The Effect of Common Interventions in the Intensive Care Unit on Right Ventricular Function After Cardiac Surgery-An Intervention Study.

OBJECTIVE: Critical care therapy after cardiac surgery includes interventions to aid pulmonary and cardiac function. The aim of this study was to investigate the effect of such interventions on right ventricular function (RVF). DESIGN: This was a prospective intervention study. SETTING: This study was conducted at a single tertiary university hospital. PARTICIPANTS: Thirty elective coronary artery bypass graft (CABG) patients were studied in the intensive care unit (ICU) following CABG surgery. INTERVENTIONS: The following interventions were investigated: Trendelenburg position; positive end-expiratory pressure (PEEP) 0, 5, and 10 cmH2O; increased oxygen fraction; and AAI, DDD, and VVI pacing. MEASUREMENTS AND MAIN RESULTS: Transesophageal echocardiography and a pulmonary artery catheter were used to assess hemodynamics and RVF. Transesophageal echocardiography measures included right ventricular (RV) fractional area change, RV ejection fraction, RV stroke volume (SV), and RV global longitudinal strain (RV-GLS). Trendelenburg increased global echocardiographic measures of RVF as well as cardiac output (CO) 0.44 L/min (95% CI: 0.21-0.67). Increasing PEEP from 0 to 10 reduced SV and consequently CO by 0.41 L/min. Pulmonary vascular resistance was not changed by increasing PEEP. AAI or DDD pacing (15 beats above baseline) increased CO 0.35 L/min (95% CI 0.07-0.63). In contrast VVI pacing decreased CO by 24% (1.2 L/min [95% CI 0.9-1.6]). Applying 100% O2 did not affect hemodynamics, but RV-GLS was improved -4.4% (95% CI: -6.9 to -1.9). CONCLUSION: In patients with normal RVF undergoing CABG, several routine interventions in the ICU affect RVF, in particular PEEP and VVI pacing, which induces clinically important reductions in stroke volume.

Right ventricular transverse displacement increases following cardiac surgery: possibly compensating loss in tricuspid annular plane systolic excursion (TAPSE).

Right Ventricular (RV) output mostly derives from longitudinal shortening in normal hearts. However, following even uncomplicated cardiac surgery with preserved RV function a significant and sustained decrease in longitudinal contraction has been observed. How the RV compensates and sustains output in this setting remains unsettled. The aim of this study was to evaluate the RV contraction pattern by speckle tracking echocardiography to elucidate possible compensatory mechanisms mitigating the reduced RV longitudinal contraction after cardiac surgery. Thirty patients with normal preoperative ejection fraction and no valvulopathy underwent coronary artery bypass grafting (CABG) with the use of cardiopulmonary bypass (CPB). RV dedicated speckle tracking software measuring longitudinal and transverse displacement, as well as strain, was employed on transesophageal echocardiographic (TEE) images as part of the Right Ventricular Echocardiography in cardiac SurgEry (ReVERSE) study. Data was recorded at baseline (after anesthesia induction), immediately after CPB and upon chest closure. Tricuspid Annulus Plane Systolic Excursion (TAPSE) was reduced from 2.0 [1.6-2.5 cm] to 0.8 [0.6-11 mm] from baseline to after chest closure. RV longitudinal displacement was reduced from 6.1 [3.4-8.8 mm] to 2.9 [0.4-5.4 mm] at the same time-points. RV speckle tracking revealed concomitantly that transverse displacement of the free wall increased significantly from 1.2 [0-2.7 mm] at baseline to 5.4 [3.6-7.2 mm] after chest closure. RV speckle tracking strain did not change significantly. Increased transverse displacement likely compensates for reduction in RV longitudinal contraction following cardiac surgery and maintains cardiac output. The sustained output from the right ventricle was not related to an increased contractility.

Severe loss of right ventricular longitudinal contraction occurs after cardiopulmonary bypass in patients with preserved right ventricular output.

Assessment of right ventricular (RV) function is crucial since RV failure with a reduced cardiac output (CO) is associated with compromised outcome in cardiac surgery. Echocardiographic evaluation of RV function is commonly used, but a reduction in tricuspid annular plane systolic excursion (TAPSE) and tricuspid annulus tissue Doppler imaging (S') have been observed independently of clinical signs of RV failure. This has led to uncertainty of these variables' validity in cardiac surgery. To describe transesophageal echocardiographic (TEE) measures of RV function during coronary artery bypass graft surgery with detailed haemodynamic assessment using pulmonary artery catheter (PAC) measurements to describe "natural" changes in the absence of RV failure. We prospectively studied 30 patients with concomitant PAC and TEE measurements at four time-points, namely after: anaesthesia induction, sternotomy, cardiopulmonary bypass (CPB) and upon arrival in the intensive care unit. TAPSE and S' were significantly reduced by 43% (p < 0.0001) and 22% (p = 0.006), respectively after CPB without any change in stroke volume (SV). RV ejection fraction (RVEF), RV fractional area change (RVFAC) and global longitudinal strain (RV-GLS) remained unchanged. SV measured with 3D echocardiography correlated with PAC measured SV (r = 0.66[95% CI 0.50; 0.78], p < 0.0001), but 3D showed a minor, but statistically significant underestimation of SV (8.5 ml (95% CI 2.7 ml; 14 ml, p = 0.004). TAPSE and S' were both reduced after CPB despite maintained CO. RVFAC, RVEF and RV-GLS remained stable, however, these measures were unable to detect minor changes in SV. 3D-echocardiographyshowed a strong correlation with SV measured by thermodilution, but with a consistent underestimation of approximately 10%.

Tricuspid annular plane systolic excursion is significantly reduced during uncomplicated coronary artery bypass surgery: A prospective observational study.

OBJECTIVES: Longitudinal shortening constitutes most of the right ventricle (RV) contraction in the normal heart. However, after even uncomplicated cardiac surgery with preserved RV function a significant and sustained decrease in longitudinal contraction expressed as a reduction in tricuspid annular plane systolic excursion (TAPSE) has been observed. Why and exactly when this happens remains unsettled. The aim of this study was to evaluate the magnitude and timing of changes in TAPSE in relation to sternotomy, pericardial opening, cardiopulmonary bypass (CPB), and chest closure. METHODS: Fifty patients with normal preoperative ejection fraction and no valvulopathy, who underwent coronary artery bypass grafting with the use of CPB, were included. TAPSE was assessed using transthoracic echocardiography (TTE) at baseline and immediately after chest closure. Transesophageal echocardiography was performed at the following time points: after (1) anesthesia induction and transthoracic echocardiography; (2) sternotomy; (3) pericardiotomy; (4) completion of CPB; and (5) chest closure. RESULTS: TAPSE was significantly reduced to approximately half of its initial value in all patients (from 22 [95% confidence interval, 21-23 mm] after anesthesia induction to 9 [95% confidence interval, 8-10 mm] after chest closure). No change was seen after pericardiotomy. The most prominent reduction (30%-40%) was observed after weaning from CPB. An additional significant decrease of 13% to 16% was seen after chest closure. CONCLUSIONS: TAPSE was consistently reduced to approximately half of its initial value after uncomplicated coronary artery bypass grafting surgery. The reduction happened mainly after weaning from CPB, possibly reflecting conformational change of the RV.

Measures of right ventricular function after transcatheter versus surgical aortic valve replacement.

Objectives: Describe changes in measures of right ventricular (RV) function in patients treated for aortic stenosis using open-chest surgery (SAVR) or transcatheter treatment (TAVR). Methods: Patients in the Nordic Aortic Valve Intervention (NOTION) trial were randomized 1:1 to TAVR (n = 114) or SAVR (n = 106). Echocardiography was performed at baseline and 3 and 12 months post-procedure. Tricuspid annular plane systolic excursion (TAPSE) and right ventricular fractional area change (RVFAC) were used as measures of longitudinal and transverse RV contraction. Left ventricular ejection fraction (LVEF) and LV atrioventricular plane displacement (AVPD) were recorded as measures of LV function. Association to NYHA class was examined. Results: There were no differences in echocardiographic measurements between TAVR and SAVR at baseline. In the SAVR group, TAPSE was reduced after 3 months (2.4 ± 0.5 cm vs 1.6 ± 0.4 cm; P < 0.001), and 12 months (2.4 ± 0.5 cm vs 1.7 ± 0.4 cm; P < 0.001). RVFAC was reduced after 3 months (44% ± 11% vs 39% ± 10%; P = 0.001), but recovered at 12 months (43% ± 10%; P = 0.39). AVPD lateral increased during follow-up (1.4 ± 0.3 cm vs 1.6 ± 0.4 cm (P = 0.001) and 1.7 ± 0.4 cm, respectively; P < 0.001), whereas AVPD medial remained stable (baseline vs 3 months: P = 0.06 and baseline vs 12 months: P = 0.59). In the TAVR group, all echocardiographic measures remained unchanged from baseline to 12 months postoperatively. We found no association between echocardiographic changes and NYHA class. Conclusions: TAPSE and AVPD lateral differed between TAVR and SAVR at 3 and 12 months follow-up, but these findings were not related to any changes in NYHA class. These observations indicate that following SAVR, echocardiographic changes may not reflect right ventricular function, but merely a change in the physiological conditions. Clinicaltrials.gov identifier: NCT01057173.

Current management of von Willebrand disease and von Willebrand syndrome.

PURPOSE OF REVIEW: Anesthesiologists frequently care for patients with altered hemostasis and coagulation. Where a clear history of familial and personal bleeding exists, a thoughtful plan can be developed in advance to manage the issue perioperatively. However, in some cases, it may not be known that the patient has a disorder until excessive bleeding is noted during or after surgery. Recognition of the issue and appropriate targeted therapy are the keys to successful management. RECENT FINDINGS: With an estimated prevalence approaching 1% of the population, von Willebrand disease (vWD) is the most common hereditary bleeding diathesis, but the estimated prevalence of acquired vWD (often termed von Willebrand syndrome or vWS) is now believed to be significantly higher, especially in patients with malignancies, autoimmune diseases, cardiac valvular lesions, and in patients on mechanical circulatory support devices. Acquired vWD may also occur with certain medications. SUMMARY: The mainstay of the diagnosis of vWD is laboratory testing. Preoperative clinical assessment and a high level of suspicion are often effective to alert the anesthesiologist to the possibility of vWS, thus allowing for appropriate testing and potential prophylaxis in elective situations, as well as appropriately targeted therapy of unexpected bleeding when a hemostatic derangement was not anticipated preoperatively.

Does goal-directed fluid therapy affect postoperative orthostatic intolerance?: A randomized trial.

BACKGROUND: Early mobilization is important for postoperative recovery but is limited by orthostatic intolerance (OI) with a prevalence of 50% 6 h after major surgery. The pathophysiology of postoperative OI is assumed to include hypovolemia besides dysregulation of vasomotor tone. Stroke volume-guided fluid therapy, so-called goal-directed therapy (GDT), corrects functional hypovolemia, and the authors hypothesized that GDT reduces the prevalence of OI after major surgery and assessed this in a prospective, double-blinded trial. METHODS: Forty-two patients scheduled for open radical prostatectomy were randomized into standard fluid therapy (control group) or GDT groups. Both groups received a fixed-volume crystalloid regimen supplemented with 1:1 replacement of blood loss with colloid, and in addition, the GDT group received colloid to obtain a maximal stroke volume (esophageal Doppler). The primary outcome was the prevalence of OI assessed with a standardized mobilization protocol before and 6 h after surgery. Hemodynamic and hormonal orthostatic responses were evaluated. RESULTS: Twelve (57%) versus 15 (71%) patients in the control and GDT groups (P = 0.33), respectively, demonstrated OI after surgery, group difference 14% (CI, -18 to 45%). Patients in the GDT group received more colloid during surgery (1,758 vs. 1,057 ml; P = 0.001) and reached a higher stroke volume (102 vs. 89 ml; P = 0.04). OI patients had an increased length of hospital stay (3 vs. 2 days; P = 0.02) and impaired hemodynamic and norepinephrine responses on mobilization. CONCLUSION: GDT did not reduce the prevalence of OI, and patients with OI demonstrated impaired cardiovascular and hormonal responses to mobilization.

Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial.

CONTEXT: Use of 80% oxygen during surgery has been suggested to reduce the risk of surgical wound infections, but this effect has not been consistently identified. The effect of 80% oxygen on pulmonary complications has not been well defined. OBJECTIVE: To assess whether use of 80% oxygen reduces the frequency of surgical site infection without increasing the frequency of pulmonary complications in patients undergoing abdominal surgery. DESIGN, SETTING, AND PATIENTS: The PROXI trial, a patient- and observer-blinded randomized clinical trial conducted in 14 Danish hospitals between October 2006 and October 2008 among 1400 patients undergoing acute or elective laparotomy. INTERVENTIONS: Patients were randomly assigned to receive either 80% or 30% oxygen during and for 2 hours after surgery. MAIN OUTCOME MEASURES: Surgical site infection within 14 days, defined according to the Centers for Disease Control and Prevention. Secondary outcomes included atelectasis, pneumonia, respiratory failure, and mortality. RESULTS: Surgical site infection occurred in 131 of 685 patients (19.1%) assigned to receive 80% oxygen vs 141 of 701 (20.1%) assigned to receive 30% oxygen (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.72-1.22; P = .64). Atelectasis occurred in 54 of 685 patients (7.9%) assigned to receive 80% oxygen vs 50 of 701 (7.1%) assigned to receive 30% oxygen (OR, 1.11; 95% CI, 0.75-1.66; P = .60), pneumonia in 41 (6.0%) vs 44 (6.3%) (OR, 0.95; 95% CI, 0.61-1.48; P = .82), respiratory failure in 38 (5.5%) vs 31 (4.4%) (OR, 1.27; 95% CI, 0.78-2.07; P = .34), and mortality within 30 days in 30 (4.4%) vs 20 (2.9%) (OR, 1.56; 95% CI, 0.88-2.77; P = .13). CONCLUSION: Administration of 80% oxygen compared with 30% oxygen did not result in a difference in risk of surgical site infection after abdominal surgery. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00364741.

Antibiotic treatment delay and outcome in acute bacterial meningitis.

OBJECTIVES: To identify to what degree in-hospital delay of antibiotic therapy correlated to outcome in community acquired bacterial meningitis. METHODS: All cases of culture-positive cerebrospinal fluids in east Denmark from 2002 to 2004 were included. Medical records were collected retrospectively with 98.4% case completeness. Glasgow Outcome Scale was used. Multiple regression outcome analyses included the hypothesised factors: delay of therapy, age, bacterial aetiology, adjuvant steroid therapy, coma at admission and the presence of risk factors. RESULTS: One hundred and eighty seven cases were included. Adult mortality was 33% and the proportion of unfavourable outcome in adults was 52%, which differed significantly from that of children (<18 years) with a mortality of 3% (OR=15.8, 95% confidence interval: 3.7-67.6) and an unfavourable outcome of 14% (OR=12.7, CI: 4.3-37.2). Delay of antibiotic therapy correlated independently to unfavourable outcome (OR=1.09/h, CI: 1.01-1.19) among the 125 adult cases. In the group of adults receiving adequate antibiotic therapy within 12h (n=109), the independent correlation between antibiotic delay and unfavourable outcome was even more prominent (OR=1.30/h, CI: 1.08-1.57). The median delay to the first dose of adequate antibiotics was 1h and 39min (1h and 14min in children vs. 2h in adults, p<0.01), and treatment delay exceeded 2h in 21-37% of the cases with clinically evident meningitis. CONCLUSION: The delay in antibiotic therapy correlated independently to unfavourable outcome. The odds for unfavourable outcome may increase by up to 30% per hour of treatment delay.

Adjunctive steroid treatment: local guidelines and patient outcome in adult bacterial meningitis.

Our objective was to evaluate local guidelines regarding early steroid treatment in adult community acquired bacterial meningitis, and assess the actual treatment given and its correlation to clinical outcome. Patient outcome was obtained retrospectively from the medical records of 210 adults admitted to 47 hospitals in Denmark during 2002-2004 (population 5.4 million) and was combined with results from a questionnaire regarding treatment guidelines in these hospitals. In 36 of 47 departments responding to the questionnaire, 21 recommended early steroid treatment, but none did so initially during 2002. Early steroid treatment was given to 15% of patients and was given more often when recommended locally (41% vs 11%, OR=5.7 (2.4-13.5)). Unfavourable outcome was demonstrated rarely in patients treated with early steroids compared to the non-steroid group (17% vs 42%, p<0.05). In the 32 cases with petechial skin lesions, these were caused by pneumococci (15), meningococci (15), Staphylococcus aureus (1) and enterococci (1), and thus the presence of such lesions should not make the clinician abstain from early steroid treatment of bacterial meningitis. In conclusion, concordance with the new consensus of early steroid treatment was poor on a national basis, and better (41%) when adequate local guidelines were available. Early steroid treatment was associated with favourable outcome, and improved implementation of adequate guidelines may contribute to better patient outcome in bacterial meningitis.

[Bacterial meningitis in Denmark 2002-2003. A nation-wide laboratory-based registration]. / Bakteriel meningitis i Danmark 2002 og 2003. Landsdaekkende registrering baseret på laboratoriedata.

UNLABELLED: Notification of bacterial meningitis (BM) is likely to be incomplete, and a recent Danish study indicated that unbalanced notification may bias expected aetiology of BM. Therefore the Danish Bacterial Meningitis Group initiated a national registration of culture-positive BM. METHODS: Laboratory data on all bacterial isolates from cerebrospinal fluid deemed to be clinically relevant were identified on a national basis during 2002 and 2003. Bacterial findings were compared to cases notified during the same period. RESULTS: A total of 404 BM cases were identified. The distribution of bacterial species differed from the national notification data during the same period especially with respect to Staphylococcus aureus (6.7% vs. 0.6%), Escherichia coli (3.5% vs. 0%) and non-Streptococcus pneumoniae streptococci (10% vs. 1.9%). The overall notification-rate was 66%, and was below 20% for S. aureus, E. coli, Enterococcus faecalis, non-S. pneumoniae streptococci and for 13 cases of "other bacteria". Sensitivity to antibiotics in the BM cases was as expected for Northern Europe. Reduced sensitivity to penicillin was found in 2/202 S. pneumoniae, in 2/10 Listeria monocytogenes, and 21/27 S. aureus were penicillin resistant. E. coli was resistant to ampicillin in 5 of 13 cases and to gentamicin in 1 of 11 cases. DISCUSSION: A suboptimal notification rate with an unbalanced species distribution was found. Laboratory based data thus constitute an improved basis for future recommendations for empirical treatment of BM. A continued national collaboration may promote the development of quality indicators for diagnosis and initial treatment of BM.