Incidence of endotracheal tube colonization with the use of PneuX endotracheal tubes in patients following cardiac surgery.

INTRODUCTION: Ventilator-associated pneumonia (VAP) develops in up to 25% of patients following cardiac surgery. Colonization of the endotracheal tube (ETT) contributes to VAP. The PneuX ETT has been shown to halve VAP in high-risk patients undergoing cardiac surgery. This article reports on the secondary analysis of bacterial colonization in relation to VAP between the PneuX and standard ETTs. METHODS: In this randomized controlled trial, patients were randomized on a 1:1 basis to Group A (PneuX ET, N=120) or Group B (standard ETT, N=120). Patients aged >70 years with or without impaired left ventricular function (<50%) undergoing elective and urgent cardiac surgery were included in this study. Incidence of postoperative VAP and analysis of bacterial colonization within the ETT (N=234) were measured for patients requiring <24 h, 24-48 h and >48 h of intubation. RESULTS: Baseline patient demographics were comparable. VAP was lower in Group A compared with Group B (10.8% vs 21%; P=0.03). The incidence of VAP was lower at each time point for Group A. There was a lower incidence of ETT colonization in Group A for patients needing >48 h of intubation. There was no difference in the type of bacterial colonization (P=0.5) or the mean number of colony-forming units [4.35x107 (1.18x108) and 2.16x108 (1.24x109) in Groups A and B, respectively (P=0.8)]. CONCLUSION: Colonization of the ETT does not seem to play an important role in early-onset VAP. There is a tendency for reduced colonization in the PneuX ETT with longer intubation times. This may have an impact on reducing the incidence of late-onset VAP.

Assessing the effectiveness of retrograde autologous priming of the cardiopulmonary bypass machine in isolated coronary artery bypass grafts.

INTRODUCTION: Currently, around 35-80% of patients undergoing cardiac surgery in the UK receive a blood transfusion. Retrograde autologous priming (RAP) of the cardiopulmonary bypass circuit has been suggested as a possible strategy to reduce blood transfusion during cardiac surgery. METHODS: Data from 101 consecutive patients undergoing isolated coronary artery bypass grafts (where RAP was used) were collected prospectively and compared with 92 historic patients prior to RAP use in our centre. RESULTS: Baseline characteristics (ie age, preoperative haemoglobin [Hb] etc) were not significantly different between the RAP and non-RAP groups. The mean pump priming volume of 1,013ml in the RAP group was significantly lower (p<0.001) than that of 2,450ml in the non-RAP group. The mean Hb level at initiation of bypass of 9.1g/dl in patients having RAP was significantly higher (p<0.001) than that of 7.7g/dl in those who did not have RAP. There was no significant difference between the RAP and non-RAP groups in transfusion of red cells, platelets and fresh frozen plasma, 30-day mortality, re-exploration rate and predischarge Hb level. The median durations of cardiac intensive care unit stay and in-hospital stay of 1 day (inter-quartile range [IQR]: 1-2 days) and 5 days (IQR: 4-6 days) in the RAP group were significantly shorter than those of the non-RAP group (2 days [IQR: 1-3 days] and 6 days [IQR: 5-9 days]). CONCLUSIONS: In the population group studied, RAP did not influence blood transfusion rates but was associated with a reduction in duration of hospital stay.

Haemorrhagic peritonitis as a late complication of echocardiography guided pericardiocentesis.

Clinically significant pericardial effusion is an uncommon complication after cardiac surgery. Pericardiocentesis can be performed either through a mini-sternotomy or under echocardiography guidance. Echocardiography guidance is a relatively safe procedure and it avoids the need for another general anaesthetic. However, in this post cardiac surgical patient echocardiography guided pericardiocentesis was complicated several days later by haemorrhagic peritonitis.

Improved outcome with organs from carbon monoxide poisoned donors for intrathoracic transplantation.

BACKGROUND: The success of intrathoracic organ transplantation has lead to a growing imbalance between the demand and supply of donor organs. Accordingly, there has been an expansion in the use of organs from nonconventional donors such as those who died from carbon monoxide poisoning. We describe our experience with 7 patients who were transplanted using organs after fatal carbon monoxide poisoning. METHODS: A retrospective study of the 1,312 intrathoracic organ transplants between January 1979 and February 2000 was completed. Seven of these transplants (0.5%) were fulfilled with organs retrieved from donors after fatal carbon monoxide poisoning. There were six heart transplants and one single lung transplant. The history of carbon monoxide inhalation was obtained in all of these donors. RESULTS: Five of 6 patients with heart transplant are alive and well with survival ranging from 68 to 1,879 days (mean, 969 +/- 823 days). One patient (a 29-year-old male) died 12 hours posttransplant caused by donor organ failure. The patient who had a right single lung transplant did well initially after the transplant, but died after 8 months caused by Pneumocystis carinii pneumonia. All those recipients who were transplanted from carbon monoxide poisoned donors and ventilated for more than 36 hours, survived for more than 30 days. Moreover, these donors were assessed and optimized by the Papworth donor management protocol. CONCLUSIONS: Carbon monoxide poisoned organs can be considered for intrathoracic transplantation. In view of the significant risk of donor organ failure, a cautious approach is still warranted. Ideally, the donor should be hemodynamically stable for at least 36 hours from the time of poisoning and on minimal support. A formal approach of invasive monitoring and active management further improves the chances of successful outcome.

Cryofibrination: did it really happen?

Cryofibrin precipitation is a phenomenon which has only recently been described, although it might have been present since the advent of membrane oxygenators for cardiopulmonary bypass procedures. The deposition of the cold-reactive protein, cryofibrin, causes progressive occlusion of the heat-exchanger part of the cardiopulmonary circuit, thus leading to a high pressure-drop phenomenon. We describe our experience with a few cases in which the cryofibrination phenomenon developed while using the 'Avecor-Affinity Medtronic' membrane oxygenator.

Pulmonary thromboendarterectomy.

Pulmonary thromboendarterectomy (PTE) provides a curative alternative to the otherwise fatal condition of chronic thromboembolic pulmonary hypertension (CTEPH). However, the condition is under-diagnosed due to a lack of awareness. An acceptable operative mortality of around 10% and long-term survival exceeding medical therapy or transplantation makes PTE a favourable choice for the treatment of CTEPH. Outcome is further optimised if the disease is diagnosed early and patients referred to specialised centres. An increase in the number of surgical procedures will also contribute to lower the mortality associated with this condition.