Short-term high-dose intravenous iron reduced peri-operative transfusion after staggered bilateral total knee arthroplasty: A retrospective cohort study.

BACKGROUND AND OBJECTIVES: Staggered bilateral total knee arthroplasty, two procedures performed 4-7 days apart during a single hospitalization, has an increased risk of blood transfusion. This observational study aimed to evaluate whether immediate post-operative single, high-dose intravenous iron supplementation could reduce transfusion requirements and facilitate anaemia recovery in patients. MATERIALS AND METHODS: We retrospectively analysed 131 patients who underwent staggered bilateral total knee arthroplasty. The ferric carboxymaltose (FCM) group received 1000 mg of FCM after the first operation. The non-FCM group did not receive intravenous iron. The transfusion rate and post-operative complications were compared between the groups. The anaemia rate was evaluated pre-operatively, during hospitalization, and 5 weeks after the second total knee arthroplasty. RESULTS: The FCM group comprised 78 patients (59.5%). The rate (21.8% vs. 47.2%, p = 0.004) and amount of transfusion (0 [0-2] vs. 0 [0-0], p = 0.001) was significantly lower in the FCM group than in the non-FCM group. Although both groups' pre-operative haemoglobin concentrations were not significantly different, the FCM group demonstrated higher haemoglobin values 5 weeks post surgery (12.25 ± 0.83 mg/dl vs. 11.48 ± 1.36 mg/dl, p < 0.001). More non-FCM patients developed moderate to severe anaemia at 5 weeks post surgery (p < 0.001). The mortality and complication rates were not significantly different. CONCLUSIONS: Immediate post-operative, high-dose, intravenous iron treatment may contribute to reduced transfusion rates, facilitate haemoglobin recovery after staggered bilateral total knee arthroplasty, and minimize the development of moderate to severe anaemia.

Hemodilution on microvascular oxygen delivery potential of the blood during coronary bypass surgery.

PURPOSE: The hematocrit-to-whole blood viscosity ratio (Hct/WBV) reflects the blood O2 delivery potential (O2-DP). WBV is variable to the dynamic vascular shear rate (SR), 1-5/s at microcirculation and 300/s at larger vessels. To estimate the impact of hemodilution on the blood O2-DP to the myocardium, we analyzed the hemodilution-induced change of Hct/WBV at SR 5/s (Hct/WBV5) during off-pump coronary bypass (OPCAB) surgery. METHODS: During OPCAB surgery (n = 21), 10% acute normovolemic hemodilution (HD 10%) was applied. Arterial blood samples were taken: one before and two after HD 10%. One of which after HD 10% underwent an additional 33% in vitro hemodilution (reaching 40% hemodilution in total, HD 40%). WBV of all blood samples was determined using a scan-capillary tube viscometer (Hemovister™). The changes of Hct/WBV5 were analyzed as a primary measure of the study and compared with those of Hct/WBV at SR 300/s (Hct/WBV300). RESULTS: Median[IQR] of Hct/WBV5 [3.5 (2.8-4.2)%/cPoise] was significantly increased by HD 10 and HD 40% [3.6 (3.2-4.6)%/cPoise and 4.2 (3.3-5.2)%/cPoise, respectively, all P < 0.001], but the degrees of changes after HD 10 and HD 40% were not different. Median[IQR] of Hct/WBV300 [10.3(8.6‒10.8)%/cPoise] was not changed by HD 10% [10.3(9.1-11.1)%/cPoise], but it was significantly decreased by HD 40% [8.4(7.4‒9.2)%/cPoise, P < 0.001]. CONCLUSION: The increased Hct/WBV5 suggests that 10-40% hemodilution improves the blood O2-DP to the myocardium during OPCAB surgery. The SR-specific discrepancy in Hct/WBV changes advocates using microvascular WBV and Hct/WBV to evaluate the blood O2-DP changes to the myocardium. Further study is warranted to assess the actual changes in myocardial O2 delivery.

Perioperative temperature management: a survey of 6 Asia-Pacific countries.

BACKGROUND: Anesthesia leads to impairments in central and peripheral thermoregulatory responses. Inadvertent perioperative hypothermia is hence a common perioperative complication, and is associated with coagulopathy, increased surgical site infection, delayed drug metabolism, prolonged recovery, and shivering. However, surveys across the world have shown poor compliance to perioperative temperature management guidelines. Therefore, we evaluated the prevalent practices and attitudes to perioperative temperature management in the Asia-Pacific region, and determined the individual and institutional factors that lead to noncompliance. METHODS: A 40-question anonymous online questionnaire was distributed to anesthesiologists and anesthesia trainees in six countries in the Asia-Pacific (Singapore, Malaysia, Philippines, Thailand, India and South Korea). Participants were polled about their current practices in patient warming and temperature measurement across the preoperative, intraoperative and postoperative periods. Questions were also asked regarding various individual and environmental barriers to compliance. RESULTS: In total, 1154 valid survey responses were obtained and analyzed. 279 (24.2%) of respondents prewarm, 508 (44.0%) perform intraoperative active warming, and 486 (42.1%) perform postoperative active warming in the majority of patients. Additionally, 531 (46.0%) measure temperature preoperatively, 767 (67.5%) measure temperature intraoperatively during general anesthesia, and 953 (82.6%) measure temperature postoperatively in the majority of patients. The availability of active warming devices in the operating room (p < 0.001, OR 10.040), absence of financial restriction (p < 0.001, OR 2.817), presence of hospital training courses (p = 0.011, OR 1.428), and presence of a hospital SOP (p < 0.001, OR 1.926) were significantly associated with compliance to intraoperative active warming. CONCLUSIONS: Compliance to international perioperative temperature management guidelines in Asia-Pacific remains poor, especially in small hospitals. Barriers to compliance were limited temperature management equipment, lack of locally-relevant standard operating procedures and training. This may inform international guideline committees on the needs of developing countries, or spur local anesthesiology societies to publish their own national guidelines.

Pharmacodynamic Analysis of the Influence of Propofol on Left Ventricular Long-Axis Systolic Performance in Cardiac Surgical Patients.

BACKGROUND: Propofol induced a decline in the left ventricular (LV) systolic performance in non-cardiac surgery. We tested the hypothesis that propofol decreased the LV contractile function by dose dependent manner in cardiac surgery patients. METHODS: Anesthesia was maintained with target-controlled infusions of propofol and remifentanil in cardiac surgery patients. With a fixed effect-site concentration (Ce) of remifentanil (20 ng/mL) after sternotomy, the Ce of propofol was adjusted to maintain a Bispectral index of 40-60 (Ce1). Mitral annular Doppler tissue image tracings and other echocardiographic variables, including end-diastolic and end-systolic volumes, stroke volume, and mitral inflow pulse wave Doppler profile at Ce1, were recorded using transesophageal echocardiography. Echocardiographic recordings were repeated after the Ce-values of propofol were doubled and tripled at 10-minute intervals (defined as Ce2 and Ce3, respectively). Serial changes in echocardiographic variables for each Ce of propofol were assessed using generalized linear mixed effect modeling. The pharmacodynamic relationship between the Ce of propofol and peak systolic mitral annular velocity (Sm) was analyzed by logistic regression using non-linear mixed effect modeling (NONMEM). RESULTS: Means of Ce1, Ce2, and Ce3 were 0.8, 1.6, and 2.4 µg/mL, respectively, and their means of Sm (95% confidence interval) were 9.7 (9.3-10.2), 8.7 (8.2-9.1), and 7.5 cm/sec (7.0-8.0), respectively (P < 0.01). Ce values of propofol and Sm showed a significant inter-correlation and predictability (intercept, 10.8; slope-1.0 in generalized mixed linear modeling; P < 0.01). Ce values producing 10% and 20% decline of Sm with 50%-probability were 1.4 and 2.1 µ/mL, respectively. CONCLUSION: Propofol reduces LV systolic long-axis performance in a dose-dependent manner. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01826149.

Isoflurane's Effect on Intraoperative Systolic Left Ventricular Performance in Cardiac Valve Surgery Patients.

BACKGROUND: Isoflurane, a common anesthetic for cardiac surgery, reduced myocardial contractility in many experimental studies, few studies have determined isoflurane's direct impact on the left ventricular (LV) contractile function during cardiac surgery. We determined whether isoflurane dose-dependently reduces the peak systolic velocity of the lateral mitral annulus in tissue Doppler imaging (S') in patients undergoing cardiac surgery. METHODS: During isoflurane-supplemented remifentanil-based anesthesia for patients undergoing cardiac surgery with preoperative LV ejection fraction greater than 50% (n = 20), we analyzed the changes of S' at each isoflurane dose increment (1.0, 1.5, and 2.0 minimum alveolar concentration [MAC]: T1, T2, and T3, respectively) with a fixed remifentanil dosage (1.0 µg/min/kg) by using transesophageal echocardiography. RESULTS: Mean S' values (95% confidence interval [CI]) at T1, T2, and T3 were 10.5 (8.8-12.2), 9.5 (8.3-10.8), and 8.4 (7.3-9.5) cm/s, respectively (P < 0.001 in multivariate analysis of variance test). Their mean differences at T1 vs. T2, T2 vs. T3, and T1 vs. T3 were -1.0 (-1.6, -0.3), -1.1 (-1.7, -0.6), and -2.1 (-3.1, -1.1) cm/s, respectively. Phenylephrine infusion rates were significantly increased (0.26, 0.22, and 0.47 µg/kg/min at T1, T2, and T3, respectively, P < 0.001). CONCLUSION: Isoflurane increments (1.0-2.0 MAC) dose-dependently reduced LV systolic long-axis performance during cardiac surgeries with a preserved preoperative systolic function.

Intraoperative echocardiographic delineation of the high take-off coronary ostia during an extensive surgical repair of the bicuspid aortic valve and dilated sinotubular junction: a case report.

BACKGROUND: This study reports the efficacy of intraoperative transesophageal echocardiography (TEE) for evaluation of high take-off coronary ostia and proximal coronary arterial flows as an alternative to preoperative coronary angiography. CASE PRESENTATION: In a 65-year old male undergoing the bicuspid aortic valve (BAV) repair and the extensive remodeling of dilated sinus and tubular junction, and preoperative coronary angiography were unsuccessfully completed due to an allergic reaction to the contrast medium. Intraoperative TEE by employing various 3-dimensional volume images of coronary ostia and Doppler tracings of the coronary arterial flows enabled a thorough pre-procedural evaluation of the high take-off coronary arteries and post-procedural evaluation by confirming the absence of any compromise in coronary arterial flow. CONCLUSION: In the present case, intraoperative application of various TEE imaging modalities enabled comprehensive evaluation of high-taking off coronary artery, as an alternative to preoperative coronary angiography, in a patient undergoing an extensive aortic valve and aortic root repair procedure.

Effects of sevoflurane increments on left ventricular systolic long-axis performance during sevoflurane-remifentanil anesthesia for cardiovascular surgery.

BACKGROUND: The direct impact of sevoflurane on intraoperative left ventricular (LV) systolic performance during cardiac surgery has not been fully elucidated. Peak systolic tissue Doppler velocities of the lateral mitral annulus (S') have been used to evaluate LV systolic long-axis performance. We hypothesized that incremental sevoflurane concentration (1.0-3.0 inspired-vol%) would dose-dependently reduce S' in patients undergoing cardiac surgery due to mitral or aortic insufficiency. METHODS: In 20 patients undergoing cardiac surgery in sevoflurane-remifentanil anesthesia, we analyzed intraoperative S' values which were determined after 10 min exposure to sevoflurane at 1.0, 2.0, and 3.0 inspired-vol% (T1, T2, and T3, respectively) with a fixed remifentanil dose (1.0 µg/kg/min) using transesophageal echocardiography. RESULTS: Linear mixed-effect modeling demonstrated dose-dependent declines in S' according to the end-tidal sevoflurane concentration increments (C(ET)-sevoflurane, p < 0.001): the mean value of S' reduction for each 1.0 vol%-increment of C(ET)-sevoflurane was 1.7 cm/s (95 % confidence interval 1.4-2.1 cm/s). Medians of S' at T1, T2, and T3 (9.6, 8.9, and 7.5 cm/s, respectively) also exhibited significant declines (by 6.6, 15.6, and 21.2 % for T1 vs. T2, T2 vs. T3, and T1 vs. T3, p < 0.001, =0.002, and <0.001 in Friedman pairwise comparisons, respectively). CONCLUSIONS: Administering sevoflurane as a part of a sevoflurane-remifentanil anesthesia regimen appears to dose-dependently reduce S', indicating LV systolic performance, in patients undergoing cardiac surgery. Further studies may be required to evaluate the clinical implications of these findings.

Randomized comparison of recovery time after use of remifentanil alone versus midazolam and meperidine for colonoscopy anesthesia.

BACKGROUND AND AIM: Although the combination of midazolam-meperidine has been widely used as a sedation regimen for colonoscopy, its residual effect which is longer than the duration of a colonoscopy procedure can delay patient recovery and discharge. Remifentanil, an ultra-short-acting opioid, has a very brief duration of action. We hypothesized that using remifentanil alone for colonoscopy would provide shorter recovery time compared with the midazolam-meperidine combination. METHODS: Time to achieve Aldrete score = 10 was determined and compared in patients who were randomly allocated to receive remifentanil alone (group-R, n = 27) or a midazolam-meperidine combination (group-MM, n = 27) for colonoscopy. Intergroup differences in sedation, recall analgesia, cardio-respiratory profiles, and satisfaction of patient and endoscopist were also determined during and after colonoscopy. RESULTS: Group-R showed a significantly shorter recovery time than group-MM (median [25-75%], 0 [0-10] vs 30 [15-30] min, P < 0.001). Group-R showed significantly higher bispectral-index values during colonoscopy (92 [85-96] vs 84 [80-87], P = 0.001); a higher incidence of recall of explanations given during and after colonoscopy (100 vs 48% and 96 vs 52%, both P < 0.001); and a lower distress score (visual analog scale 30/100 vs 37/100 mm, P = 0.002), than did group-MM. Neither extent of pain, incidence of hemodynamic instability nor incidence of respiratory depression differed between the groups. CONCLUSIONS: Remifentanil for colonoscopy afforded faster recovery compared to midazolam-meperidine combination. It also provided greater patient-endoscopist communication and satisfaction with comparable patient analgesia and cardiorespiratory profile during colonoscopy.

Placing a saline bag underneath the heart enhances transgastric transesophageal echocardiographic imaging during cardiac displacement for off-pump coronary artery bypass surgery.

OBJECTIVE: The authors hypothesized that placing a saline bag (saline-filled surgical glove) underneath a displaced heart would improve ultrasound transmission for transgastric (TG) imaging and transesophageal echocardiography (TEE) to visualize left ventricular regional wall motion (LV-RWM) during cardiac displacement for off-pump coronary artery bypass (OPCAB) surgery. DESIGN: Prospective observational study. SETTING: Tertiary University Hospital. PARTICIPANTS: Adult patients undergoing OPCAB surgery. INTERVENTIONS: Intraoperative TEE examination MEASUREMENT AND MAIN RESULTS: For off-line analyses of LV-readable segments, mid-esophageal (ME, 4-chamber, 2-chamber, and long-axis) and TG (basal- and mid-short-axis) TEE views were recorded under 3 different intraoperative conditions in 13 cases of OPCAB surgery: Before cardiac displacement (Tcontrol), after cardiac displacement (Tdisplaced), and after placing the saline bag underneath the displaced heart (Tsaline-bag). There were more LV-readable segments in the 17-segment model using integrated ME and TG views(ME + TG views) at Tsaline-bag and Tcontrol (mean[95% confidence interval], 17[17-17] and 17[17-17]) than using ME+TG at Tdisplaced (15[15-16], P = 0.002 and P<0.001, respectively). Using ME + TG views provided more LV-readable segments in the 17-segment model than using ME views at Tsaline-bag (vs. 16[14-16], P < 0.001), but not at Tdisplaced (vs. 15[14-15]). Incidences of inadequate RWM monitoring (LV-readable segments<14/17 using ME + TG views) at Tsaline-bag and Tcontrol (all 0/13) were less frequent than at Tdisplaced (3/13, all P = 0.038). There were more LV-readable segments in TG basal- and mid-short-axis views at Tsaline-bag (median [range], 6[5-6] and 5[5-6]) than at Tdisplaced (0[0-2] and 0[0-1], all P < 0.05). CONCLUSIONS: Placing a saline bag underneath the displaced heart enhances the ability of TEE to visualize global LV-RWM by improving TG TEE imaging during OPCAB surgery.

Preoperative evaluation of systolic murmur with point-of-care echocardiography before an elective thoracic surgery - A case report.

BACKGROUND: Systolic murmur suggesting the association of aortic valve (AV) stenosis or obstructive pathology in the left ventricular outflow tract (LVOT) usually requires preoperative echocardiographic evaluation for elective surgery. CASE: In a 63-year-old female patient undergoing elective thoracic surgery, the systolic murmur was auscultated on the right sternal border of the second intercostal space in the preoperative patient holding area. Point-of-care (POC) transthoracic echocardiography (TTE) demonstrated a systolic jet flow in the LVOT area. The peak systolic velocity of the continuous wave Doppler tracing, aligned to the LVOT and the AV, was approximately 1.5 m/s. The peak/mean pressure gradient was 11/6 mmHg for the AV and 9/5 mmHg for the LVOT. Anesthesia was induced under continuous TTE imaging. Intraoperative transesophageal echocardiography also confirmed the absence of any cardiac pathology. CONCLUSIONS: POC echocardiography offered a thorough preoperative evaluation of an unexpectedly identified systolic murmur, avoiding a potential delay in the operation schedule for conventional preoperative echocardiographic evaluation.

Effect of ultrafiltration on whole blood coagulation profile during cardiopulmonary bypass in cardiac surgery: a retrospective analysis.

BACKGROUND: Ultrafiltration (UF) would enhance coagulation profiles by concentrating coagulation elements during cardiopulmonary bypass (CPB) for cardiac surgery. METHODS: We retrospectively reviewed electronic medical records of 75 patients who had undergone cardiac surgery with rotational thromboelastometry-based coagulation management in a university hospital and analyzed the UF-induced changes in the maximum clot firmness (MCF) of extrinsically activated test with tissue factor (EXTEM) during CPB in 30 patients. RESULTS: The median volume of filtered-free water was 1,350 ml, and median hematocrit was significantly increased from 22.5% to 25.5%. As the primary measure, UF significantly increased the median MCF-EXTEM from 48.0 mm to 50.5 mm (P = 0.015, effect size r = 0.44). The area under the receiver operating characteristic curve pre-UF MCF-EXTEM for discrimination of any increase of MCF-EXTEM after applying UF was 0.89 (95% CI [0.77, 1.00], P < 0.001), and its cut-off value was 50.5 mm (specificity of 81.8% and sensitivity of 84.2% in Youden's J statistic). In the secondary analyses using the cut-off value, UF significantly increased the median MCF-EXTEM from 40.5 mm to 42.5 mm in 18 patients with pre-UF MCF-EXTEM ≤ 50.5 mm. However, it did not increase MCF-EXTEM in 12 patients with pre-UF MCF-EXTEM > 50.5 mm. There was a significant interaction between pre-UF MCF-EXTEM values and applying UF (P < 0.001 for the subgroup, P = 0.046 for UF, P = 0.003 for interaction). CONCLUSIONS: Applying UF improved clot firmness, and the improvement was more pronounced when pre-UF MCF-EXTEM had been reduced during CPB.

Detection of left atrial thrombus in patients with mitral stenosis and atrial fibrillation: retrospective comparison of two-phase computed tomography, transoesophageal echocardiography and surgical findings.

OBJECTIVE: This retrospective study aims to assess the accuracy of two-phase computed tomography (CT) and transoesophageal echocardiography (TEE) for the detection of left atrial (LA) thrombus in patients with mitral stenosis (MS) and atrial fibrillation (AF), by using intraoperative findings as the reference standard. METHODS: Preoperative two-phase CT and intraoperative TEE were performed in 106 patients with MS and AF. The ratio (LAA/AAL) of Hounsfield units (HU) in the LA appendage (LAA) to the ascending aorta (AA) was calculated on the late-phase CT image. RESULTS: LA echodense masses on TEE and LA filling defects on two-phase CT were observed in 29 and 39 patients, respectively. Thirty-five LA thrombi were identified at surgery in 27 patients. Compared with the intraoperative findings, per-patient sensitivity, specificity, positive and negative predictive values of two-phase CT were 100 %, 85 %, 69 % and 100 %, and those by using TEE were 93 %, 95 %, 86 % and 97 % in detecting LAA thrombus. After adopting the cut-off value of 0.5 for the LAA/AAL HU ratio, the specificity and positive predictive value of two-phase CT were increased to 96 % and 90 %, respectively. CONCLUSION: Two-phase CT with a cut-off value of LAA/AAL HU ratio of 0.5 provides high performance for the detection of LAA thrombus. KEY POINTS: • Accurate detection of left atrial appendage (LAA) thrombus is extremely important. • However artefacts from flow effects influence both CT and ultrasound findings. • Two-phase ECG-gated CT offers new insight into thrombus detection. • Analysis of aortic/atrial opacification helps differentiate LAA thrombus from artefact at CT.

The effects of the Trendelenburg position and intrathoracic pressure on the subclavian cross-sectional area and distance from the subclavian vein to pleura in anesthetized patients.

BACKGROUND: The effects of maneuvers to increase intrathoracic pressure and of Trendelenburg position on the cross-sectional area (CSA) of the subclavian vein (SCV) and the relationship between the SCV and adjacent structures have not been investigated. METHODS: In ultrasonography-guided SCV catheterization (N = 30), the CSA of the SCV and the distance between the SCV and pleura (DSCV-pleura) were determined during 10-second airway opening, and 10-second positive inspiratory hold with 20 cm H2O in the supine position (S-0, and S-20) and the 10° Trendelenburg position (T-0, and T-20). In addition to a statistical significance of P < 0.05, CSA and DSCV-pleura differences of ≥15% were defined as clinically relevant changes. RESULTS: CSA (mean [95% confidence interval]) in S-20, T-0, and T-20 (1.02 [0.95-1.14] cm(2), 1.04 [0.95-1.15] cm(2), and 1.14 [1.04-1.24] cm(2), respectively) was significantly larger than a CSA in S-0 (0.93 [0.86-1.00] cm(2), all P < 0.001). However, only the increase of CSA in T-20 vs S-0 (0.21 cm(2), 23.2%) was clinically meaningful (≥15%). The number of patients who showed CSA increase ≥15% was more in S-0 to T-20 (57%) compared with those in S-0 to S-20 (23%) and S-0 to T-0 (27%). DSCV-pleura measurements (mean) in S-20 and T-20 (0.61 and 0.60 cm) were significantly shorter than those in S-0 (0.70 cm, all P < 0.001), but the reductions of DSCV-pleura were not clinically meaningful (≥15%). CONCLUSIONS: The combined application of inspiratory hold and Trendelenburg position provided a greater and more relevant degree of CSA increase without compromising DSCV-pleura, which may facilitate SCV catheterization. Further investigations are needed to determine whether these results affect the success rate of catheterization and the risk of procedural injury.

Intraoperative transesophageal echocardiographic imaging of double valve repair for aortic and mitral stenosis.

An intraoperative echocardiographic evaluation to determine the feasibility and adequacy of the valve repair procedure is crucial for a successful repair. However, aortic valve repair in severe aortic stenosis (AS) is very limited and, consequently, its intraoperative echocardiographic evaluation has not been described well. Here, we describe an intraoperative transesophageal echocardiographic evaluation of a double-valve repair procedure for a patient with severe AS, moderate aortic insufficiency, and severe mitral stenosis.

Postoperative hypoalbuminemia is associated with outcome in patients undergoing off-pump coronary artery bypass graft surgery.

OBJECTIVE: The authors aimed to investigate whether immediate postoperative hypoalbuminemia could be associated with outcomes after off-pump coronary artery bypass graft (OPCAB) surgery. DESIGN: A retrospective analysis of the medical data. SETTING: Cardiac operating room and adult cardiovascular intensive care unit at a single institution. PARTICIPANTS: Six hundred ninety adult patients underwent elective OPCAB surgery over a 30-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: To evaluate the clinical relevance of immediate postoperative hypoalbuminemia, the lowest serum albumin level measured over the first 12 hours postoperatively was recorded. A cutoff point was calculated by the area under the curve in the receiver operating characteristic plot for 30-day adverse events including death. Patients were classified according to the cutoff value, and outcomes were compared between groups using propensity score-matching analysis. The impact of immediate postoperative hypoalbuminemia on OPCAB outcome was investigated using multivariate analysis. The cutoff value for immediate postoperative albumin concentration for predicting 30-day adverse events was 2.3 g/dL. Immediate postoperative hypoalbuminemia (<2.3 g/dL) was associated independently with postoperative respiratory failure (odds ratio [OR] = 8.85, p = 0.04), wound infection (OR = 4.44, p = 0.04), the need for an intra-aortic balloon pump after the operation (OR = 13.7, p = 0.02), renal failure (OR = 7.98, p = 0.01), reoperation for bleeding (OR = 4.33, p = 0.05), and the need for inotropes in the intensive care unit (OR = 1.79, p = 0.02). CONCLUSIONS: Immediate postoperative hypoalbuminemia was associated with poorer outcomes in OPCAB patients. Monitoring of albumin levels after OPCAB could identify patients at risk for short-term adverse events.

Anthropometric estimation of femoral venous cannula length for cardiovascular surgery.

BACKGROUND: Femoral vein cannulation is an alternative method for central cannulation. However, no clinical guidelines have been established for optimal insertion length of femoral venous cannula. The purpose of the present study was to evaluate the correlation between the insertion length of femoral venous cannula (L), and the sum of the length from femoral artery (FA) puncture site to umbilicus (P-U) and the length from umbilicus to lower border of the sternum (U-S) as an anthropometric estimation for adult patients undergoing cardiovascular surgery using femoral vein cannulation. We also attempted to determine the insertion length of femoral venous cannula by the patient's height and weight. METHODS: P-U and U-S were measured after anesthesia induction. L was measured after femoral venous cannula tip was positioned at the junction of inferior vena cava and right atrium using transesophageal echocardiography. The relationship between the sum of P-U and U-S (P-U-S), and L was analyzed by Pearson's correlation analysis. Bland-Altman analysis was used to compare the agreement between P-U-S and L. Multiple linear regression analysis was performed to identify the height and weight factors capable of predicting L. RESULTS: One-hundred study patients were enrolled. P-U-S was highly correlated with L (r = 0.95). The bias and precision were -2.60 ± 8.57 mm. L was predicted from height and weight: L (mm) = 0.82 × height (cm) + 1.18 × weight (kg) + 188.46. CONCLUSIONS: P-U-S can be used as a reliable anthropometric estimation of L during adult cardiovascular surgery using femoral vein cannulation.

Comparison of the PaO2/FiO2 ratio in sternotomy vs. thoracotomy in mitral valve repair: a randomised controlled trial.

OBJECTIVE: Cardiac surgery through a thoracotomy using one-lung ventilation (OLV) is thought to be associated with worse postoperative pulmonary gas exchange than sternotomy using two-lung ventilation (TLV), but this has not been confirmed yet. We, therefore, compared postoperative pulmonary gas exchange after mitral valve repair between sternotomy (group TLV) and thoracotomy (group OLV). DESIGN: Randomised controlled study. SETTING: University teaching hospital. PARTICIPANTS: Cardiac surgery patients. INTERVENTION: Sternotomy or thoracotomy was used for mitral valve repair. MEASUREMENTS: The ratio of arterial partial pressure of oxygen (PaO2) to fraction of inspired oxygen (FiO2) was compared in both groups before induction of anaesthesia (T0) and just before departure from the operating room to the ICU (T1). Fluid administration, transfusion requirements and urine output were checked intraoperatively. Postoperative haemoglobin (Hb), haematocrit (Hct) and creatinine were evaluated. Cardiopulmonary bypass (CPB) time, intubation time and ICU stay were also recorded. RESULTS: The PaO2/FiO2 ratio (mean ±â€ŠSD) at T1 was significantly lower than at T0 in both groups (326.9 ±â€Š120.1 vs. 431.9 ±â€Š73.7 mmHg in group TLV, P < 0.001; 374.9 ±â€Š130.9 vs. 445.4 ±â€Š73.7 mmHg in group OLV, P = 0.001), but did not differ significantly between the two groups. The doses of inotropes and vaopressors used were not significantly different between the groups. Intraoperative fluid administration, transfusion requirements, urine output and postoperative Hb/Hct and creatinine did not differ significantly between the groups. CPB time, intubation time and ICU stay also did not differ significantly between the groups. CONCLUSION: Perioperative pulmonary function following OLV via a thoracotomy was not significantly worse than that following TLV via a sternotomy in mitral valve repair. CLINICAL TRIAL REGISTRATION: Not registered.

Abrupt formation and spontaneous resolution of a right atrial thrombus detected by intraoperative transesophageal echocardiography during replacement of an abdominal aortic aneurysm.

Intraoperative formation of a thrombus in the right atrium and its management has occasionally been reported. However, spontaneous resolution of right atrial thrombi, without any event, is rare. We report a case of abrupt right atrial thrombus formation and spontaneous resolution, with no events, detected by transesophageal echocardiography during the replacement of an abdominal aortic aneurysm.