Fungemia due to Saprochaete capitata in a non-neutropenic patient hospitalized in an intensive care unit after cardiac surgery.

The majority of invasive fungal infections observed in non-neutropenic patients hospitalized in an intensive care unit are caused by Candida spp and current guidelines recommend echinocandins as the first-line treatment. Fungemias caused by filamentous or arthrosporic fungi such as Saprochaete capitata (previously named Geotrichum capitatum) are extremely rare. In fact, invasive infections due to S. capitata have been reported almost exclusively in neutropenic oncohematological patients. In this report, we describe a case of fungemia caused by S. capitata in a non-neutropenic patient hospitalized in an intensive care unit after aortic valve replacement. The prompt identification of S. capitata is extremely important because of its intrinsic resistance to echinocandins.

Influence of underlying lung disease on early postoperative course after single lung transplantation.

BACKGROUND: Single lung transplantation can be a suitable therapeutic option for a wide range of end-stage lung diseases: pulmonary fibrosis, emphysema, primary pulmonary hypertension and Eisenmenger's syndrome. Yet, patients suffering from different diseases have significantly different cardiovascular and respiratory functional profiles that can exert a profound influence on their response to the perioperative procedures. Our purpose is to analyze whether the patient's underlying disease can influence the early postoperative outcome after single lung transplantation. METHODS: We carried out a retrospective analysis on perioperative charts of patients undergoing single lung transplantation during an 8-year period. We focused our attention on the following data: underlying lung disease, age, sex, baseline cardiorespiratory data (pulmonary artery pressure, cardiac index, forced expired volume, vital capacity, arterial blood gases, body mass index), intraoperative data (duration of graft ischemia, use of cardiopulmonary bypass) and indexes of adverse postoperative outcome (in-hospital death, mechanical ventilatory support >7 days). Patients were gathered in 3 groups (restrictive, obstructive and vascular) according to the kind of disease and functional data and the association between disease and outcome was assessed by means of logistic regression analysis. Moreover, we evaluated whether any of the patient's functional parameters could be considered predictive of adverse postoperative outcome. RESULTS: We observed a weak association between restrictive disease and adverse postoperative outcome while, on the other hand, obstructive and vascular forms showed a close association with an adverse outcome, with a borderline statistical significance. Among all the considered variables, only intraoperative use of CPB turned out to be predictive of adverse outcome, while other variables simply indicated a trend towards a better outcome. CONCLUSIONS: Patients with vascular and obstructive diseases have the worst postoperative course, with a higher in-hospital mortality rate and longer duration of ventilation; in particular, the perioperative course of vascular patients is heavily influenced by the intraoperative use of cardiopulmonary bypass.

Monitoring aspects during port-access cardiac surgery.

OBJECTIVE: To report the experience gained at our Cardiosurgical Centre with the recently introduced port-access technique. EXPERIMENTAL DESIGN: Prospective collection of data from the month of October 1997. SETTING: Regional University HospitaL Patients: Adult patients undergoing coronary bypass graft or mitral valve surgery. INTERVENTIONS: Port-access technique makes it possible to carry out open-heart procedures through a minithoracotomy and extrathoracic cardiopulmonary bypass with a set of properly designed catheters (Heartport EndoCPB system) for cardioplegia delivery and heart venting. MEASURES: Transesophageal echography and pressure traces are the main monitoring tools used for the correct placement of these catheters and for the clinical management of the patient. RESULTS: Sixty-two cases have been performed so far. A complete description of the procedure, with monitoring aspects and problems encountered is thoroughly presented. CONCLUSIONS: The major differences with traditional cardiac surgery are that interruption of myocardial perfusion is not achieved through a transversal clamp but through an endovascular occlusive balloon and that thoracic access is by minithoracotomy. Unlike traditional open surgery, the surgeon has no direct vision of the position of the clamp and the anesthesiologist can not visually inspect the contractile state of the heart. The operative team has to cope with a multifaceted system of monitored variables that must be continuously integrated and interpreted. Tight cooperation and continuous communication between anaesthesiologist, surgeons and perfusionist appear to be more important than in any other cardiac operation.

Port access cardiac surgery.

The port-access technique for cardiac surgery was recently developed at Stanford University in California as a less invasive method to perform some cardiac operations. The port-access system has been described in detail elsewhere. It is based on femoral arterial and venous access for cardiopulmonary bypass (CPB) and on the adoption of a specially designed triple-lumen catheter described originally by Peters, and subsequently modified and developed in the definitive configuration called the endoaortic clamp.

[Minimally invasive surgery with the Port-Access method. Preliminary experience]. / La chirurgia mini-invasiva con la metodica Port-Access. Esperienza preliminare.

METHODS: Data from the initial experience of 40 patients operated on with the Port-Access technique are reported. Indication to surgery was mitral disease in 24 patients and coronary stenosis in 16 patients. Mean age was 52 years (range 32-75). Operations performed were: 8 mitral valvuloplasties, 16 valve replacements, 9 single CABG (associated with an MVR in one case), 1 double CABG, 6 triple CABG and one quadruple CABG. Coronary endarterectomy was performed in 5 patients and left atrial isolation was associated with MV surgery in 5 cases. RESULTS: There were no operative deaths and every patient was discharged after a mean postoperative stay of 5.5 days (range 3-30). Postoperative course was complicated in 7 patients: surgical revision was necessary in 4 patients due to bleeding (through the mini-thoracotomy incision in 3 cases), 1 pacemaker was implanted for A-V block, one retained pulmonary catheter was removed through the mini-thoracotomy without the aid of cardiopulmonary bypass and in one case, there was an emergency conversion to median sternotomy due to a ventricular fibrillation unresponsive to usual resuscitative maneuvers a few hours after surgery. Some of these complications can be ascribed to the learning phase of this new technique and should disappear as experience is increased. CONCLUSIONS: Port-Access surgery is a new minimally invasive technique that utilizes a cardiopulmonary bypass with femoral access and a specialized catheter system that provides endoaortic clamping, pulmonary artery venting and myocardial preservation with infusion of cardioplegic solution in the aortic bulb or in the coronary sinus. Major contraindications to this technique are iliac-femoral disease or severe dilatation of ascending aorta. The aim of the Port-Access technique is to combine the aesthetic and functional advantages of the minimally invasive surgery with the wide range of surgical options that cardiopulmonary bypass can afford (to operate on atrioventricular valves and perform all the CABG that the patient need), without the limitations characteristic of the classic minimally invasive direct coronary artery bypass (MIDCAB) technique.

[A method for the evaluation of resource use in cardiac surgery: application of the ICR beta in an Italian reality]. / Un metodo per la valutazione del consumo di risorse in cardiochirurgia: applicabilità dell'IRC beta in una realtàa italiana.

The decreased availability of economic resources requires the use of methods to assess hospital efficiency. The aim of our study was to retrospectively evaluate the applicability to the Italian reality of a catalogue of medical acts (CdAM-champs beta) set up for the French Health System. We wanted to evaluate the amount of resource utilization of a Cardiothoracic Operating Room of a IRCCS regional general hospital. The study included 83 admissions, occurring in October 1996, to the cardiac surgery department. Medical acts were recorded for all admissions taking into account both the number of acts and the weight of acts expressed as standard cost index or ICR. This takes into account the use of human (medical and nursing staff) and technical resources. Calculation of ICR beta scores was achieved by means of two different expressions. We observed a lack of correlation between the two values of each ICR. The previous formula (1991) gives more emphasis on the different conditions in which the operation was carried out (American Society of Anesthesiology score), duration of anesthesia and patients disease with a statistical significant difference. The last formula (1995) only evaluate patients' disease. None of the two formula of ICR beta turns out to be completely appropriate index of resource utilization during anesthesia; therefore this analysis still remains a difficult problem. Yet it must be recognized that this system deserves the merit of having evaluated the anesthesiological duties, by separating them from the surgical ones.

Aortic arch surgery: retrospective analysis of outcome and neuroprotective strategies.

OBJECTIVE: To review intra- and postoperative data regarding surgical reconstruction of the aortic arch performed at our cardiosurgical centre during the past four years, and thus to deepen understanding of neurologic morbidity and of what constitutes the most effective neuroprotection. EXPERIMENTAL DESIGN: Retrospective study. SETTING: Regional University Hospital. PATIENTS: 29 patients who underwent reconstruction of aneurysm or dissection of the aortic arch. Intervention. Surgical replacement of the diseased aorta during deep hypothermia, alone or with selective cerebral perfusion (antegrade or retrograde). MEASURES: Overall mortality rate, neurologic morbidity rate, duration of extracorporeal circulation, of hypothermic circulatory arrest or of selective cerebral perfusion. Evaluation of the importance to neurological outcome of age, modality of operation (emergency or routine), biochemical parameters (glycemia, hematocrit) and perfusion technique. Recording of postoperative time of arousal, and possible correlation with length of selective cerebral perfusion. RESULTS: We observed a mortality rate of 39% (11 deaths) and a neurologic morbidity rate of 34%. Hypothermic circulatory arrest alone did not assure valid neuroprotection (5 cases, all with severe neurologic impairment), while better results were obtained with selective cerebral perfusion, especially antegrade (14 cases, with only 7% of neurologic morbidity rate). Hyperglycemia (>250 mg%) proved to be significantly associated (p=0.002) with increased incidence of adverse neurologic outcome, and the same association was observed between emergency status and adverse neurologic outcome (p=0.002). Moreover, we found an unexpected linear correlation between time of selective cerebral perfusion and postoperative time of arousal (r=0.728, p=0.000). CONCLUSIONS: Deep hypothermic circulatory arrest with selective cerebral perfusion currently represent a valid therapeutic option for brain preservation during reconstruction of the aortic arch in adults. It is mandatory to carry out a tight control of perfusion parameters (flow, pressures and temperature gradients) and biochemical variables (avoidance of hyperglycemia and modified ultrafiltration for fluid balance).

Effect of L-carnitine on myocardial metabolism: results of a balanced, placebo-controlled, double-blind study in patients undergoing open heart surgery.

The effects of L-carnitine on cardiac performance after open heart surgery were evaluated in a balanced, placebo-controlled, double-blind study in 38 patients. Preoperative haemodynamic status was good in all of them. Seventeen subjects underwent mitral valve replacement and 19 patients coronary artery bypass grafting. Five grams L-carnitine were given intravenously over 2 h, twice daily for 5 consecutive days; moreover, 10 g L-carnitine in 1500 ml cardioplegia were administered through the aortic root after aortic cross-clamping. Surgery was always planned on treatment day 3. The post-ischaemic functional recovery of the heart was assessed by clinical parameters, as well as by biochemical and ultrastructure evaluations on biopsy specimens. No differences were found between the control and the treatment group with respect to all clinical parameters of cardiac performance after cardiopulmonary bypass. At anaesthesia induction, serum carnitine was significantly increased in treated patients, but carnitine concentrations in the right atrial biopsy obtained just before aortic declamping were similar in the two groups. In patients with mitral valve replacement, L-carnitine therapy was associated with significantly higher concentrations of pyruvate, ATP and creatine phosphate in papillary muscle. Glycogen levels were also higher in the treated group, but the difference was not statistically significant. Myocardial ultrastructure on septal biopsies, obtained within 5 min from weaning from extracorporeal circulation, showed better preservation scores for all considered parameters (nucleus, sarcoplasmic reticulum, mitochondria and cellular oedema) in the treated subjects, although the difference reached statistical significance only for nuclei. When biochemical and ultrastructural data are considered, these findings suggest that L-carnitine improves myocardial metabolism. However, it cannot be concluded that L-carnitine provides an advantageous support therapy for well-compensated patients requiring cardiac surgery. In contrast, the positive effects of L-carnitine on cardiac recovery after bypass might become clinically relevant in the surgical setting for haemodynamically compromised patients, in which further investigations are required.

[Qualitative characteristics of human exposure to air chemical pollutants in operating rooms]. / Caratteristiche qualitative dell'esposizione umana a contaminanti chimici aerodispersi in sale operatorie.

UNLABELLED: For more than two decades many studies have been published searching for a link between exposure to volatile anaesthetic agents and health damage even if it is noteworthy that many other chemical substances can be found in the Operating Room. Purpose of this study was to demonstrate that the Operating Room is not a totally confined environment and that it is possible to perform an, at least qualitative, evaluation of many different polluting contaminants, even unexpected, to whom the working staff is exposed. MATERIAL AND METHODS: The study has been performed in the Operating Rooms of the Departments of Urology and Orthopaedics. Two methods have been employed: a long-casting sampling of volumes of air (with a sampling device composed of an enrichment system and a low flow aspirating pump) and an anaesthetic vapours and gas continuous analyzer. Results. We never recorded environmental levels of anesthetic higher than the currently accepted ones. Many other organic compounds of different kind have been found (irritants, cancer-organs). Their presence, not desirable in a place where a demanding work is performed, deserve further investigation and a quantitative evaluation of these compounds.

[Anesthesiology problems for implant and explant of left ventricular Novacor systems]. / Problematiche anestesiologiche per l'impianto e l'espianto di sistemi di assistenza ventricolare sinistra Novacor.

OBJECTIVES: To review experience with anaesthetic management in patients undergoing a left ventricular assist system (LVAS) Novacor implant as a bridge to cardiac transplantation. DESIGN: Retrospective clinical study. SETTING: Cardiothoracic operating room in a university hospital. PATIENTS: Nine, aged 37-62 years, suffering from 8 dilated and 1 postischemic cardiomyopathy at end stage heart failure. INTERVENTIONS OR METHODS: Under general anaesthesia and cardio-pulmonary bypass the LVAS pump is placed in the abdomen and connected to the left ventricle through an inflow cannula and to the aorta through an outflow cannula. The pump has an output of 5-7 l/min and works in synchronous counterpulsation with the left ventricle. RESULTS: The mean Novacor support has been 75.56 days (DS +/- 85.95). Five out of 9 patients have been transplanted, while 3 are still waiting at home. Pretransplant CI was on average 1.66 l/min/m2 (DS +/- 0.27) and REF 11.44% (DS +/- 5.29); after the Novacor implant CI was 3.44 (DS +/- 0.49) and REF 22.22% (DS +/- 4.49). CONCLUSIONS: A LVAS can bridge patients to heart transplantation while improving or preserving their health conditions. Some factors are to be taken into account for the anaesthesiological management of the implant/explant of a LVAS: the patients' poor clinical conditions; the knowledge of the components and functioning of the LVAS that conditions the choice of the anaesthesiological drugs and volemia; the unassisted right ventricle function that has to be pharmacologically supported; the bleeding problem because of the adherences during the explant surgery.

Platelet composition and function in patients undergoing cardiopulmonary bypass for heart surgery.

BACKGROUND: Previous studies showed severe biochemical and functional damage to platelets in patients undergoing cardiopulmonary bypass for cardiac surgery, and suggested that this derived from the proteolytic action of plasmin on the platelet surface. METHODS: A double-blind study was carried out to compare platelet function and composition in patients randomized to receive the protease inhibitor aprotinin or placebo during reoperation for valvular prosthesis replacement or coronary artery bypass grafting. RESULTS: Flow cytometry with specific monoclonal antibodies and polyacrylamide gel electrophoresis did not show any significant proteolysis of platelet glycoprotein Ib and IIb-IIIa either in the placebo or the aprotinin group. Functional studies were consistent with these results, since ristocetin-induced platelet agglutination was unchanged and platelet aggregation and ATP release induced by collagen and ADP were only slightly reduced by cardiopulmonary bypass. These mild defects in platelet function were partially prevented by aprotinin infusion. CONCLUSIONS: On the basis of our data and those from literature, we suggest that platelets may be affected very little or severely damaged during cardiopulmonary bypass for cardiac surgery, probably depending on some aspects of the technical procedure which remain to be identified. Aprotinin infusion significantly protects platelets in the latter condition, while its role is obviously slight in the former.

[Current views on the use of vasodilators in pulmonary hypertension]. / Attuali vedute sull'impiego dei vasodilatatori nell'ipertensione polmonare.

Vasodilators represent one of the main steps for the medical treatment of pulmonary hypertension; the rationale for their use is the reversibility of the pulmonary vasoconstriction, to be tested with a correct pharmacological trial. In this report the authors consider the use of calcium-channel blockers, prostaglandin and nitric oxide. Calcium blockers, the only drugs active when administered orally, provide a satisfactory clinical response in 25-30% of treated patients. Prostaglandins are active in a higher percentage of patients and can be infused in a domiciliary regimen with portable pumps even for long periods of time. Nitric oxide is the only selective pulmonary vasodilator; it is used in paediatric and adult cardiac surgery and in patients affected by respiratory distress syndrome, but its use is restricted to intensive care units and many cautions must be adopted. Finally some future therapeutic strategies are briefly reviewed: endothelin inhibitors, cGMP phosphodiesterase inhibitors etc.

[Drepanocytosis in patients undergoing heart surgery. Anesthesiologic problems]. / Drepanocitosi in pazienti sottoposti a chirurgia cardiaca. Problematiche anestesiologiche.

The authors report their experience with the management of patients with sickle cell trait undergoing open heart surgery. They focus their attention mainly on those factors potentially able to precipitate episodes of sickling, i.e. hypoxia, hypothermia, vascular stasis and acidosis.

[Comparison between propofol and isoflurane in patients undergoing aorto-coronary bypass. Effect on systemic and coronary circulation]. / Confronto tra propofol e isoflurano in pazienti sottoposti ad intervento di bypass aorto-coronarico. Effetti sul circolo sistemico e coronarico.

The Authors report their experience with the use of two different anaesthetic techniques (propofol-fentanil versus isoflurane-fentanyl) for induction and maintenance of anaesthesia in patients undergoing coronary artery surgery. Haemodynamic data (regarding systemic and coronary circulation) showed an almost similar pattern of change after induction, intubation, skin incision and sterotomy, except for a greater decrease of systemic vascular resistances after induction in patients who received propofol. Cardiac output decreased more in the isoflurane group while changes in coronary sinus flow were equal in the two groups.

Effect of myocardial ischaemia-reperfusion on granulocyte elastase release.

During extracorporeal circulation, activation and degranulation of neutrophil granulocytes occur, with subsequent massive release of elastase, a neutral protease stored in the azurophil granules. Neutrophil granulocytes and oxygen-derived free radicals are intimately involved in the occurrence of reperfusion injury, which affects especially the lungs and the myocardium. In this study we evaluated changes in the leucocyte count and of the plasma elastase levels in the coronary circulation during open heart surgery. We collected blood samples from the radial artery and the coronary sinus before skin incision, after onset of cardiopulmonary bypass and 5, 15, 30, 60, 120 minutes after the release of the aortic cross-clamp. The leucocyte count did not change significantly during the operation and no difference in leucocyte count was found between the radial artery and the coronary sinus. Plasma elastase levels significantly increased after the onset of cardiopulmonary bypass (P = 0.007) and after the release of the aortic cross-clamp (P = 0.001). Moreover, significantly higher values were found in the coronary sinus than in the radial artery 5 (P = 0.04), 15 (P = 0.02) and 30 (P = 0.02) minutes after the release of the aortic cross-clamp. We assume, therefore, that during the early phase of reperfusion, degranulation of neutrophil granulocytes occurs in the coronary circulation.

[Hypokalemic myopathy. Our experience at an intensive care unit]. / Miopatia ipokaliemica. Nostra esperienza in un reparto di terapia intensiva.

Disturbances of potassium homeostasis are frequently iatrogenic: some drugs, especially diuretics, are sometimes taken without proper electrolyte control and replacement; this can lead to more or less severe hypokalemic states. After some physiopathologic remarks, the Authors report their experience with four patients admitted for severe hypokalemia; the clinical picture was always quite typical: severe muscle weakness (even quadriparesis), cardiac rhythm abnormalities, metabolic alkalosis. A reliable diagnostic tool is muscle biopsy that shows aspects of vacuolar myopathy.