Post-Cardiac Arrest Syndrome Is Not Associated With an Early Bacterial Translocation.

BACKGROUND: The aim of this study was to investigate bacterial translocation and its possible role in the development of post-resuscitation inflammatory response following Cardio-Pulmonary Resuscitation (CPR) after cardiac arrest. METHODS: Munich female swine were employed for a model of cardiac arrest via application of electrical current. After 7 min, CPR was initiated, and animals were either successfully return to spontaneous circulation (ROSC) within 40 min or not (no-ROSC). At the end of experimental period and prior to sacrifice, samples from the intestine, mesenteric lymph nodes (MLN), liver and portal vein blood were obtained. Evaluation of inflammation and gut permeability was performed; MLN, liver and portal vein samples were analyzed for 16 s rRNA detection and cytokine mRNA expression. RESULTS: A decreased expression of the tight junction protein Occludin, with higher levels of inflammation, greater epithelial disintegration, ulceration, loss of crypts and villi height were found in the intestines of the ROSC swine in comparison to no-ROSC. The macrophage surface antigen CD-14 staining was relatively more intense in the ROSC than in no-ROSC. Higher levels of TNF-α mRNA expression were present in the liver of the ROSC group. Finally, despite the inflammatory response and the gut mucosal alterations in ROSC group, no bacterial translocation was detected in liver, MLN and portal vein. CONCLUSIONS: We show that resuscitation from cardiac arrest induces inflammatory response and intestinal permeability in swine 4h after resuscitation, but not a bacterial translocation. Bacterial translocation is not an early phase phenomenon but probably part of the pathophysiologic sequelae.

Percutaneous endoscopic gastrostomy through a cervical esophageal fistula. An alternative, much improved technique for patient safety.

PURPOSE: Percutaneous endoscopic gastrostomy [PEG] by the pull-technique is easy and safe to perform through the oral cavity. However, the presence of a cervical esophageal fistula, either due to tumor invasion or simply inflammation and tissue necrosis after previous intervention or radiotherapy, in the anterior cervical region is of crucial importance when passing the endoscope and the PEG catheter from the mouth downwards. METHODS: We describe a modification of the standard peroral PEG, which is to insert the endoscope from the cervical esophageal opening instead of the oral cavity, and we support the use of this "stoma" as a way to protect it and avoid possible forceful dilatation/expansion when advancing the endoscope and the gastrostomy catheter through the mouth. RESULTS: The performance of PEG through the cervical esophageal opening was applied in 8 cases of esophageal fistula of different primary etiology but where the oro-pharyngeal passage was easily accessible. The procedure was technically successful in all patients, and no bleeding or tearing of the friable esophageal wall was evident. CONCLUSION: The use of the esophageal fistula at the anterior cervical region as a route for PEG insertion is a safe and practical alternative, highly to be recommended.

Circulatory effects of dexmedetomidine in early sepsis: a randomised controlled experimental study.

We designed this experimental study with a view to evaluate the effects of dexmedetomidine (DEX) on cardiac performance and systemic and peripheral hemodynamics in healthy and early-stage endotoxemia swine models. Our study hypothesis was that DEX can ensure hemodynamic stability during the course of endotoxemia. Thirty-two male pigs (25-27 kg) were assigned into four groups: (1) no intervention (group A), (2) DEX 0.8 µg/kg was administered in non-septic animals (group B), (3) sepsis induced by intravenous Escherichia coli endotoxin (group C) and (4) DEX 0.8 µg/kg was administered in septic animals (group D). Hemodynamic parameters such as heart rate, mean blood pressure, central venous pressure, pulmonary artery pressures, pulmonary artery occlusion pressure, pulmonary vascular resistance and cardiac output were continuously recorded. Central venous oxygen saturation was also measured in order to obtain a complete evaluation of cardiovascular response to sepsis. Heart rate was decreased, whilst mean arterial pressure decrease was alleviated after DEX administration in septic animals. In addition, central venous pressure was stable in animals with sepsis after DEX infusion. Sepsis dramatically elevated pulmonary function indicators but DEX succeeded in ameliorating this effect. The important decrease measured in central venous oxygen saturation in both sepsis groups reflected the decreased perfusion of tissues that takes place at the end of early sepsis. Our findings support the hypothesis that DEX has beneficial effects on heart rate and pulmonary artery pressure, whilst reduction in systemic blood pressure occurs at acceptable levels.

Quantification of Operational Learning in Minimal Invasive Extracorporeal Circulation.

Minimal invasive extracorporeal circulation (MiECC) has initiated important new efforts within science and technology towards a more physiologic perfusion. In this study, we aim to investigate the learning curve of our center regarding MiECC. We studied a series of 150 consecutive patients who underwent elective coronary artery bypass grafting by the same surgical team during the initial phase of MiECC application. Patients were randomly assigned into two groups. Group A (n = 75) included patients operated on MiECC, while group B (n = 75) included patients operated with conventional cardiopulmonary bypass (cCPB). The primary end-point of the study was to identify whether there is a learning curve when operating on MiECC. The following parameters were unrelated with increasing experience, even though the results favored MiECC use: reduced CPB duration (102.9 ± 25 vs. 122.2 ± 33 min, P <0.001), peak troponin release (0.07 ± 0.02 vs. 0.1 ± 0.04 ng/mL, P < 0.01), peak creatinine levels (0.97 ± 0.24 vs. 1.2 ± 0.3 mg/dL, P < 0.001), duration of mechanical ventilation (14.1 ± 7.2 vs. 36.9 ± 59.8 h, P < 0.01) and ICU stay (2.1 ± 0.7 vs. 4.4 ± 6.4 days, P < 0.01). However, need for intraoperative blood transfusion showed a trend towards a gradual decrease as experience with MiECC system was accumulating (R2 = 0.094, P = 0.007). Subsequently, operational learning applied to postoperative hematocrit and hemoglobin levels (R2 = 0.098, P = 0.006). We identified that advantages of MiECC technology in terms of reduced hemodilution and improved end-organ protection and clinical outcome are evident from the first patient. Optimal results are obtained with 50 cases; this refers mainly to significant reduction in the need for intraoperative blood transfusion. Teamwork from surgeons, anesthesiologists, and perfusionists is of paramount importance in order to maximize the clinical benefits from this technology.

Effectiveness of prophylactic levosimendan in patients with impaired left ventricular function undergoing coronary artery bypass grafting: a randomized pilot study.

OBJECTIVES: Perioperative low cardiac output syndrome occurs in 3-14% of patients undergoing isolated coronary artery bypass grafting (CABG), leading to significant increase in major morbidity and mortality. Considering the unique pharmacological and pharmacokinetic properties of levosimendan, we conducted a prospective, double-blind, randomized pilot study to evaluate the effectiveness of prophylactic levosimendan in patients with impaired left ventricular function undergoing CABG. METHODS: Thirty-two patients undergoing CABG with low left ventricular ejection fraction (LVEF ≤ 40%) were randomized to receive either a continuous infusion of levosimendan at a dose of 0.1 µg/kg/min for 24 h without a loading dose or a placebo. The primary outcome of the study was the change in the LVEF assessed with transthoracic echocardiography on the seventh postoperative day. Secondary outcomes included the physiological and clinical effects of levosimendan. RESULTS: All patients tolerated preoperative infusion of levosimendan well. The LVEF improved in both groups; this increase was statistically significant in the levosimendan group (from 35.8 ± 5% preoperatively to 42.8 ± 7.8%, P = 0.001) compared with the control group (from 37.5 ± 3.4% preoperatively to 41.2 ± 8.3%, P = 0.1). The cardiac index, SvO2, pulmonary capillary wedge pressure and right ventricular stroke work index showed a similar trend, which was optimized in patients treated with levosimendan. Moreover, an increase in extravascular lung water was noticed in this group during the first 24 h after surgery. CONCLUSIONS: This pilot study shows that prophylactic levosimendan infusion is safe and effective in increasing the LVEF postoperatively in patients with impaired cardiac function undergoing coronary surgery. This finding may be translated to 'optimizing' patients' status before surgery.

Minimally invasive extracorporeal circulation improves quality of life after coronary artery bypass grafting.

OBJECTIVES: The effect on postoperative health-related quality of life (HRQoL) after coronary artery bypass grafting (CABG) surgery with conventional cardiopulmonary bypass (cCPB) and off-pump surgery has been investigated extensively; however, there are no studies focusing on HRQoL after surgery with minimally invasive extracorporeal circulation (MiECC). Therefore, we sought to prospectively investigate the effect of MiECC on postoperative HRQoL when compared with cCPB in patients undergoing CABG over a short-term (3-month) follow-up period. METHODS: Sixty patients scheduled for elective CABG surgery were randomly assigned into two groups: those who had surgery on MiECC system (n = 30) and those who underwent CABG using cCPB (n = 30). Quality-of-life assessment was performed preoperatively (baseline-T0), at first postoperative month (T1) and at 3-month follow-up (T3). The RAND SF-36 scale was used for data collection, which included both sociodemographic and clinical characteristics of patients. The primary outcome of the study was quantitative measurement of postoperative HRQoL at 3-month follow-up. RESULTS: Both groups were balanced in terms of demographic, socio-economic and operative characteristics. At 3-month follow-up, mean SF-36 component and summary scores in each group were higher in absolute values than the respective mean baseline scores, apart from role-physical score in patients operated with cCPB. Patients operated on MiECC showed uniformly significantly higher values in all individual and summary domains, whereas patients operated on cCPB showed significant improvement in 6/8 individual domains. Patients operated on MiECC showed a more pronounced increase in SF-36 individual domain scores from the first to the third postoperative month when compared with cCPB, which was statistically significant regarding physical functioning (P = 0.001), role-physical (P < 0.001), vitality (P = 0.01) and role-emotional (P = 0.004). This resulted in a significant improvement in physical (P = 0.002) and mental (P = 0.01) summary scores. CONCLUSIONS: The current study proves that MiECC significantly improves HRQoL after coronary surgery compared with cCPB. This finding, combined with results from large-scale studies showing superior clinical outcomes from its use, enhances the role of MiECC as a dominant technique in coronary revascularization surgery.

Postoperative analgesia after low-frequency electroacupuncture as adjunctive treatment in inguinal hernia surgery with abdominal wall mesh reconstruction.

OBJECTIVE: To determine whether an electroacupuncture (EA) technique that was developed for a surgical population under general anaesthesia reduces pain after mesh inguinal hernia open repair. METHODS: A total of 54 patients with right or left inguinal hernia were randomised to group I (preoperative, intraoperative, postoperative EA), group II (preoperative, postoperative EA), or a sham control group (group III; preoperative and postoperative placement of needles, but without skin penetration). The Visual Analogue Scale (VAS) (primary outcome) and the State-Trait Anxiety Spielberger Inventory were evaluated preoperatively and at 30 min, 90 min, 10 h and 24 h after surgery. Pain threshold and tolerance were evaluated using an algometer at these same time points and preoperatively before and after EA. Levels of the stress hormones cortisol, corticotrophin and prolactin were determined at 30 min, 90 min and 10 h after surgery and preoperatively before and after EA. RESULTS: The results showed significant differences between the true EA and control groups. The true EA groups (I and II) showed statistically significantly greater improvements in the primary (VAS pain, p<0.05) and secondary outcome measures (Anxiety scale; algometer measurements, p<0.05 and stress hormones, p<0.01) compared to the control group. There were no statistically significant differences between groups I and II. CONCLUSIONS: Electroacupuncture reduces postoperative pain after mesh inguinal hernia repair and decreases stress hormone levels and anxiety during the postoperative period. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov identifier NCT01722253.

Enhanced recovery after elective coronary revascularization surgery with minimal versus conventional extracorporeal circulation: a prospective randomized study.

OBJECTIVE: A minimal extracorporeal circulation (MECC) circuit integrates the advances in cardiopulmonary bypass (CPB) technology into a single circuit and is associated with improved short-term outcome. The aim of this study was to prospectively evaluate MECC compared with conventional CPB in facilitating fast-track recovery after elective coronary revascularization procedures. DESIGN: Prospective randomized study. SETTING: All patients scheduled for elective coronary artery surgery were evaluated, excluding those considered particularly high risk for fast-track failure. The fast-track protocol included careful preoperative patient selection, a fast-track anesthetic technique based on minimal administration of fentanyl, surgery at normothermia, early postoperative extubation in the cardiac recovery unit, and admission to the cardiothoracic ward within the first 24 hours postoperatively. PARTICIPANTS: One hundred twenty patients were assigned randomly into 2 groups (60 in each group). INTERVENTIONS: Group A included patients who were operated on using the MECC circuit, whereas patients in Group B underwent surgery on conventional CPB. MEASUREMENTS AND MAIN RESULTS: Incidence of fast-track recovery was significantly higher in patients undergoing MECC (25% v 6.7%, p = 0.006). MECC also was recognized as a strong independent predictor of early recovery, with an odds ratio of 3.8 (p = 0.011). Duration of mechanical ventilation and cardiac recovery unit stay were significantly lower in patients undergoing MECC together with the need for blood transfusion, duration of inotropic support, need for an intra-aortic balloon pump, and development of postoperative atrial fibrillation and renal failure. CONCLUSIONS: MECC promotes successful early recovery after elective coronary revascularization procedures, even in a nondedicated cardiac intensive care unit setting.