Redefining global cardiac surgery through an intersectionality lens.

Although cardiovascular diseases are the leading cause of morbidity and mortality worldwide, six billion people lack access to safe, timely and affordable cardiac surgical care when needed. The burden of cardiovascular disease and disparities in access to care vary widely based on sociodemographic characteristics, including but not limited to geography, sex, gender, race, ethnicity, indigeneity, socioeconomic status and age. To date, the majority of cardiovascular, global health and global surgical research has lacked intersectionality lenses and methodologies to better understand access to care at the intersection of multiple identities and traditions. As such, global (cardiac) surgical definitions and health system interventions have been rooted in reductionism, focusing, at most, on singular sociodemographic characteristics. In this article, we evaluate barriers in global access to cardiac surgery based on existing intersectionality themes and literature. We further examine intersectionality methodologies to study access to cardiovascular care and cardiac surgery and seek to redefine the definition of 'global cardiac surgery' through an intersectionality lens.

Erector spinae plane block as perioperative analgesia for midline sternotomy in cardiac surgery: A systematic review and meta-analysis.

BACKGROUND: Inadequate analgesia following cardiac surgery increases postoperative complications. Opioid-based analgesia is associated with side effects that may compromise postoperative recovery. Regional anesthetic techniques provide an alternative thereby reducing opioid requirements and potentially enhancing postoperative recovery. The erector spinae plane block has been used in multiple surgical procedures including sternotomy for cardiac surgery. We, therefore, aimed to characterize the impact of this block on post-sternotomy pain and recovery in cardiac surgery patients. METHODS: We conducted an electronic search for studies reporting on the use of the erector spinae plane block in adult cardiac surgery via midline sternotomy. Randomized controlled trials, cohort studies, and case-control studies were considered for inclusion. Outcomes of interest included postoperative pain, time-to-extubation, and intensive care unit length of stay. RESULTS: In total, 498 citations were identified and five were included in the meta-analysis. The erector spinae plane block did not significantly reduce self-reported postoperative pain scores at 4 h (-2.04; 95% confidence interval [CI] -8.15 to 4.07; p = .29) or 12 h (-0.27; 95% CI -2.48 to 1.94; p = .65) postextubation, intraoperative opioid requirements (-3.07; 95% CI -6.25 to 0.11; p = .05], time-to-extubation (-1.17; 95% CI -2.81 to 0.46; p = .12), or intensive care unit (ICU) length of stay (-4.51; 95% CI -14.23 to 5.22; p = .24). CONCLUSIONS: Erector spinae plane block was not associated with significant reduction in postoperative pain, intraoperative opioid requirements, time-to-extubation, and ICU length of stay in patients undergoing cardiac surgery. The paucity of large randomized controlled trials and the high heterogeneity among studies suggest that further studies are required to assess its effectiveness in cardiac surgery patients.

The use of FEIBA for refractory bleeding in cardiac surgery - a systematic review.

INTRODUCTION: Significant blood loss during cardiac surgery is associated with a dramatic increase in morbidity and mortality. Factor Eight Inhibitor Bypassing Activity (FEIBA), a hemostatic bypassing agent mainly used in hemophiliac patients, has also been used for intractable bleeding during cardiac surgical procedures in non-hemophiliac patients. However, concerns exist that its use may be linked to increased incidence of perioperative adverse effects including thrombotic complications. AREAS COVERED: A systematic literature search was performed on MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases for all studies that reported the administration of FEIBA for treatment of bleeding during adult cardiac surgery in non-hemophiliac patients. After selecting the title and abstracts, two authors assessed the methodological quality of the full-text articles prior to final inclusion in the manuscript. EXPERT OPINION: The safety profile of FEIBA was determined through an aggregate count of adverse events. Major complications included renal failure, re-operation for unresolved bleeding, postoperative mortality, and thromboembolic events. Overall, there is insufficient robust evidence to make a definitive conclusion about the safety or efficacy of using of FEIBA as a hemostatic agent in the setting of cardiac surgery.

Topical Vancomycin and Risk of Sternal Wound Infections: A Double-Blind Randomized Controlled Trial.

BACKGROUND: The use of topical vancomycin in the reduction of sternal wound infection (SWI) risk has become a point of contention. The earlier literature consists of observational studies and 1 unblinded trial. Hence, the objective of this study was to assess whether vancomycin reduces the incidence of SWI in a double-blind randomized controlled trial. METHODS: Patients were randomized 1:1 to either vancomycin-soaked (vancomycin) or saline-soaked (control) sponges. The sponges were applied once the sternum was opened and were removed just before sternal closure. Patients were followed up at 3 months and at 1 year postoperatively to determine the incidence of SWI in each group. Results were analyzed according to the modified intention-to-treat principle. RESULTS: This study assessed 1038 patients for eligibility and enrolled 1037 patients. There were 517 patients randomized to the vancomycin group and 520 patients randomized to the control group. Analysis was performed on 1021 patients. At 3 months postoperatively, there was no significant difference in the incidence of SWI between the vancomycin and control groups (2.7% vs 4.1%; P = .23). There was also no significant difference between the vancomycin and control groups in the risk of superficial, deep, and organ-space infections. Similar findings were observed 1 year postoperatively. The most common organism isolated was coagulase-negative Staphylococcus. CONCLUSIONS: The use of vancomycin applied to the sternum during cardiac surgery does not reduce the incidence of SWI.

Antithymocyte Globulin at Clinically Relevant Concentrations Kills Leukemic Blasts.

In contrast to cyclosporine or methotrexate, rabbit antithymocyte globulin (ATG) used for graft-versus-host disease (GVHD) prophylaxis with myeloablative conditioning does not increase the risk of relapse after hematopoietic cell transplantation. The reason for this is unknown. We hypothesized that ATG at concentrations achieved with our standard ATG dose of 4.5 mg/kg exerts antileukemic activity. We measured ATG-induced killing of leukemic blasts via complement-dependent cytotoxicity (CDC) and via complement-independent cytotoxicity (CIC) in marrow or blood from 36 patients with newly diagnosed acute leukemia. The median percentage of blasts killed by CDC was 0.3% at 1 mg/L ATG, 2.8% at 10 mg/L ATG, 12.6% at 25 mg/L ATG, and 42.2% at 50 mg/L ATG. The median percentage of blasts killed by CIC after a 4-hour incubation with ATG was 1.9% at 1 mg/L ATG, 7.15% at 10 mg/L ATG, 12.1% at 25 mg/L ATG, and 13.9% at 50 mg/L ATG. CIC appeared to represent a direct induction of apoptosis by ATG. There was a high variability in the sensitivity of the blasts to ATG; at 50 mg/L, the percentage of blasts killed ranged from 2.6% to 97.2% via CDC and from 1.4% to 69.9% via CIC. In conclusion, ATG at clinically relevant concentrations kills leukemic blasts in vitro. Some acute leukemias are highly sensitive to ATG, whereas others are relatively resistant. This finding could lead to personalized administration of ATG.