempo de Internación , Respiración Artificial/métodos , Desconexión del Ventilador/métodos , Anciano , Extubación Traqueal/tendencias , Procedimientos Quirúrgicos Cardíacos/tendencias , Protocolos Clínicos , Femenino , Humanos , Unidades de Cuidados Intensivos/tendencias , Tiempo de Internación/tendencias , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Respiración Artificial/tendencias , Factores de Tiempo , Desconexión del Ventilador/tendenciasAsunto(s)
Infarto del Miocardio , Procedimientos Quirúrgicos Operativos , American Heart Association , Humanos , Atención Perioperativa , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Procedimientos Quirúrgicos Operativos/efectos adversosRESUMEN
The present study furthered the concept of simulation-based medical education by applying a personalized active learning component. We tested this novel approach utilizing a noninvasive hemodynamic monitor with the capability to measure and display in real time numerous hemodynamic parameters in the exercising participant. Changes in medical knowledge concerning physiology were examined with a pre-and posttest. Simply by observation of one's own hemodynamic variables, the understanding of complex physiological concepts was significantly enhanced.