Intraoperative transesophageal echocardiography in cardiovascular surgery. Consensus document from the Spanish Society of Anesthesia and Critical Care (SEDAR) and the Spanish Society of Endovascular and Cardiovascular Surgery (SECCE). / Ecocardiografía transesofágica intraoperatoria en cirugía cardiovascular. Documento de consenso de la Sociedad Española de Anestesiología y Reanimación (SEDAR) y Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE).

Transesophageal echocardiography is a semi-invasive technique that allows an evaluation of cardiac morphology and function in real time and it is a quality standard in cardiovascular surgery. It has become a fundamental tool for both monitoring and diagnosis in the intraoperative period that allows decide the correct surgical planning and pharmacological management. The goal of this document is to answer the questions of when and how the perioperative TEE should be performed in cardiovascular surgery, what are their applications in the intraoperative, who should perform it and how the information should be transmitted. The authors made a systematic review of international guidelines, review articles and clinical trials to answer by consensus to these questions.

Prognostic Value of High-Sensitivity Troponin-T to Identify Patients at Risk of Left Ventricular Graft Dysfunction After Heart Transplantation.

Primary graft dysfunction after heart transplantation (HTx) has a very high mortality rate, especially if the left ventricle (PGD-LV) is involved. Early diagnosis is important to select the appropriate therapy to improve prognosis. The value of high-sensitivity troponin T (HS-TNT) measurement obtained at patient arrival at the intensive care unit was analyzed in 71 HTx patients. Mild or moderate PGD-LV was defined by hemodynamic compromise with one of the following criteria: left ventricular ejection fraction <40%, hemodynamic compromise with right atrial pressure >15 mm Hg, pulmonary capillary wedge pressure >20 mm Hg, cardiac index <2.0 L/min/m2, hypotension (mean arterial pressure <70 mm Hg), and need for high-dose inotropes (inotrope score >10) or newly placed intra-aortic balloon pump. The mean recipient age was 54 ± 12 years (73% men), and donor age was 47 ± 11 years. Ischemic time was 200 ± 51 minutes, and coronary bypass time was 122 ± 31 minutes. Nine (13%) HTx patients were diagnosed with PGD-LV post-HTx, 8 with biventricular dysfunction. Four patients died, 2 with PGD-LV (22%) and 2 without PGD (4%). Mean HS-TNT before HTx was 158 ± 565 ng/L, and post-HT was 1621 ± 1269 ng/L. The area under the curve (receiver-operator characteristic) of HS-TNT to detect patients at risk of PGD-LV was 0.860 (P < .003). A cutoff value of HS-TNT >2000 ng/L had a sensitivity of 75% and specificity of 87% to identify patients at risk of PGD-LV. Multivariate analysis identified HS-TNT >2000 ng/L (P < .02) and coronary bypass-time (P < .01) as independent predictors of PGD-LV. HS-TNT >2000 ng/L at intensive care admission after HT and prolonged coronary bypass time were the most powerful predictors of PGD-LV. HS-TNT may be helpful for early detection of HTx patients at risk of PGD-LV.

[Impossibility of intubation due to angioedema secondary to an angiotensin-converting enzyme inhibitor]. / Imposibilidad de intubación por angioedema secundario a IECA.

Angioedema secondary to treatment of one year's duration with angiotensin converting enzyme inhibitor (ACEI) (lisinopril) in a 56-year-old man scheduled for elective cardiac surgery led unexpectedly to impossible intubation. Surgical access (tracheostomy) was required when airway control was threatened. We review the clinical course, etiology and treatment of angioedema secondary to ACEI therapy. This is a life threatening complication which, though rare, is becoming increasingly frequent with increased use of such drugs.

[Comparison of an auditory evoked potentials index and a bispectral index versus clinical signs for determining the depth of anesthesia produced by propofol or sevoflurane]. / Comparación de la efectividad de un índice de potenciales evocados auditivos y un índice biespectral con los signos clínicos en la determinación de la profundidad hipnótica durante anestesia con propofol o sevoflurano.

OBJECTIVES: To evaluate an anesthetic depth index (ADI) obtained from auditory evoked potentials and a bispectral EEG index (BIS) in comparison with clinical assessment of anesthetic depth using the modified observer's assessment of awareness/sedation scale (MOAA/SS), for induction of anesthesia with propofol or sevoflurane as the only agent. PATIENTS AND METHODS: The ADI and BIS were recorded simultaneously in this prospective study and compared to the MOAA/SS during the anesthetic induction of 26 adults undergoing elective heart surgery. Assignment of patients to two groups was random. Group A (n = 13) patients were induced with propofol (target dose 5 micrograms.ml-1 in 5 min). Induction in group B (n = 13) was with sevoflurane (8% tidal volume). A scheme of awake-sleeping-awake-sleeping was followed. The means of the two indexes were compared (Mann-Whitney test) one minute before the patient slept (awake) and one minute later (sleeping), and the evolution of the indexes was compared during awake/sleep and sleep/awake phase changes and while the patients were in a stable sleep phase. The sensitivity and specificity of each index was analyzed in function of the MOAA/SS. We also analyzed the time elapsing from the moment the patient fell asleep (MOAA/SS 2) until the two indexes reached published reference values (ADI = 38, BIS = 60). RESULTS: After induction with propofol (group A) the ADI fell to 29.2 +/- 11.7 and the BIS fell to 63.5 +/- 13.4. After induction with sevoflurane (group B) the ADI fell to 33.8 +/- 14.9 and the BIS to 66.8 +/- 15. The ADI value that best discriminated between arousal and sleeping (sensitivity 100%) was 38; the BIS value that best discriminated was 60. The responses to sound in decibels (dB) during "awake/sleeping" and "sleeping/awake" phases were, respectively, -3.8 dB and -4.5 dB for the ADI and -1.5 dB and -0.8 dB for the BIS. With the patient in stable sleep, response to the two indexes was at -0.79 dB. In group A, the ADI detected MOAA/SS 2 significantly earlier (ADI 13.1 +/- 30 s; BIS 56 +/- 36 s; p < 0.05). No patient reported remembering the study period. CONCLUSIONS: Monitoring anesthetic depth with the ADI or BIS was technically easy and effective for detecting whether patients were awake or sleeping. The ADI response was faster and identified awake/sleeping and sleeping/awake phase changes better than did the BIS.