RESUMEN
BACKGROUND: Extubation in the operating room (OR) after cardiac surgery remains controversial due to safety concerns. Its feasibility had been suggested in select patients after off-pump surgery. AIM: To review the outcomes of patients extubated in the OR after on-pump cardiac valve surgery (cohort of interest) in comparison with patients extubated conventionally in the intensive care unit (ICU) (control). We hypothesized that the timing of extubation was not associated with postoperative complications. METHODS: Retrospective review of 272 consecutive patients who had undergone cardiac valve surgery at Jackson Memorial Hospital, Miami, Florida between January 1, 2009 and December 30, 2013. RESULTS: Compared with the control group, patients extubated in the OR had shorter cardiopulmonary bypass (CPB) (87 vs. 113 min, p < 0.0001) and aortic cross-clamp times (60 vs. 78 min, p < 0.0001), lower transfusion requirements (41.38% vs. 57.01%, p = 0.0342), shorter ICU (four vs. five days, p = 0.0002), and hospital stays (7.8 vs. 10 days, p = 0.0151). Mortality, overall rates of complications in all categories, ICU readmissions, and reintubations were similar in both groups. Each additional minute of CPB decreased the odds of extubation in the OR by a factor of 0.988 (odds ratio = 0.988; 95%CI: 0.980, 0.997). Pulmonary perfusion and ventilation during CPB increased the likelihood of extubation in the OR by a factor of 2.45 (odds ratio = 2.453; 95%CI: 1.247, 4.824). CONCLUSIONS: In select patients, extubation in the OR after on-pump valve surgery is safe. It is facilitated by shorter duration of CPB and pulmonary perfusion and ventilation during CPB. doi: 10.1111/jocs.12736 (J Card Surg 2016;31:274-281).
Asunto(s)
Extubación Traqueal/métodos , Procedimientos Quirúrgicos Cardíacos/métodos , Válvulas Cardíacas/cirugía , Complicaciones Posoperatorias/epidemiología , Femenino , Florida/epidemiología , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Quirófanos , Periodo Posoperatorio , Estudios Retrospectivos , Factores de TiempoAsunto(s)
Puente Cardiopulmonar/efectos adversos , Isquemia/etiología , Isquemia/prevención & control , Pulmón/irrigación sanguínea , Perfusión/métodos , Arteria Pulmonar , Daño por Reperfusión/etiología , Daño por Reperfusión/prevención & control , Sangre , Glucosa/administración & dosificación , Humanos , Inflamación , Manitol/administración & dosificación , Cloruro de Potasio/administración & dosificación , Procaína/administración & dosificaciónAsunto(s)
Circulación Extracorporea/métodos , Complicaciones Intraoperatorias/terapia , Trasplante de Riñón/efectos adversos , Trasplante de Hígado/efectos adversos , Cardiomiopatía de Takotsubo/terapia , Anciano , Femenino , Humanos , Complicaciones Intraoperatorias/diagnóstico por imagen , Complicaciones Intraoperatorias/etiología , Cardiomiopatía de Takotsubo/diagnóstico por imagen , Cardiomiopatía de Takotsubo/etiología , Cardiomiopatía de Takotsubo/fisiopatologíaRESUMEN
BACKGROUND: Extubation in the operating room (OR) after cardiac surgery is hampered by safety concerns, psychological reluctance, and uncertain economic benefit. We have studied the factors affecting the feasibility of extubation in the OR after cardiac surgery and its safety. METHODS: The outcomes of 78 patients extubated in the OR after open heart surgery were retrospectively compared to a matched control group of 80 patients with similar demographics, co-morbidities, and operative procedures, that were performed over the same time period, but extubated in the intensive care unit (ICU) following a standard weaning protocol. Variables collected included the incidence of subsequent unplanned tracheal reintubation in the ICU, postoperative complications, need for mediastinal re-exploration, surgical and OR times, and ICU and hospital lengths of stay. RESULTS: Out of a total of 372 cardiac procedures performed during the designated time frame, 78 (21%) resulted in extubation in the OR, mostly after off-pump coronary revascularization (41%) and aortic valve replacement (19.4%). Preoperative hypertension, EF ≥30%, off-bypass revascularization and shorter surgical times increased the likelihood of extubation in the OR. Extubation in the OR did not increase perioperative morbidity and mortality rates, but decreased the length of ICU and hospital stays. The incidence of unanticipated subsequent tracheal intubation in the ICU was comparable to noncardiac high-risk procedures (2.5%). CONCLUSIONS: Extubation in the OR can be safely performed in a select group of cardiac surgery patients without any increase in postoperative morbidity or mortality. The proposed mathematical model performed reasonably well in predicting a successful extubation in the OR.
Asunto(s)
Extubación Traqueal/métodos , Procedimientos Quirúrgicos Cardíacos , Cuidados Posoperatorios/métodos , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos/mortalidad , Técnicas de Apoyo para la Decisión , Femenino , Humanos , Unidades de Cuidados Intensivos , Tiempo de Internación/estadística & datos numéricos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Quirófanos , Complicaciones Posoperatorias/epidemiología , Estudios RetrospectivosRESUMEN
Contrast-enhanced CT angiography (CTA) currently is considered the diagnostic modality of choice in the diagnosis of acute type A aortic dissection. However, pitfalls associated with acquisition and interpretation of CTA images may result in misdiagnosis. We present examples of false-positive and false-negative interpretations of CTA in emergency situations that underline the importance of intraoperative preincision transesophageal echocardiography (TEE) in the diagnosis and management of this highly lethal entity.
Asunto(s)
Aneurisma de la Aorta Torácica/diagnóstico , Disección Aórtica/diagnóstico , Medios de Contraste , Ecocardiografía Transesofágica/métodos , Tomografía Computarizada por Rayos X/métodos , Adulto , Disección Aórtica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Prótesis Vascular , Diagnóstico Diferencial , Resultado Fatal , Estudios de Seguimiento , Humanos , MasculinoAsunto(s)
Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Corazón Auxiliar/normas , Monitoreo Intraoperatorio/normas , Sístole , Disfunción Ventricular Izquierda/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/fisiopatología , Insuficiencia de la Válvula Aórtica/cirugía , Humanos , Persona de Mediana Edad , Monitoreo Intraoperatorio/métodos , Sístole/fisiología , Ultrasonografía , Disfunción Ventricular Izquierda/cirugíaAsunto(s)
Conducto Arterioso Permeable/diagnóstico por imagen , Conducto Arterioso Permeable/cirugía , Adolescente , Procedimientos Quirúrgicos Cardíacos , Cateterismo , Conducto Arterioso Permeable/diagnóstico , Ecocardiografía , Ecocardiografía Transesofágica , Endocarditis/etiología , Endocarditis/terapia , Humanos , Complicaciones Posoperatorias/terapia , Arteria Pulmonar/diagnóstico por imagenRESUMEN
OBJECTIVES: Clinical trials of either pulmonary perfusion or ventilation during cardiopulmonary bypass (CBP) are equivocal. We hypothesized that to achieve significant improvement in outcomes both interventions had to be concurrent. DESIGN: Retrospective case-control study. SETTINGS: Major academic tertiary referral medical center. PARTICIPANTS: Two hundred seventy-four consecutive patients who underwent open heart surgery with CBP 2009-2013. INTERVENTIONS: The outcomes of 86 patients who received pulmonary perfusion and ventilation during CBP were retrospectively compared to the control group of 188 patients. MEASUREMENTS AND MAIN RESULTS: Respiratory complications rates were similar in both groups (33.7 vs. 33.5%), as were the rates of postoperative pneumonia (4.7 vs. 4.3%), pleural effusions (13.9 vs. 12.2%), and re-intubations (9.3 vs. 9.1%). Rates of adverse postoperative cardiac events including ventricular tachycardia (9.3 vs. 8.5%) and atrial fibrillation (33.7 vs. 28.2%) were equivalent in both groups. Incidence of sepsis (8.1 vs. 5.3%), postoperative stroke (2.3 vs. 2.1%), acute kidney injury (2.3 vs. 3.7%), and renal failure (5.8 vs. 3.7%) was likewise comparable. Despite similar transfusion requirements, coagulopathy (12.8 vs. 5.3%, p = 0.031) and the need for mediastinal re-exploration (17.4 vs. 9.6%, p = 0.0633) were observed more frequently in the pulmonary perfusion and ventilation group, but the difference did not reach the statistical significance. Intensive care unit (ICU) and hospital stays, and the ICU readmission rates (7.0 vs. 8.0%) were similar in both groups. CONCLUSION: Simultaneous pulmonary perfusion and ventilation during CBP were not associated with improved clinical outcomes.
Asunto(s)
Ecocardiografía Transesofágica/métodos , Transposición de los Grandes Vasos/cirugía , Obstrucción del Flujo Ventricular Externo/diagnóstico por imagen , Adulto , Desfibriladores Implantables , Electrodos , Cuerpos Extraños/cirugía , Humanos , Terapia por Láser , Masculino , Monitoreo Intraoperatorio , Derrame Pericárdico/diagnóstico por imagen , Transposición de los Grandes Vasos/diagnóstico por imagenAsunto(s)
Anomalía de Ebstein/diagnóstico por imagen , Ecocardiografía Transesofágica , Defectos del Tabique Interatrial/diagnóstico por imagen , Válvula Tricúspide/diagnóstico por imagen , Disfunción Ventricular Derecha/diagnóstico por imagen , Adulto , Anomalía de Ebstein/cirugía , Femenino , Defectos del Tabique Interatrial/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Pericardio/trasplante , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Válvula Tricúspide/anomalías , Válvula Tricúspide/cirugía , Disfunción Ventricular Derecha/cirugíaAsunto(s)
Ecocardiografía Transesofágica , Derrame Pericárdico/cirugía , Técnicas de Ventana Pericárdica , Transposición de los Grandes Vasos/diagnóstico por imagen , Adulto , Desfibriladores Implantables/efectos adversos , Válvulas Cardíacas/diagnóstico por imagen , Ventrículos Cardíacos/diagnóstico por imagen , Hemodinámica , Humanos , Marcapaso Artificial/efectos adversos , Derrame Pericárdico/diagnóstico por imagen , Derrame Pericárdico/etiología , Transposición de los Grandes Vasos/complicaciones , Transposición de los Grandes Vasos/fisiopatología , Resultado del TratamientoAsunto(s)
Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/diagnóstico , Ecocardiografía Transesofágica , Anciano , Circulación Coronaria/fisiología , Diagnóstico Diferencial , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Periodo Intraoperatorio , Masculino , Infarto del Miocardio/complicaciones , Infarto del Miocardio/diagnóstico por imagen , Revascularización Miocárdica , Músculos Papilares/diagnóstico por imagen , Pericarditis/diagnóstico por imagenRESUMEN
Fontan and Baudet described in 1971 the separation of the pulmonary and systemic circulations resulting in univentricular physiology. The evolution of the Fontan procedure, most notably the substitution of right atrial-to-pulmonary artery anastomosis with cavopulmonary connections, resulted in significantly improved late outcomes. Many patients survive well into adulthood and are able to lead productive lives. While ideally under medical care at specialized centers for adult congenital cardiac pathology, these patients may present to the outside hospitals for emergency surgery, electrophysiologic interventions, and pregnancy. This presentation presents a "train of thought," linking the TEE images to the perioperative physiologic considerations faced by an anesthesiologist caring for a patient with Fontan circulation in the perioperative settings. Relevant effects of mechanical ventilation on pulmonary vascular resistance, pulmonary blood flow and cardiac preload, presence of coagulopathy and thromboembolic potential, danger of abrupt changes of systemic vascular resistance and systemic venous return are discussed.
RESUMEN
A 4-mm patent ductus arteriosus (PDA) was serendipitously diagnosed during intraoperative transesophageal echocardiography for a noncardiac procedure in an obese adult patient with a history of decreased exercise tolerance and dyspnea, despite a negative preoperative transthoracic examination. This uncommon event poses questions regarding the relevance of this finding to the differential diagnosis of dyspnea in an obese adult with a negative transthoracic echocardiography study, given the unknown prevalence of this pathology and the absence of consensus regarding the clinical management.