The importance of being the morning case in adult cardiac surgery: a propensity-matched analysis.

OBJECTIVES: The quality of the outcome after cardiac surgery with cardiopulmonary bypass depends on the patient demographics, co-morbidities, complexity of the surgical procedure and expertise of surgeons and the whole staff. The purpose of the present study is to analyse the timing of surgery (morning versus afternoon) with respect to morbidity and mortality in adult cardiac surgery. METHODS: The primary end point was the incidence of major morbidity defined according to a modified Society of Thoracic Surgeon criterion. We consecutively included all the adult (>18 years) patients receiving a cardiac surgery operation at our Institution. RESULTS: From 2017 through 2019, a total of 4003 cardiac surgery patients were operated. With a propensity-matching technique a final patient population of 1600 patients was selected, with 800 patients in the first-case surgery group and 800 in the second-case surgery group. Patients in the second-case group had a major morbidity rate of 13% vs 8.8% in the first-case group (P = 0.006), and a higher rate of 30-day mortality (4.1% vs 2.3%, P = 0.033). After correction for EuroSCORE and operating surgeon, the second-case group confirmed a higher rate of major morbidity (odds ratio 1.610, 95% confidence interval 1.16-2.23, P = 0.004). CONCLUSION: Our study suggests that patients operated as second cases are exposed to an increased morbidity and mortality probably due to fatigue, loss of attention and hurriedness in the operating room and decreased human resources in the intensive care unit.

Mesenteric Artery Thrombosis, Microvascular Intestinal Endothelitiis, and Guillain-Barrè Syndrome in the Same SARS-CoV-2 Patient.

Coronavirus disease 2019 (COVID-19) in humans is a novel disease that can affect every organ of the body, with life-threatening consequences. Microvascular lesions and thrombosis have been previously reported in the lung, kidney, and brain. We report a case of combined intestinal lesions and Guillain-Barrè Syndrome in a patient suffering from COVID-19 in the absence of clear laboratory predictors of upcoming complications. The patient survived the severe respiratory syndrome but died after virus-related systemic organ failure.

Recovery of consciousness after 7 years in vegetative state of non-traumatic origin: A single case study.

PRIMARY OBJECTIVE: To report consistent recovery of consciousness to a state of severe disability in a young patient after 7 years in vegetative state due to severe acquired brain injury, with reflections on protraction of intensive care and expert follow-up for the purpose of intercepting possible, albeit infrequent, cases of late recovery of consciousness. RESEARCH DESIGN: Single case study Methods: This study describes the 9-year history of a healthy 15-year-old who suffered cerebellar haemorrhage due to rupture of an arteriovenous malformation, followed by a brief period of coma then protracted vegetative state; late stabilization of general condition with resolution of neurosurgical complications. Clinical monitoring employed scales for structured assessment of severe disability and disorders of consciousness. RESULTS: The transition from vegetative state to full consciousness occurred over a period of ~ 3 months, 7 years after onset. In the subsequent 2 years the patient has shown slow but progressive overall improvement in a framework of severe residual motor and cognitive disability. CONCLUSIONS: Cases of recovery of consciousness after periods of vegetative state exceeding 1 year are rare, but remind one that a negative prognosis decided too early may be a self-fulfilling forecast.

The efficacy and safety of extending the ischemic time with a modified cardioplegic technique for coronary artery surgery.

BACKGROUND AND AIM: The need to intermittently discontinue the administration of cardioplegia in order to complete the surgical procedure is a major drawback of antegrade warm blood cardioplegia. An ischemic time of 15 minutes is generally considered safe based on empirical observation. The aim of this study was the evaluation of the efficacy and safety of an intermittent warm blood cardioplegia with intervals between administrations prolonged to 25 minutes. METHODS: Ninety-seven patients undergoing primary elective coronary artery revascularization were prospectively randomized into two groups. The first, Intermittent Antegrade Warm Blood Cardioplegia (IAWBC) group, comprising 49 patients, received standard intermittent antegrade warm blood cardioplegia repeated every 15 minutes. The second, Modified Intermittent Antegrade Warm Blood Cardioplegia (M-IAWBC) group, comprising 48 patients, received intermittent antegrade warm blood cardioplegia supplemented with magnesium sulfate (MgSO(4)), delivered in volumes proportional to the ventricular mass and repeated every 25 minutes. The clinical outcomes were evaluated. The levels of creatine kinase-MB (CK-MB) isoenzyme, in addition to the echocardiographic assessment of septal dyskinesia and tricuspid annulus plane systolic excursion (TAPSE), have been used as markers of myocardial damage. RESULTS: There were no statistically significant differences in clinical outcomes, need for inotropes and vasodilators, length of stay in the intensive care unit, and postoperative levels of CK-MB between the two groups. Likewise, postoperative echocardiographic assessment showed no relevant differences. CONCLUSIONS: Administration of warm antegrade cardioplegic solution supplemented with MgSO(4), delivered in volumes proportional to ventricular mass every 25 minutes, provides adequate myocardial protection for coronary artery surgery.

[Aortic valve replacement on two octogenarians awake patients without tracheal intubation, with thoracic epidural anesthesia]. / Sostituzione valvolare aortica in due pazienti ottuagenari coscienti senza intubazione tracheale in anestesia peridurale toracica.

The association of advanced age with various comorbidities increases the risk of mortality and morbidity in cardiac surgery. The utilization of high thoracic epidural anesthesia (HTEA) in this setting presents numerous potential benefits, including early recovery of consciousness and of spontaneous ventilation, hemodynamic stability, enhanced analgesia, improved pulmonary function, and earlier recovery. Moreover, this anesthesiological technique allows the performance of surgical procedures on the conscious patient, thus making continuous monitoring of the cerebral function feasible. We have employed HTEA without tracheal intubation on 2 gravely compromised octogenarian patients who underwent aortic valve replacement for critical aortic stenosis. Epidural anesthesia without tracheal intubation in these patients permitted the avoidance of general anesthetics and allowed the continuous evaluation of their cognitive function. Further, by avoiding the positive pulmonary pressures of mechanical ventilators, the technique contributed to preserve physiologic intrapulmonary pressures, thus positively affecting the pulmonary circulation. In our opinion, the utilization of HTEA without tracheal intubation may decrease the surgical risk in selected patients.

High thoracic epidural anesthesia in cardiac surgery: risk factors for arterial hypotension.

There is an interest in the use of high thoracic epidural anesthesia in cardiac surgery, because experimental and clinical studies have suggested that central neuroaxial blockade attenuates the response to surgical stress and improves myocardial metabolism and perioperative analgesia-thus enabling earlier extubation and a smoother postoperative course. Matters of major concern in the adoption of high thoracic epidural anesthesia in cardiac surgery are neurologic injury secondary to neuroaxial hematoma and hypotension secondary to sympatholysis. The risk associated with possible neuraxial hematoma caused by high thoracic epidural anesthesia has been thoroughly investigated and largely discounted, but scant attention has been devoted to the onset of hypotensive episodes in the same setting. We analyzed the hypotensive episodes that occurred in a series of 144 patients who underwent on-pump cardiac surgery procedures. Among the patient variables that we tested in a multivariate logistic-regression model, only female sex was found to be significantly correlated with hypotension. In order to decrease the incidence and severity of hypotensive episodes resulting from anesthetic blockade, anesthesiologists need to monitor, with special care, women patients who are under high thoracic epidural anesthesia. Further studies are needed in order to determine why women undergoing open heart surgery under high thoracic epidural anesthesia are at a relatively greater risk of hypotension.