Quantitative Transthoracic Echocardiography of the Response to Dobutamine in Cardiac Surgery Patients With Low Cardiac Output Syndrome.

OBJECTIVE: To quantify the acute effects of dobutamine in postoperative low cardiac output syndrome (LCOS) using transthoracic echocardiographic, hemodynamic, and blood biomarker monitoring and to assess its association with clinical outcomes. DESIGN: Observational prospective study. SETTING: Single university hospital. PARTICIPANTS: Patients undergoing elective cardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Echocardiographic parameters, hemodynamic data, and plasma biomarkers were obtained before and early after inotrope initiation. The diagnostic value of transthoracic echocardiographic parameters and their association with clinical outcome were evaluated. Thirty-eight LCOS patients and 12 control patients were included. The left ventricular outflow tract velocity time integral was significantly lower in LCOS patients (11.75 v 19.08 cm; p < 0.001) and showed a marked improvement after dobutamine administration (∼37% increase). Dobutamine improved left and right ventricular function, increased mean arterial pressure and urine output, and lowered lactate levels. The duration of dobutamine support, but not in-hospital mortality, was associated with echocardiographic estimates of cardiac performance early after dobutamine initiation. CONCLUSIONS: Early transthoracic echocardiographic assessment and the acute response to inotropic therapy may provide rapid and highly valuable information in the diagnostic workup and risk evaluation of patients with suspected LCOS after cardiac surgery.

Use of Dexmedetomidine in Cardiothoracic and Vascular Anesthesia.

Dexmedetomidine is a highly selective α2-adrenergic agonist with analgesic and sedative properties. In the United States, the Food and Drug Administration approved the use of the drug for short-lasting sedation (24 h) in intensive care units (ICUs) in patients undergoing mechanical ventilation and endotracheal intubation. In October 2008, the Food and Drug Administration extended use of the drug for the sedation of nonintubated patients before and during surgical and nonsurgical procedures. In the European Union, the European Medicine Agency approved the use of dexmedetomidine in September 2011 with a single recognized indication: ICU adult patients requiring mild sedation and awakening in response to verbal stimulus. At present, the use of dexmedetomidine for sedation outside the ICU remains an off-label indication. The benefits of dexmedetomidine in critically ill patients and in cardiac, electrophysiology-related, vascular, and thoracic procedures are discussed.

Postoperative costs associated with outcomes after cardiac surgery with extracorporeal circulation: role of antithrombin levels.

OBJECTIVE: To study the impact on postoperative costs of a patient's antithrombin levels associated with outcomes after cardiac surgery with extracorporeal circulation. DESIGN: An analytic decision model was designed to estimate costs and clinical outcomes after cardiac surgery in a typical patient with low antithrombin levels (<63.7%) compared with a patient with normal antithrombin levels (≥63.7%). The data used in the model were obtained from a literature review and subsequently validated by a panel of experts in cardiothoracic anesthesiology. SETTING: Multi-institutional (14 Spanish hospitals). PARTICIPANTS: Consultant anesthesiologists. MEASUREMENTS AND MAIN RESULTS: A sensitivity analysis of extreme scenarios was carried out to assess the impact of the major variables in the model results. The average cost per patient was €18,772 for a typical patient with low antithrombin levels and €13,881 for a typical patient with normal antithrombin levels. The difference in cost was due mainly to the longer hospital stay of a patient with low antithrombin levels compared with a patient with normal levels (13 v 10 days, respectively, representing a €4,596 higher cost) rather than to costs related to the management of postoperative complications (€215, mostly owing to transfusions). Sensitivity analysis showed a high variability range of approximately ±55% of the base case cost between the minimum and maximum scenarios, with the hospital stay contributing more significantly to the variation. CONCLUSIONS: Based on this analytic decision model, there could be a marked increase in the postoperative costs of patients with low antithrombin activity levels at the end of cardiac surgery, mainly ascribed to a longer hospitalization.

Herramientas diagnósticas para la monitorización intraoperatoria de la insuficiencia ventricular derecha en cirugía cardiaca / Diagnostic tools for the intraoperative monitoring of right ventricular function during cardiac surgery

La función del ventrículo derecho tiene un importante papel en la morbilidad y la mortalidad de los pacientes sometidos a cirugía cardiaca. En este artículo se hace una revisión de las diferentes herramientas diagnósticas disponibles en quirófano, entre las que destacan la visión directa del corazón, la ecocardiografía en sus distintas modalidades (transesofágica, epicárdica), el estudio hemodinámico invasivo con el catéter de Swan-Ganz y, en casos de infarto del ventrículo derecho, el electrocardiograma. Los diferentes métodos diagnósticos disponibles son complementarios y no excluyentes, ya que cada uno de ellos aporta información que subsana las limitaciones de los diferentes sistemas de monitorización hemodinámica (AU)

Right ventricular function has a substantial effect on morbidity and mortality in patients undergoing cardiac surgery. This article contains a review of the range of diagnostic tools available in the operating room, including those that provide a direct view of the heart, different types of echocardiography (e.g. transesophageal and epicardial), invasive hemodynamic measurement using a Swan-Ganz catheter and, in patients with right ventricular infarction, electrocardiography. The various diagnostic methods available are complementary and none should be used exclusively since each provides information that compensates for the limitations of other hemodynamic monitoring techniques (AU)