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The aim of this study is to describe the anaesthesia management of two patients undergoing carinal resection under veno-venous extracorporeal membrane oxygenation (VV ECMO). In both cases, anaesthesia was induced and then maintained with inhalational agents during pneumonectomy and mediastinoscopy (respectively). Then the jugular and femoral veins were cannulated and VV ECMO was started after heparinization. One of the patients presented bleeding during surgery, which was treated with low-dose vasopressors (norepinephrine) and transfusion of platelets, fresh frozen plasma, and concentrated red blood cells. During VV ECMO, anaesthesia was maintained with target-controlled infusion of propofol. VV ECMO can be expected to improve surgical conditions in tracheal surgery; however, it is still a novel technique in this context. In selected patients, it would guarantee ventilatory support during carinal resection, but it is essential to carefully plan anaesthesia maintenance and prepare for VV ECMO-related complications. This technique should only be used in tertiary centres with experience in VV ECMO management.
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Background: This study aims to evaluate the entire experience in heart-lung transplantation (HLTx) in a country of the European Union with 47 million inhabitants according to the etiologies that motivated the procedure. Methods: A retrospective study on 1,751 consecutive transplants (HLTx: 78) was performed from 1990 to 2020 in two centers. Overall survival, adjusted for clinical profile and etiological subgroups, was compared. 7 subgroups were considered: 1) Cardiomyopathy with pulmonary hypertension (CM + PH). 2) Eisenmenger syndrome. 3) Congenital heart disease (CHD). 4) Idiopathic pulmonary arterial hypertension (IPAH). 5) Cystic fibrosis. 6) Chronic obstructive pulmonary disease (COPD)/Emphysema. 7) Diffuse interstitial lung disease (ILD). Results: Early mortality was 44% and that of the rest of the follow-up was 31%. There were differences between HTLx and HTx in survival, also comparing groups with a similar clinical profile with propensity score (p= 0.04). Median survival was low in CM + PH (18 days), ILD (29 days) and CHD (114 days), intermediate in Eisenmenger syndrome (600 days), and longer in IPAH, COPD/Emphysema and cystic fibrosis. Conclusion: HLTx has a high mortality. The etiological analysis is of the utmost interest to make the most of the organs and improve survival.
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BACKGROUND AND OBJECTIVE: Cardiovascular surgery (CCV) patients have a high incidence of perioperative anemia and bleeding that determines a high rate of allogeneic blood transfusion (AST). This is associated with an increase in morbidity, mortality and prolongs length of stay in hospital. Unnecessary transfusion is one of the measures to avoid and Patient Blood Management (PBM) programs have proven their effectiveness. Our objective was to reduce the transfusion of patients in cardiac surgery, without inferior results in morbidity and mortality, length of stay in hospital and being cost-effective, through the implementation of a PBM program. MATERIAL AND METHODS: A mixed cohort study of 226 patients divided into 2 groups: retrospective pre-PBM (GP), from 2016, and intervention group (IG), prospective from 2018, with the results of the implementation of the guide. RESULTS: The clinical results obtained allowed reducing the TSA from 92.59% to 79.69% (P<.001), saving 2.59 units of CH and 2.5 of PFC per patient (P<.001). A decrease was found in patients with fever (12.35% vs 1.56% with P=.006) and the need to escalate antibiotics (64.8% vs 42.19%, P=.002). The rest of postoperative complications and mortality at 3months did not present statistically significant differences. The length of stay was reduced by an average 3.6days in the IG, (95%CI: -8.10 to 0.9, P=.18). The cost decreased by 163.29 per patient, taking into account exclusively the saving of blood components. CONCLUSION: The PBM program is effective in reducing TSA in cardiac surgery in a tertiary hospital with high complexity patients and high transfusion rate. There are signs suggestive of a decrease in infections and a tendency to decrease the length of stay and mortality. In the economic approximation carried out, the cost of the intervention was lower than the savings implied by the decrease in transfusion.
Assuntos
Transfusão de Sangue , Estudos de Coortes , Humanos , Estudos Prospectivos , Estudos Retrospectivos , Centros de Atenção TerciáriaRESUMO
Heart failure (HF) is a syndromic condition with a high incidence in current medicine. When the symptoms of HF progress, and become refractory, cardiac transplant is the best therapeutic option. However, due to the shortage of donors and the long waiting lists, many of those patients are candidates for implantation of ventricular assist devices as a bridge to the cardiac transplant, or when this is not an option, as a definitive therapy. A series of four clinical cases of patients with ventricular assist devices that required surgical intervention, is presented. Three of them were assisted with long-term care: two EXCOR (pulsatile and para-corporeal) and one HEARTWARE (non-pulsatile and intra-corporeal), and the last one with short-term assistance; CentriMag biventricular Levitronix. There is no significant literature on the peri-operative implications of these patients when they undergo urgent or scheduled surgery. The experience in our centre leads us to raise the need to determine a series of aspects: operation of each device, emphasising the correct placement of the cannulas during the surgery; the proper management of any medication, emphasising the importance of anticoagulant and anti-platelet therapies; the Pathophysiological changes at cardiopulmonary level due to the implantation of these devices; and the importance of the administration of a correct antibiotic therapy. Given the complexity of these cases, the limited experience in this field, and the few cases that exist in these situations, it is recommended to create protocols to ensure their proper management.
