Infraglottic versus supraglottic jet-ventilation for endobronchial ultrasound-guided transbronchial needle aspiration: A randomised controlled trial.

BACKGROUND: For endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) under general anaesthesia, both rigid bronchoscopy and laryngeal masks (LMAs) with superimposed high-frequency jet ventilation can be used. Despite the fact that in Europe rigid bronchoscopy for EBUS-TBNA is still widely used, an increasing number of centres use jet ventilation via the LMA for this procedure. To our knowledge no clinical trials have ever been made to compare these two methods. This trial aimed to evaluate whether patients recover from the procedure more quickly when a LMA is used for ventilation compared with rigid bronchoscopy where muscle relaxants and deep anaesthesia are required. OBJECTIVES: We wanted to test the hypothesis that there is no difference in the postoperative recovery of patients in the postanaesthesia care unit (PACU) after EBUS-TBNA with jet ventilation via a rigid bronchoscope and a LMA. Secondary outcomes were the difference of duration of anaesthesia, the diagnostic outcome of the procedure and drug quantities for both groups. DESIGN: Prospective randomised single blinded two centre controlled trial. SETTING: Two centres in Austria participated. Patients were enrolled from December 2016 until January 2018. PATIENTS: Ninety patients for elective EBUS-TBNA were enrolled and assigned to one of two intervention groups. Two patients were excluded before and eleven patients were excluded after EBUS-TBNA. Seventy-seven were analysed. INTERVENTIONS: Patients assigned to group 1 were ventilated with a LMA; those assigned to group 2 were ventilated via a rigid bronchoscope. Vital signs, drug dosage, duration of anaesthesia, recovery, PACU stay and Aldrete score at the PACU were recorded. MAIN OUTCOME MEASURES: The primary endpoint was an integral over time of a modified Aldrete score. Secondary endpoints were the durations of the interventions, the recovery from anaesthesia and PACU stay, initial and mean Aldrete values at PACU, the effect site concentration of Propofol according to the Schnider pharmacokinetic model, the peak ultiva rates and the diagnostic outcome. RESULTS: We were not able to show any significant difference regarding the postoperative recovery criteria based on the Aldrete score, the durations measured and the diagnostic outcomes. Vital signs remained stable and in an equal range in both groups. There were no differences in the mean effect site propofol concentration and the peak ultiva rates. CONCLUSION: EBUS-TBNA under general anaesthesia using a LMA with SHJV is equal to rigid bronchoscopy with superimposed high-frequency jet ventilation for the variables analysed. TRIAL REGISTRATION: ISRCTN (ISRCTN58911367).

Duration of extracorporeal membrane oxygenation support and survival in cardiovascular surgery patients.

OBJECTIVE: The overall therapeutic goal of venoarterial extracorporeal membrane oxygenation (ECMO) in patients with postcardiotomy shock is bridging to myocardial recovery. However, in patients with irreversible myocardial damage prolonged ECMO treatment would cause a delay or even withholding of further permanent potentially life-saving therapeutic options. We therefore assessed the prognostic effect of duration of ECMO support on survival in adult patients after cardiovascular surgery. METHODS: We enrolled into our single-center registry a total of 354 patients who underwent venoarterial ECMO support after cardiovascular surgery at a university-affiliated tertiary care center. RESULTS: Through a median follow-up period of 45 months (interquartile range, 20-81 months), 245 patients (69%) died. We observed an increase in mortality with increasing duration of ECMO support. The association between increased duration of ECMO support and mortality persisted in patients who survived ECMO support with a crude hazard ratio of 1.96 (95% confidence interval, 1.40-2.74; P < .001) for 2-year mortality compared with the third tertile and the second tertile of ECMO duration. This effect was even more pronounced after multivariate adjustment using a bootstrap-selected confounder model with an adjusted hazard ratio of 2.30 (95% confidence interval, 1.52-3.48; P < .001) for 2-year long-term mortality. CONCLUSIONS: Prolonged venoarterial ECMO support is associated with poor outcome in adult patients after cardiovascular surgery. Our data suggest reevaluation of therapeutic strategies after 7 days of ECMO support because mortality disproportionally increases afterward.

Impact of Right Ventricular Performance in Patients Undergoing Extracorporeal Membrane Oxygenation Following Cardiac Surgery.

BACKGROUND: Extracorporeal membrane oxygenation following cardiac surgery safeguards end-organ oxygenation but unfavorably alters cardiac hemodynamics. Along with the detrimental effects of cardiac surgery to the right heart, this might impact outcome, particularly in patients with preexisting right ventricular (RV) dysfunction. We sought to determine the prognostic impact of RV function and to improve established risk-prediction models in this vulnerable patient cohort. METHODS AND RESULTS: Of 240 patients undergoing extracorporeal membrane oxygenation support following cardiac surgery, 111 had echocardiographic examinations at our institution before implantation of extracorporeal membrane oxygenation and were thus included. Median age was 67 years (interquartile range 60-74), and 74 patients were male. During a median follow-up of 27 months (interquartile range 16-63), 75 patients died. Fifty-one patients died within 30 days, 75 during long-term follow-up (median follow-up 27 months, minimum 5 months, maximum 125 months). Metrics of RV function were the strongest predictors of outcome, even stronger than left ventricular function (P<0.001 for receiver operating characteristics comparisons). Specifically, RV free-wall strain was a powerful predictor univariately and after adjustment for clinical variables, Simplified Acute Physiology Score-3, tricuspid regurgitation, surgery type and duration with adjusted hazard ratios of 0.41 (95%CI 0.24-0.68; P=0.001) for 30-day mortality and 0.48 (95%CI 0.33-0.71; P<0.001) for long-term mortality for a 1-SD (SD=-6%) change in RV free-wall strain. Combined assessment of the additive EuroSCORE and RV free-wall strain improved risk classification by a net reclassification improvement of 57% for 30-day mortality (P=0.01) and 56% for long-term mortality (P=0.02) compared with the additive EuroSCORE alone. CONCLUSIONS: RV function is strongly linked to mortality, even after adjustment for baseline variables and clinical risk scores. RV performance improves established risk prediction models for short- and long-term mortality.

Cardiac arrest does not affect survival in post-operative cardiovascular surgery patients undergoing extracorporeal membrane oxygenation.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (ECMO) is rapidly evolving as bailout option in patients with refractory cardiogenic shock after cardiovascular surgery (CV). Cardiac arrest represents a common and severe complication in the immediate post-operative phase. We therefore evaluated the impact of cardiac arrest at time of ECMO implantation on short- and long-term mortality in patients following CV surgery. METHODS AND RESULTS: We included 385 patients undergoing veno-arterial extracorporeal membrane oxygenation therapy following CV surgery at a university-affiliated tertiary-care center into our single-center registry. Thirty patients underwent cardiopulmonary resuscitation (CPR) followed by immediate initiation of ECMO support. During a median follow-up time of 44 months (IQR 21-76 months), 68% of patients (n=262) died. We did not detect a significant impact of CPR during ECMO initiation on 30-day mortality (HR 1.04, 95%CI 0.89-1.83, P=0.86) as well as for long-term mortality (HR 1.01, 95%CI 0.63-1.61, P=0.97). Results were virtually unchanged for 30-day (HR 0.88, 95%CI 0.44-1.73, P=0.70) and long-term mortality (HR 0.93, 95%CI 0.54-1.60, P=0.79) after adjustment for age, sex, left ventricular ejection fraction, SAPS2 score, type of CV surgery, and year of study inclusion in order to unveil a potential negative confounding. CONCLUSION: Cardiac arrest did not affect short-tem and long-term mortality in a large cohort of patients with therapy refractory cardiogenic shock undergoing ECMO support following CV surgery. Our results suggest that the decision to initiate ECMO support in this specific patient population should not be influenced by the occurrence of cardiac arrest.

Liver function predicts survival in patients undergoing extracorporeal membrane oxygenation following cardiovascular surgery.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) represents a valuable and rapidly evolving therapeutic option in patients with severe heart or lung failure following cardiovascular surgery. However, despite significant advances in ECMO techniques and management, prognosis remains poor and accurate risk stratification challenging. We therefore evaluated the predictive value of liver function variables on all-cause mortality in patients undergoing venoarterial ECMO support after cardiovascular surgery. METHODS: We included into our single-center registry a total of 240 patients undergoing venoarterial ECMO therapy following cardiovascular surgery at a university-affiliated tertiary care center. RESULTS: The median follow-up was 37 months (interquartile range 19-67 months), and a total of 156 patients (65%) died. Alkaline phosphatase and total bilirubin were the strongest predictors for 30-day mortality, with adjusted hazard ratios (HRs) per 1-standard deviation increase of 1.36 (95% confidence interval [CI] 1.10-1.68; P = 0.004) and 1.22 (95% CI 1.07-1.40; P = 0.004), respectively. The observed associations persisted for long-term mortality, with adjusted HRs of 1.27 (95% CI 1.03-1.56; P = 0.023) for alkaline phosphatase and 1.22 (95% CI 1.07-1.39; P = 0.003) for total bilirubin. CONCLUSIONS: The present study demonstrates that elevated values of alkaline phosphatase and total bilirubin are sensitive parameters for predicting the short-term and long-term outcomes of ECMO patients.

Urinary Output Predicts Survival in Patients Undergoing Extracorporeal Membrane Oxygenation Following Cardiovascular Surgery.

OBJECTIVES: Extracorporeal membrane oxygenation represents a valuable and rapidly evolving therapeutic option in patients with severe heart or lung failure following cardiovascular surgery. However, survival remains poor and accurate risk stratification challenging. Therefore, we evaluated the predictive value of urinary output within 24 hours after extracorporeal membrane oxygenation initiation on mortality in patients undergoing venoarterial extracorporeal membrane oxygenation support following cardiovascular surgery and aimed to improve established risk prediction models. DESIGN: Single-center, observational registry. SETTING: University-affiliated tertiary care center. PATIENTS: We included 205 patients undergoing veno-arterial extracorporeal membrane oxygenation therapy following cardiovascular surgery at a university-affiliated tertiary-care center into our single-centre registry. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During a median follow-up time of 35 months (interquartile range, 19-69), 64% of patients died. Twenty-four-hour urinary output was the strongest predictor of outcome among renal function variables with an adjusted hazard ratio per 1 SD of 0.55 (95% CI, 0.40-0.76; p < 0.001) for 30-day mortality and of 0.65 (95% CI, 0.53-0.86; p = 0.002) for 2-year long-term mortality. Most remarkably, 24-hour urinary output showed additional prognostic value beyond that achievable with the simplified acute physiology score-3 and sequential organ failure assessment score indicated by improvements in the category-free net reclassification index for 30-day mortality (simplified acute physiology score-3: 36%, p = 0.015; sequential organ failure assessment score: 36%, p = 0.02), as well as for 2-year mortality (simplified acute physiology score-3: 33%, p = 0.02; sequential organ failure assessment score: 43%, p = 0.005). CONCLUSIONS: We identified 24-hour urinary output as a strong and easily available predictor of mortality in patients undergoing extracorporeal membrane oxygenation therapy following cardiovascular surgery. Implementation of 24-hour urinary output leads to a substantial improvement of established risk prediction models in this vulnerable patient population. These results are particularly compelling because measurement of urinary output is inexpensive and routinely performed in all critical care units.

Serum butyrylcholinesterase predicts survival after extracorporeal membrane oxygenation after cardiovascular surgery.

INTRODUCTION: Risk stratification in patients undergoing extracorporeal membrane oxygenation (ECMO) support after cardiovascular surgery remains challenging, because data on specific outcome predictors are limited. Serum butyrylcholinesterase demonstrated a strong inverse association with all-cause and cardiovascular mortality in non-critically ill patients. We therefore evaluated the predictive value of preoperative serum butyrylcholinesterase levels in patients undergoing venoarterial ECMO support after cardiovascular surgery. METHODS: We prospectively included 191 patients undergoing venoarterial ECMO therapy after cardiovascular surgery at a university-affiliated tertiary care center in our registry. RESULTS: All-cause and cardiovascular mortality were defined as primary study end points. During a median follow-up time of 51 months (IQR, 34 to 71) corresponding to 4,197 overall months of follow-up, 65% of patients died. Cox proportional hazard regression analysis revealed a significant and independent inverse association between higher butyrylcholinesterase levels and all-cause mortality with an adjusted hazard ratio (HR) of 0.44 (95% CI, 0.25 to 0.78; P = 0.005), as well as cardiovascular mortality, with an adjusted HR of 0.38 (95% CI, 0.21 to 0.70; P = 0.002), comparing the third with the first tertile. Survival rates were higher in patients within the third tertile of butyrylcholinesterase compared with patients within the first tertile at 30 days (68% versus 44%) as well as at 6 years (47% versus 21%). CONCLUSIONS: The current study revealed serum butyrylcholinesterase as a strong and independent inverse predictor of all-cause and cardiovascular mortality in patients undergoing venoarterial ECMO therapy after cardiovascular surgery. These findings advance the limited knowledge on risk stratification in patients undergoing ECMO support and represent a valuable addition for a comprehensive decision making before ECMO implantation.

A randomised trial of oral versus intravenous opioids for treatment of pain after cardiac surgery.

BACKGROUND: Cardiac surgery and sternotomy are procedures accompanied by substantial postoperative pain which is challenging to treat. In general, intravenous (IV) opioids are used in the immediate postoperative phase, followed by oral opioids. Oral opioids are easier to use and generally less expensive. Our goal was thus to determine whether a new opioid preparation provides adequate analgesia after sternotomy. In particular, we tested the primary hypothesis that total opioid use (in morphine equivalents) is not greater with oral opioid compared with patient-controlled IV morphine. Our secondary hypothesis was that analgesic efficacy is similar with oral and IV opioids. METHODS: A total of 51 patients having elective cardiac surgery were enrolled in this study. After rapid postoperative respiratory weaning, the patients were randomised into one of two groups receiving different types of analgesia: oral Targin (a combination of oxycodone-hydrochloride and the opioid antagonist naloxone hydrochloride-dihydrate) or patient-controlled IV morphine. Pain score (visual analogue scale), sedation (Ramsey score), respiratory rate and side effects were assessed at 3, 5, 7, 9 and 11 h after surgery, and every 6 h throughout the third postoperative evening. RESULTS: The total opioid dose in morphine equivalent doses was significantly lower with oral opioid than with IV morphine (adjusted geometric means [95 % confidence interval]: 34 [29; 38] vs. 69 [61; 78] mg, respectively). Pain scores were similar in each group. CONCLUSIONS: Analgesic quality was comparable with oral and IV opioids, suggesting that postoperative pain even after very painful procedures can be sufficiently managed with oral opioids.

Long-term mortality in patients with chronic obstructive pulmonary disease following extracorporeal membrane oxygenation for cardiac assist after cardiovascular surgery.

PURPOSE: Information on predisposing risk factors influencing long-term survival after extracorporeal membrane oxygenation (ECMO) support remains scarce. In critically ill patients chronic obstructive pulmonary disease (COPD) is an independent risk factor for mortality and morbidity. We assessed the influence of COPD on cardiovascular and all-cause mortality in patients undergoing ECMO therapy. METHODS: We prospectively included 191 patients undergoing veno-arterial ECMO therapy following cardiovascular surgery at a university-affiliated tertiary care center into our registry. RESULTS: The median follow-up time was 51 months (IQR 34-71 months) corresponding to 4,197 overall months of follow-up. A total of 125 patients (65 %) died; 88 % of deaths were due to cardiovascular causes. Long-term survival was decreased in patients with COPD after 1 year (23 % vs. 44 %) and after 6 years (14 % vs. 35 %) compared to patients without COPD. COPD was independently associated with all-cause mortality with a hazard ratio of 4.22 (95 % CI 1.04-17.11, p = 0.04) and cardiovascular mortality with a hazard ratio of 5.87 (95 % CI 1.41-24.47, p = 0.02). CONCLUSIONS: We identified COPD as a strong and independent predictor of long-term all-cause mortality and cardiovascular mortality in patients undergoing ECMO therapy following cardiovascular surgery. The current study presents valuable information for a comprehensive decision-making process prior to ECMO implantation and helps to identify high-risk patients that may benefit from intensified treatment of co-morbidities and close check-ups after hospital discharge.

A manually powered mechanical resuscitation device used by a single rescuer: a randomised controlled manikin study.

PURPOSE: The goal of this randomized, open, controlled crossover manikin study was to compare the performance of "Animax", a manually operated hand-powered mechanical resuscitation device (MRD) to standard single rescuer basic life support (BLS). METHODS: Following training, 80 medical students performed either standard BLS or used an MRD for 12 min in random order. We compared the quality of chest compressions (effective compressions, compression depth and rate, absolute hands-off time, hand position, decompression), and of ventilation including the number of gastric inflations. An effective compression was defined as a compression performed with correct depth, hand position and decompression. RESULTS: The use of the MRD resulted in a significantly higher number of effective compressions compared to standard BLS (67 ± 34 vs. 41 ± 34%, p<0.001). In a comparison with standard BLS, the use of the MRD resulted in less absolute hands-off time (264 ± 57 vs. 79 ± 40 s, p<0.001) and in a higher minute-volume (1.86 ± 0.7 vs. 1.62 ± 0.7 l, p=0.020). However, ventilation volumes were below the 2005 ERC guidelines for both methods. Gastric inflations occurred only in 0 ± 0.1% with the MRD compared to 3 ± 7% during standard BLS (p<0.001). CONCLUSION: Single rescuer cardio-pulmonary resuscitation with the manually operated MRD was superior to standard BLS regarding chest compressions in this simulation study. The MRD delivered a higher minute-volume but did not achieve the recommended minimal volume. Further clinical studies are needed to test the MRD's safety and efficacy in patients.

Quality of resuscitation: flight attendants in an airplane simulator use a new mechanical resuscitation device--a randomized simulation study.

PURPOSE: Cardiopulmonary resuscitation (CPR) during flight is challenging and has to be sustained for long periods. In this setting a mechanical-resuscitation-device (MRD) might improve performance. In this study we compared the quality of resuscitation of trained flight attendants practicing either standard basic life support (BLS) or using a MRD in a cabin-simulator. METHODS: Prospective, open, randomized and crossover simulation study. Study participants, competent in standard BLS were trained to use the MRD to deliver both chest compressions and ventilation. 39 teams of two rescuers resuscitated a manikin for 12 min in random order, standard BLS or mechanically assisted resuscitation. Primary outcome was "absolute hands-off time" (sum of all periods during which no hand was placed on the chest minus ventilation time). Various parameters describing the quality of chest compression and ventilation were analysed as secondary outcome parameters. RESULTS: Use of the MRD led to significantly less "absolute hands-off time" (164±33 s vs. 205±42 s, p<0.001). The quality of chest compression was comparable among groups, except for a higher compression rate in the standard BLS group (123±14 min(-1) vs. 95±11 min(-1), p<0.001). Tidal volume was higher in the standard BLS group (0.48±0.14 l vs. 0.34±0.13 l, p<0.001), but we registered fewer gastric inflations in the MRD group (0.4±0.3% vs. 16.6±16.9%, p<0.001). CONCLUSION: Using the MRD resulted in significantly less "absolute hands-off time", but less effective ventilation. The translation of higher chest compression rate into better outcome, as shown in other studies previously, has to be investigated in another human outcome study.

Performance of supraglottic airway devices and 12 month skill retention: a randomized controlled study with manikins.

PURPOSE: Airway management for successful ventilation by laypersons and inexperienced healthcare providers is difficult to achieve. Bag-valve mask (BVM) ventilation requires extensive training and is performed poorly. Supraglottic airway devices (SADs) have been successfully introduced to clinical resuscitation practice as an alternative. We evaluated recently introduced (i-gel™ and LMA-Supreme™) and established SADs (LMA-Unique™, LMA-ProSeal™) and BVM used by laypeople in training sessions on manikins. METHODS: In this randomized controlled study, 267 third-year medical students participated with informed consent and IRB approval. After brief standardized training, each participant applied all devices in a randomized order. Success of device application and ventilation was recorded. Without further training, skill retention was assessed in the same manner 12 months later. Outcome parameters were the number of application attempts, application time, tidal volume and gastric inflation rate recorded at successful attempts, and subjective ease-of-use rating by the participants. RESULTS: i-gel™ and LMA-Supreme™ were the most successful in the first attempt at both assessments and in the subjective ease-of-use rating. The shortest application time was found with BVM (8 ± 5s in 2008 vs. 9 ± 5s in 2009) and i-gel (10 ± 3s vs. 12 ± 5s). Tidal volumes were disappointing with no device reaching 50% volume within the recommended range (0.4-0.6L). Gastric inflation rate was highest with BVM (18% vs. 20%) but significantly lower with all SADs (0.4-6%; p < 0.001 for 2008 and 2009). CONCLUSION: SADs showed clear advantages over BVM. Compared with LMA-Unique™ and LMA-ProSeal™, i-gel™ and LMA-Supreme™ led to higher first-attempt success rates and a shorter application time.

Incidence of complications in intrahospital transport of critically ill patients--experience in an Austrian university hospital.

BACKGROUND: During the past decade, considerable changes and advances have been made in intrahospital transport of critically ill patients. Despite the fact that intrahospital transport is nowadays regarded an extension of the intensive care continuum, it still poses a risk for the patient. MATERIALS AND METHODS: This prospective, observational study was designed to determine the occurrence rate of transport-related complications in the altered setting of intrahospital transports and to identify possible confounding sources of increased risk. In an eight-month period, adults and infants from anesthesiologic intensive care units were analyzed. RESULTS: A total of 226 patients underwent 452 intrahospital transports. The overall rate of critical incidents was low (4.2%) and no direct association between mortality and intrahospital transport was observed. In addition to the known risk factors of ventilatory support with positive end-expiratory pressure and requirement for catecholamine support, the necessity for intrahospital transport in the acute vs. elective situation was found to significantly increase the risk of complications. CONCLUSIONS: We conclude that advances in the management of intrahospital transport of critically ill patients have led to an overall decrease of complications. However, an undeniable risk remains, especially in relation to disease severity and the urgency of such transports.

Improved outcome in thoracoabdominal aortic aneurysm repair: the role of cerebrospinal fluid drainage.

INTRODUCTION: To evaluate the protective effect and the optimum duration of cerebrospinal fluid drainage (CSFD) during and after thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: From April 2001 to October 2003, we retrospectively compared 17 (n = 17) consecutive patients who have been electively operated on by Martin Grabenwoger for left heart bypass and selective perfusion of the visceral and renal organs. RESULTS: The first 7 patients had CSFD for 72 hours; the duration of CSFD was increased to 100 hours in the remaining 10 patients. Median drained cerebrospinal fluid (CSF) volume was 680 milliliters in the 72-hour group versus 1441 milliliters in the 100-hour group. A characteristic increase in CSF volume was noted between POD No. 2 and POD No. 4 indicating persistent spinal cord edema. Univariate and multivariate analysis demonstrated that CSFD for 100 hours is a significant predictor for decreased incidence of late onset paraplegia (p < 0.001). The overall incidence of postoperative neurological deficit was 17.6% (3 of 17). There was one patient (6%) who developed permanent paraplegia and two patients (12%) with transient paraplegia. These patients sustained late-onset paraplegia 72 hours after surgery for removal of a CSFD device. Complete motor function could be restored after re-insertion of a CSFD device. In one patient, permanent paraplegia was evident after awakening from anesthesia. Because of technical difficulties, only two intercostal arteries could be re-implanted, which was obviously not sufficient to restore spinal cord perfusion. In contrast, no neurological deficit occurred in patients in whom a CSFD instrument was left for 100 hours. CONCLUSION: The extended duration of CSFD may lower the risk of late-onset paraplegia and could improve outcome in patients undergoing thoracoabdominal aortic surgery.

Postoperative analgesia with remifentanil in patients undergoing cardiac surgery.

Remifentanil, a short-acting opioid, is commonly used in cardiac anesthesia. In this study we sought to demonstrate the feasibility of pain treatment and to determine the remifentanil dose necessary for adequate analgesia in tracheally extubated patients after cardiac surgery. Thirty patients undergoing elective cardiac surgery were included in this study. After surgery, the intraoperatively administered remifentanil was initially continued at 0.05 microg . kg(-1) . min(-1). Before tracheal extubation, a nonsteroidal antiinflammatory drug was administered and remifentanil was reduced to 0.035 microg . kg(-1) . min(-1). Pain assessment using a visual analog scale (VAS) was performed after tracheal extubation, in 2-min intervals for 10 min, every 10 min until the end of the first hour and every 30 min during the ensuing 5 h. A VAS score > or =30 or a respiratory rate <10 breaths/min was followed by an increase or decrease in the remifentanil dose by 0.005 microg . kg(-1) . min(-1), respectively. For rapid dose adaptation during the first 10 min, remifentanil was increased twice by 0.005 microg. kg(-1) . min(-1) and then 3 times by 0.01 microg . kg(-1) . min(-1). With a mean remifentanil dose of 0.051 microg . kg(-1) . min(-1) VAS decreased to 26 +/- 14 after 30 min. Sufficient analgesia was achieved with remifentanil doses ranging from 0.03 to 0.09 microg. kg(-1) . min(-1). A maximum mean remifentanil dose of 0.057microg. kg(-1) . min(-1) was reached after 4 h. The combination of remifentanil with a nonsteroidal antiinflammatory drug provided adequate analgesia in 73% of patients 30 min after tracheal extubation. Rapid dose titration was necessary during the first 10 min in 50% of patients. Increasing the initial remifentanil dose could shorten the titration period but may be associated with respiratory complications.

Impact of surgical era on outcomes of patients undergoing elective atherosclerotic ascending aortic aneurysm operations.

OBJECTIVE: This retrospective study evaluates, if recent refinements in peri-operative management, have an impact on clinical outcome of patients undergoing elective repair of their ascending thoracic aorta. METHODS: One hundred sixty five (n = 165) consecutive patients were operated during a 7 year period at our department. The cohort was divided in an early group I (from Jan 1997 to Dec 1999, n = 75) and a late group II (from Jan 2000 to Jan 2003, n = 90). The mean age was 60.9+/-13.1 years in group I versus 58.1+/-13.6 years in group II. In group I 50 patients (66.6%) underwent replacement of the ascending thoracic aorta alone, 17 patients (22.6%) received a composite graft, 8 patients (10.6%) had an additional aortic valve replacement and 14 patients (18.6%) needed concomitant coronary artery bypass grafting. In group II the procedures were as follows: interposition graft alone in 58 patients (64.4%), composite graft in 26 patients (28.8%), aortic valve replacement in 6 (6.6%) and CABG in 11 patients (12.2%). RESULTS: Overall hospital mortality for the entire cohort was 6.6% (11/165) with no significant differences between the early and late group with 6.6% (5/75) and 6.6% (6/90), respectively, P = 0.985. Causes were multi organ failure in 63.3% (n = 7), stroke in 9% (n = 1) myocardial infarction in 18.1% (n = 2) and refractory bleeding in 9% (n = 1). Concomitant CABG, repair of the aortic valve and composite graft, emerged as independent risk factor for mortality in multivariate logistic regression analysis with P = 0.001. Differences, became apparent in ICU as well as hospital stay with a median ICU stay in group I of 7.1+/-12.9 days versus 4.4+/-6.8 days in group II, and median hospital stay of 16.7+/-5.3 days versus 9.5+/-8.4 days for group I and II, P < 0.05, respectively. Furthermore through the implementation of blood conservation techniques, a substantial reduction of transfusion requirements could be achieved (PRBC from 3.2+/-4 to 1.1+/-1.7 units, FFP 5.2+/-3 to 2.3+/-0.5 units, Platelets from 1.3+/-2 to 0.3+/-0.07 units). CONCLUSIONS: Even with the implementation of various refinements in surgical and anaesthetic techniques, the current risk of mortality for ascending aortic aneurysm repair has not changed in the last 7 years. However, shortened ICU and hospital stays as well as diminished usage of blood derivates are mainly the result of a more aggressive and improved peri- and post-operative management due to economic considerations.

The incidence of transient neurologic dysfunction after ascending aortic replacement with circulatory arrest.

BACKGROUND: Transient neurologic dysfunction (TND) namely postoperative confusion, delirium, and agitation after aortic operation, particularly after deep hypothermic circulatory arrest (DHCA), remains an underestimated adverse event in the early outcome of these patients. Although no influence on long-term outcome has been reported so far, this entity markedly affects the early outcome and leads to prolonged intensive care unit and hospital stay. METHODS: Between January 1997 and January 2003, 160 consecutive patients (130 type A dissections [81%] and 30 elective atherosclerotic aneurysms [19%]) had surgical repair with DHCA for a thoracic aortic aneurysm limited to the ascending aorta. From those, 40 patients (25%) underwent DHCA alone, whereas in 13 patients (8%) antegrade cerebral perfusion and in 103 patients (64%) retrograde cerebral perfusion was used for further brain protection. RESULTS: The overall incidence of TND was 18% (28 of 160) with a significant association between duration of circulatory arrest and the incidence of TND (13.8% in DHCA < 30 minutes versus 37.9% in DHCA > 40 minutes; p < 0.05). Furthermore the severity of TND was directly associated with the duration of circulatory arrest and age. In contrast, however, the use of retrograde cerebral perfusion had no influence on the incidence of TND, (p < 0.05). Intensive care unit stay as well as hospital stay were prolonged in the patients with TND (intensive care unit 14.3 +/- 14.2 days versus 10.8 +/- 13.7 days, p < 0.05; hospital stay 15.6 +/- 10.1 days versus 11.4 +/- 7.9 days, p < 0.05). CONCLUSIONS: Duration of DHCA, regardless of whether retrograde cerebral perfusion was used, was the most important predictor of the incidence of transient neurologic dysfunction in patients who had replacement of the ascending thoracic aorta. The occurrence of TND leads to impaired functional recovery as well as prolonged intensive care unit and hospital stay.

Occlusion of the right subclavian artery after insertion of a transoesophageal echocardiography probe in a neonate.

We present a case of occlusion of the right arm's blood supply in a neonate with a lusorian artery, a rare anomaly of the right subclavian artery, after insertion of a transoesophageal echocardiography (TOE) probe and discuss the impact of a lusorian artery on intraoperative TOE monitoring.

A double patch sandwich technique for surgical repair of acute aortic dissection type A.

BACKGROUND: This study compares two groups of patients with acute aortic dissection type A in whom two different techniques of anastomotic reinforcement were used, and evaluates the impact of these two techniques on perioperative blood loss and surgical outcome. METHODS: One hundred eighty-five consecutive patients with acute aortic dissection type A between 1998 and 2002 were grouped according to the technique utilized for reinforcing the aortic anastomotic site. Group A consisted of 21 patients in whom a novel double patch sandwich technique was used, whereas in group B (164 patients) conventional Teflon felt strips served as reinforcement. RESULTS: Preoperative profiles were comparable for both groups. Deep hypothermia and circulatory arrest were used in 180 patients (97%). Retrograde cerebral perfusion and retrograde cardioplegia were used in 70 patients (38%). Hospital mortality for the two groups was 4.7% (1 of 21) and 18% (29 out of 164), p < 0.30, respectively. On average 2 versus 6 U of PRBC (p < 0.21), and 3 versus 5 U of FFP (p < 0.004) were given during operation in groups A and B, respectively, and indicates reduced suture line bleeding in group A. CONCLUSIONS: Modifications in the surgical technique for repair of acute aortic dissection type A, and in anastomotic reinforcement in particular, may lead to substantial reduction of suture line bleeding and diminished blood loss and transfusion requirements, and favorably affects patient outcome. Nevertheless, continued effort is mandatory to further enhance surgical outcome in this patient population.