Acute normovolemic hemodilution in cardiac surgery: Rationale and design of a multicenter randomized trial.

BACKGROUND: Minimizing the use of blood component can reduce known and unknown blood transfusion risks, preserve blood bank resources, and decrease healthcare costs. Red Blood Cell (RBC) transfusion is common after cardiac surgery and associated with adverse perioperative outcomes, including mortality. Acute normovolemic hemodilution (ANH) may reduce bleeding and the need for blood product transfusion after cardiac surgery. However, its blood-saving effect and impact on major outcomes remain uncertain. METHODS: This is a single-blinded, multinational, pragmatic, randomized controlled trial with a 1:1 allocation ratio conducted in Tertiary and University hospitals. The study is designed to enroll patients scheduled for elective cardiac surgery with planned cardiopulmonary bypass (CPB). Patients are randomized to receive ANH before CPB or the best available treatment without ANH. We identified an ANH volume of at least 650 ml as the critical threshold for clinically relevant benefits. Larger ANH volumes, however, are allowed and tailored to the patient's characteristics and clinical conditions. RESULTS: The primary outcome is the percentage of patients receiving RBCs transfusion from randomization until hospital discharge, which we hypothesize will be reduced from 35% to 28% with ANH. Secondary outcomes are all-cause 30-day mortality, acute kidney injury, bleeding complications, and ischemic complications. CONCLUSION: The trial is designed to determine whether ANH can safely reduce RBC transfusion after elective cardiac surgery with CPB. STUDY REGISTRATION: This trial was registered on ClinicalTrials.gov in April 2019 with the trial identification number NCT03913481.

Effect of intraoperative dexamethasone on major complications and mortality among infants undergoing cardiac surgery The DECISION Randomized Clinical Trial

IMPORTANCE Corticosteroids are widely used in pediatric cardiac surgery to blunt systemic inflammatory response and to reduce complications; nevertheless, their clinical efficacy is uncertain. OBJECTIVE To determine whether intraoperative administration of dexamethasone is more effective than placebo for reducing major complications and mortality during pediatric cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS The Intraoperative Dexamethasone in Pediatric Cardiac Surgery was an investigator-initiated, double-blind, multicenter randomized trial that involved 4 centers in China, Brazil, and Russia. A total of 394 infants younger than 12 months, undergoing cardiac surgery with cardiopulmonary bypass were enrolled from December 2015 to October 2018, with follow-up completed in November 2018. INTERVENTIONS The dexamethasone group (n = 194) received 1mg/kg of dexamethasone; the control group (n = 200) received an equivolume of 0.9%sodium chloride intravenously after anesthesia induction. MAIN OUTCOMES AND MEASURES The primary end pointwas a composite of death, nonfatalmyocardial infarction, need for extracorporeal membrane oxygenation, need for cardiopulmonary resuscitation, acute kidney injury, prolonged mechanical ventilation, or neurological complications within 30 days after surgery. There were 17 secondary end points, including the individual components of the primary end point, and duration of mechanical ventilation, inotropic index, intensive care unit stay, readmission to intensive care unit, and length of hospitalization. RESULTS All of the 394 patients randomized (median age, 6 months; 47.2%boys) completed the trial. The primary end point occurred in 74 patients (38.1%) in the dexamethasone group vs 91 patients (45.5%) in the control group (absolute risk reduction, 7.4%; 95%CI, −0.8%to 15.3%; hazard ratio, 0.82; 95%CI, 0.60 to 1.10; P = .20). Of the 17 prespecified secondary end points, none showed a statistically significant difference between groups. Infections occurred in 4 patients (2.0%) in the dexamethasone group vs 3 patients (1.5%) in the control group. CONCLUSIONS AND RELEVANCE Among infants younger than 12 months undergoing cardiac surgery with cardiopulmonary bypass, intraoperative administration of dexamethasone, compared with placebo, did not significantly reduce major complications and mortality at 30 days. However, the study may have been underpowered to detect a clinically important difference.

New oropharyngeal double lumen cannula for sedation for transesophageal echocardiography: case series / Nova cânula orofaríongea de duplo lúmen para sedação em ecocardiografia transesofágica: série de casos

Abstract Introduction: Currently, transesophageal echodopplercardiography is frequently performed under sedation on an outpatient basis. Sedation is related with increase in incidents on airways. Bearing in mind this scenario, we developed a new double lumen oropharyngeal cannula aimed at keeping airway patency, in addition to reducing risks to patients during endoscopy procedures performed under sedation. The main objective of our study was to assess the incidence of oxygen desaturation in a series of cases of adult patients submitted to outpatient transesophageal echo exam, under sedation and using the oropharyngeal cannula. Method: 30 patients under sedation with intravenous midazolam and propofol were assessed. After loss of consciousness, the cannula was placed and patients were maintained on spontaneous breathing. Oxygen saturation, capnometry, heart rate and non-invasive arterial blood pressure, in addition to subjective data: airway patency, handling of cannula insertion and, comfort of examiner were analyzed. Results: The incidence of mild desaturation was 23.3%, and there was no severe desaturation in any of the cases. The insertion of the oropharyngeal cannula was considered easy for 29 patients (96.6%), and transesophageal echo probe handling was appropriate in 93.33% of exams performed. Conclusions: Transesophageal echo exams under sedation aided by the double-lumen oropharyngeal cannula presented a low incidence of desaturation in patients assessed, and allowed analysis of expired CO2 during the exams.

Resumo Introdução: Nos dias atuais, exames de ecocardiografia transesofágica (ETE) são realizados de forma frequente sob sedação em regime ambulatorial. A sedação está relacionada com aumento de intercorrências nas vias aéreas. Dentro desse contexto, desenvolvemos uma cânula orofaríngea de duplo-lúmen com finalidade de manutenção da via aérea pérvia, reduzindo riscos aos pacientes durante procedimentos endoscópicos sob sedação. O principal objetivo do nosso estudo foi avaliar a incidência de dessaturação em uma série de casos de pacientes adultos submetidos a ETE ambulatorial sob sedação com o uso da cânula orofaríngea. Métodos: Foram avaliados 30 pacientes sedados com midazolam e propofol intravenoso. A cânula foi inserida após perda da consciência e os pacientes foram mantidos com ventilação espontânea. Analisados saturação de oxigênio, capnometria, frequência cardíaca e pressão arterial não invasiva, além de dados subjetivos: patência das vias aéreas, manuseio e inserção da cânula e conforto ao examinador. Resultados: A incidência de dessaturação leve foi de 23.3% e não houve dessaturação grave em nenhum caso. A inserção da cânula orotraqueal foi considerada fácil em 29 pacientes (96,6%) e o manuseio da sonda de ETE foi adequada em 93,33% dos exames realizados. Conclusões: A realização dos exames de ETE sob sedação com auxílio da cânula orofaríngea de duplo lúmen apresentou baixa incidência de dessaturação nos pacientes avaliados, além de permitir análise do CO2 expirado durante a realização dos exames.

Evaluation of a Brazilian's cardiovascular anesthesia fellowship by its former trainees / Avaliação do programa de aprimoramento em anestesia cardiovascular por seus ex-estagiários

Abstract Background: After advancement of cardiovascular surgery, there is also exponential development of anesthetic techniques in this field. Patients with increasing clinical complexity challenge cardiac anesthesiologists to keep constantly updated. An evaluation of Brazilian's cardiovascular anesthesia fellowship at Dante Pazzanese Institute of Cardiology has been made and information has been collected to evaluate the fellowship program in cardiovascular anesthesia. Method: Target participants were made up of former fellowships, contacted via e-mail containing an invitation to voluntarily participate. Explanation of the survey's purpose was provided. This communication was signed by the authors and contained a hyperlink to the survey, which was constructed on and hosted on a web platform. The survey was composed of 10 objectives questions designed to describe training and subsequent career. Results: The adjusted survey response rate was 71%. Two-thirds of respondents agreed that fellowship training provided them an advantage in the job market and 93% of respondents currently work with cardiac anesthesia. At least 87% of participants would recommend the course to other anesthesiologists. Conclusion: Fellowship graduates judge their technical training as excellent and incorporated the knowledge acquired in their daily practice. However, there are improvements to be made. We believe this document may be useful as a reference for other institutions to develop their own cardiovascular anesthesia fellowship programs.

Resumo Justificativa: Com o avanço da cirurgia cardiovascular nos últimos anos, houve também um desenvolvimento exponencial das técnicas anestésicas. Pacientes com complexidade clínica crescente desafiam os anestesiologistas cardíacos a se manterem constantemente atualizados. Uma avaliação do programa de aprimoramento em anestesia cardiovascular brasileira do Instituto Dante Pazzanese de Cardiologia foi feita e informações foram coletadas para avaliar o programa. Método: Os participantes-alvo eram formados por ex-aprimorandos, contatados via e-mail com um convite para participação voluntária. A explicação do objetivo da pesquisa foi fornecida. Essa comunicação foi assinada pelos autores e continha um link para a pesquisa, que foi construída e hospedada em uma plataforma web. A pesquisa foi composta por 10 questões objetivas destinadas a descrever o treinamento e a carreira subsequente. Resultados: A taxa de resposta ajustada para a pesquisa foi de 71%. Dois terços dos entrevistados concordaram que o treinamento do programa lhes proporcionou uma vantagem no mercado de trabalho e 93% dos entrevistados trabalham atualmente com anestesia cardíaca. Pelo menos 87% dos participantes recomendariam o curso a outros anestesiologistas. Conclusão: Os graduados do programa de aprimoramento julgam sua formação técnica como excelente e incorporaram os conhecimentos adquiridos em sua prática diária. No entanto, há melhorias a serem feitas. Acreditamos que este documento possa ser útil como referência para outras instituições desenvolverem seus próprios programas de aprimoramento em anestesia cardiovascular.

Inhalational anesthesia maintenance with the Janus facial mask for transcatheter aortic-valve replacement: a case series / Manutenção da anestesia inalatória com a máscara facial Janus para substituição de válvula aórtica transcateter: uma série de casos

Abstract Background and objectives Aortic stenosis is the most common type of heart valve disease. Percutaneous aortic valve replacement has become the alternative for patients considered at high risk for surgery. Controlled mechanical ventilation with tracheal intubation has been the choice for this type of procedure, however the use of noninvasive ventilation in cardiac patients has shown to be beneficial. Janus is a novel full-face mask that allows application of noninvasive ventilation support during anesthesia. Our main objective was to evaluate the feasibility of transcatheter aortic valve replacement with prolonged transesophageal echocardiographic monitoring under deep inhalational sedation delivered through a new mask for noninvasive ventilation. Methods A case series observational study that included five patients with critical aortic stenosis that underwent inhalational anesthesia with sevoflurane for transcatheter aortic valve replacement in a hybrid room of a teaching hospital. Standard monitors and bispectral index were used, followed by inhalational induction and placement of the Janus mask. Anesthesia was maintained with sevoflurane. Patients were transferred to intensive care unit after the procedure. Complications related to the mask use, transesofageal echocardiography accessibility and respiratory implications to the patients were recorded. Results All procedures were uneventful and no major complications were observed intraoperatively. One patient presented CO2 retention (50 mmHg) and sevoflurane leak around the central opening of the mask, both without clinical significance. Conclusions The use of inhalational anesthesia with the facial mask Janus is a safe and efficient alternative to general anesthesia with tracheal intubation for transcatheter aortic valve replacement and can easily accommodate the use of transesophageal echocardiography intraoperatively.

Resumo Justificativa e objetivos A estenose aórtica é o tipo mais comum de doença valvular cardíaca. A substituição percutânea de válvula aórtica tornou-se a alternativa para pacientes cirúrgicos considerados de alto risco. A ventilação mecânica controlada com intubação traqueal tem sido a escolha para esse tipo de procedimento; porém, o uso de ventilação não invasiva em pacientes cardíacos mostrou ser benéfico. Janus é uma nova máscara facial que permite a aplicação de suporte à VNI durante a anestesia. Nosso objetivo primário foi avaliar a viabilidade da substituição transcateter de valva aórtica com monitoração ecocardiográfica transesofágica prolongada sob sedação inalatória profunda através de uma nova máscara para ventilação não invasiva. Métodos Estudo observacional de série de casos que incluiu cinco pacientes com estenose aórtica em fase crítica, submetidos à anestesia inalatória com sevoflurano para substituição transcateter de valva aórtica em uma sala híbrida de um hospital universitário. Monitores padrão e índice bispectral foram usados, seguidos de indução inalatória e colocação da máscara Janus. A anestesia foi mantida com sevoflurano. Os pacientes foram transferidos para a unidade de terapia intensiva após o procedimento. As complicações relacionadas ao uso da máscara, a acessibilidade da ecocardiografia transesofágica e as implicações respiratórias para os pacientes foram registradas. Resultados Todos os procedimentos transcorreram sem incidentes e não foram observadas complicações maiores no intraoperatório. Um paciente apresentou retenção de CO2 (50 mmHg) e vazamento de sevoflurano em torno da abertura central da máscara, ambos sem significância clínica. Conclusões O uso de anestesia inalatória com a máscara facial Janus é uma opção segura e eficiente à anestesia geral com intubação traqueal para substituição transcateter de valva aórtica e pode facilmente acomodar o uso de ecocardiografia transesofágica no intraoperatório.

Nonsurgical Strategies to Reduce Mortality in Patients Undergoing Cardiac Surgery: An Updated Consensus Process

OBJECTIVE:A careful choice of perioperative care strategies is pivotal to improve survival in cardiac surgery. However, there is no general agreement or particular attention to which nonsurgical interventions can reduce mortality in this setting. The authors sought to address this issue with a consensus-based approach.DESIGN:A systematic review of the literature followed by a consensus-based voting process.SETTING:A web-based international consensus conference.PARTICIPANTS:More than 400 physicians from 52 countries participated in this web-based consensus conference.INTERVENTIONS:The authors identified all studies published in peer-reviewed journals that reported on interventions with a statistically significant effect on mortality in the setting of cardiac surgery through a systematic Medline/PubMed search and contacts with experts. These studies were discussed during a consensus meeting and those considered eligible for inclusion in this study were voted on by clinicians worldwide.MEASUREMENTS AND MAIN RESULTS:Eleven interventions finally were selected: 10 were shown to reduce mortality (aspirin, glycemic control, high-volume surgeons, prophylactic intra-aortic balloon pump, levosimendan, leuko-depleted red blood cells transfusion, noninvasive ventilation, tranexamic acid, vacuum-assisted closure, and volatile agents), whereas 1 (aprotinin) increased mortality. A significant difference in the percentages of agreement among different countries and a variable gap between agreement and clinical practice were found for most of the interventions.CONCLUSIONS:This updated consensus process identified 11 nonsurgical interventions with possible survival implications for patients undergoing cardiac surgery. This list of interventions may help cardiac anesthesiologists and intensivists worldwide in their daily clinical practice and can contribute to direct future research in the field.

Vasodilator Agents in Pediatric Cardiac Surgery with Cardiopulmonary Bypass

Surgical management of congenital heart disease has become regularly performed in tertiary hospitals worldwide. Although routinely needed, cardiopulmonary bypass (CPB) deleteriously affects physiological processes being among the main causes of increased morbidity in cardiac surgery, especially in neonates and children.Recent studies have shown that vasodilator agents’ use during CPB improved peripheral tissue perfusion while maintaining high flow during bypass. Hence, an improvement in perfusion and oxygenation of the skin, musculature and intestinal mucosa has been demonstrated, with favorable result throughout the postoperative period.These agents, by reducing systemic vascular resistance (SVR), lead to greater peripheral blood flow, improvement in peripheral perfusion, decreased base deficit and lactic acidosis and therefore improved respiratory and circulatory status.The present article reviews the main aspects of vasodilator agents most commonly used in pediatric cardiac surgery with CPB, including: chlorpromazine, phentolamine, phenoxybenzamine, sodium nitroprusside, volatile anesthetic agents, calcium channel blockers, angiotensin blockers and inodilators.

MortalitY in caRdIAc surgery (MYRIAD): A randomizeD controlled trial of volatile anesthetics. Rationale and design

Objective: There is initial evidence that the use of volatile anesthetics can reduce the postoperative release of cardiac troponin I, the need for inotropic support, and the number of patients requiring prolonged hospitalization following coronary artery bypass graft (CABG) surgery. Nevertheless,small Randomized Controlled Trials have failed to demonstrate a survival advantage. Thus, whethervolatile anesthetics improve the postoperative outcome of cardiac surgical patients remains uncertain. An adequately powered randomized controlled trial appears desirable.Design: Single blinded, international, multicenter randomized controlled trial with 1:1 allocation ratio.Setting: Tertiary and University hospitals.

A Novel Anti-Pollution Filter for Volatile Agents During Cardiopulmonary Bypass: Preliminary Tests

There are issues regarding pollution of the operating room by volatile anesthetics such ashazards to operating theatre personnel and effects on the level of atmospheric ozone depletioncontributing to greenhouse effect.1,2 The most commonly used volatile anesthetics used for surgery—isoflurane, sevoflurane, anddesflurane—are recognized greenhouse gases and a potential deleterious effect to the earth’sozone layer.3Volatile agents are commonly used during cardiopulmonary bypass (CPB) to provide anesthesia independent of any supposed myocardial protective effects. De Hert et al suggeststhat their cardioprotective properties might also be related to the modalities of their administration..

Randomized evidence for reduction of perioperative mortality: an updated consensus process

Objective: Out of the 230 million patients undergoing major surgical procedure every year, morethan 1 million will die within 30 days. Thus, any nonsurgical interventions that help reduce perioperative mortality might save thousands of lives. We decided to update a previous consensus process to identify all the nonsurgical interventions, supported by randomized evidence, that may help reduce perioperative mortality. Design and Setting: A web-based international consensus conference. Participants: 500 hundred clinicians from 61 countries. Interventions: A systematic literature search was performed to identify published literature aboutnonsurgical interventions, supported by randomized evidence showing a statistically significant impact on mortality. Eligible papers were discussed by a Consensus Conference of experts. The interventions identified by the conference were then submitted to colleagues worldwide through aweb-based survey...

An innovative technique to improve safety of volatile anesthetics suction from the cardiopulmonary bypass circuit

CONTEXT: Myocardial injury during cardiac surgery on cardiopulmonary bypass (CPB) is a major determinant of morbidity and mortality. Preclinical and clinical evidence of dose- and time-related cardioprotective effects of volatile anesthetic drugs exist and their use during the whole surgery duration could improve perioperative cardiac protection. Even if administering volatile agents during CPB are relatively easy, technical problems, such as waste gas scavenging, may prevent safe and manageable administration of halogenated vapors during CPB. AIMS: The aim of this study is to improve the safe administration of volatile anesthesia during CPB. SETTINGS AND DESIGN: Tertiary teaching hospital. SUBJECTS AND METHODS: We describe an original device that collects and disposes of any volatile anesthetic vapors present in the exit stream of the oxygenator, hence preventing its dispersal into the operating theatre environment and adaptively regulates pressure of oxygenator chamber in the CPB circuit. RESULTS: We have so far applied a prototype of this device in more than 1300 adult cardiac surgery patients who received volatile anesthetics during the CPB phase...

Beneficial impact of levosimendanin critically ill patients with or at riskfor acute renal failure: a meta-analysisof randomized clinical trials

The incidence of Acute Kidney Injury is nowadays high in critically ill patients. Its etiology ismultifactorial and a primary role is played by low cardiac output syndrome. Everything targeted to normalizecardiac output should increase the renal perfusion and abolish the secondary vasoconstriction. Levosimendanis a calcium sensitizer drug with inotropic properties that improves cardiac output and seems to increase renalblood flow. The aim of this meta-analysis was to evaluate the role of levosimendan in critically ill patients withor at risk of Acute Kidney Injury.Methods: We performed a meta-analysis of randomized controlled trials searching for trials that comparedlevosimendan with any comparator. The endpoints were the number of patients receiving Renal ReplacementTherapy after randomization and the number of patients developing Acute Kidney Injury.Results: Final analysis included 33 trials and 3,879 patients (2,024 levosimendan and 1,855 control). Theoverall analysis showed that the use of levosimendan was associated with a significant reduction in the riskof Renal Replacement Therapy (17 of 492 [3.5%] in the levosimendan group versus 37 of 427 [8.7%] in thecontrol group, relative risk =0.52 [0.32 to 0.86], p for effect =0.01) and of Acute Kidney Injury (114 of 1,598[7.1%] in the levosimendan group versus 143 of 1,529 [9.4%] in the control arm, relative risk =0.79 [0.63 to0.99], p for effect =0.048).Conclusions: This meta-analysis suggests that the use of levosimendan is associated with a significant reductionof Renal Replacement Therapy in critically ill patients.

Use of lyophilized fibrinogenconcentrate in cardiac surgery: a systematic review

Use of fibrinogen concentrate among cardiac anesthetists is growing especially for the benefitsrelated to the reduction in the administration of bleeding and allogeneic blood components, which are exacerbatedby cardiopulmonary bypass. Moreover, these products underwent complete viral inactivation, reducingthe risks of contamination associated with transfusion. The purpose of this research was to review the literaturelooking for randomized controlled trials regarding fibrinogen concentrate and its benefits in cardiac surgery.Method: The papers used in this review were searched in BioMed Central, PubMed, Embase, and the CochraneCentral Register of Clinical Trial by two investigators. The full search strategy was performed to identify allrandomized controlled trials in the last 10 years, comparing the use of fibrinogen in the adult treatment of perioperativebleeding to standard treatment or placebo.Results: Only four articles matching the selection criteria for final analysis were identified and only 79 patientsreceived therapy with fibrinogen concentrate in randomized trials performed in cardiac surgery.Conclusions: During the last 10 years, few randomized controlled trials were performed to confirm the realbenefit of using lyophilized fibrinogen to reduce bleeding in cardiac surgery. However, when indicated, it may bea good option in order to reduce the consumption of blood products in the treatment of perioperative bleeding,following an algorithm based on point-of-care testing.

Sufentanil intratecal para revascularização do miocárdio / Intrathecal sufentanil for coronary artery bypass grafting / Sufentanilo intratecal para revascularización del miocardio

Contexto: pacientes de cirurgia cardíaca submetidos a revascularização do miocárdio com circulação extracorpórea. Objetivo: avaliar o efeito hemodinâmico da adição de sufentanil intratecal para anestesia geral. Desenho: estudo prospectivo, randômico e aberto, após aprovação do Comitê de Ética em Pesquisa. Cenário: estudo monocêntrico feito no Instituto Dante Pazzanese de Cardiologia, São Paulo, Brasil. Pacientes: foram submetidos à revascularização eletiva 40 pacientes de ambos os sexos que assinaram o termo de consentimento informado. Critérios de exclusão: doença renal crônica, procedimentos de emergência, reoperações, contraindicação para raquianestesia, fração de ejeção do ventrículo esquerdo inferior a 40%, índice de massa corporal acima de 32 kg/m2 e uso de nitroglicerina. Intervenções: os pacientes foram randomizados para receber (ou não) 1μg/kg de sufentanil intratecal. Anestesia foi induzida e mantida com infusão contínua de sevoflurano e remifentanil. Principais medidas de desfecho: variáveis hemodinâmicas, níveis sanguíneos de troponina I cardíaca, peptídeo natriurético do tipo B, interleucina-6 e fator de necrose tumoral alfa durante e após a cirurgia. Resultados: os pacientes do grupo sufentanil precisaram de menos suporte inotrópico com dopamina, comparados aos do grupo controle (9,5% vs 58%, p = 0,001), e menos aumentos de doses de remifentanil (62% vs 100%, p = 0,004). Os dados hemodinâmicos em oito intervalos de tempo diferentes e os dados bioquímicos não apresentaram diferenças entre os grupos. Conclusões: os pacientes que receberam sufentanil intratecal apresentaram uma estabilidade hemodinâmica ...

Context: Cardiac surgery patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. Objective: Evaluate the effect of adding intrathecal sufentanil to general anesthesia on hemodynamics. Design: Prospective, randomized, not blinded study, after approval by local ethics in Research Committee. Setting: Monocentric study performed at Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil. Patients: 40 consenting patients undergoing elective coronary artery bypass, both genders. Exclusion criteria: Chronic kidney disease; emergency procedures; reoperations; contraindication to spinal block; left ventricular ejection fraction less than 40%; body mass index above 32 kg/m2 and use of nitroglycerin. Interventions: Patients were randomly assigned to receive intrathecal sufentanil 1 μg/kg or not. Anesthesia induced and maintained with sevoflurane and continuous infusion of remifentanil. Main outcome measures: Hemodynamic variables, blood levels of cardiac troponin I, B-type natriuretic peptide, interleukin-6 and tumor necrosis factor alfa during and after surgery. Results: Patients in sufentanil group required less inotropic support with dopamine when compared to control group (9.5% vs 58%, p = 0.001) and less increases in remifentanil doses (62% vs 100%, p = 0.004). Hemodynamic data at eight different time points and biochemical data showed no differences between groups. Conclusions: Patients receiving intrathecal sufentanil have more hemodynamical stability, as suggested by the reduced inotropic support and fewer adjustments in intravenous opioid doses. .

Contexto: pacientes de cirugía cardíaca sometidos a revascularización miocárdica con circulación extracorpórea. Objetivo: evaluar el efecto hemodinámico de la adición de sufentanilo intratecal para anestesia general. Proyecto: estudio prospectivo, aleatorizado y abierto, con posterior aprobación del Comité de Ética en Investigación. Escenario: estudio monocéntrico realizado en el Instituto Dante Pazzanese de Cardiología, São Paulo, Brasil. Pacientes: cuarenta pacientes de ambos sexos que firmaron el consentimiento informado fueron sometidos a revascularización electiva. Criterios de exclusión: enfermedad renal crónica, procedimientos de urgencia, reintervenciones, contraindicación para la raquianestesia, fracción de eyección del ventrículo izquierdo inferior al 40%, índice de masa corporal por encima de 32 kg/m2 y uso de nitroglicerina. Intervenciones: los pacientes fueron aleatorizados para recibir (o no), 1 µg/kg de sufentanilo intratecal. La anestesia se indujo y se mantuvo con infusión continua de sevoflurano y remifentanilo. Principales medidas de resultados: variables hemodinámicas, niveles sanguíneos de troponina i cardíaca, péptido natriurético del tipo B, interleucina 6 y factor de necrosis tumoral alfa durante y después de la cirugía. Resultados: los pacientes del grupo sufentanilo necesitaron menos soporte inotrópico con dopamina, comparado con el grupo control (9,5 vs. 58%, p = 0,001) y menos aumentos de dosis de remifentanilo (62 vs. 100%, p = 0,004). Los datos hemodinámicos en 8 intervalos de tiempo diferentes y los datos bioquímicos no presentaron diferencias entre los grupos. Conclusiones: los pacientes que recibieron sufentanilo intratecal tuvieron una estabilidad hemodinámica mayor, evidenciada por el soporte ...

Use of volatile anesthetics during cardiopulmonary bypass: a systematic reviewof adverse events

Objectives: Recently,evidenceofreductioninmortalitydue totheuseofvolatileagentsduringcardiacsurgeryledto anincreaseintheiruseduringcardiopulmonarybypass(CPB). Becausethistechniquecouldbebeneficial topatients,but mightpresentseveralhazardstonewusers,theauthorsdecided toperformasystematicreviewofthemainprob-lems andcomplications.Design: Systematicliteraturereview.Setting: Hospital.Participants: Adults undergoingcardiacsurgerywithuseof volatileanestheticagentsduringCPB.Intervention: Several databasesweresearchedforperti-nent studiestoidentifyallreportsontheadverseeventsofusing volatileagentsduringCPBandallrandomizedcon-trolled trialsusingvolatileagentsduringCPB.MeasurementsandMainResults: Six nonrandomizedtrials reportingadverseeventsorcomplicationswiththeuse ofvolatileagentsduringCPBforcardiacsurgerywereidentified: 2reportinglowtransferofisoflurane tothebloodwith diffusionmembraneoxygenators;2reportingiatro-genic causesofdamageafterspillingliquidisoflurane ontothe surfaceofthemembraneoxygenatorswhile filling thevaporizer;and2suggestingthattheuseofvolatileagentsduring CPBincreasedthepollutionoftheroomandtheriskof occupationalexposureoftheoperatingroomstaff.Ontheother hand,noadverseeventwasreportedin19studiesthatrandomized1,195patientstoreceiveisoflurane, desflurane,or sevoflurane duringCPB.Conclusion: It ismandatoryforindustrytoprovidesafeand easy-to-usedevicestoadministervolatileagentsduringCPB withthestandardmembraneoxygenators.

Assessment of sternal closure using titanium plate / Avaliação do fechamento esternal com placa de titânio

INTRODUCTION: The use of plates and screws for more rigid fixation of the sternum, without maintaining contact between the upper portion of the sternum and mediastinum. The present study seeks new choice of plate with a significant difference, the same does not need to be removed in order to proceed to open when necessary sternal emerging opening of the bone. OBJECTIVE: The current study aims to evaluate the efficacy and safety of this procedure. METHODS: To this end, we selected ten patients with coronary artery disease have shown no significant risk factors for mediastinitis. The surgery was thus performed in the usual way that all patients with coronary artery disease surgeries are done at the institution. Only at the time of sternal closure is that there was a change, with the combination of steel wires and plates. RESULTS: All cases had sternal closure properly with good outcome in the medium term. CONCLUSION: The use of plates ENGIMPLAN proved safe and effective for sternal closure.

INTRODUÇÃO: A utilização de placas e parafuso para a mais rígida fixação do esterno, sem manter contato entre a porção superior do esterno e o mediastino. O estudo atual busca nova opção de placa, com um diferencial importante; a mesma não precisa ser retirada para que se proceda à abertura esternal em caso de necessidade emergente de abertura do osso. OBJETIVO: O presente estudo tem por objetivo avaliar a eficácia e a segurança de tal procedimento. MÉTODOS: Para tal, foram selecionados dez pacientes portadores de doença arterial coronária que não apresentassem importantes fatores de risco para mediastinite. As cirurgias foram, portanto, realizadas da maneira habitual, a todas os procedimentos em portadores de coronariopatias são feitas na Instituição. Somente no momento do fechamento esternal é que houve uma modificação, com a associação de fios de aço e placas. RESULTADOS: Todos os casos apresentaram fechamento esternal de forma adequada com boa evolução a médio prazo. CONCLUSÃO: O emprego das placas ENGIMPLAN se mostrou seguro e eficaz no fechamento esternal.

Randomized trial on the effect of sevoflurane on polypropylene membrane oxygenator performance

Objectives: Volatile anesthetics have cardioprotectiveproperties that improve clinically relevant outcomes in car-diac surgery, and can be used during cardiopulmonary bypass (CPB)through adapted calibrated vaporizers together with air and oxygen(O2). The effect of volatile agents on themembrane oxygenator is unknown. The aim of this study was to evaluate, for the first time, the performance of semiporous polypropylene membrane oxygenators after the use of sevoflurane vaporized during CPB in cardiacsurgery.Design: A prospective, randomized, controlled trial.Setting: Teaching hospital.Participants: Thirty-two consecutive patients scheduled to undergo coronary artery bypass graft with CPB.Interventions: Patients were allocated randomly toreceive either a volatile anesthetic (sevoflurane1%-3%, 16 patients) or an intravenous hypnotic (midazolam, 16patients)during CPB. After surgery, the membrane oxygen-ators used during CPB were tested with regard to O2 transfer, carbon dioxide transfer, and pressure decrease.Measurements and Main Results: The authors observed no protocol deviation or crossover. The performance ofthemembrane oxygenator was similar between the 2 groups, as documented by O2 transfer (55+- 6.4mL/min/L in the sev o-flurane group versus 57+- 4.7mL/min/L in the midazolam group, p= 0.4), carbon dioxide transfer, and pressure drop.Conclusions: The use of sevoflurane during CPB in cardiacsurgery does not affect membrane oxygenator performance.