Intraoperative Diagnosis of Bronchovenous Fistula During Lung Transplantation Using Transesophageal Echocardiography.

Bronchovenous fistula (BVF) is a rare complication and can cause arterial gas embolism in vital organs, including the heart and the brain, resulting in a high mortality rate. A 51-year-old man developed a BVF during pneumonectomy for lung transplantation, which quickly was diagnosed by transesophageal echocardiography (TEE). He required highairway-pressure ventilation due to his severely restrictive ventilatory impairment and had severe left pleural adhesion due to a history of pleurodesis. Intraoperatively, he had a coronary air embolism and required temporary treatment with central venoarterial extracorporeal membrane oxygenation (VA-ECMO), but showed no postoperative cardiac or neurologic complications. BVF may be formed during lung transplantation because lung transplantation recipients often receive high-airway-pressure ventilation and are vulnerable to bronchi and pulmonary vessel injuries during surgery. Intraoperative TEE can contribute to the early detection of air bubbles in the left heart circulation and is helpful for the prevention of arterial gas embolism.

The impact of relative hypotension on acute kidney injury progression after cardiac surgery: a multicenter retrospective cohort study.

BACKGROUND: Cardiac surgery is performed worldwide, and acute kidney injury (AKI) following cardiac surgery is a risk factor for mortality. However, the optimal blood pressure target to prevent AKI after cardiac surgery remains unclear. We aimed to investigate whether relative hypotension and other hemodynamic parameters after cardiac surgery are associated with subsequent AKI progression. METHODS: We retrospectively enrolled adult patients admitted to 14 intensive care units after elective cardiac surgery between January and December 2018. We defined mean perfusion pressure (MPP) as the difference between mean arterial pressure (MAP) and central venous pressure (CVP). The main exposure variables were time-weighted-average MPP-deficit (i.e., the percentage difference between preoperative and postoperative MPP) and time spent with MPP-deficit > 20% within the first 24 h. We defined other pressure-related hemodynamic parameters during the initial 24 h as exploratory exposure variables. The primary outcome was AKI progression, defined as one or more AKI stages using Kidney Disease: Improving Global Outcomes' creatinine and urine output criteria between 24 and 72 h. We used multivariable logistic regression analyses to assess the association between the exposure variables and AKI progression. RESULTS: Among the 746 patients enrolled, the median time-weighted-average MPP-deficit was 20% [interquartile range (IQR): 10-27%], and the median duration with MPP-deficit > 20% was 12 h (IQR: 3-20 h). One-hundred-and-twenty patients (16.1%) experienced AKI progression. In the multivariable analyses, time-weighted-average MPP-deficit or time spent with MPP-deficit > 20% was not associated with AKI progression [odds ratio (OR): 1.01, 95% confidence interval (95% CI): 0.99-1.03]. Likewise, time spent with MPP-deficit > 20% was not associated with AKI progression (OR: 1.01, 95% CI 0.99-1.04). Among exploratory exposure variables, time-weighted-average CVP, time-weighted-average MPP, and time spent with MPP < 60 mmHg were associated with AKI progression (OR: 1.12, 95% CI 1.05-1.20; OR: 0.97, 95% CI 0.94-0.99; OR: 1.03, 95% CI 1.00-1.06, respectively). CONCLUSIONS: Although higher CVP and lower MPP were associated with AKI progression, relative hypotension was not associated with AKI progression in patients after cardiac surgery. However, these findings were based on exploratory investigation, and further studies for validating them are required. Trial Registration UMIN-CTR, https://www.umin.ac.jp/ctr/index-j.htm , UMIN000037074.

Successful recovery without any neurological complication after intraoperative cardiopulmonary resuscitation for an extended period of time in the lateral position: a case report.

No successful resuscitation has ever been reported about intraoperative cardiopulmonary resuscitation (CPR) for an extended period of time in the lateral position. Here we report a case of successful resuscitation without any neurological complication after cardiac arrest due to massive hemorrhage and 25 min of CPR in the lateral position. The patient was a 65-year-old man. During open hemostasis for the postoperative hemorrhage, the patient's rhythm changed sinus to ventricular fibrillation (VF), followed by asystole. We started CPR immediately with the patient in the left lateral position. Chest compression was performed by two practitioners, one pressing patient's sternum and the other pressing simultaneously patient's mid-thoracic spine from his back. During CPR, though the value of end-tidal CO2 (EtCO2) was significantly low (around 5-20 mmHg), the value of systolic arterial pressure was kept about 35-50 mmHg, and diastolic pressure about 20-30 mmHg. After the 25 min of lateral CPR, he achieved the return of spontaneous circulation (ROSC). He was hemodynamically stable after ROSC. He regained his consciousness at the next postoperative day. He was discharged from our hospital on the 60th day of operation without any cardiac and neurological complication. Successful neurological outcome suggests that we may expect satisfactory neurological outcome even in the case of lateral position and prolonged CPR if we perform effective CPR with the feedback of arterial blood pressure and EtCO2 and with the immediate intervention to culprit injuries.