Volatile-based short-term sedation in cardiac surgical patients: a prospective randomized controlled trial.

OBJECTIVE: To evaluate the differences in extubation times in a group of cardiac surgical patients who were anesthetized and sedated with either IV propofol or inhaled volatile anesthetic agents. DESIGN: This was a prospective randomized controlled trial performed between September 2009 and August 2011. SETTING: Cardiovascular ICU within a tertiary referral university-affiliated teaching hospital. PATIENTS: One hundred forty-one patients undergoing coronary artery bypass graft surgery with normal or mildly reduced left ventricular systolic function. INTERVENTION: Participants were randomly assigned to receive anesthesia and postoperative sedation using IV propofol (n = 74) or inhaled volatile (isoflurane or sevoflurane) anesthetic agent (n = 67). MEASUREMENTS AND MAIN RESULTS: Patients sedated using inhaled volatile agent displayed faster readiness to extubation time at 135 minutes (95-200 min) compared with those receiving IV propofol at 215 minutes (150-280 min) (p < 0.001). Extubation times were faster within the volatile group at 182 minutes (140-255 min) in comparison with propofol group at 291 minutes (210-420 min) (p < 0.001). The volatile group showed a higher prevalence of vasodilatation with hypotension and higher cardiac outputs necessitating greater use of vasoconstrictors. There was no difference in postoperative pain scores, opioid consumption, sedation score, ICU or hospital length of stay, or patient mortality. CONCLUSIONS: Inhaled volatile anesthesia and sedation facilitates faster extubation times in comparison with IV propofol for patient undergoing coronary artery bypass graft surgery.

Early results of treatment for congenital clubfoot using the Ponseti method.

The purpose of this study was to evaluate the early results of the Ponseti method in reducing extensive corrective surgery rates for congenital idiopathic clubfoot in patients treated in Children's Orthopaedic Clinic and Rehabilitation Department Medical University of Lublin between the years 2007-2011. Thirty-five patients with 47 idiopathic clubfeet were followed prospectively while being managed with the Ponseti method. Clubfoot severity was graded with use of the Dimeglio system. The initial correction was achieved, and early results were measured by using Pirani scoring method.

A comparison of aprotinin and lysine analogues in high-risk cardiac surgery.

BACKGROUND: Antifibrinolytic agents are commonly used during cardiac surgery to minimize bleeding and to reduce exposure to blood products. We sought to determine whether aprotinin was superior to either tranexamic acid or aminocaproic acid in decreasing massive postoperative bleeding and other clinically important consequences. METHODS: In this multicenter, blinded trial, we randomly assigned 2331 high-risk cardiac surgical patients to one of three groups: 781 received aprotinin, 770 received tranexamic acid, and 780 received aminocaproic acid. The primary outcome was massive postoperative bleeding. Secondary outcomes included death from any cause at 30 days. RESULTS: The trial was terminated early because of a higher rate of death in patients receiving aprotinin. A total of 74 patients (9.5%) in the aprotinin group had massive bleeding, as compared with 93 (12.1%) in the tranexamic acid group and 94 (12.1%) in the aminocaproic acid group (relative risk in the aprotinin group for both comparisons, 0.79; 95% confidence interval [CI], 0.59 to 1.05). At 30 days, the rate of death from any cause was 6.0% in the aprotinin group, as compared with 3.9% in the tranexamic acid group (relative risk, 1.55; 95% CI, 0.99 to 2.42) and 4.0% in the aminocaproic acid group (relative risk, 1.52; 95% CI, 0.98 to 2.36). The relative risk of death in the aprotinin group, as compared with that in both groups receiving lysine analogues, was 1.53 (95% CI, 1.06 to 2.22). CONCLUSIONS: Despite the possibility of a modest reduction in the risk of massive bleeding, the strong and consistent negative mortality trend associated with aprotinin, as compared with the lysine analogues, precludes its use in high-risk cardiac surgery. (Current Controlled Trials number, ISRCTN15166455 [controlled-trials.com].).

The effect of nasogastric tube application during cardiac surgery on postoperative nausea and vomiting--a randomized trial.

OBJECTIVE: Postoperative nausea and vomiting (PONV) are significant morbidities following cardiac surgery. The purpose of this study was to determine if application of a nasogastric (NG) tube during cardiac surgery can reduce the prevalence of postoperative PONV. DESIGN: This study was a prospective randomized controlled trial. SETTING: University tertiary referral center. PARTICIPANTS: Two hundred two patients undergoing elective cardiac procedures. INTERVENTIONS: Patients were prospectively enrolled and randomized to either receive or not receive an NG tube after induction of anesthesia. Standard anesthetic technique and postoperative care were employed in all patients. Preoperative demographic data, pain score, nausea score and incidence of vomiting were recorded early (0-8 hours) and late (8-16 hours) following extubation. Antiemetic and analgesic medications were compared between the 2 groups. MEASUREMENTS AND MAIN RESULTS: One hundred three patients were randomized to no an NG tube (controls) and 99 received an NG tube as part of their perioperative management. Demographic data and surgical characteristics were similar between the 2 groups. However, the control group had more smokers. Incidence and severity of nausea, pain scores, and analgesic requirements were similar between the 2 groups. Prevalence of vomiting was more frequent in the control group (24%) than in the NG tube group (10%, p = 0.007), and was more frequent in patients who underwent valve and redo procedures. CONCLUSIONS: Use of an NG tube during cardiac surgery may reduce the incidence of postoperative vomiting.

Early complications and immediate postoperative outcomes of paravalvular leaks after valve replacement surgery.

OBJECTIVES: To evaluate the incidence of perivalvular leaks (PVLs) after valve replacement and assess its impact on immediate postoperative outcomes. DESIGN: A retrospective review. SETTINGS: A tertiary care university hospital. PARTICIPANTS: Four hundred forty-two consecutive patients undergoing aortic (AVR) and/or mitral (MVR) valve replacement. MEASUREMENTS AND MAIN RESULTS: All patients had comprehensive intraoperative transesophageal echocardiography. Follow-up transthoracic echocardiography was performed at 5 to 7 days and 1 year after surgery. PVLs were classified as trace, mild, moderate, and severe. Perioperative variables including demographic data, surgical characteristics including the degree of valve calcification, and postoperative outcomes were compared between patients with and without PVLs. Multivariate logistic regression analysis was used to identify the variables predictive of PVLs. PVLs were identified in a total of 53 (12%) patients, 29 (13%) after MVR and 24 (11%) after AVR. At the 1-year transthoracic echocardiographic follow-up, 2 (7%) of 27 patients had residual PVLs after MVR and none after AVR. The duration of cardiopulmonary bypass (CPB) was predictive of PVLs. The presence of PVLs was associated with postoperative sepsis. CONCLUSIONS: The incidence of PVLs was similar after MVR and AVR. Bioprosthetic MVR and mechanical AVR were associated with higher-incidence PVLs when compared with controls. Mitral annular calcification was a potential risk factor for PVLs with bioprosthetic valves. The prolonged CPB time was predictive of PVLs. After adjusting for covariates, the overall presence of PVLs was associated with an increased risk of sepsis after surgery.

Left-sided migration of Sideris button atrial septal occluder device.

We report the case of a left-sided migrated 'Sideris button' atrial septal defect occlusion device 6 years post-implantation with a residual secundum atrial septal defect and left atrial mass. The aims of this case report are to highlight an uncommonly seen atrial septal occlusion device, the importance of a complete echocardiographic examination of the path traversed by the device to assess for local trauma to structures, and the additional anatomical information gained and diagnostic use of intraoperative 3D transoesophageal echocardiography.

Preoperative use of statins is associated with reduced early delirium rates after cardiac surgery.

BACKGROUND: Delirium is an acute deterioration of brain function characterized by fluctuating consciousness and an inability to maintain attention. Use of statins has been shown to decrease morbidity and mortality after major surgical procedures. The objective of this study was to determine an association between preoperative administration of statins and postoperative delirium in a large prospective cohort of patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS: After Institutional Review Board approval, data were prospectively collected on consecutive patients undergoing cardiac surgery with cardiopulmonary bypass from April 2005 to June 2006 in an academic hospital. All patients were screened for delirium during their hospitalization using the Confusion Assessment Method in the intensive care unit. Multivariable logistic regression analysis was used to identify independent perioperative predictors of delirium after cardiac surgery. Statins were tested for a potential protective effect. RESULTS: Of the 1,059 patients analyzed, 122 patients (11.5%) had delirium at any time during their cardiovascular intensive care unit stay. Administration of statins had a protective effect, reducing the odds of delirium by 46%. Independent predictors of postoperative delirium included older age, preoperative depression, preoperative renal dysfunction, complex cardiac surgery, perioperative intraaortic balloon pump support, and massive blood transfusion. The model was reliable (Hosmer-Lemeshow test, P = 0.3) and discriminative (area under receiver operating characteristic curve = 0.77). CONCLUSIONS: Preoperative administration of statins is associated with the reduced risk of postoperative delirium after cardiac surgery with cardiopulmonary bypass.

Continuous-flow cell saver reduces cognitive decline in elderly patients after coronary bypass surgery.

BACKGROUND: Cerebral microembolization during cardiopulmonary bypass may lead to cognitive decline after cardiac surgery. Transfusion of the unprocessed shed blood (major source of lipid microparticulates) into the patient during cardiopulmonary bypass is common practice to reduce blood loss and blood transfusion. Processing of shed blood with cell saver before transfusion may limit cerebral microembolization and reduce cognitive decline after surgery. METHODS AND RESULTS: A total of 226 elderly patients were randomly allocated to either cell saver or control groups. Anesthesia and surgical management were standardized. Epiaortic scanning of the proximal thoracic aorta was performed in all patients. Transcranial Doppler was used to measure cerebral embolic rates. Standardized neuropsychological testing was conducted 1 week before and 6 weeks after surgery. The raw scores for each test were converted to Z scores, and then a combined Z score of 10 main variables was calculated for both study groups. The primary analysis was based on dichotomous composite cognitive outcome with a 1-SD rule. Cognitive dysfunction was present in 6% (95% confidence interval, 1.3% to 10.7%) of patients in the cell saver group and 15% (95% confidence interval, 8% to 22%) of patients in the control group 6 weeks after surgery (P=0.038). The severity of aortic atheroma and cerebral embolic count were similar between the 2 groups. CONCLUSIONS: The present report demonstrates that processing of shed blood with cell saver results in clinically significant reduction in postoperative cognitive dysfunction after cardiac surgery. These findings emphasize the clinical importance of lipid embolization in contributing to postoperative cognitive decline in patients exposed to cardiopulmonary bypass.

External compression of superior vena cava after the replacement of ascending aorta.

We present a rare complication after open-heart surgery resulting in compression of the superior vena cava (SVC) with the concurrent findings of the hypertrophic obstructive cardiomyopathy physiology. A 59-year-old woman developed a low cardiac output syndrome, persistent hypotension, and increasing filling pressures after emergency replacement of the ascending aorta and resuspension of the aortic valve due to a type A aortic dissection. Transesophageal echocardiography (TEE) evaluation revealed partial SVC obstruction, under-filled left ventricle (LV), and a persistent mitral systolic anterior motion with increasing pressure gradient in the left ventricular outflow tract (LVOT). Surgical exposure uncovered an intrapericardial thrombus around the aortic graft compressing the SVC. Removal of the thrombus resulted in immediate haemodynamic improvement and elimination of both SVC and LVOT obstructions. A comprehensive TEE exam should always be performed, and all the structures should be visualized for the proper diagnosis and management of patients after cardiac surgery.

Epiaortic scanning modifies planned intraoperative surgical management but not cerebral embolic load during coronary artery bypass surgery.

BACKGROUND: Patients with aortic atheroma are at increased risk for neurological injury after coronary artery bypass graft (CABG) surgery. We sought to determine the role of epiaortic ultrasound scanning for reducing cerebral embolic load, and whether its use leads to changes of planned intraoperative surgical management in patients undergoing CABG surgery. METHODS: Patients >70-yr-of-age scheduled for CABG surgery were prospectively randomized to either an epiaortic scanning (EAS) group (aortic manipulation guided by epiaortic ultrasound) or a control group (manual aortic palpation without EAS). All patients received a comprehensive transesophageal echocardiographic examination. Transcranial Doppler (TCD) was used to monitor the middle cerebral arteries for emboli continuously from 2 min before aortic cannulation to 2 min after aortic decannulation. Neurological assessment was performed with the National Institute of Health stroke scale before surgery and at hospital discharge. The NEECHAM confusion scale was used for assessment and monitoring of patient global cognitive function on each day after surgery until hospital discharge. RESULTS: Intraoperative surgical management was changed in 16 of 55 (29%) patients in the EAS group and in 7 of 58 (12%) patients in the control group (P = 0.025). These changes included adjustments of the ascending aorta cannulation site for cardiopulmonary bypass (CPB), the avoidance of aortic cross-clamping by using ventricular fibrillatory arrest during surgery, or by conversion to off-pump surgery. During surgery, 7 of 58 (12%) patients in the control group crossed over to the EAS group based on the results of manual aortic palpation. The median [range] TCD detected cerebral embolic count did not differ between the EAS and control groups during aortic manipulations (EAS, 11.5 [1-516] vs control, 22.0 [1-160], P = 0.91) or during CPB (EAS, 42.0 [4-516] vs control, 63.0 [5-758], P = 0.46). The NEECHAM confusion scores and National Institute of Health stroke scale scores were similar between the two groups. CONCLUSIONS: These results show that the use of EAS led to modifications in intraoperative surgical management in almost one-third of patients undergoing CABG surgery. The use of EAS did not lead to a reduced number of TCD-detected cerebral emboli before or during CPB.

Cat Scratch Disease in a 1.5-year-old girl - Case report.

INTRODUCTION: The paper is a case report presenting Cat Scratch Disease (CSD) in a 1.5-year- old girl. Bartoneloses, including CSD, are a group of infectious diseases which are rarely detected, therefore there are no statistical data concerning the aetiology, and the incidence of CSD noted in Poland is low in comparison with other European countries. OBJECTIVE: The purpose of the paper is to discuss several problems related to CSD. MATERIAL AND METHODS: A 1.5-year-old girl who was seen in hospital for the sparing use of her left arm when crawling. X-rays showed osteolytic lesions which radiologists described as multi-ocular cyst or infection. As neither clinical examination nor laboratory investigations found pathological signs, the patient was followed-up on an ambulant basis. Repeated x-ray taken 4 weeks later showed increased periosteal proliferation accompanied by pain. The baby was admitted to the Clinic but additional investigations found no pathologies. The baby was consulted by a rheumatologist and haematologist; however, they did not facilitate a definitive diagnosis. As the baby developed, because of a thickening of the soft tissues on the dorsal side of the distal epiphisis in the forearm the doctors decided to inspect the condition operatively. Macroscopic examination found brownish granulated tissue. Suction drainage was inserted and a tissue sample was tested for aerobic and anaerobic bacteria, tuberculosis and borelliosis. The test results were negative. The baby was in good condition, was not pyrexial and suffered from less pain. The diagnostics was further expanded and the baby tested for yersinia, chlamydia, tuberculosis and bartonella, i.e. CSD. The postoperative wound healed soon and radiological bony lesions began to resolve. After a month, we received a positive bartonella test result, the baby tested positively for Bartonella henselae IgG class, which confirmed past or active infection of CSD. A repeated test for B. henselae taken 6 months later showed a lower level of antibodies. CONCLUSIONS: It should be remembered that CSD, which is an extremely rare infection, can be diagnosed despite mediocre clinical and radiological manifestations. Thus, in the case of infections of unexplained aetiology and mediocre manifestations diagnostics should include testing for Bartonella henselae.

Clavicle fracture associated with atlantoaxial rotatory displacement, type II in an 8-year-old girl: A case report.

RATIONALE: Fracture of the clavicle is a very common injury in children. However, association between clavicle fracture and atlantoaxial rotatory displacement is rarely observed. PATIENT CONCERNS: We present a case of an 8-year-old girl, who suffered a right clavicle fracture as a result of a sledge accident. Six weeks after figure of 8 casting for a right clavicle fracture, an 8-year-old girl was brought to the Pediatric Orthopedic Department due to torticollis. DIAGNOSES: Standard X-ray examination revealed nonunion of the clavicle without any clinical symptoms. Computed tomography (CT) examination was performed and subluxation of cervical vertebrae 1/cervical vertebrae 2 was detected. INTERVENTIONS: The use of Glisson's traction followed by a soft cervical collar resulted in the resolution of all the symptoms. Control CT and magnetic resonance imaging confirmed reduction. OUTCOMES: The patient fully recovered and currently is fully active. The neurological status of the child before and after procedure remained normal. LESSONS: Clavicle fracture rarely may be associated with atlantoaxial rotatory displacement. Therefore, careful examination including rotation of the neck is necessary to confirm that associations. Moreover, three-dimensional CT scan enables proper spine examination and provides correct diagnosis. As shown in available literature and as well in presented case report, none operative treatment is usually effective.

The anesthesiologist's role in adults with congenital heart disease.

Anesthesia for adults with congenital heart disease has many challenging physiologic considerations. Collaborative relationships of a multidisciplinary team including cardiology, cardiac surgery, anesthesiology, and intensive care are essential to ensure positive outcomes in this population for noncardiac and cardiac surgery.

Transesophageal echocardiography in the intensive care unit.

Transesophageal echocardiography provides unique diagnostic capabilities, allowing for a very precise look at the structure and hemodynamics of the human heart. It is minimally invasive and portable, and quickly diagnoses sudden hemodynamic changes in intensive care patients. It provides invaluable and precise information about myocardial dysfunction and intracardiac volume status. It can diagnose dynamic left ventricular outflow obstruction, infrequent but serious complication of aortic valve replacement, septal myectomy, or mitral valve repair. Transesophageal echocardiography examination can exclude cardiac tamponade and intracardiac source of embolization, and it offers the ability to visualize native or prosthetic valves and assesses their function in the postoperative period. It is helpful in diagnosing endocarditis and the presence of intracardiac masses. In the diagnosis of blunt chest trauma, transesophageal echocardiography offers a fast and safe look at ascending and descending aorta and pericardial effusion, facilitating future decisions about patient management. In patients with postoperative hypoxia, it can exclude intracardiac shunt. Finally, in heart transplants or in managing patients with mechanical heart assist devices, transesophageal echocardiography is an invaluable tool in assessing progress of treatment and complications arising from the procedures. With the introduction of multiplane transesophageal echocardiography probes, technology, and experienced personnel, transesophageal echocardiography becomes the extension of the physical examination in the intensive care unit. This example is one of only a few whereby technology brings the physician closer to the patient.

"Syndrome of contractures" (according to Mau) with the abduction contracture of the right hip as causative factor for development of the so-called idiopathic scoliosis.

The article provides basic explanation of "syndrome of contractures" (Mau) at newborns and babies and it's conjunction with biomechanical etiology of the so-called idiopathic scoliosis (Karski 1995-2006). The authors analyzed children with "syndrome of contractures" and noted its relevance to some clinical symptoms at children with scoliosis. Newborns and babies with clinical signs of "syndrome of contractures" require further spine examination already at age of 3-4 in order to detect "danger of oncoming scoliosis" and to introduce neo-prophylaxis. The research based on "syndrome of contractures" can explain predominance of female gender of patients with scoliosis, sides of curves, side of rib hump, progression and sensibility to new rehabilitation exercises.

Calcium antagonists reduce cardiovascular complications after cardiac surgery: a meta-analysis.

OBJECTIVES: We sought to determine the efficacy of calcium antagonists (CAs) in reducing death, myocardial infarction (MI), ischemia, and supraventricular tachyarrhythmia (SVT) after cardiac surgery. BACKGROUND: Calcium antagonists may reduce complications after cardiac surgery-namely, death, MI, and renal failure. However, they are underused, possibly due to the results from previous observational studies. METHODS: Both MEDLINE (1966 to December 2001) and EMBASE (1980 to December 2001) were searched, with supplementation by reference list searches. No language restrictions were applied. Included studies were randomized, controlled trials (RCTs) evaluating preoperative, intraoperative, or postoperative (first 48 h) CA use (intravenous or oral) during aortocoronary bypass or valve surgery. Studies were excluded if they exclusively recruited transplant recipients, individuals <18 years old, or patients with pre-existing SVT. Two reviewers independently evaluated study quality by using the Jadad score; a minimal score of 1/5 was required. Forty-one studies, encompassing 3,327 patients, were included. No studies assessed treatment exclusively with short-acting oral nifedipine. Treatment effects were calculated using the random-effects model. Heterogeneity was assessed using the Q test. RESULTS: Calcium antagonists significantly reduced MI (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.37 to 0.91; p = 0.02) and ischemia (OR 0.53, 95% CI 0.39 to 0.72; p < 0.001). Non-dihydropyridines significantly reduced SVT (OR 0.62, 95% CI 0.41 to 0.93; p = 0.02). Calcium antagonists were associated with trends toward decreased mortality during aortocoronary bypass (OR 0.66, 95% CI 0.26 to 1.70, p = 0.4). CONCLUSIONS: Use of CAs during cardiac surgery significantly reduced rates of MI, ischemia, and SVT. Further study using large RCTs is justified.

Tranexamic acid and early saphenous vein graft patency in conventional coronary artery bypass graft surgery: a prospective randomized controlled clinical trial.

OBJECTIVE: Use of antifibrinolytic agents reduces the risk of bleeding and decreases the need for blood product use in patients undergoing cardiac surgery. The purpose of this study was to determine whether perioperative use of tranexamic acid decreases the rate of saphenous vein graft patency in the early postoperative period after conventional coronary artery bypass grafting surgery. METHODS: A total of 312 patients scheduled for elective coronary artery bypass grafting surgery with cardiopulmonary bypass were randomized to receive either tranexamic acid 100 mg/kg (n = 147) or placebo (n = 165) in a double-blinded fashion before the initiation of cardiopulmonary bypass. Saphenous vein graft patency was assessed with magnetic resonance imaging 5 to 30 days after surgery. RESULTS: Both groups were comparable with respect to baseline demographic data and surgical characteristics. A total of 237 (76%) patients underwent magnetic resonance imaging assessment. A total of 297 saphenous vein grafts were performed and 253 (85.2%; 95% confidence interval, 83.5%-86.9%) were seen in the tranexamic acid group, and 265 saphenous vein grafts were performed and 231 (87.2%; 95% confidence interval, 85.5%-88.9%) were seen in the placebo group (P = .4969). The blood loss and blood product transfusion rates in the tranexamic acid group were significantly lower than in the placebo group. There was no difference between groups with respect to postoperative morbidity and mortality. CONCLUSIONS: The administration of tranexamic acid before cardiopulmonary bypass did not seem to compromise early venous graft patency rates but reduced perioperative blood product transfusion rates. Consequently, tranexamic acid could be advocated for routine use in patients undergoing conventional coronary artery bypass grafting surgery.

"Contracture syndrome" in newborns and infants according to Prof. Hans Mau as an explanation of the "geography" and certain clinical features of idiopathic scoliosis.

Background. Many malformations and dysfunctions of the skeletal system are connected with the "contracture syndrome" described by Prof. Hans Mau. The clinical features include plagiocephaly, torticollis, infantile scoliosis, pelvic deformity, foot deformity, adductor contracture mostly of the left hip, abductor contracture mostly of the right hip. Material and methods. The authors analyzed 300 histories of children aged from 3 weeks to 12 months treated in the years 1999-2001, and 100 histories of children with idiopathic scoliosis. Conclusions. Newborns and babies with clinical features of "contracture syndrome" require further spinal examination at age 3-4 in order to detect the risk of incipient scoliosis and to introduce appropriate preventive measures.

New conservative treatment of idiopathic scoliosis: effectiveness of therapy.

Background. This article provides basic information concerning a new conservative treatment for idiopathic scoliosis, with appropriate asymmetric flexion-rotation exercises and special redressing positions. Material and method. The analysis was based on 288 children with scoliosis and a control group of 268 children. The authors describe the most important exercises and provide a statistical analysis of treatment outcome in children with idiopathic scoliosis. Results and Conclusions. Early detection of the risk of scoliosis and correct therapy through new conservative treatment based on exercises make it possible not only to limit the progression of spinal deformity (61%), but also, in some cases of incipient scoliosis, to reduce the curvature (32%).