Continuous Glucose Monitoring System After Coronary Artery Bypass Graft Surgery: A Feasibility Study.

BACKGROUND: Blood glucose level variability has been associated with increased risk of complication in the postoperative setting of cardiovascular surgery. Although interesting for optimization of blood glucose management in this context, continuous blood glucose (CBG) devices can have a limited reliability in this context, in particular because of the use of paracetamol. The aim of this study was to evaluate the reliability of Dexcom G6®, a recently developed continuous glucose monitoring device. METHODS: We performed a prospective, observational, non-randomized, single-centre study comparing Dexcom G6® CBG level monitoring with the standard methods routinely used in this context. The standard blood glucose values were paired to the time corresponding values measured with Dexcom G6®. Agreement between the two methods and potential correlation in case of paracetamol use were calculated. RESULTS: From May 2020 to August 2021, 36 out of 206 patients operated for isolated coronary artery bypass grafting were enrolled; 673 paired blood glucose level were analyzed. Global agreement (ρc) was 0.85 (95% C.I.: 0.84-0.86), intensive care unit agreement was 0.78 (95%C.I.: 0.74-0.82) and ward agreement was 0.91 (95%C.I.: 0.89-0.93). In the diabetic population, it was 0.87 (95%C.I.: 0.85-0.90). When paracetamol was used, the difference was 0.02 mmol/l (95%C.I.: 0.29-0.33). CONCLUSIONS: Dexcom G6® provides good blood glucose level accuracy in the postoperative context of cardiac surgery compared to the standard methods of measurements. The results are particularly reliable in the ward where the need for repeated capillary glucose measurements implies patient discomfort and time-consuming manipulations for the nursing staff.

Burkholderia cepacia complex outbreak originating from contaminated wash gloves.

Burkholderia cepacia complex isolates were detected from four patients who were admitted to the heart centre of southern Switzerland, between April and June 2019. An outbreak investigation was conducted. The three available patient samples were whole genome sequenced, showing that they all are Burkholderia cepacia species, and that two are identical. Isolates grown from sealed packages of disinfectant-free wash gloves used for personal hygiene were also genomically identical. The wash gloves appear to be the origin of the outbreak, contamination of which most likely occurred at the manufacturing site.

Clinical utility of routine use of continuous transesophageal echocardiography monitoring during transvenous lead extraction procedure.

BACKGROUND: Data on the use of transesophageal echocardiography (TEE) during transvenous lead extraction (TLE) procedures are scarce. OBJECTIVE: The purpose of this study was to assess the routine use of TEE during transvenous lead extraction. METHODS: From January 2009 to January 2014, TLE of 241 leads in 168 patients (mean age 70 ± 13 years, 129 male, left ventricular ejection fraction 37% ± 13%) was performed. Indication for TLE was lead dysfunction (56.5%), upgrade (27.0%), infection (13%), or other (3.1%). TLE techniques combined a mechanical approach amended by laser technique if required. Extraction procedures were performed with patients under general anesthesia with continuous invasive arterial blood pressure and TEE monitoring. RESULTS: TEE was possible in all except 1 patient. TEE images in different projections were acquired and stored before and immediately after extraction of each lead. TLE was complete for 236 of 241 leads (97.9%); 4 distal lead tips (1.7%) remained in situ, and 1 dual-coil implantable cardioverter-defibrillator electrode (0.4%) could not be removed. New TEE findings after TLE were observed in 7 of 161 cases (4.3%): pericardial effusion (mild in 4 [2.5%] and severe in 1 [0.6%]) and worsening of tricuspid valve insufficiency (2 patients [1.2%]). The only case of severe pericardial effusion occurred after laceration of the superior vena cava, which required immediate rescue surgery (0.6%, confidence interval 0.01-3.3). In all other cases, TEE findings did not entail immediate diagnostic or therapeutic measures. CONCLUSION: New TEE findings produced during TLE necessitating immediate therapeutic measures occurred in only 0.6% of cases, suggesting the limited utility of routine continuous TEE monitoring during TLE.

Changes in core temperature during peritoneal insufflation: comparison of two CO2 humidification devices in pigs.

BACKGROUND: Various modifications of the physical status of CO2 have been used to reduce hypothermia caused by flow of insufflating gas. This animal study aimed to investigate the effects on core temperature, of insufflation with CO2 using two different humidification devices: unheated, humidified CO2 using the Modified-Aeroneb system (Nektar, San Carlos, CA) and warmed, humidified CO2 using the HME-Booster (Medisize, Hillegom, The Netherlands). METHODS: We undertook a prospective four-session study on a homogeneous group of four pigs. After general anesthesia, all animals were treated successively with the following protocols in a randomized order at 8-d intervals: Control (no pneumoperitoneum), Standard (unheated, unhumidified CO2), Modified-Aeroneb (unheated, humidified CO2 by cold nebulization), HME-Booster (heated, humidified CO2). The core temperature of the animals was recorded every 10 min. RESULTS: The temperature decrease is significantly influenced by time (P=0.0001; ANOVA), by the insufflation method (P=0.01), and by the interaction between time and the insufflation method (P=0.0001). The method of contrasts showed the following results:--The temperature decrease in the Standard group and HME-Booster group became greater than in the Control group after 40 min (P=0.02)--The temperature decrease in the Modified-Aeroneb group became greater than in the Control group after 100 min (P=0.04)--The temperature decrease in the Modified-Aeroneb group was less than in the HME-Booster group after 40 min (P=0.04) and less than in the Standard group after 60 min (P=0.01)--The temperature decrease in the Standard group was greater than in the HME-Booster group after 160 min (P=0.005). CONCLUSIONS: Compared with the HME-Booster system, the Modified-Aeroneb is at least as effective in limiting the drop in core temperature during laparoscopic insufflation.

The pharmacokinetics of ropivacaine after intraperitoneal administration: instillation versus nebulization.

BACKGROUND: Intraperitoneal local anesthetic administration provides perioperative analgesia during laparoscopic procedures. We compared the pharmacokinetics of intraperitoneal ropivacaine administered by instillation or nebulization. METHODS: A crossover study was performed on 5 pigs under standardized general anesthesia with a carbon dioxide pneumoperitoneum of 12 mm Hg for 1 hour. Each animal, acting as its own control, was studied twice with an 8-day interval and received, in a randomized sequence, 3 mg/kg ropivacaine either by intraperitoneal instillation at the time of pneumoperitoneum exsufflation or by continuous nebulization in the carbon dioxide insufflation tubing. Arterial blood samples were taken every 10 minutes up to 120 minutes, and then hourly up to 6 hours. Ropivacaine concentrations were measured using high-performance liquid chromatography with ultraviolet-visible detection. The plasma-free fraction was evaluated after plasma ultracentrifugation. Pharmacokinetic parameters were calculated using both noncompartmental and compartmental analysis. The mean values were compared using the Student t test, or Wilcoxon test for paired series. RESULTS: The data were described by a 1-compartment model for both ropivacaine administration techniques, with a delay of 10 minutes for the nebulization group. The maximal ropivacaine concentrations were 0.96 µg/mL for the nebulization group and 0.92 µg/mL for the instillation group (P = 0.66). The ropivacaine absorption constant was lower in the nebulization group (0.043 vs 0.083 min(-1), P = 0.02). There were no differences in the elimination half-life, elimination constant, mean total body clearance, distribution volume, mean area under the curve, and mean residence time. The free fraction of ropivacaine was also similar in the 2 groups. CONCLUSIONS: The pharmacokinetic profile of ropivacaine nebulization is similar to direct intraperitoneal instillation, but with a lower absorption rate.

An evaluation of gas humidifying devices as a means of intraperitoneal local anesthetic administration for laparoscopic surgery.

BACKGROUND: Intraperitoneal local anesthetic administration has been reported to provide perioperative analgesia during laparoscopic procedures. The aim of this in vitro study was to assess the efficiency of commercially available humidification devices to deliver ropivacaine and to determine the effects of modifying the device's position between the insufflator and the Veress needle on the amount of ropivacaine delivered. METHODS: In the first experiment, four humidification devices filled with ropivacaine (0.20% and 0.75%) were placed at the outlet of a laparoscopic insufflation system delivering a constant carbon dioxide flow. A catheter was connected to the humidifier's outlet and the other end submerged in a calibrated vial containing 25 mL of 50% methanol in water. The concentration of ropivacaine collected in the methanol-water solution was measured using high performance liquid chromatography. In the second experiment, the clinical situation was imitated by placing 3 m of silicone tubing between the humidifier and the collection vial to evaluate its influence on the amount of ropivacaine delivered. Only one humidifier was tested in the second experiment because the other three tested humidification devices did not efficiently deliver ropivacaine. RESULTS: The evaporation-based humidifiers delivered very small or nonmeasurable quantities of ropivacaine. In contrast, the microvibration-based aerosol humidification device delivered significant amounts (89.1%-94.3%) of the drug. The insertion of silicone tubing between the humidifier and the collecting vial reduced the amount of delivered ropivacaine to 62.3%. CONCLUSIONS: The microvibration-based aerosol humidification device may be used to deliver local anesthetics during laparoscopic procedures. Further research is necessary to confirm these results in clinical practice and to provide effective humidification that does not blur the surgeon's view.

Cold nebulization used to prevent heat loss during laparoscopic surgery: an experimental study in pigs.

BACKGROUND: Prolonged abdominal laparoscopy is responsible for a significant drop in core body temperature. Various modifications of the conditioning for the insufflating carbon dioxide (CO(2)) to prevent the specific hypothermia related to the insufflated gas have been tested. This study aimed to investigate the effects on core temperature of insufflation with unheated humidified CO(2) using the Aeroneb system compared with the use of standard gas and gas made hot and wet using a warming and humidifying system (Pall system). METHODS: A prospective four-session study was conducted to investigate a homogeneous group of four pigs. After inducation of general anesthesia, all the animals were treated successively with the following protocols in a randomized order at 8-day intervals: control (no pneumoperitoneum), standard (unheated, unhumidified CO(2)), Aeroneb (unheated, humidified CO(2) by cold nebulization), and Pall (heated, humidified CO(2)). The core temperature of the animals was recorded every 10 min. RESULTS: Analysis of variance (ANOVA) confirmed a difference between the insufflation conditions in the evolution of temperature over time (p = 0.004). The method of contrast showed the following results. After 30 min, the core temperature of the Aeroneb group fell significantly less than that of the standard group (p = 0.036). After 100 min, the core temperature of the Pall group fell significantly less than that of the standard group (p = 0.024). After 80 min, the core temperature of the standard group fell significantly more than that of the control group (p = 0.035). In the Aeroneb group, the core temperature dropped less than in the Pall and control groups, but the difference did not reach statistical significance. CONCLUSIONS: Cold humidification of insufflating CO(2) prevents heat loss associated with pneumoperitoneal insufflation at least as efficaciously as warmed humidification of the gas.