Preoperative Diaphragm Function Is Associated With Postoperative Pulmonary Complications After Cardiac Surgery.

OBJECTIVES: Postoperative pulmonary complications increase mortality, length, and cost of hospitalization. A better diaphragmatic strength may help face an increased work of breathing postoperatively. We, therefore, sought to determine if a low preoperative diaphragm thickening fraction (TFdi) determined by ultrasonography helped predict the occurrence of postoperative pulmonary complications after cardiac surgery independently of indicators of frailty, sarcopenia, and pulmonary function. DESIGN: Prospective observational cohort study. SETTING: Montreal Heart Institute, an academic cardiac surgery center in Canada. PATIENTS: Adults undergoing nonemergency cardiac surgery. INTERVENTIONS: We measured the preoperative thickness of the right and left hemidiaphragms at their zone of apposition at end-expiration (Tdi,ee) and peak-inspiration (Tdi,ei) with ultrasonography. Maximal thickening fraction of the diaphragm during inspiration (TFdi,max) was calculated using the following formula: TFdi,max = (Tdi,ei-Tdi,ee)/Tdi,ee. We also evaluated other potential risk factors including demographic parameters, comorbidities, Clinical Frailty Scale, grip strength, 5-meter walk test, and pulmonary function tests. We repeated TFdi,max measurements within 24 hours of extubation. The primary composite outcome of this study was the occurrence of postoperative pulmonary complications, defined as pneumonia, clinically significant atelectasis, or prolonged mechanical ventilation (> 24 hr). MEASUREMENT AND MAIN RESULTS: Of the 115 patients included, 34 (29.6%) developed postoperative pulmonary complications, including two with pneumonia, four with prolonged mechanical ventilation, and 32 with clinically significant atelectasis. Those with postoperative pulmonary complications had prolonged ICU and hospital length of stays. They had a lower TFdi,max (37% [interquartile range, 31-45%] vs 44% [interquartile range, 33-58%]; p = 0.03). In multiple logistic regression, a TFdi,max less than 38.1% was associated with postoperative pulmonary complications (odds ratio, 4.9; 95% CI, 1.81-13.50; p = 0.002). All patients who developed pneumonia or prolonged mechanical ventilation had a TFdi,max less than 38.1%. Respiratory rate and diabetes were also independently associated with postoperative pulmonary complications, while pulmonary function tests and the assessed indicators of frailty and sarcopenia were not. CONCLUSIONS: A low preoperative TFdi,max can help to identify patients at increased risk of postoperative pulmonary complications after cardiac surgery.

The Association Between Pulsatile Portal Flow and Acute Kidney Injury after Cardiac Surgery: A Retrospective Cohort Study.

OBJECTIVE: Venous congestion is a possible mechanism leading to acute kidney injury (AKI) following cardiac surgery. Portal vein flow pulsatility is an echographic marker of cardiogenic portal hypertension and might identify clinically significant organ congestion. This exploratory study aims to assess if the presence of portal flow pulsatility measured by transthoracic echography in the postsurgical intensive care unit is associated with AKI after cardiac surgery. DESIGN: Retrospective cohort study. SETTING: Specialized care university hospital. PARTICIPANTS: Patients who underwent cardiac surgery between May 2015 and February 2016 and had at least 1 Doppler assessment of portal flow performed by the attending critical care physician during the week following cardiac surgery. INTERVENTIONS: The association between portal flow pulsatility defined as a pulsatility fraction ≥50% and the risk of subsequent AKI was assessed using univariate and multivariate logistic regression analysis. MEASUREMENTS AND MAIN RESULTS: The files of 132 consecutive patients were reviewed and 102 patients were included in the analysis. Significant portal flow pulsatility was detected in 38 patients (37.3%) in the week following surgery. During this period, 60.8% developed AKI and 13.7% progressed to severe AKI. The detection of portal flow pulsatility was associated with an increased risk for the development of AKI (odds ration [OR] 4.31, confidence interval [CI] 1.50-12.35, p = 0.007). After adjustment, portal flow pulsatility and AKI were independently associated (OR 4.88, CI 1.54-15.47, p = 0.007). CONCLUSIONS: Assessment of portal flow using Doppler ultrasound at the bedside might be a promising tool to detect patients at risk for AKI due to cardiogenic venous congestion.

Clinical Significance of Portal Hypertension Diagnosed With Bedside Ultrasound After Cardiac Surgery.

BACKGROUND: Portal venous flow pulsatility detected by Doppler ultrasound is a sign of congestive heart failure in noncritically ill patients. The assessment of portal and splenic venous flows has never been reported in patients undergoing cardiac surgery. METHODS: This is a case series performed in patients undergoing cardiac surgery between February 2014 and February 2015 in which portal and/or splenic venous flows were assessed by the attending anesthesiologist during surgery or by the intensivist after surgery using transthoracic echography in 9 patients or transesophageal echocardiography in 5 patients. Data collection was done retrospectively by reviewing intraoperative and postoperative monitoring documents. The technique of assessment is detailed in this article. RESULTS: We report the abnormal portal and/or splenic venous flow pulsatility from 14 patients perioperatively. At the time of pulsatility detection, patients had a median cumulative fluid balance of 3.8 L (interquartile range: 0-4.6 L) and a median right atrial pressure of 14.0 mm Hg (interquartile range: 12.0-15.5 mm Hg). In some patients (4/14), signs of right ventricular dysfunction on echocardiography and/or right ventricular pressure monitoring were present. CONCLUSIONS: Doppler evaluation of portal and splenic venous flow using transthoracic echography and transesophageal echocardiography may represent a promising modality to assess end-organ venous congestion in cardiac surgery patients.

Albumin administration for fluid resuscitation in burn patients: A systematic review and meta-analysis.

OBJECTIVE: The objective was to systematically review the literature summarizing the effect on mortality of albumin compared to non-albumin solutions during the fluid resuscitation phase of burn injured patients. DATA SOURCES: We searched MEDLINE, EMBASE and CENTRAL and the content of two leading journals in burn care, Burns and Journal of Burn Care and Research. STUDY SELECTION: Two reviewers independently selected randomized controlled trials comparing albumin vs. non-albumin solutions for the acute resuscitation of patients with >20% body surface area involvement. DATA EXTRACTION: Reviewers abstracted data independently and assessed methodological quality of the included trials using predefined criteria. DATA SYNTHESIS: A random effects model was used to assess mortality. We identified 164 trials of which, 4 trials involving 140 patients met our inclusion criteria. Overall, the methodological quality of the included trials was fair. We did not find a significant benefit of albumin solutions as resuscitation fluid on mortality in burn patients (relative risk (RR) 1.6; 95% confidence interval (CI), 0.63-4.08). Total volume of fluid infusion during the phase of resuscitation was lower in patients receiving albumin containing solution -1.00ml/kg/%TBSA (total body surface area) (95% CI, -1.42 to -0.58). CONCLUSION: The pooled estimate demonstrated a neutral effect on mortality in burn patients resuscitated acutely with albumin solutions. Due to limited evidence and uncertainty, an adequately powered, high quality trial could be required to assess the impact of albumin solutions on mortality in burn patients.

Hypoalbuminemia in the first 24h of admission is associated with organ dysfunction in burned patients.

OBJECTIVE: Hypoalbuminemia is a common finding in burned patients, but its association with increased morbidity and mortality has not been well established. We assessed whether hypoalbuminemia in the first 24h of admission is associated with organ dysfunction in patients with severe burns. METHODS: For a two year period (2008-2009), we reviewed the records of burn adult patients with a total body surface area 20% admitted in our unit within the first 24h of injury. A multiple linear regression analysis was conducted to assess hypoalbuminemia as an independent predictor of organ dysfunction. RESULTS: 56 subjects were analyzed. Multiple linear regression analysis showed that hypoalbuminemia in the first 24h of admission was an independent predictor of organ dysfunction. Serum albumin concentration ≤ 30 g/L was associated with a two-fold increase in organ dysfunction [SOFA scores at day 0 (p=0.005), day 1 (p=0.005) and first week mean values (p=0.004)], but not with mortality (p=0.061). CONCLUSION: Hypoalbuminemia is associated with organ dysfunction in burned patients. Unlike unmodifiable predictors such as age, burn surface and inhalation burn, correction of hypoalbuminemia might represent a goal for a future trial in burn patients.

Ultrasonido de la cabeza a los pies: opinión actual sobre su utilidad en inestabilidad hemodinámica, hipoxemia, oligoanuria y en el paciente con estado neurológico alterado / Head to toe ultrasound: Current opinion on its role in hemodynamic instability, hypoxemia, oligoanuria and the patient with altered neurological status

Abstract Introduction: Bedside ultrasound is now more commonly used in anesthesiology and critical care. There are numerous applications beyond its role in regional anesthesia and vascular access. Objective: To describe how bedside ultrasound can be integrated to current clinical management is dealingwith hemodynamicallyunstable, hypoxemic, oligoanuric patient and in the patient with altered neurological status. Material and methods: Essay article describing a synthesis of the current literature, expert opinion, currentpracticeand recentclinicaltrials in the developmentofproposed algorithm dealing with the use of bedside ultrasound in the management hemodynamic instability and hypoxemia. Results: Three algorithms currently used in the hemodynamically unstable and the hypox-emic patient and the patient are described. In addition, a simple bedside ultrasound approach to oligoanuria and altered neurological status is proposed. Conclusion: Further studies incorporating head-to-toe bedside ultrasound by trained clinicians will need to be validated but are likely to demonstrate the significant advantages of incorporating bedside ultrasound in the practice of anesthesiology and critical care.

Resumen Introducción: El ultrasonido realizado al lado de la cama del paciente se utiliza cada vez con más frecuencia en anestesiología y cuidado crítico. Son muchas sus aplicaciones aparte de la anestesia regional y el acceso vascular. Objetivo: Describir la forma de integrar el ultrasonido al lado de la cama del paciente en el actual manejo clínico del paciente hemodinámicamente inestable, hipoxémico y oligoanúrico, y del paciente con estado neurológico alterado. Materiales y métodos: Ensayo que describe una síntesis de la literatura actual, las opiniones de expertos, la práctica corriente y los experimentos clínicos recientes para el desarrollo de la propuesta de un algoritmo relativo al uso del ultrasonido al lado de la cama del paciente en el manejo de la inestabilidad hemodinámica y la hipoxemia. Resultados: Se describen 3 algoritmos utilizados actualmente en el paciente hemodinámicamente inestable e hipoxémico. Adicionalmente se propone un enfoque simple de ultrasonido a la cabecera del paciente para la oligoanuria y el estado neurológico alterado. Conclusión: Será necesario validar estudios ulteriores que incorporen la realización de ultrasonido de la cabeza a los pies por parte de clínicos entrenados, pero es probable que demuestren las ventajas importantes de incorporar el ultrasonido a la cabecera del paciente en la práctica de la anestesiología y el cuidado crítico.

Grosor de la íntima-media de las carótidas en pacientes con VIH / Thickness of the carotid arteries intimae-media in patients with HIV

Objetivo: los pacientes con VIH pueden tener mayor riesgo de enfermedad coronaria. El propósito del presente estudio fue determinar el grosor de la intima-media (GIM) de la arteria carótida común como marcador de aterosclerosis temprana en pacientes con VIH, en comparación con sujetos sanos sin infección por VIH. Métodos: se realizó un estudio de casos y controles donde se hizo medición del GIM en las arterias carótidas a 25 pacientes con VIH y 31 pacientes sanos. Al grupo de pacientes con VIH se les realizó medición de glucemia, perfil lipídico, carga viral y recuento de CD4; se subdividieron en dos grupos, pacientes que recibían o no inhibidores de proteasa (IP), y se compararon los resultados obtenidos. Resultados: el GIM fue de 0,76 mm en los pacientes con VIH y 0,79 mm en los sanos (p=0,24). En los pacientes con VIH, el GIM de los que recibieron o no IP fue: 0,76 y 0,75 mm respectivamente p=0,79. Los pacientes que recibieron IP tenían más frecuencia de dislipidemia, principalmente disminución de las HDL-colesterol (12 pacientes, contra cinco pacientes en el grupo que no los recibía; p=0,04). Conclusiones: estos datos sugieren que no hay mayor riesgo de aterosclerosis en los pacientes con infección por VIH, aunque se necesitan estudios longitudinales para establecer con claridad. El hallazgo de mayor frecuencia de dislipidemia en los que reciben IP puede ser debido a la terapia o a niveles previos al inicio del tratamiento, los cuales no fueron medidos en este estudio.

Aim: the patients with HIV may be at higher risk of coronary disease. The purpose of this study was to determine the thickness of the intimae media (IMT) of the common carotid artery as a marker of early atherosclerosis in patients with HIV, as compared to healthy subjects without HIV infection.Methods: a case study and controls was carried out taking measurements of the (IMT) in the carotid arteries in 25 patients with HIV and 31 healthy patients. Glycemia, lipids profile, virus load and CD4 count were measured in HIV patients: they were divided into two groups, patients receiving or not protease inhibitors (PI), and the results obtained were compared. Results: the IMT was 0,76 mm in patients with HIV and 0,79 mm in healthy patients (p=0,24). In patients with HIV, the IMT, regardless if they received PI or not was: 0,76 and 0,75 mm respectivelyp=0,79. The patients that received PI had dislipidemia more frequently, mainly a decrease of HDL cholesterol (12 patients against 5 in the group that did received them; p=0,04). Conclusions: these data suggest that there is no high risk of atherosclerosis in patients with HIV, although longitudinal studies will be needed for further clarification. Higher frequency of dislipidemiain those receiving PI may be due to the therapy or to high levels before the treatment and that were not measured in this study.