WITHDRAWN: Dealing With the Right Side: Carcinoid Heart Disease.

The Publisher regrets that this article is an accidental duplication of an article that has already been published in Journal of Cardiothoracic and Vascular Anesthesia, 36 (2022) 2793-2802, http://dx.doi.org/10.1053/j.jvca.2021.10.030. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Spontaneous Coronary Artery Dissection: Rediscovering an Old Cause of Myocardial Infarction.

Spontaneous coronary artery dissection is an uncommon, but not insignificant cause of acute coronary syndrome that overwhelmingly affects middle-aged women. The pathophysiology of coronary dissection appears to be an outside-in mechanism, where the initiating event is not an intimal tear but rather the formation of an intramural hematoma, which compromises blood flow by reducing the arterial lumen. Considering this mechanism, it is clear to see how intracoronary imaging techniques, such as optical coherence tomography and intravascular ultrasound, are most accurate in the diagnosis. However, they carry a high rate of complications and are therefore generally avoided when the clinical scenario and angiographic appearance both support the diagnosis of spontaneous coronary artery dissection. The natural history of the disease is toward healing of the vessel wall and restoration of blood flow. Therefore, conservative medical management is the preferred approach unless there are high-risk factors such as hemodynamic instability, signs of ischemia and severe proximal or multivessel lesions, in which percutaneous or surgical revascularization should be considered. Perioperative evaluation of these patients must take into account several aspects of this disease. Most of these patients will be receiving single or dual antiplatelet therapy, so one must consider the timing of the event and the surgical hemorrhagic risk when deciding to stop these therapies. Extracoronary vascular disease also must be assessed because it can have an effect on patient monitoring and risk of postoperative complications.

The Effects of Escalation of Respiratory Support and Prolonged Invasive Ventilation on Outcomes of Cardiac Surgical Patients: A Retrospective Cohort Study.

OBJECTIVES: The aim of this study was to determine the effects of escalation of respiratory support and prolonged postoperative invasive ventilation on patient-centered outcomes, and identify perioperative factors associated with these 2 respiratory complications. DESIGN: A retrospective cohort analysis of cardiac surgical patients admitted to the cardiothoracic intensive care unit (ICU) between August 2015 and January 2018. Escalation of respiratory support was defined as "unplanned continuous positive airway pressure," "non-invasive ventilation," or "reintubation" after surgery; prolonged invasive ventilation was defined as "invasive ventilation beyond the first 12 hours following surgery." The primary endpoint was the composite of escalation of respiratory support and prolonged ventilation. SETTING: Tertiary cardiothoracic ICU. PARTICIPANTS: A total of 2,098 patients were included and analyzed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The composite of escalation of support or prolonged ventilation occurred in 509 patients (24.3%). Patients who met the composite had higher mortality (2.9% v 0.1%; p < 0.001) and longer median [interquartile range] length of ICU (2.1 [1.0-4.9] v 0.9 [0.8-1.0] days; p < 0.0001) and hospital (10.6 [8.0-16.0] v 7.2 [6.2-10.0] days; p < 0.0001) stay. Hypoxemia and anemia on admission to ICU were the only 2 factors independently associated with the need for escalation of respiratory support or prolonged invasive ventilation. CONCLUSIONS: Escalation of respiratory support or prolonged invasive ventilation is frequently seen in cardiac surgery patients and is highly associated with increased mortality and morbidity. Hypoxemia and anemia on admission to the ICU are potentially modifiable factors associated with escalation of respiratory support or prolonged invasive ventilation.

Acute Pain and Analgesic Requirements After Pulmonary Endarterectomy With Deep Hypothermic Circulatory Arrest.

OBJECTIVES: To assess postoperative pain intensity and the analgesic requirements in the postoperative period in patients undergoing sternotomy for pulmonary endarterectomy involving deep hypothermic circulatory arrest. DESIGN: Retrospective cohort study. SETTING: Single-center hospital study. PARTICIPANTS: Patients 18 years and older undergoing sternotomy for cardiac surgery between August 2012 and August 2014. INTERVENTIONS: No modification to usual clinical practice. MEASUREMENTS AND MAIN RESULTS: Intraoperative opioid and steroid administration, referral to the chronic pain unit, intensive care unit pain scores, and analgesic administration in the first 48 hours after the admission to the intensive care unit were recorded. Postoperative pain was evaluated by means of a categoric verbal scale from no pain (0) to severe pain (3); this is the routine analgesic scale used in the authors' intensive care unit. A total of 200 consecutive patients undergoing pulmonary endarterectomy (PEA group) were included in the study. No patient in the PEA group received morphine during surgery. The mean (standard deviation) postoperative pain intensity score at 24 hours was 0.30 (0.54) in the PEA group. Postoperative morphine was administered in 39% of patients. No PEA patient was referred to the chronic pain unit after hospital discharge. CONCLUSION: The total analgesic requirements and pain score of patients undergoing sternotomy for pulmonary endarterectomy with deep hypothermic circulatory arrest seemed to be low.

Sedation-analgesia with propofol and remifentanil: concentrations required to avoid gag reflex in upper gastrointestinal endoscopy.

BACKGROUND: The purpose of this study was to identify optimal target propofol and remifentanil concentrations to avoid a gag reflex in response to insertion of an upper gastrointestinal endoscope. METHODS: Patients presenting for endoscopy received target-controlled infusions (TCI) of both propofol and remifentanil for sedation-analgesia. Patients were randomized to 4 groups of fixed target effect-site concentrations: remifentanil 1 ng•mL (REMI 1) or 2 ng•mL (REMI 2) and propofol 2 µg•mL (PROP 2) or 3 µg•mL (PROP 3). For each group, the other drug (propofol for the REMI groups and vice versa) was increased or decreased using the "up-down" method based on the presence or absence of a gag response in the previous patient. A modified isotonic regression method was used to estimate the median effective Ce,50 from the up-down method in each group. A concentration-effect (sigmoid Emax) model was built to estimate the corresponding Ce,90 for each group. These data were used to estimate propofol bolus doses and remifentanil infusion rates that would achieve effect-site concentrations between Ce,50 and Ce,90 when a TCI system is not available for use. RESULTS: One hundred twenty-four patients were analyzed. To achieve between a 50% and 90% probability of no gag response, propofol TCIs were between 2.40 and 4.23 µg•mL (that could be achieved with a bolus of 1 mg•kg) when remifentanil TCI was fixed at 1 ng•mL, and target propofol TCIs were between 2.15 and 2.88 µg•mL (that could be achieved with a bolus of 0.75 mg•kg) when remifentanil TCI was fixed at 2 ng•mL. Remifentanil ranges were 1.00 to 4.79 ng•mL and 0.72 to 3.19 ng•mL when propofol was fixed at 2 and 3 µg•mL, respectively. CONCLUSIONS: We identified a set of propofol and remifentanil TCIs that blocked the gag response to endoscope insertion in patients undergoing endoscopy. Propofol bolus doses and remifentanil infusion rates designed to achieve similar effect-site concentrations can be used to prevent gag response when TCI is not available.

Assessment of the feasibility of high-concentration capsaicin patches in the pain unit of a tertiary hospital for a population of mixed refractory peripheral neuropathic pain syndromes in non-diabetic patients.

BACKGROUND: High-concentration-capsaicin-patches (Qutenza®) have been put on the market as a treatment for peripheral neuropathic pain. A minimum infrastructure and a determinate skill set for its application are required. Our aim was to assess the feasibility of treatment with high-concentration-capsaicin-patches in clinical practice in a variety of refractory peripheral neuropathic pain syndromes in non-diabetic patients. METHODS: Observational, prospective, single-center study of patients attended to in the Pain Unit of a tertiary hospital, ≥ 18 year-old non-responders to multimodal analgesia of both genders. The feasibility for the application of capsaicin patch in clinical practice was evaluated by means of the number of patients controlled per day when this one was applied and by means of the times used for patch application. RESULTS: Between October 2010 and September 2011, 20 consecutive non-diabetic patients (7 males, 13 females) with different diagnoses of refractory peripheral neuropathic pain syndromes, with a median (range) age of 60 (33-88) years-old were treated with a single patch application. The median (range) number of patients monitored per day was not modified when the capsaicin patch was applied [27 (26-29)] in comparison with it was not applied [28 (26-30)]. The median (range) total time to determine and mark the painful area was 9 (6-15) minutes and of patch application was 60 (58-65) minutes. No important adverse reactions were observed. CONCLUSION: High-concentration-capsaicin-patch treatment was feasible in our unit for the treatment of a population with refractory peripheral neuropathic pain. The routine of our unit was not affected by its use.

Neuropathic pain with features of complex regional syndrome in the upper extremity after herpes zoster.

We report a case of a 73-year-old female who developed unbearable neuropathic pain after a herpes zoster episode. The pain persisted and could not be controlled despite multimodal analgesia. In addition to postherpetic neuralgia, myelitis and complex regional pain syndrome were diagnosed during the evolution of neuropathic pain. This complex neuropathic pain was resolved after sympathetic ganglion block.

The intracellular fluid compartment is smaller than commonly believed when measured by whole-body bioimpedance.

OBJECTIVES: To report our data on the total body water (TBW), intracellular volume (ICV), extracellular volume (ECV), and fat-free mass (FFM) from studies using whole-body bioimpedance (BIA) with the aim of contrasting them to commonly cited reference values. METHODS: Data were retrospectively retrieved from three single-center studies of adult healthy male volunteers and one study of women scheduled for abdominal hysterectomy where multifrequency BIA had been applied to obtain measurements of TBW, ICV, ECV, and FFM. RESULTS: Based on measurements performed in 44 males, the TBW, ICV, ECV, and FFM represented 49.1 (4.9)%, 23.32 (3.1)%, 25.8 (2.2)%, and 67.4 (7.4)% of the BW, respectively (mean, SD). In 15 females, these volumes were 40.4 (4.5)%, 18.0 (2.1)%, 22.4 (2.6)%, and 55.6 (6.1)% per kg BW, respectively. The deviation of these measurements from the reference values increased linearly with body weight and age. CONCLUSIONS: Body fluid volumes indicated by BIA showed that TBW amounted to 80% of the reference volume, which is 60% per kg BW in adult males. The ratio between the ICV and the ECV was approximately 1:1, while this ratio is traditionally reported to be 2:1.

Comparison between two solute equations and bioimpedance for estimation of body fluid volumes.

BACKGROUND: The extracellular volume (ECV) and intracellular volume (ICV) estimated by bioimpedance analysis (BIA) deviates markedly from the textbook volumes of 20% and 40% of the body weight (BW). We estimated the transcellular exchange of water by calculating solute equilibriums after fluid challenges to examine whether the BIA or the textbook volumes are likely to be most correct. METHODS: Data was retrieved from 8 healthy male volunteers who received 25 mL/kg of Ringer's solution or 3-5 mL/kg of hypertonic (7.5%) saline over 30 min after the ECV and ICV had been estimated by BIA. The exchange of water between the ECV and the ICV was calculated according to a sodium equation and an osmolality equation. Simulations were performed, where deviating body fluid volumes were applied. RESULTS: The mean ECV measured with BIA was 24.9% of BW (p < 0.05 versus the "textbook" volume). Mean ICV measured with BIA was 22.3% of BW (p < 0.05). The sodium and osmolality equations correlated closely with respect to the translocation of water across the cell membrane (r2 = 0.86). By applying the "textbook" ECV, the sodium equation indicated that Ringer's solution exchanged negligible amounts of water, while hypertonic saline withdrew 1.4 L from the ICV to the ECV. By contrast, applying the BIA-derived ECV to the sodium equation implied that 3 L of water would be translocated from the ECV to the ICV once hypertonic saline was administered. CONCLUSION: The "textbook" ECV and ICV volumes but not the BIA-derived volumes were consistent with the fluid shifts obtained by two solute equations.

Impact of surgical technique and analgesia on clinical outcomes after lung transplantation: A STROBE-compliant cohort study.

There is paucity of data on the impact of surgical incision and analgesia on relevant outcomes.A retrospective STROBE-compliant cohort study was performed between July 2007 and August 2017 of patients undergoing lung transplantation. Gender, age, indication for lung transplantation, and the 3 types of surgical access (Thoracotomy (T), Sternotomy (S), and Clamshell (C)) were used, as well as 2 analgesic techniques: epidural and intravenous opioids. Outcome variables were: pain scores; postoperative hemorrhage in the first 24 hours, duration of mechanical ventilation, and length of stay at intensive care unit (ICU).Three hundred forty-one patients were identified. Thoracotomy was associated with higher pain scores than Sternotomy (OR 1.66, 95% CI: 1.01; 2.74, P: .045) and no differences were found between Clamshell and Sternotomy incision. The median blood loss was 800 mL [interquartile range (IQR): 500; 1238], thoracotomy patients had 500 mL [325; 818] (P < .001). Median durations of mechanical ventilation in Thoracotomy, Sternotomy, and Clamshell groups were 19 [11; 37] hours, 34 [IQR 16; 57.5] hours, and 27 [IQR 15; 50.5] hours respectively. Thoracotomy group were discharged earlier from ICU (P < .001).Thoracotomy access produces less postoperative hemorrhage, duration of mechanical ventilation, and lower length of stay in ICU, but higher pain scores and need for epidural analgesia.

Design and implementation of an enhanced recovery program in thoracic surgery.

Despite significant improvements in perioperative care, major surgery is still associated with major complications. Enhanced recovery after surgery was introduced by the National Health Service in the UK with the aim of improving patient outcomes and reducing length of stay in hospital. The degree of applicability differs between surgical specialties, and in thoracic surgery it has not been developed until recently. We have therefore reviewed recent literature specific to thoracic surgery, and will discuss key elements of the design, implementation and monitoring of an enhanced recovery (ER) program based on our recent experience. The program is divided into several high impact intervention measures that involve the preoperative, intraoperative and postoperative periods. Physical activity promotion and educational programs that provide information about the surgery and the surgical pathway are an essential part of the preoperative strategies. During surgery, an optimal pain control strategy, antibiotic prophylaxis and protective ventilation are important. Minimally invasive surgery and well-planned postoperative care including early drain removal and planned discharge are also important. Overall, we have shown that ER in thoracic surgery can facilitate early discharge from hospital and possibly reduce postoperative complications. Further studies are required to understand the extent of ER benefits when applied to thoracic surgery, and to test individual components in a prospective manner.