RESUMO
Patient blood management (PBM) guidelines for patients undergoing cardiac surgery under cardiopulmonary bypass (CPB) have increased during the past decade, and pharmacotherapy plays an important role in PBM. In the face of the undefined consistency in the methodologic quality and pharmacotherapy recommendations across multiple guidelines, this study exclusively evaluated methodologies of the related guideline development process, and compiled medication recommendations of PBM for cardiac surgery patients. PBM guidelines for cardiac surgery under CPB were searched through some mainstream literature and guideline databases from database establishment to May 15, 2023. Nine guidelines meeting inclusion criteria were included in this study. The quality of the guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. "Stakeholder involvement" received the lowest mean score of 49.38% in the AGREE II scoring among the guidelines. PBM for cardiac surgery patients spans the perioperative phase. Drug therapy strategies of PBM for cardiac surgery patients involve anemia therapy, perioperative administration of antithrombotic drugs, intraoperative anticoagulation, and the use of hemostatic drugs. Unlike for adults, there is less evidence about the management of antithrombotic drugs and hemostatic drugs for pediatric cardiac surgery patients. Recombinant activated factor VII (rFVIIa) and desmopressin (DDAVP) are not recommended after pediatric cardiac surgery, whereas prothrombin complex concentrate could be considered in clinical trials. As for the controversies regarding the administration of rFVIIa and DDAVP after adult cardiac surgery by different societies, clinicians should exercise their clinical judgment based on individual patient features.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Guias de Prática Clínica como Assunto , Humanos , Ponte Cardiopulmonar/métodos , Ponte Cardiopulmonar/normas , Procedimentos Cirúrgicos Cardíacos/métodos , Guias de Prática Clínica como Assunto/normasRESUMO
BACKGROUND: In the recent ALBICS (ALBumin In Cardiac Surgery) trial, 4% albumin used for cardiopulmonary bypass priming and volume replacement increased perioperative bleeding compared with Ringer acetate. In the present exploratory study, albumin-related bleeding was further characterized. METHODS: Ringer acetate and 4% albumin were compared in a randomized, double-blinded fashion in 1386 on-pump adult cardiac surgery patients. The study end points for bleeding were the Universal Definition of Perioperative Bleeding (UDPB) class and its components. RESULTS: The UDPB bleeding grades were higher in the albumin group than the Ringer group: "insignificant" (albumin vs Ringer: 47.5% vs 62.9%), "mild" (12.7% vs 8.9%), "moderate" (28.7% vs 24.4%), "severe" (10.2% vs 3.2%), and "massive" (0.9% vs. 0.6%; P < .001). Patients in the albumin group received red blood cells (45.2% vs 31.5%; odds ratio [OR], 1.80; 95% CI, 1.44-2.24; P < .001), platelets (33.3% vs 21.8%; OR, 1.79; 95% CI, 1.41-2.28; P < .001), and fibrinogen (5.6% vs 2.6%; OR, 2.24; 95% CI, 1.27-3.95; P < .05), and underwent resternotomy (5.3% vs 1.9%; OR, 2.95; 95% CI, 1.55-5.60, P < .001) more often than patients in the Ringer group. The strongest predictors of bleeding were albumin group allocation (OR, 2.18; 95% CI, 1.74-2.74) and complex (OR, 2.61; 95% CI, 2.02-3.37) and urgent surgery (OR, 1.63; 95% CI, 1.26-2.13). In interaction analysis, the effect of albumin on the risk of bleeding was stronger in patients on preoperative acetylsalicylic acid. CONCLUSIONS: Perioperative administration of albumin, compared with Ringer's acetate, resulted in increased blood loss and higher UDBP class. The magnitude of this effect was similar to the complexity and urgency of the surgery.
Assuntos
Albuminas , Perda Sanguínea Cirúrgica , Procedimentos Cirúrgicos Cardíacos , Solução de Ringer , Humanos , Albuminas/administração & dosagem , Albuminas/efeitos adversos , Perda Sanguínea Cirúrgica/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/normas , Ponte Cardiopulmonar/métodos , Ponte Cardiopulmonar/normas , Solução de Ringer/administração & dosagem , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Resultado do TratamentoRESUMO
Surgical pulmonary embolectomy has a storied history in the domain of cardiothoracic surgery. This article provides insight on the history, current data, and future directions of surgical pulmonary embolectomy.
Assuntos
Ponte Cardiopulmonar/normas , Embolectomia/história , Embolectomia/normas , Embolectomia/tendências , Guias de Prática Clínica como Assunto , Embolia Pulmonar/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Embolectomia/estatística & dados numéricos , Feminino , Previsões , História do Século XX , História do Século XXI , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Minimally invasive cardiac surgery options, which originated with off-pump coronary artery bypass grafting and aortic valve procedures, continue to evolve in order to address complex conditions, including those requiring mitral and tricuspid valve repair. Although these procedures are primarily indicated for high-risk patient populations, favorable patient outcomes have resulted in recommendations being expanded to include intermediate-risk groups. This article increases nursing-related knowledge of minimally invasive cardiac procedures, providing an overview of current minimally invasive cardiac surgeries and their associated risks and benefits.
Assuntos
Procedimentos Cirúrgicos Cardíacos/normas , Ponte Cardiopulmonar/normas , Doença da Artéria Coronariana/cirurgia , Enfermagem de Cuidados Críticos/normas , Implante de Prótese de Valva Cardíaca/normas , Procedimentos Cirúrgicos Minimamente Invasivos/normas , Esternotomia/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte Cardiopulmonar/métodos , Feminino , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Guias de Prática Clínica como Assunto , Medição de Risco , Esternotomia/métodos , Resultado do TratamentoRESUMO
Pulmonary fibroelastomas are a rare primary cardiac tumor with less than 50 cases reported in the literature to date. We performed a minimally invasive valve-sparing tumor resection through a left anterior mini-incision (LAMI). The procedure was performed without cardiac arrest or aortic cross clamp, expediting postoperative recovery and allowing for an uncomplicated discharge on postoperative day 5. LAMI is a safe and reliable alternative to median sternotomy for patients requiring interventions on the right ventricular outflow tract and main pulmonary artery, including pulmonary fibroelastoma resection and pulmonary valve replacement when needed.
Assuntos
Fibroma/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Artéria Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/cirurgia , Procedimentos Cirúrgicos Cardíacos/tendências , Ponte Cardiopulmonar/normas , Cateterismo/métodos , Ecocardiografia/métodos , Feminino , Artéria Femoral/cirurgia , Fibroma/patologia , Doenças das Valvas Cardíacas/patologia , Doenças das Valvas Cardíacas/cirurgia , Humanos , Imageamento por Ressonância Magnética/métodos , Pessoa de Meia-Idade , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/patologia , Toracotomia/métodos , Resultado do TratamentoRESUMO
PURPOSE: Data on the benefit or or harmful effects of oxygen level on ischemic reperfusion injuries in cardiac surgery are insufficient. We hypothesized that hyperoxia during cardiopulmonary bypass decreases the incidence of postoperative atrial fibrillation (POAF) and ventricular fibrillation, and therefore decreases cardiovascular morbidity (CARDIOX study). METHODS: An open-label, randomized clinical trial including adults undergoing elective cardiac surgery, i.e. cardiopulmonary bypass (CPB) randomized 1:1 to an intervention group or standard group at two French University Hospitals from June 2016 to October 2018. The intervention consisted in delivering of an inspired fraction of oxygen of one to one during CPB. The standard care consisted in delivering oxygen to achieve a partial arterial blood pressure less than 150 mmHg. The primary endpoint was the occurrence of POAF and/or ventricular tachycardia/ventricular fibrillation (VT/VF) within the 15 days following cardiac surgery. The secondary endpoint was the occurrence of major adverse cardiovascular events (MACCE: in-hospital mortality, stroke, cardiac arrest, acute kidney injury, and mesenteric ischemia). RESULTS: 330 patients were randomly assigned to either the intervention group (n = 161) or the standard group (n = 163). Mean PaO2 was 447 ± 98 mmHg and 161 ± 60 mmHg during CPB, for the intervention and standard group (p < 0.0001) respectively. The incidence of POAF or VT/VF were similar in the intervention group and the standard group (30% [49 of 161 patients] and 30% [49 of 163 patients], absolute risk reduction 0.4%; 95% CI, - 9.6-10.4; p = 0.94). MACCE was similar between groups with, an occurrence of 24% and 21% for the intervention group and the standard groups (absolute risk reduction 3.4%; 95% CI, - 5.7-12.5; p = 0.47) respectively. After adjustment, the primary and secondary endpoints remained similar for both groups. CONCLUSION: Hyperoxia did not decrease POAF and cardiovascular morbidity following cardiac surgery with CPB. CLINICALTRIAL. GOV IDENTIFIER: NCT02819739.
Assuntos
Ponte Cardiopulmonar/normas , Doenças Cardiovasculares/etiologia , Hiperóxia/complicações , Idoso , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/etiologia , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte Cardiopulmonar/métodos , Ponte Cardiopulmonar/estatística & dados numéricos , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/cirurgia , Feminino , França/epidemiologia , Humanos , Hiperóxia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Oxigênio/uso terapêutico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Período Pós-OperatórioRESUMO
Cardiac presentations of Marfan syndrome are not uncommon. Patients with Marfan syndrome can present with aortic pathology, valvular pathology, or both. Hence, Marfan syndrome patients can undergo more than one cardiac surgery in their lifetime. Endoscopic mitral valve surgery can be a good alternative to redo sternotomy. We present a case of a 77-year-old woman who had an aortic root replacement and replacement of the ascending aorta. She presented to our center 13 years later with severe mitral regurgitation. Femoral cannulation for cardiopulmonary bypass was not possible due to the presence of a type B aortic dissection that occurred sometime after the initial procedure. Mitral valve replacement was performed with an empty beating heart using axillary artery inflow with an excellent result.
Assuntos
Artéria Axilar/cirurgia , Endoscopia/métodos , Síndrome de Marfan/complicações , Insuficiência da Valva Mitral/cirurgia , Idoso , Dissecção Aórtica/etiologia , Dissecção Aórtica/fisiopatologia , Aorta/diagnóstico por imagem , Aorta/cirurgia , Ponte Cardiopulmonar/normas , Cateterismo Periférico/instrumentação , Angiografia por Tomografia Computadorizada/métodos , Feminino , Humanos , Insuficiência da Valva Mitral/etiologia , Reoperação/métodos , Reimplante/métodos , Resultado do TratamentoRESUMO
OBJECTIVE: Aortic root enlargement may be necessary to implant adequately sized valves to avoid patient-prosthetic mismatch. Our objective was to assess the feasibility of annular enlargement during aortic valve replacement via a right anterior minithoracotomy. METHODS: Twelve consecutive patients undergoing elective minimally invasive aortic valve replacement requiring annular enlargement over a 2-year period were retrospectively reviewed. A right anterior minithoracotomy was performed in all patients. Cardiopulmonary bypass and aortic crossclamp times, hospital length of stay, postoperative complications, rate of reoperation, echocardiographic data, and mortality were analyzed. RESULTS: Mean age was 66 years ± 14. Mean body mass index was 34 ± 7.8 kg/m2. All patients had normal preoperative ejection fractions. Indications for aortic valve replacement were severe (3/12, 25%) or critical (9/12, 75%) aortic stenosis due to degenerative aortic valve disease (10/12, 83%) and congenitally bicuspid aortic valve (2/12, 17%). Cardiopulmonary bypass and aortic crossclamp times were 144.7 ± 14.7 minutes and 111.7 ± 10.6 minutes, respectively. The median postoperative length of stay was 4 days. Peak and mean aortic valve gradients on postreplacement intraoperative transesophageal echocardiography were 14.5 ± 9.4 mmHg and 7.2 ± 4.2 mmHg, respectively, with no perivalvular leak on intraoperative or follow-up transthoracic echocardiogram. Postoperative transthoracic echocardiography had peak and mean aortic valve gradients of 12.1 ± 6.9 mmHg and 6.3 ± 3.7 mmHg, respectively. There were no postoperative mortalities. Freedom from reoperation was 100%. CONCLUSIONS: Annular enlargement performed during minimally invasive aortic valve replacement is feasible. Basic minimally invasive skills are recommended prior to instituting these more advanced techniques.
Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Anuloplastia da Valva Cardíaca/métodos , Implante de Prótese de Valva Cardíaca/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/anormalidades , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/patologia , Estenose da Valva Aórtica/etnologia , Anuloplastia da Valva Cardíaca/mortalidade , Ponte Cardiopulmonar/normas , Ecocardiografia/métodos , Estudos de Viabilidade , Feminino , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Toracotomia/métodos , Toracotomia/tendênciasRESUMO
OBJECTIVE: The authors hypothesized that grading valvular aortic stenosis (AS) with dimensionless index (DI) during intraoperative pre-cardiopulmonary bypass (pre-CPB) transesophageal echocardiography (TEE) would match the grade of AS during preoperative transthoracic echocardiography (TTE) for the same patients more often than when using peak velocity (Vp), mean pressure gradient (PGm), or aortic valve area (AVA). DESIGN: Retrospective, observational. SETTING: Single university hospital. PARTICIPANTS: The participants in this study included 123 cardiac surgical patients with any degree of AS, who underwent open cardiac surgery between 2010 and 2016 at the Medical University of South Carolina and had Vp, PGm, AVA, and DI values available from reporting databases or archived imaging. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: When using DI, pre-CPB TEE grading of AS severity was 1 grade higher 21.1% of the time and 1 grade lower 13.0% of the time compared with TTE, for an overall disagreement rate of 34.1%. The overall disagreement rates between pre-CPB TEE and TTE for Vp, PGm, and AVA were 39.8%, 33.3%, and 33.3%, respectively. CONCLUSIONS: The authors could not demonstrate that DI was better than Vp, PGm, or AVA at matching AS grades between intraoperative pre-CPB TEE and preoperative TTE. When DI was used, pre-CPB TEE was more likely to overestimate than underestimate the severity of AS compared with TTE. However, when Vp or PGm was used, pre-CPB TEE was more likely to underestimate the severity of AS compared with TTE. A comprehensive approach without overemphasis on 1 parameter should be used for AS assessment by intraoperative TEE.
Assuntos
Estenose da Valva Aórtica/diagnóstico por imagem , Ponte Cardiopulmonar/normas , Ecocardiografia Transesofagiana/normas , Ecocardiografia/normas , Cuidados Pré-Operatórios/normas , Índice de Gravidade de Doença , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/cirurgia , Ponte Cardiopulmonar/métodos , Ecocardiografia/métodos , Ecocardiografia Transesofagiana/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/métodos , Estudos RetrospectivosRESUMO
This is a narrative review of recent articles (mainly published in 2017 and 2018) related to the conduct of cardiopulmonary bypass (CPB) that should be of interest to the cardiac anesthesiologist. Some of the topics covered include recent guidelines on temperature management, anticoagulation, perfusion practice, use of transesophageal echocardiography during CPB, optimal mean arterial pressure, vasoplegia, bleeding, perioperative anemia, post-cardiac surgery transfusion, acute kidney injury, delirium and cognitive decline, CPB during pregnancy, lung management, radial-to-femoral artery pressure gradients during CPB, prophylactic perioperative intra-aortic balloon pump, del Nido cardioplegia, antibiotic prophylaxis, and use of levosimendan in cardiac surgery. The review concludes with a perspective on the effect of these development on the practice of cardiac anesthesia.
Assuntos
Ponte Cardiopulmonar/normas , Ponte Cardiopulmonar/tendências , Doenças Cardiovasculares/diagnóstico por imagem , Doenças Cardiovasculares/cirurgia , Guias de Prática Clínica como Assunto/normas , Ponte Cardiopulmonar/métodos , HumanosRESUMO
OBJECTIVES: The aim of this study was to evaluate the accuracy, precision, and trending ability of the fourth-generation FloTrac/Vigileo system (version 4.00; Edwards Lifesciences, Irvine, CA) by comparing cardiac output derived from FloTrac/Vigileo system (COAP) with that measured by a pulmonary artery catheter (COTD), and to determine the effects of hemodynamic variables on the bias between COTD and COAP. DESIGN: A prospective study. SETTING: University hospital. PARTICIPANTS: Thirty patients undergoing elective cardiac surgery using cardiopulmonary bypass. INTERVENTIONS: Including hemodynamic variables, COTD and COAP were measured simultaneously at the following 10 time points: after the induction of anesthesia, at the start of operation, after sternotomy, before and after the administration of heparin, before and after the administration of protamine, at the start of sternal closure, at the end of operation, and on arrival to intensive care unit. MEASUREMENTS AND MAIN RESULTS: In total, 280 pairs of datasets were obtained. Bland-Altman analysis showed a bias of -0.41 L/min, a precision of 0.72 L/min, and limits of agreement of -1.85 and 1.03 L/min, with a percentage error of 37.1%. The concordance rate determined by 4-quadrant plot analysis and the polar concordance rate were 76% and 79%, respectively. The linear mixed-effect model revealed that the bias was influenced strongly by the difference in pulse pressure between the radial and femoral artery (p < 0.001), and the systemic vascular resistance index (p < 0.001). CONCLUSION: The fourth-generation FloTrac/Vigileo system still lacks accuracy and trending ability in cardiac surgery, and the discrepancy in cardiac output measurement depends on the peripheral vascular tone. Further improvement of this system is needed.
Assuntos
Débito Cardíaco/fisiologia , Procedimentos Cirúrgicos Cardíacos/normas , Ponte Cardiopulmonar/normas , Monitorização Intraoperatória/normas , Termodiluição/normas , Idoso , Pressão Sanguínea/fisiologia , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte Cardiopulmonar/métodos , Feminino , Humanos , Masculino , Monitorização Intraoperatória/métodos , Estudos Prospectivos , Termodiluição/métodosRESUMO
BACKGROUND: Optimization of blood-saving strategies during open heart surgery in infants is still required. This study aimed to study a comprehensive blood-saving strategy during cardiopulmonary bypass (CPB) on postoperative recovery in low-weight infants undergoing open heart surgery. METHODS: This was a prospective study of 86 consecutive infants (weighing <5âkg) with acyanotic congenital heart disease treated at the Tianjin Chest Hospital between March and December 2016, and randomized to the control (traditional routine CPB) and comprehensive blood-saving strategy groups. The primary endpoints were blood saving and clinical prognosis. The secondary endpoints were safety and laboratory indicators, prior to CPB (T1), after 30 minutes of CPB (T2), after modified ultrafiltration (T3), and postoperative 12 (T4), 24 (T5), 48 (T6), and 72âh (T7). RESULTS: The total priming volume and banked red blood cells in the comprehensive strategy group were significantly lower than in the control group (Pâ=â.009 and Pâ=â.04, respectively). In the comprehensive strategy group, immediately after CPB, the amount of salvaged red blood cells exceeded the priming red blood cells by 40â±â11âmL. Postoperatively, the comprehensive strategy group showed a significant decrease in the inotrope score (Pâ=â.03), ventilation time (Pâ=â.03), intensive care unit stay (Pâ=â.04), and hospital stay (Pâ=â.03) in comparison with the control group. CONCLUSION: The comprehensive blood-saving strategies for CPB were associated with less blood use and favorable postoperative recovery in low-weight infants with congenital heart disease undergoing open heart surgery.
Assuntos
Procedimentos Médicos e Cirúrgicos sem Sangue/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte Cardiopulmonar/métodos , Cardiopatias Congênitas/cirurgia , Perda Sanguínea Cirúrgica/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/normas , Feminino , Humanos , Lactente , Recém-Nascido de Baixo Peso , Recém-Nascido , Terapia Intensiva Neonatal/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Período Pós-Operatório , Prognóstico , Estudos ProspectivosRESUMO
OBJECTIVE: Point-of-care (POC) devices allow for prothrombin time/international normalized ratio (PT/INR) testing in whole blood (WB) and timely administration of plasma or prothrombin complex concentrate during cardiopulmonary bypass surgery. This study evaluated the sensitivities of a new POC PT test, a dry-hematology method with heparin neutralization technology (DRIHEMATO PT-S [DRI PT-S]; A&T Corporation, Kanagawa, Japan), and compared it with other POC tests currently available. DESIGN: Prospective, observational study. SETTING: University hospital, single center. PARTICIPANTS: Healthy volunteers and warfarin-treated and cardiac surgical patients. MEASUREMENT AND MAIN RESULTS: In WB samples obtained from 6 healthy volunteers, PT-INR results of DRI PT-S were not affected by an in vitro addition of heparin <6.0 U/mL. In warfarin-treated samples (n = 88, PT/INR 0.98-3.87), PT-INR with DRI PT-S showed acceptable correlation with the laboratory method (r2 = 0.85, p < 0.001). In blood samples obtained from cardiac surgical patients (n = 72), heparin prolonged the PT/INR with the laboratory assay, dry-hematology method with non heparin neutralization technology (DRI PT), Coaguchek XS (Roche Diagnostics, Basel, Switzerland), and Hemochron Jr. (Accriva Diagnostics, Edison, NJ), but DRI PT-S was not affected by heparin anticoagulation. In nonheparinized samples, different methods between DRI PT-S and the laboratory method yielded acceptable correlations (r2 = 0.76, p < 0.0001). There was a moderate correlation between factor levels and the PT-INR with DRI PT-S (factor [F]II: r2 = 0.63, FVII: r2 = 0.47, FX: r2 = 0.67; p < 0.0001). CONCLUSIONS: This study demonstrated that PT/INR can be accurately assessed using the dry-hematology method in WB under therapeutic heparin levels. Currently available other POC PT/INR tests are affected by heparin, and thus they are not recommended for coagulation monitoring during cardiopulmonary bypass.
Assuntos
Ponte Cardiopulmonar/métodos , Monitorização Intraoperatória/métodos , Sistemas Automatizados de Assistência Junto ao Leito , Tempo de Protrombina/métodos , Adulto , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Ponte Cardiopulmonar/normas , Feminino , Humanos , Coeficiente Internacional Normatizado/métodos , Coeficiente Internacional Normatizado/normas , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/normas , Sistemas Automatizados de Assistência Junto ao Leito/normas , Estudos Prospectivos , Tempo de Protrombina/normas , Varfarina/administração & dosagem , Varfarina/efeitos adversos , Adulto JovemRESUMO
Despite more than a half century of "safe" cardiopulmonary bypass (CPB), the evidence base surrounding the conduct of anticoagulation therapy for CPB has not been organized into a succinct guideline. For this and other reasons, there is enormous practice variability relating to the use and dosing of heparin, monitoring heparin anticoagulation, reversal of anticoagulation, and the use of alternative anticoagulants. To address this and other gaps, The Society of Thoracic Surgeons, the Society of Cardiovascular Anesthesiologists, and the American Society of Extracorporeal Technology developed an Evidence Based Workgroup. This was a group of interdisciplinary professionals gathered to summarize the evidence and create practice recommendations for various aspects of CPB. To date, anticoagulation practices in CPB have not been standardized in accordance with the evidence base. This clinical practice guideline was written with the intent to fill the evidence gap and to establish best practices in anticoagulation therapy for CPB using the available evidence. To identify relevant evidence, a systematic review was outlined and literature searches were conducted in PubMed using standardized medical subject heading (MeSH) terms from the National Library of Medicine list of search terms. Search dates were inclusive of January 2000 to December 2015. The search yielded 833 abstracts, which were reviewed by two independent reviewers. Once accepted into the full manuscript review stage, two members of the writing group evaluated each of 286 full papers for inclusion eligibility into the guideline document. Ninety-six manuscripts were included in the final review. In addition, 17 manuscripts published before 2000 were included to provide method, context, or additional supporting evidence for the recommendations as these papers were considered sentinel publications. Members of the writing group wrote and developed recommendations based on review of the articles obtained and achieved more than two thirds agreement on each recommendation. The quality of information for a given recommendation allowed assessment of the level of evidence as recommended by the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Recommendations were written in the three following areas: (1) heparin dosing and monitoring for initiation and maintenance of CPB; (2) heparin contraindications and heparin alternatives; and (3) reversal of anticoagulation during cardiac operations. It is hoped that this guideline will serve as a resource and will stimulate investigators to conduct more research and to expand on the evidence base on the topic of anticoagulation therapy for CPB.
Assuntos
Anestesiologia , Ponte Cardiopulmonar/normas , Doenças Cardiovasculares/terapia , Circulação Extracorpórea/normas , Guias de Prática Clínica como Assunto , Cirurgia Torácica , Terapia Trombolítica/normas , Humanos , Cuidados Intraoperatórios/normas , Sociedades Médicas , Estados UnidosRESUMO
BACKGROUND: Despite the recent introduction of a number of technical and pharmacologic blood conservation measures, bleeding and allogeneic transfusion remain persistent problems in open-heart surgical procedures. Efforts should be made to decrease or completely avoid transfusions to avoid these negative reactions. METHODS: Our coronary artery bypass grafting database was reviewed retrospectively and a total of 243 patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) were studied in a 12-month period (January-December 2016) after the implementation of the new program, and compared with 275 patients of the previous 12-month period.All the staff involved in the care of the patients were educated about the risks and benefits of blood transfusions and the new transfusion guidelines in a 45-min training. We revised our guidelines for transfusions based on the STS. A transfusion log was created. Reduction in IV fluid volume was targeted. CPB circuitry was redesigned to achieve significantly less prime volume. Results: The proportion of patients transfused with red blood cells was 56% (n =154) in the control group and reduced by 26.8% in the study group (29.2%; 71 patients; P < .01). Blood transfusion rate (1.7 ± 1/3.05 ± 1 units), postoperative hemorrhage (545 ± 50/ 775 ± 55 mL), respiratory support duration (12.4 ± 7/16.8 ± 8 h) and ICU stay (2.2±1.1/ 3.5±1.2 days) were significantly better in the blood conservation group. Conclusion: These findings, in addition to risks and side effects of blood transfusion and the rising cost of safer blood products, justify blood conservation in adult cardiac operations.
Assuntos
Procedimentos Cirúrgicos Cardíacos/normas , Ponte Cardiopulmonar/normas , Gerenciamento Clínico , Transfusão de Eritrócitos/normas , Hemorragia Pós-Operatória/terapia , Guias de Prática Clínica como Assunto , Idoso , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte Cardiopulmonar/métodos , Feminino , Humanos , Masculino , Estudos RetrospectivosRESUMO
Minimally invasive, robotic-assisted cardiac surgery has been shown to decrease transfusion rates, decrease wound infection rates, shorten hospital length of stay, and allow for a faster return to full activity compared with traditional sternotomy approaches. However, its application has chiefly been limited to primary, isolated procedures such as primary mitral valve repair or replacement. We describe the first reported use of a robotic surgery platform to perform reoperative mitral valve replacement using a minimally invasive, totally endoscopic, port-access approach.
Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Implante de Prótese de Valva Cardíaca/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Ponte Cardiopulmonar/métodos , Ponte Cardiopulmonar/normas , Ecocardiografia Transesofagiana/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/diagnóstico por imagem , Reoperação , Resultado do TratamentoRESUMO
OBJECTIVE: To create a universal checklist of key preparatory steps to aid anesthesiologists in patient separation from cardiopulmonary bypass. DESIGN: Multistep, iterative survey with statistically guided refinement of survey items using a modified Delphi technique. SETTING: Internet-based surveys. PARTICIPANTS: Ninety active members of the Society of Cardiovascular Anesthesiologists volunteered to participate, including geographically distributed private practice and academic physicians. INTERVENTIONS: A series of checklist items was created and distributed to 90 anesthesiologists, who assessed each item's importance in preparing for patient separation from cardiopulmonary bypass and added, deleted, or modified any items as they saw fit. Items meeting a threshold of greater than 90% group acceptance were carried forward to a second survey. These items then were evaluated using a 5-point Likert scale to grade relative importance and then compared with the group's responses, creating a third survey with refined checklist items. The results then were used to generate a final survey based on each item achieving certain predefined statistical criteria, which then were scored again by the participants, generating a final checklist via statistically guided consensus. MEASUREMENTS AND MAIN RESULTS: An initial checklist containing 28 possible items was proposed to the participants. After the iterative process was completed, a final checklist of 10 items deemed essential to prepare for bypass separation was created. CONCLUSIONS: A checklist to aid in bypass separation was created with key steps derived from a statistically driven Delphi process. This technique of iterative consensus building may be useful in developing additional safety checklists.
Assuntos
Procedimentos Cirúrgicos Cardíacos/normas , Ponte Cardiopulmonar/normas , Lista de Checagem , Anestesiologia/normas , Ponte Cardiopulmonar/métodos , Competência Clínica/normas , Técnica Delphi , Humanos , Erros Médicos/prevenção & controle , Melhoria de Qualidade , Gestão da Segurança/métodos , TexasRESUMO
Gaps remain in our understanding of the contribution of bypass-related practices associated with red blood cell (RBC) transfusions after cardiac surgery. Variability exists in the reporting of bypass-related practices in the peer-reviewed literature. In an effort to create uniformity in reporting, a draft statement outlining proposed minimal criteria for reporting cardiopulmonary bypass (CPB)- related contributions (i.e., RBC data collection/documentation, clinical considerations for transfusions, equipment details, and clinical endpoints) was presented in conjunction with the American Society of ExtraCorporeal Technology's (AmSECT's) 2014 Quality and Outcomes Meeting (Baltimore, MD). Based on presentations and feedback from the conference, coauthors (n = 14) developed and subsequently voted on each proposed data element. Data elements receiving a total of 4 votes were dropped from further consideration, 5-9 votes were considered as "Recommended," and elements receiving ≥10 votes were considered as "Mandatory." A total of 52 elements were classified as mandatory, 16 recommended, and 14 dropped. There are 8 mandatory data elements for RBC data collection/documentation, 24 for clinical considerations for transfusions, 13 for equipment details, and 7 for clinical endpoints. We present 52 mandatory data elements reflecting CPB-related contributions to RBC transfusions. Consistency of such reporting would offer our community an increased opportunity to shed light on the relationship between intra-operative practices and RBC transfusions.