Efficacy and safety of 1C class antiarrhythmic agent (propafenone) for supraventricular arrhythmias in septic shock compared to amiodarone: protocol of a prospective randomised double-blind study.

INTRODUCTION: Supraventricular arrhythmias contribute to haemodynamic compromise in septic shock. A retrospective study generated the hypothesis that propafenone could be more effective than amiodarone in achieving and maintaining sinus rhythm (SR). Certain echocardiographic parameters may predict a successful cardioversion and help in the decision on rhythm or rate control strategy. METHODS AND ANALYSIS: The trial includes septic shock patients with new-onset arrhythmia, but without severe impairment of the left ventricular ejection fraction. After baseline echocardiography, the patient is randomised to receive a bolus and maintenance dose of either amiodarone or propafenone. The primary outcome is the proportion of patients that have achieved rhythm control at 24 hours after the start of the infusion. The secondary outcomes are the percentages of patients that needed rescue treatments (DC cardioversion or unblinding and crossover of the antiarrhythmics), the recurrence of arrhythmias, intensive care unit mortality, 28-day and 1-year mortality. In the posthoc analysis, we separately assess subgroups of patients with pulmonary hypertension and right ventricular dysfunction. In the exploratory part of the study, we assess whether the presence of a transmitral diastolic A wave and its higher velocity-time integral is predictive for the sustainability of mechanical SR and whether the indexed left atrial endsystolic volume is predictive of recurrent arrhythmia. Considering that the restoration of SR within 24 hours occurred in 74% of the amiodarone-treated patients and in 89% of the patients treated with propafenone, we plan to include 200 patients to have an 80% chance to demonstrate the superiority of propafenone at p=0.05. ETHICS AND DISSEMINATION: The trial is recruiting patients according to its second protocol version approved by the University Hospital Ethical Board on the 6 October 2017 (No. 1691/16S-IV). The results will be disseminated through peer reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT03029169.

Perioperative Tight Glucose Control Reduces Postoperative Adverse Events in Nondiabetic Cardiac Surgery Patients.

CONTEXT: Tight glucose control (TGC) reduces morbidity and mortality in patients undergoing elective cardiac surgery, but only limited data about its optimal timing are available to date. OBJECTIVE: The purpose of this article was to compare the effects of perioperative vs postoperative initiation of TGC on postoperative adverse events in cardiac surgery patients. DESIGN: This was a single center, single-blind, parallel-group, randomized controlled trial. SETTINGS: The setting was an academic tertiary hospital. PARTICIPANTS: Participants were 2383 hemodynamically stable patients undergoing major cardiac surgery with expected postoperative intensive care unit treatment for at least 2 consecutive days. INTERVENTION: Intensive insulin therapy was initiated perioperatively or postoperatively with a target glucose range of 4.4 to 6.1 mmol/L. MAIN OUTCOME MEASURES: Adverse events from any cause during postoperative hospital stay were compared. RESULTS: In the whole cohort, perioperatively initiated TGC markedly reduced the number of postoperative complications (23.2% vs 34.1%, 95% confidence interval [CI], 0.60-0.78) despite only minimal improvement in glucose control (blood glucose, 6.6 ± 0.7 vs 6.7 ± 0.8 mmol/L, P < .001; time in target range, 39.3% ± 13.7% vs 37.3% ± 13.8%, P < .001). The positive effects of TGC on postoperative complications were driven by nondiabetic subjects (21.3% vs 33.7%, 95% CI, 0.54-0.74; blood glucose 6.5 ± 0.6 vs 6.6 ± 0.8 mmol/L, not significant; time in target range, 40.8% ± 13.6% vs 39.7% ± 13.8%, not significant), whereas no significant effect was seen in diabetic patients (29.4% vs 35.1%, 95% CI, 0.66-1.06) despite significantly better glucose control in the perioperative group (blood glucose, 6.9 ± 1.0 vs 7.1 ± 0.8 mmol/L, P < .001; time in target range, 34.3% ± 12.7% vs 30.8% ± 11.5%, P < .001). CONCLUSIONS: Perioperative initiation of intensive insulin therapy during cardiac surgery reduces postoperative morbidity in nondiabetic patients while having a minimal effect in diabetic subjects.

A pilot evaluation of the 3gLM-R - A new supraglottic airway device.

INTRODUCTION: Supraglottic airway devices are designed for airway management during anaesthesia. The 3gLM is a novel device with a non-inflatable soft cuff and separate channels for gas delivery and drainage of gastric content. MATERIAL AND METHODS: This prospective observational study of the 3gLM, version R, size 4 in 40 adult patients scheduled for elective surgery, evaluated the insertion success rate at the 1st attempt as the primary outcome. Secondary aims included insertion parameters, such as total success rate, insertion time, oropharyngeal seal pressures, postoperative complications and a comparison between males and females. RESULTS: First attempt insertion success rate was 80% (70% in males, 90% in female patients, p=0.24), while total insertion success rate was 92.5% (85% in males, 100% in females, p=0.23). The oropharyngeal seal pressures were 27cmH2O, higher in females (29.4cmH2O) than in males (24.2cmH2O) - p=0.002. Postoperative complications were only temporary and included sore throat (24.3%), hoarseness (10.8%), pain on swallowing (10.8%) and minor tongue haematoma (2.5%). There was no difference in the incidence of postoperative complications between the genders apart from hoarseness. No aspiration of gastric contents or other long-term complications occurred in this cohort. CONCLUSIONS: The 3gLM exhibited oropharyngeal seal pressures adequate for the controlled ventilation in most patients. Size 4 of the device showed higher pressures in females than in men.

Interventional treatment of pain in refractory angina. A review.

BACKGROUND: Refractory angina is characterized by repeated attacks of chest pain in patients on maximal anti-anginal pharmacotherapy, with a professional conscensus that further surgical or radiological revascularization would be futile. Refractory angina is a serious but relatively uncommon health problem, with a reported incidence of approximately 30 patients per million people/year. In this condition simply treating the associated pain alone is important as this can improve exercise tolerance and quality of life. METHODS: An extensive literature search using five different medical databases was performed and from this, eighty-three papers were considered appropriate to include within this review. RESULTS AND CONCLUSION: Available literature highlights several methods of interventional pain treatment, including spinal cord stimulation and video-assisted upper thoracic sympathectomy which can provide good analgesia whilst improving physical activities and quality of life. The positive effect of spinal cord stimulation on the intensity of pain and quality of life has been confirmed in nine randomized controlled trials. Other potential treatment methods include stellate ganglion blocks, insertion of thoracic epidural or spinal catheters and transcutaneous electrical nerve stimulation. These approaches however appear more useful for diagnostic purposes and perhaps as short-term treatment measures.

The effects of a novel calcium-free lactate buffered dialysis and substitution fluid for regional citrate anticoagulation--prospective feasibility study.

BACKGROUND: Testing metabolic effects of a novel calcium-free, magnesium, phosphate and lactate containing solution (Lactocitrate) in combination with citrate anticoagulation. METHODS: Patients on CRRT (2,000 ml/h, blood flow (Qb) 100 ml/min, trisodium citrate (4% TSC)) with arterial lactate <3 mmol/l were included. At start, bicarbonate-buffered fluid was changed to Lactocitrate and the substitution of magnesium and phosphorus ceased. At 9 h the Qb was increased to 150 ml/min. At 18 h the CRRT dosage was increased to 3,000 ml/h. RESULTS: In 22 CVVHDF patients and another 23 on CVVH the pH, aHCO3 and Na (all p > 0.05) showed no significant changes regardless of the increased dosage of 4% TSC at 9 h (p < 0.001). Mgtot and phosphorus stabilised within normal range. Arterial lactate increased to 1.9 (1.6-2.6) mmol/l at 3,000 ml/h, p < 0.001). Citrate- and lactate-related energetic gains were up to 74 (61-86) kJ/h. CONCLUSIONS: The fluid performed well within ordinary CRRT dosage and Qb up to 150 ml/min. Lactate levels mildly increased and no magnesium and phosphorus replenishments were necessary.

Common viper bites in the Czech Republic - epidemiological and clinical aspects during 15 year period (1999-2013).

The aim of this study was to analyse most important epidemiological and clinical aspects of registered snakebites caused by a native common European viper Vipera berus in the Czech Republic over a period of 15 years (1999–2013). Data have been collected retrospectively from a database of the Toxinology Centre belonging to the General University Hospital in Prague. In total, 191 cases of snakebites caused by common viper were registered during the study period. Systemic envenoming occurred in 49 (25.7%) patients, local envenoming without systemic symptoms was recorded in 91 (47.6%) and asymptomatic dry bites were seen in 51 (26.7%) cases, respectively. Twenty-four patients (12.6% of all bites) were treated with administration of antivenom. None of the victims died as a result of snakebite during the observation period. Native viper snakes usually did not cause serious harm to the patients, with the exception of children. Antivenom should be administered in all cases with systemic manifestations, in children even with serious local affection and administered as soon as possible. Envenomed patients should be admitted to the hospital and treated at least under supervision of specialists with experience in snakebite treatment, who can indicate and provide administration of the antivenom.

Postoperative outcome in awake, on-pump, cardiac surgery patients.

PURPOSE: Thoracic epidural anesthesia (TEA) alone or combined with general anesthesia (TEA-GA) has been assumed to improve early postoperative outcome in cardiac surgery. The aim of our study was to investigate data of early and late postoperative outcome results of awake TEA patients undergoing cardiac surgery with comparison to patients under combined and general anesthesia (GA). METHODS: Forty-seven patients undergoing elective on-pump cardiac surgery were assigned to receive either epidural (group TEA, n = 17), combined (group TEA-GA, n = 15), or general (group GA, n = 15) anesthesia. Early and late postoperative outcome data, including hospital and 3-year mortality rates, were recorded and compared among the study groups. RESULTS: There was no major difference in early or late postoperative outcome data across all study groups, except for lower incidence of atrial fibrillation in the TEA group compared with the GA group (23.5% vs. 66.7%, respectively, P < 0.05). Also, TEA and TEA-GA groups compared with the GA group had lower pain visual analogue scale scores at 24 h postoperatively (4 ± 7, 6 ± 7, 14.7 ± 11, respectively, P < 0.05) and morphine requirements during the first 24 h after surgery (30 ± 6, 30 ± 6, 250 ± 140 µg/kg, respectively, P < 0.05). CONCLUSIONS: Based on our data, all three anesthetic methods were equivalent in terms of major determinants of postoperative outcome, except for lower incidence of atrial fibrillation in awake patients compared with patients under general anesthesia. Methods using postoperative epidural analgesia provided superior pain relief.

New recommendations for thromboelastography reference ranges for pregnant women.

INTRODUCTION: The target of this study was to compare thromboelastography coagulation parameters in pregnant and non-pregnant women. If appropriate, we would propose recommendations for new reference ranges for pregnant women in their third trimester. MATERIALS AND METHODS: Prospective observational study, comparing, by using thromboelastography, the blood samples of 60 healthy women in third trimester of pregnancy (group GRAV) to the samples of the control group of 43 healthy non-pregnant fertile women (group NON-GRAV). Selective percentiles were used to determine new reference limits. RESULTS: Mean values and standard deviations (SD) in both groups were as follows (GRAV vs NON-GRAV): time r 4.7 min (SD 1.7) vs. 7.8 (SD 2.8); time k1.5 min (SD 0.5) vs. 2,7 (SD 0,9); alpha angle 69.6° (SD 5.5) vs. 54.4 (SD 11.5); maximum amplitude 71.3mm (SD 4.5) vs. 63.1 (SD 5.4); coagulation index 2.7 (SD 1.8) vs. -1.9 (SD 3.0); LY60 1.1% (SD 1.8) vs. 4.8 (SD 3.6). Due to statistically significant differences between both groups, we established, based on our results, these new thromboelastography reference limits for pregnant women: time r 2-8 min ("common" range 4-8 min), time k 1-3 min ("common" range 1-4 min), alpha angle 60-77° ("common" range 47-74°), maximum amplitude 64-76 mm ("common" range 55-73 mm), LY60 0-3% ("common" range 0-15%), coagulation index 0-5 ("common" range (-3) - (+3)). CONCLUSIONS: It may not be suitable to use the same reference ranges for pregnant women as for the general population. Therefore, we suggest new reference limits for thromboelastography in pregnant women.

Standard blood flow rates of cardiopulmonary bypass are adequate in awake on-pump cardiac surgery.

OBJECTIVE: Standard blood flow rates for cardiopulmonary bypass have been assumed to be the same for awake cardiac surgery with thoracic epidural anesthesia (TEA) as for general anesthesia. However, compared with general anesthesia, awake cardiac surgery with epidural anesthesia may be associated with higher oxygen consumption and may result in lactic acidosis when standard blood flow rates were used. The aim of our study was to investigate if standard blood flow rates are adequate in awake cardiac surgery. METHODS: Forty-five patients undergoing elective on-pump cardiac surgery were assigned to receive either epidural (Group TEA, n=15), combined (Group TEA-GA, n=15) or general (Group GA, n=15) anesthesia. To monitor the adequacy of standard blood flow rates, arterial lactate, acid base parameters, and central venous and jugular bulb saturation were measured at six time points (before, during, and after the surgery) in all groups. Blood flow rates were adjusted when needed. RESULTS: No lactic acidosis has developed in any group (p=NS). TEA as compared with TEA-GA and GA groups had lower central venous (67±4%, 75±11%, and 72±13%, respectively, p<0.05) and jugular bulb oxygen saturations during cardiopulmonary bypass (60±7%, 68±9%, and 75±12%, respectively, p<0.05) during the post-cardiopulmonary bypass period. The TEA group as compared with the TEA-GA and GA groups also had mild hypercapnic respiratory acidosis (56±10, 42±8, and 37±4 mmHg, respectively, p<0.05) and mild decrease of arterial oxygen saturation (93±4%, 97±2%, and 96±1%, respectively, p<0.05) at the end of surgery without any clinical consequences. Thus, no additional blood flow rates adjustments in any study group and no ventilatory support in TEA group were required. CONCLUSIONS: Under careful monitoring, the use of standard blood flow rates is adequate for patients undergoing awake on-pump normothermic cardiac surgery.

Comparison of three protocols for tight glycemic control in cardiac surgery patients.

OBJECTIVE: We performed a randomized trial to compare three insulin-titration protocols for tight glycemic control (TGC) in a surgical intensive care unit: an absolute glucose (Matias) protocol, a relative glucose change (Bath) protocol, and an enhanced model predictive control (eMPC) algorithm. RESEARCH DESIGN AND METHODS: A total of 120 consecutive patients after cardiac surgery were randomly assigned to the three protocols with a target glycemia range from 4.4 to 6.1 mmol/l. Intravenous insulin was administered continuously or in combination with insulin boluses (Matias protocol). Blood glucose was measured in 1- to 4-h intervals as requested by the protocols. RESULTS: The eMPC algorithm gave the best performance as assessed by time to target (8.8 +/- 2.2 vs. 10.9 +/- 1.0 vs. 12.3 +/- 1.9 h; eMPC vs. Matias vs. Bath, respectively; P < 0.05), average blood glucose after reaching the target (5.2 +/- 0.1 vs. 6.2 +/- 0.1 vs. 5.8 +/- 0.1 mmol/l; P < 0.01), time in target (62.8 +/- 4.4 vs. 48.4 +/- 3.28 vs. 55.5 +/- 3.2%; P < 0.05), time in hyperglycemia >8.3 mmol/l (1.3 +/- 1.2 vs. 12.8 +/- 2.2 vs. 6.5 +/- 2.0%; P < 0.05), and sampling interval (2.3 +/- 0.1 vs. 2.1 +/- 0.1 vs. 1.8 +/- 0.1 h; P < 0.05). However, time in hypoglycemia risk range (2.9-4.3 mmol/l) in the eMPC group was the longest (22.2 +/- 1.9 vs. 10.9 +/- 1.5 vs. 13.1 +/- 1.6; P < 0.05). No severe hypoglycemic episode (<2.3 mmol/l) occurred in the eMPC group compared with one in the Matias group and two in the Bath group. CONCLUSIONS: The eMPC algorithm provided the best TGC without increasing the risk of severe hypoglycemia while requiring the fewest glucose measurements. Overall, all protocols were safe and effective in the maintenance of TGC in cardiac surgery patients.

Use of high-thoracic epidural analgesia in pulmonary endarterectomy: a randomized feasibility study.

BACKGROUND: The suitability of combined high-thoracic epidural anesthesia for pulmonary endarterectomy was studied. METHODS: A prospective randomized clinical study was conducted in a university medical center from November 2005 to December 2006. The primary endpoint of this study was to evaluate perioperative hemodynamic data; secondary endpoints were to evaluate the duration of artificial ventilation, length of stay in the intensive care unit, and the impact on postoperative morbidity and mortality. RESULTS: The 16 patients in the study group received high-thoracic epidural anesthesia plus general anesthesia; the 16 control patients received total intravenous anesthesia alone. Hemodynamic parameters and drug use, as well as the time to extubation, rate of complications, postoperative pain, the length of intensive care unit stay, and mortality, were recorded. The 2 groups were comparable with respect to hemodynamic stability during induction of anesthesia. The study group patients had significantly lower sufentanil consumption (mean +/- SD, 2.1 +/- 0.7 microg/kg versus 9.1 +/- 3.1 microg/kg; P <.001), a shorter period of artificial ventilation (34 +/- 35 hours versus 52 +/- 49 hours; P = .0318), and lower postoperative pain scores at 3 hours (0.10 +/- 0.26 versus 0.93 +/- 1.38; P = .015), 12 hours (0.14 +/- 0.53 versus 0.93 +/- 0.79; P = .002), and 24 hours (0.35 +/- 0.49 versus 1.33 +/- 1.04; P = .007). CONCLUSIONS: This study has shown that combined epidural and general anesthesia is a suitable anesthetic option in patients who are selected for pulmonary endarterectomy. It provides hemodynamic stability and reduces the duration of tracheal intubation postoperatively and improves postoperative pain relief, although this option has not been shown to decrease either the length of the intensive care unit stay or mortality.

Hepatic tear as an elusive cause of hemoperitoneum complicating cardiac surgery.

We report an unusual source of intra-operative bleeding in a patient undergoing cardiosurgical reoperation. After sternotomy, hematocrit dropped significantly. Only intra-thoracic bleeding from adhesions was considered to be responsible for the anemia. During reperfusion, abdominal wall was distended with a bluish bulge in the right hemidiaphragm. Immediate laparotomy revealed bleeding from a tear in the right hepatic lobe without any diaphragm injury. The tear was likely caused by blunt trauma from an oscillating saw. We emphasize cautious use of an oscillating saw in patients with hepatic congestion undergoing a repeat sternotomy. We propose that lifting the sternum in redo procedures might prevent the hepatic tear.

Standard surgical versus percutaneous dilatational tracheostomy in intensive care patients.

OBJECTIVE: The present prospective randomized trial compared surgical tracheostomy (ST) and percutaneous dilatational tracheostomy (PDT) in intensive care unit (ICU) patients in terms of outcomes and complications. METHODS: Between January 2003 and December 2005 tracheostomies were performed on critically ill ICU patients in Medical Faculty Hospital in Prague, with a random allocation of 105 patients for ST and 100 for PDT. RESULTS: The 2 groups did not differ significantly in terms of basic demographic characteristics or length of endotracheal intubation prior to the procedure. Following the procedures, the 2 groups did not differ significantly in terms of the time required for decannulation, decannulated patients or mortalities. Post-mortem examination showed that both groups were similar in terms of placement of the tracheostomy tube. Surgical tracheostomy was found to take longer time to perform than PDT (p<0.001). In terms of early postoperative complications, PDT was associated with a higher rate of postoperative bleeding compared to ST (p=0.0302). CONCLUSION: Percutaneous dilatational tracheostomy is a simpler and faster technique to perform, but is associated with a higher occurrence of early complications, particularly postoperative bleeding.

Endoscopic thoracic sympathectomy--its effect in the treatment of refractory angina pectoris.

OBJECTIVE: To document an improvement in the quality of life in a group of patients with refractory angina and videothoracoscopic sympathectomy (VTSY) during the early postoperative period and a six-month follow-up. METHODS: Ten patients with angina CCS IV refractory to a conventional therapy underwent VTSY between the years 1998 and 2002 at our institution. All patients underwent a complex preoperative evaluation, including pain assessment using a visual analog scale (VAS). Proximal thoracic sympathetic blockage was performed in all patients as a diagnostic test. The resection of bilateral Th2-Th4 ganglions was performed under general anesthesia and selective lung ventilation. All patients were monitored 6 months after the VTSY. RESULTS: No deaths occurred in our group of patients, with an average hospital stay of 4.1 days. Nine of the ten operated patients referred an important subjective relief of pain. There was a drop from 10 to 4 according to VAS (P<0.05), and from 4 to 2.4 according to CCS (P<0.05). Decreases in basal heart rate, norepinephrine level, and an occurrence of ventricular premature beats reached the level of statistical significance. CONCLUSIONS: The increasing number of patients with refractory angina prompted a search for an effective and safe therapy to improve the quality of their life. New evidence in the pathophysiology of an ischemic myocardium and investigation of the impact of thoracic sympathectomy suggests sympathetic denervation seems to be a possible alternative method for the treatment of refractory angina pectoris.

Port access video-assisted proximal anastomosis with the symmetry aortic connector in MIDCABG procedure.

We present an alternative way to create a video-assisted port access proximal anastomosis in the ascending aorta with the Symmetry Bypass System Aortic Connector (St. Jude Medical ATG, St. Paul, MN). This technique was successfully used in a patient undergoing urgent minimally invasive direct coronary artery bypass grafting (MIDCABG), in whom the left internal mammary artery was not harvested owing to subtotal occlusion of the left subclavian artery. Port access use of mechanical anastomotic devices may increase the indications for minimally invasive coronary artery surgery.

Video-assisted multivessel revascularization through a left anterior small thoracotomy approach with the Symmetry Aortic Connector System.

OBJECTIVE: We sought to demonstrate the applicability of video-assisted multivessel revascularization through a left anterior small thoracotomy approach with the use of the Symmetry Aortic Connector System (St Jude Medical Anastomotic Technology Group, Inc, St Paul, Minn) as an alternative to the standard median sternotomy approach and to evaluate predischarge angiographically documented graft patency. METHODS: From October 2001 through February 2002, a total of 15 patients with triple-vessel disease were operated on through a left anterior small thoracotomy approach with video-assisted port-access construction of proximal aorta-to-saphenous vein anastomoses with the Symmetry Aortic Connector System and cardiopulmonary bypass with femoral cannulation and without cardioplegic arrest. There were 9 male and 6 female subjects with a mean age of 68.3 +/- 3.6 years and an average ejection fraction of 55.8% +/- 19.6%. Subject inclusion criteria consisted of female sex (initially but not throughout the study), coronary artery reoperations, and sternal bone disease. Subject exclusion criteria consisted of an age younger than 65 years, extensive atheromatous plaques in the ascending aorta, and aortoiliac occlusive disease. All but 1 patient underwent angiographic patency evaluation before discharge. RESULTS: Fifteen operations were performed successfully without any deaths. Twenty-nine sutureless proximal anastomoses were performed, with an average of 3.13 +/- 0.62 distal anastomoses per patient. Eleven (73%) patients underwent a fast track protocol with extubation in the operating room. We did not observe any instances of low cardiac output syndrome, stroke, renal insufficiency, wound complication, or perioperative myocardial infarction. A single episode of atrial fibrillation occurred in this group. Angiographic assessment of 44 bypass grafts and target arteries was performed, and 86% of those examined were widely patent (FitzGibbon score A). CONCLUSIONS: We have demonstrated a potential advantage of the sutureless Symmetry Aortic Connector System as a suitable approach that affords minimal access. Video-assisted multivessel revascularization through a left anterior small thoracotomy approach with an automated mechanical anastomosis device is particularly useful in patients undergoing coronary artery bypass reoperations or those at risk of poor sternal healing or infection. This approach seems to be a safe alternative to standard median sternotomy.