Survey on the Updated German S3 Guideline for Intensive Care in Cardiac Surgery Patients.

BACKGROUND: The German guideline on intensive care treatment of cardiac surgical patients provides evidence-based recommendations on management and monitoring. It remains unclear if, respectively, to which degree the guidelines are implemented into the daily practice. Therefore, this study aims to characterize the implementation of guideline recommendations in German cardiac surgical intensive care units (ICUs). METHODS: An internet-based online survey (42 questions, 9 topics) was sent to 158 German head physicians of cardiac surgical ICUs. To compare the effect over time, most questions were based on a previously performed survey (2013) after introduction of the last guideline update in 2008. RESULTS: A total of n = 65 (41.1%) questionnaires were included. Monitoring changed to increased provision of available transesophageal echocardiography specialists in 86% (2013: 72.6%), SvO2 measurement in 93.8% (2013: 55.1%), and electroencephalography in 58.5% (2013: 2.6%). The use of hydroxyethyl starch declined (9.4% vs. 2013: 38.7%), gelatin 4% presented the most administered colloid with 23.4% (2013: 17.4%). Low cardiac output syndrome was primarily treated with levosimendan (30.8%) and epinephrine (23.1%), while norepinephrine (44.6%) and dobutamine (16.9%) represented the most favored drug combination. The main way of distribution was web-based (50.9%), with increasing impact on therapy regimens (36.9% vs. 2013: 24%). CONCLUSION: Changes were found in all questioned sectors compared with the preceding survey, with persisting variability between ICUs. Recommendations of the updated guideline have increasingly entered clinical practice, with participants valuing the updated publication as clinically relevant.

Potentials of Acetylcholinesterase and Butyrylcholinesterase Alterations in On-Pump Coronary Artery Bypass Surgery in Postoperative Delirium: An Observational Trial.

Cardiac surgery is regularly associated with postoperative delirium (POD), affected by neuro-inflammation and changes in cholinergic activity. Therefore, this prospective observational study aimed to evaluate whether pre- and perioperative changes in blood acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) activity were associated with POD development in patients undergoing isolated elective coronary artery bypass graft (CABG) surgery. It included 93 patients. Pre- and postoperative blood AChE and BChE activities were measured with photometric rapid-point-of-care-testing. The Intensive Care Delirium Screening Checklist and the Confusion Assessment Method for the Intensive Care Unit were used to screen patients for POD. POD developed in 20 patients (21.5%), who were older (p = 0.003), had higher EuroSCOREs (p ≤ 0.001), and had longer intensive care unit stays (p < 0.001). On postoperative day one, BChE activity decreased from preoperative values more in patients with (31.9%) than without (23.7%) POD (group difference p = 0.002). Applying a cutoff of ≥32.0% for BChE activity changes, receiver operating characteristic analysis demonstrated a moderate prediction capability for POD (area under the curve = 0.72, p = 0.002). The risk of developing POD was 4.31 times higher with a BChE activity change of ≥32.0% (p = 0.010). Monitoring the pre- to postoperative reduction in BChE activity might be a clinically practicable biomarker for detecting patients at risk of developing POD after CABG surgery.

Minimized Extracorporeal Circulation Is Associated with Reduced Plasma Levels of Free-Circulating Mitochondrial DNA Compared to Conventional Cardiopulmonary Bypass: A Secondary Analysis of an Exploratory, Prospective, Interventional Study.

The use of minimized extracorporeal circulation (MiECC) during cardiac surgery is associated with a reduced inflammatory reaction compared to conventional cardiopulmonary bypass (cCPB). Since it is unknown if MiECC also reduces the amount of free-circulating mitochondrial DNA (mtDNA), this study aims to compare MiECC-induced mtDNA release to that of cCPB as well as to identify potential relations between the plasma levels of mtDNA and an adverse outcome. Overall, 45 patients undergoing cardiac surgery with either cCPB or MiECC were included in the study. MtDNA encoding for NADH dehydrogenase 1 was quantified with quantitative polymerase chain reaction. The plasma amount of mtDNA was significantly lower in patients undergoing cardiac surgery with MiECC compared to cCPB (MiECC: 161.8 (65.5−501.9); cCPB 190.8 (82−705.7); p < 0.001). Plasma levels of mtDNA showed comparable kinetics independently of the study group and peaked during CPB (MiECC preoperative: 68.2 (26.5−104.9); MiECC 60 min after start of CPB: 536.5 (215.7−919.6); cCPB preoperative: 152.5 (80.9−207.6); cCPB 60 min after start of CPB: 1818.0 (844.2−3932.2); all p < 0.001). Patients offering an mtDNA blood concentration of >650 copies/µL after the commencement of CPB had a 5-fold higher risk for postoperative atrial fibrillation independently of the type of cardiopulmonary bypass. An amount of mtDNA being higher than 650 copies/µL showed moderate predictive power (AUROC 0.71 (0.53−071)) for the identification of postoperative atrial fibrillation. In conclusion, plasma levels of mtDNA were lower in patients undergoing cardiac surgery with MiECC compared to cCPB. The amount of mtDNA at the beginning of the CPB was associated with postoperative atrial fibrillation independent of the type of cardiopulmonary bypass.

Pulse Wave Analysis Using the Pressure Recording Analytical Method to Measure Cardiac Output in Pediatric Cardiac Surgery Patients: A Method Comparison Study Using Transesophageal Doppler Echocardiography as Reference Method.

BACKGROUND: Cardiac output (CO) is a key determinant of oxygen delivery, but choosing the optimal method to obtain CO in pediatric patients remains challenging. The pressure recording analytical method (PRAM), implemented in the MostCareUp system (Vygon), is an invasive uncalibrated pulse wave analysis (PWA) method to measure CO. The objective of this study is to compare CO measured by PRAM (PRAM-CO; test method) with CO simultaneously measured by transesophageal Doppler echocardiography (TEE-CO; reference method) in pediatric patients. METHODS: In this prospective observational method comparison study, PRAM-CO and TEE-CO were assessed in pediatric elective cardiac surgery patients at 2 time points: after anesthesia induction and after surgery. The study was performed in a German university medical center from March 2019 to March 2020. We included pediatric patients scheduled for elective cardiac surgery with arterial catheter and TEE monitoring. PRAM-CO and TEE-CO were compared using Bland-Altman analysis accounting for repeated measurements per subject, and the percentage error (PE). RESULTS: We included 52 PRAM-CO and TEE-CO measurement pairs of 30 patients in the final analysis. Mean ± SD TEE-CO was 2.15 ± 1.31 L/min (range 0.55-6.07 L/min), and mean PRAM-CO was 2.21 ± 1.38 L/min (range 0.55-5.90 L/min). The mean of the differences between TEE-CO and PRAM-CO was -0.06 ±0.38 L/min with 95% limits of agreement (LOA) of 0.69 (95% confidence interval [CI], 0.53-0.82 L/min) to -0.80 L/min (95% CI, -1.00 to -0.57 L/min). The resulting PE was 34% (95% CI, 27%-41%). CONCLUSIONS: With a PE of <45%, PRAM-CO shows clinically acceptable agreement with TEE-CO in hemodynamically stable pediatric patients before and after cardiac surgery.

Interrelations of Intraoperative Changes in Cerebral Tissue Oxygen Saturation with Brain Volumes and Neurodevelopment Outcome After the Comprehensive Stage II Procedure in Infants With Hypoplastic Left Heart Syndrome: A Retrospective Cohort Study.

OBJECTIVES: The monitoring of cerebral tissue oxygen saturation by near-infrared spectroscopy (ScerebO2) is used widely in pediatric cardiac anesthesia. However, little information is available on the effects of changes in perioperative ScerebO2 on brain morphology and neurologic outcome. The primary hypothesis tested in this study was that intraoperative ScerebO2 during the comprehensive stage II procedure correlated with brain volumes assessed by magnetic resonance imaging and neurodevelopmental scores. DESIGN: Retrospective observational cohort study. SETTING: University Hospital, Pediatric Heart Centre. PATIENTS AND MEASUREMENTS: In 19 infants, the intraoperative course of ScerebO2 during the comprehensive stage II procedure was examined. Minimal ScerebO2 and integrated ScerebO2 below 45% (AUC) during surgery, as well as cerebral magnetic resonance imaging (MRI) examinations and Bayley III test at the ages of two-to-three years, were analyzed. MAIN RESULTS: A positive correlation between minimal ScerebO2 and intracranial volume (p = 0.0243), total brain volume (p = 0.0243), and white matter volume (p = 0.0276) was observed, as was a negative correlation between AUC and intracranial volume (p = 0.0454) and white matter volume (p = 0.0381), respectively. No association was found between ScerebO2 and Bayley-III Score. CONCLUSION: The correlation between ScerebO2 and brain volumes measured by MRI pointed out a possible importance of neuroprotective strategies aimed at optimizing ScerebO2 during complex congenital heart surgery. That no correlation between ScerebO2 and Bayley III Score was found suggested multifactorial causes for neurologic outcome in children with congenital heart defects.

Anesthesia for bilateral pulmonary banding as part of hybrid stage I approach palliating neonates with hypoplastic left heart syndrome.

BACKGROUND: Neonatal management of patients with hypoplastic left heart syndrome and complex remains a challenging task, whereby the "hybrid" palliation is often reserved for high-risk patients as a "rescue" procedure. AIM: This study documents the anesthetic challenges and potential complications associated with the Giessen hybrid stage I approach. METHODS: The Giessen hybrid stage I approach is focused on surgical bilateral pulmonary artery banding. Retrospective perioperative data were analyzed. Contrary to a stable group A, inotropic treatment before surgery for treatment of postnatal shock classified patients as unstable (Group B). Clinical outcomes considered were inhospital mortality, duration of postoperative mechanical ventilation, postoperative time at the intensive care unit, perioperative vasoactive medication requirements, and red blood cell transfusion. RESULTS: From June 1998 to December 2015, 185 patients were allocated to Group A (n = 165) and Group B (n = 20). The inhospital mortality was 2.2% with no difference between the groups. There was also no difference in the postoperative time on mechanical ventilation and the time in the intensive care unit. Vasoactive medication was more often required in Group B (100%) compared to Group A (19%). In Group B, more red blood cells were transfused 6.0 ± 8.3 vs 2.0 ± 5.8 mL/kg in Group A (P < .05, 95% CI 0.0 - 2.6). CONCLUSION: Considering a learning curve, anesthesia for surgical bilateral pulmonary artery banding palliating patients with hypoplastic left heart syndrome and complex can safely be performed, independent from the preoperative clinical status.

Trauma-Induced Long-Term Alterations of Human T Cells and Monocytes-Results of an Explorative, Cross-Sectional Study.

BACKGROUND: Major trauma leads to complex immune reactions, known to result in a transient immunodeficiency. The long-term consequences of severe trauma on immune function and regulation as well as its clinical impact remain unclear. METHODS: Six months (ranging from -12 to +5 days) after a major trauma event, 12 former trauma patients (Injury Severity Score ≥ 16) and 12 healthy volunteers were enrolled. The current clinical status and infection history since discharge were assessed by a standardized questionnaire. Immune cell subsets (cluster of differentiation (CD)4, CD8, CD14), cell surface receptor expression (programmed cell death protein 1 (PD-1), B- and T-lymphocyte attenuator (BTLA), cytotoxic T-lymphocyte-associated protein 4, toll-like receptor (TLR)-2, -4, and -5, Dectin-1, programmed death ligand 1 (PD-1L)), and human leucocyte antigen D-related receptor (HLA-DR)-expression were quantified by flow cytometry. Cytokine secretion (IL-2, -4, -6, -10, and 17A, tumor necrosis factor (TNF)-α, and interferon (IFN)-γ) was assessed after stimulation of whole blood with LPS-, α-CD3/28, or zymosan. RESULTS: Analysis of surface receptors on T cells revealed a significant elevation of PD-1 expression on CD4 T cells, whereas BTLA expression on CD4 and CD8 T cells was significantly suppressed in the trauma cohort. Monocytes showed a significantly reduced expression of TLR-2 and -4 as well as a reduced proportion of TLR-4 monocytes. HLA-DR receptor density revealed no significant changes between both cohorts. LPS-induced IL-6 and TNF-α secretion showed non-significant trends toward reduced values. No differences regarding clinical apparent infections could be detected. CONCLUSIONS: Six months following major trauma, changes of cell surface receptors on CD4 and CD8 T cells as well as on CD14 monocytes were present, hinting toward an immunosuppressive phenotype. Following major trauma, although IL-6 and TNF-α release after stimulation were reduced, they did not reach statistical significance. Overall, further studies are necessary to evaluate the clinical implications of these findings. TRIAL REGISTRATION: DRKS00009876, Internet Portal of the German Clinical Trials Register (DRKS), registration date 11.08.2016, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00009876.

Anesthetic Management During Pediatric Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy With Cisplatin in a Small Child: A Case Report and Systematic Literature Review.

Cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC) present a challenging task for anesthesia providers. Anesthesia management may be complicated by hyperthermia, fluid shifts, and distinct inflammatory response. Only a few reports dealing with the anesthesia management of pediatric CS and HIPEC have been published. We report a case of a 2-year-old child with a relapse of an alveolar rhabdomyosarcoma of the uterus and peritoneal carcinomatosis treated with CS and HIPEC. For children, careful temperature measurement, intraoperative prevention of hyperthermia, and sufficient volume management are important, as well as postoperative pediatric intensive care with experience CS and HIPEC patients.

LMA Protector™ Airway: first experience with a new second generation laryngeal mask.

BACKGROUND: The LMA Protector™ Airway (The Laryngeal Mask Company Ltd., Teleflex Incorporated, Athlone, Ireland) is a new supraglottic airway promising a better seal, an improved drainage of gastric secretions and the opportunity of a simplified fiberscopy-guided tracheal intubation. The aim of this study was to present a primary evaluation of the LMA Protector in a clinical setting. METHODS: After informed consent 50 patients, scheduled for minor/moderate surgery in supine position, were recruited. Pharyngeal seal pressures were examined in neutral position of the patients' head and in maximum passive extension of the neck. Additionally, the fiberscopic view on the glottis was graduated and the feasibility of fiberscope guided tracheal intubation through the device was evaluated. RESULTS: The median pharyngeal seal pressure of the LMA Protector in neutral position of the head was 34 cmH2O. Passive extension of the neck did not cause a reduction of the pharyngeal seal (median pharyngeal seal pressure: 34.7 cmH2O; P<0.039). The LMA Protector was applicable for fiberscopic tracheal intubation but is not reliable for blind tracheal intubation. CONCLUSIONS: The LMA Protector provides a high pharyngeal seal. Uncommon for laryngeal masks its pharyngeal seal is not affected by the extension of the patient's neck. As a second generation supraglottic airway which is also suitable for simplified fiberscopic guided tracheal intubation, the LMA Protector could be considered as a supraglottic airway of the third generation.

Individualized, perioperative, hemodynamic goal-directed therapy in major abdominal surgery (iPEGASUS trial): study protocol for a randomized controlled trial.

BACKGROUND: Postoperative morbidity and mortality in patients undergoing surgery is high, especially in patients who are at risk of complications and undergoing major surgery. We hypothesize that perioperative, algorithm-driven, hemodynamic therapy based on individualized fluid status and cardiac output optimization is able to reduce mortality and postoperative moderate and severe complications as a major determinant of the patients' postoperative quality of life, as well as health care costs. METHODS/DESIGN: This is a multi-center, international, prospective, randomized trial in 380 patients undergoing major abdominal surgery including visceral, urological, and gynecological operations. Eligible patients will be randomly allocated to two treatment arms within the participating centers. Patients of the intervention group will be treated perioperatively following a specific hemodynamic therapy algorithm based on pulse-pressure variation (PPV) and individualized optimization of cardiac output assessed by pulse-contour analysis (ProAQT© device; Pulsion Medical Systems, Feldkirchen, Germany). Patients in the control group will be treated according to standard local care based on established basic hemodynamic treatment. The primary endpoint is a composite comprising the occurrence of moderate or severe postoperative complications or death within 28 days post surgery. Secondary endpoints are: (1) the number of moderate and severe postoperative complications in total, per patient and for each individual complication; (2) the occurrence of at least one of these complications on days 1, 3, 5, 7, and 28 in total and for every complication; (3) the days alive and free of mechanical ventilation, vasopressor therapy and renal replacement therapy, length of intensive care unit, and hospital stay at day 7 and day 28; and (4) mortality and quality of life, assessed by the EQ-5D-5L™ questionnaire, after 6 months. DISCUSSION: This is a large, international randomized controlled study evaluating the effect of perioperative, individualized, algorithm-driven ,hemodynamic optimization on postoperative morbidity and mortality. TRIAL REGISTRATION: Trial registration: NCT03021525 . Registered on 12 January 2017.

Longitudinal Evaluation of Plasma Concentrations of Presepsin in Patients after Severe Trauma: A Prospective Observational Study.

BACKGROUND: The high mortality rate of patients suffering from severe trauma is based not only on the mechanism of injury, but also on the higher risk for development of subsequent infections. Therefore, the early recognition of infection after severe trauma is of particular importance for patient outcome. However, early diagnosis is often masked by the consequences of the sterile, damage-triggered immune response. Our study sought to analyze the course of soluble CD14-subtype (sCD14-ST, presepsin) compared with clinically established inflammatory and infectious biomarkers in a cohort of patients with severe trauma. PATIENTS AND METHODS: Between January 2015 and February 2016, 50 patients suffering from severe trauma (Injury Severity Score [ISS] > 16) were enrolled and followed up for seven consecutive days after intensive care unit (ICU) admission. Clinical routine data, signs of infection, and the inflammatory biomarkers presepsin, C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6) were assessed. RESULTS: Regarding the well-established biomarkers CRP, PCT, and IL-6, we observed trauma-associated alterations (day 1: CRP 13 mg/L, interquartile range [IQR] 0-129; PCT 1.1 µg/L, IQR 0-13; IL-6 108 pg/mL, IQR 29-795), which did not correlate with the clinical development of systemic inflammatory response syndrome (SIRS), whereas elevated plasma concentrations of presepsin in the clinical course were associated with the presence of SIRS (presepsin: no-SIRS vs. SIRS p = 0.03). CONCLUSION: Our study investigates systematically the kinetic of presepsin compared with established inflammatory and infectious markers after severe trauma. Presepsin is neither affected by the early post-traumatic nor the delayed immune response over seven days after trauma, making it a possible option as a diagnostic biomarker of infection worth further evaluation.

A case report of acute pulmonary hypertension after hyperthermic intraperitoneal chemotherapy (HIPEC) and review of the literature.

BACKGROUND: Hyperthermic intraperitoneal chemotherapy (HIPEC) poses a widely used and accepted treatment option for patients with peritoneal carcinomatosis of gastrointestinal tumors. In contrast to the well-described risks and complications of intravenous cytostatic drugs, literature offers only scarce information of serious complications following HIPEC. To our knowledge no other description of rapid progressive pulmonary hypertension (PH) and consecutive respiratory failure following HIPEC have been described in current literature. CASE PRESENTATION: A 48-year-old female suffering from a recurrent appendix-carcinoma developed progressive dyspnea and fatigue six weeks after multivisceral abdominal resection and HIPEC. Medical examinations included laboratory-checks, non-invasive imaging, scintigraphy as well as invasive examinations (left-/right-heart-catheterization) and confirmed PH of unknown origin to be the cause of dyspnea. The patient died nine days after admission of respiratory failure and rapid deterioration as a result of aggravating PH. CONCLUSION: Rapid progressive respiratory insufficiency due to PH following HIPEC procedure might represent a rare complication, but must be considered because of the high clinical impact. Further studies are necessary to investigate the correlation between HIPEC and PH.

Geburtshilfe: Anästhesie bei fetaler Chirurgie.

Due to the responsibility for the mother and the unborn child, fetal surgery represents a challenging task for the anesthesiologist. Maternal changes during pregnancy have to be considered as well as the fetal physiology and the surgeon's needs. Main principles of the anesthesiological management of fetal surgery include the stabilization of the mean arterial pressure in order to preserve a sufficient placental blood flow, sustainment of an adequate oxygenation and ventilation as well as thorough temperature surveillance. Since the mothers are at risk for perioperative pulmonary edema, extended hemodynamic monitoring might be necessary. This article presents the principles of fetal surgery, informs about pregnancy-related changes in circulatory and respiratory physiology and contains anesthesiological considerations to this topic.