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1.
Artigo em Inglês | MEDLINE | ID: mdl-32144057

RESUMO

Lung transplantation is the definitive treatment for end-stage lung disease. The pulmonary venous anastomosis has the potential for significant obstructive complications that can lead to considerable morbidity and mortality. The use of intraoperative transesophageal echocardiography, including color-flow and spectral Doppler, is instrumental in evaluating the pulmonary veins after lung transplantation. In this E-challenge, a case of intraoperative pulmonary venous obstruction after bilateral lung transplantation is described, the echocardiographic principles required to evaluate the pulmonary veins and screen for complications are reviewed, and when intervention may be required is discussed.

2.
Anesth Analg ; 2020 Feb 06.
Artigo em Inglês | MEDLINE | ID: mdl-32032103

RESUMO

Optimal analgesia is an integral part of enhanced recovery after surgery (ERAS) programs designed to improve patients' perioperative experience and outcomes. Regional anesthetic techniques in a form of various fascial plane chest wall blocks are an important adjunct to the optimal postoperative analgesia in cardiac surgery. The most common application of fascial plane chest wall blocks has been for minimally invasive cardiac surgical procedures. An abundance of case reports has been described in the anesthesia literature and reports appear promising, yet higher-level safety and efficacy evidence is lacking. Those providing anesthesia for minimally invasive cardiac procedures should become familiar with fascial plane anatomy and block techniques to be able to provide enhanced postsurgical analgesia and facilitate faster functional recovery and earlier discharge. The purpose of this review is to provide an overview of contemporary fascial plane chest wall blocks used for analgesia in cardiothoracic surgery. Specifically, we focus on relevant anatomic considerations and technical descriptions including pectoralis I and II, serratus anterior, pectointercostal fascial, transverse thoracic muscle, and erector spine plane blocks. In addition, we provide a summary of reported local anesthetic doses used for these blocks and a current state of the literature investigating their efficacy, duration, and comparisons with standard practices. Finally, we hope to stimulate further research with a focus on delineating mechanisms of action of novel emerging blocks, appropriate dosing regimens, and subsequent analysis of their effect on patient outcomes.

6.
Anesth Analg ; 129(6): 1468-1473, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31743165

RESUMO

BACKGROUND: Pain after cardiac surgery is largely treated with opioids, but their poor safety profile makes nonopioid medications attractive as part of multimodal pathways. Anti-inflammatory drugs reduce acute postoperative pain, but the role of steroids in reducing acute poststernotomy pain is unclear. We evaluated the association between the intraoperative administration of methylprednisolone and postoperative analgesia, defined as a composite of pain scores and opioid consumption, during the initial 24 hours after cardiac surgery. METHODS: We conducted a post hoc retrospective analysis of a large clinical trial in which adults having cardiac surgery were randomized 1:1 to receive 2 intraoperative doses of 250 mg IV methylprednisolone or placebo. Pain scores and opioid consumption were collected during the initial 24 hours after surgery. Methylprednisolone was considered to be associated with better pain control than placebo if proven noninferior (not worse) on both pain scores (defined a priori with delta of 1 point) and opioid consumption (delta of 20%) and superior to placebo in at least 1 of the 2 outcomes. This test was repeated in the opposite direction (testing whether placebo is better than methylprednisolone on postoperative pain management). RESULTS: Of 251 eligible patients, 127 received methylprednisolone and 124 received placebo. Methylprednisolone was noninferior to placebo on pain with difference in mean (CI) pain scores of -0.25 (-0.71 to 0.21); P < .001. However, methylprednisolone was not noninferior to placebo on opioid consumption (ratio of geometric means [CI]: 1.11 [0.64-1.91]; P = .37). Because methylprednisolone was not noninferior to placebo on both outcomes, we did not proceed to superiority testing based on the a priori stopping rules. Similar results were found when testing the opposite direction. CONCLUSIONS: In this post hoc analysis, we could not identify a beneficial analgesic effect after cardiac surgery associated with methylprednisolone administration. There are currently no data to suggest that methylprednisolone has significant analgesic benefit in adults having cardiac surgery.

8.
Artigo em Inglês | MEDLINE | ID: mdl-31558395

RESUMO

OBJECTIVES: Right ventricular failure after left ventricular assist device implantation increases postoperative morbidity and mortality. Whether intraoperative echocardiographic and hemodynamic measurements predict right ventricular failure is unclear. Speckle-tracking-derived tricuspid annulus displacement may provide a useful, effective, and straightforward predictor of severe right ventricular failure in patients having left ventricular device implantation. The aim of this study was to determine if intraoperative tricuspid annulus displacement is a stronger discriminator compared with the global longitudinal strain and modified tricuspid annular plane systolic excursion, the Michigan risk score, and pulmonary artery pulsatility index. DESIGN: Retrospective analysis. SETTING: A tertiary-care referral center. PARTICIPANTS: Patients scheduled for left ventricular assist device implantation from January 2010 to December 2017. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: The authors examined 86 patients undergoing left ventricular assist device implantation with adequate intraoperative echocardiographic images. The analyses did not demonstrate an association between tricuspid annulus displacement and severe right ventricular failure (univariate C-statistics <0.60 for all 4 echocardiographic measures). The discrimination ability was not significantly better than strain (DeLong test p = 0.44) and modified tricuspid annular plane systolic excursion (p = 0.89). The discrimination ability of tricuspid annulus displacement measurements was not better than the Michigan risk score (p = 0.65) and pulmonary artery pulsatility index (p = 0.73). CONCLUSIONS: Intraoperative echocardiographic parameters, including tricuspid annulus displacement, modified tricuspid annular plane systolic excursion, and strain, are poor discriminators of severe right ventricular failure after left ventricular assist device implantation. The preoperative Michigan risk-scoring system and intraoperative pulmonary artery pulsatility index are equally unreliable.

10.
Artigo em Inglês | MEDLINE | ID: mdl-31133354

RESUMO

OBJECTIVES: Long-axis right ventricular (RV) function, which provides nearly 80% of RV ejection, acutely decreases during cardiac surgery. RV dysfunction increases risk for perioperative morbidity and mortality. Our objective was to characterize the change in perioperative RV long-axis and global function by determining the influence of procedure type, surgical approach, and reoperative status and examining its temporal relationship to pericardiotomy versus cardiopulmonary bypass (CPB) and cardioplegia. METHODS: Standardized transesophageal echocardiographic examinations (TEEs) were prospectively performed in 109 patients undergoing coronary artery bypass grafting, mitral or aortic valve surgery, and/or aortic surgery via full sternotomy, mini-sternotomy, or right thoracotomy. Mid-esophageal, 4-chamber views centered on the RV were recorded at 4 intraoperative time points, following: (1) anesthetic induction; (2) pericardiotomy; (3) CPB; and (4) chest closure. Long-axis RV function was assessed by tricuspid annular plane systolic excursion and 2-dimensional longitudinal RV strain, and global RV function by fractional area change (FAC), calculated off-line from 2-dimensional TEE images. RESULTS: TEE measures of RV function were significantly reduced after CPB compared with baseline (baseline vs after CPB: TAPSE 2.2 [Q1, Q3: 1.8, 2.5] vs 1.5 [1.1, 1.7] mm; RV strain -22 [-24, -18] vs -16 [-20, -14] %; FAC 45 [35, 51] vs 42 [34, 49] %), but not after pericardiotomy. Reduced RV function persisted after chest closure: tricuspid annular plane systolic excursion 1.3 [1.0, 1.6] mm, RV strain -16 [-18, -13]%, FAC 38 [31, 46] %. Reduced function was demonstrated across cardiac surgical procedures, approaches, and primary and reoperative surgery. CONCLUSIONS: Acute intraoperative reduction in RV function occurs following CPB, independent of procedural characteristics and pericardiotomy. Etiology and clinical implications of reduced perioperative RV function remain to be determined.

11.
Anesth Analg ; 2019 Feb 18.
Artigo em Inglês | MEDLINE | ID: mdl-30801356

RESUMO

BACKGROUND: Pain after cardiac surgery is largely treated with opioids, but their poor safety profile makes nonopioid medications attractive as part of multimodal pathways. Anti-inflammatory drugs reduce acute postoperative pain, but the role of steroids in reducing acute poststernotomy pain is unclear. We evaluated the association between the intraoperative administration of methylprednisolone and postoperative analgesia, defined as a composite of pain scores and opioid consumption, during the initial 24 hours after cardiac surgery. METHODS: We conducted a post hoc retrospective analysis of a large clinical trial in which adults having cardiac surgery were randomized 1:1 to receive 2 intraoperative doses of 250 mg IV methylprednisolone or placebo. Pain scores and opioid consumption were collected during the initial 24 hours after surgery. Methylprednisolone was considered to be associated with better pain control than placebo if proven noninferior (not worse) on both pain scores (defined a priori with delta of 1 point) and opioid consumption (delta of 20%) and superior to placebo in at least 1 of the 2 outcomes. This test was repeated in the opposite direction (testing whether placebo is better than methylprednisolone on postoperative pain management). RESULTS: Of 251 eligible patients, 127 received methylprednisolone and 124 received placebo. Methylprednisolone was noninferior to placebo on pain with difference in mean (CI) pain scores of -0.25 (-0.71 to 0.21); P < .001. However, methylprednisolone was not noninferior to placebo on opioid consumption (ratio of geometric means [CI]: 1.11 [0.64-1.91]; P = .37). Because methylprednisolone was not noninferior to placebo on both outcomes, we did not proceed to superiority testing based on the a priori stopping rules. Similar results were found when testing the opposite direction. CONCLUSIONS: In this post hoc analysis, we could not identify a beneficial analgesic effect after cardiac surgery associated with methylprednisolone administration. There are currently no data to suggest that methylprednisolone has significant analgesic benefit in adults having cardiac surgery.

12.
J Cardiothorac Vasc Anesth ; 33(1): 60-69, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30145074

RESUMO

OBJECTIVES: To investigate short-term outcomes in patients with chronic thromboembolic pulmonary hypertension (CTEPH) presenting for pulmonary endarterectomy (PEA) and requiring extracorporeal membrane oxygenation (ECMO) during the perioperative period. DESIGN: Retrospective observational case series involving patients who underwent PEA for CTEPH, with focus on a subpopulation requiring perioperative ECMO support. SETTING: Single academic tertiary center. PARTICIPANTS: Patients who underwent PEA for CTEPH between January 1997 and December 2015 and required ECMO support. INTERVENTIONS: PEA for CTEPH with ECMO support at any time during the perioperative period. MEASUREMENTS AND MAIN RESULTS: A total of 150 patients underwent PEA for CEPTH during the study period. Of the 150 patients, 14 (9.3%) required ECMO support and (43%) survived, were discharged, and were alive at the time of the review. A total of 8 (57%) ECMO patients died during hospitalization. Although indications and type of support changed in some patients during their hospital course, the majority of patients required venovenous ECMO support for hypoxia (N = 9) versus venoarterial ECMO for hemodynamic support (N = 5) as initial indication. The mean length of stay among survivors was 42.2 ± 22 days. Severe RV dysfunction was present preoperatively among 6 patients in the nonsurvivors group (75%) and 2 in the survivors group (33%). The overall mean duration of ECMO support was 7.3 ± 5.3 days (8.3 ± 7.3 days among survivors and 6.5 ± 3.5 days among nonsurvivors). Four patients died while on ECMO. CONCLUSIONS: Although still associated with high morbidity and mortality, ECMO appears to be an important treatment adjunct providing additional time for healing and recovery of cardiopulmonary function in patients who develop severe hypoxemia or right ventricular failure after PEA.


Assuntos
Endarterectomia/métodos , Oxigenação por Membrana Extracorpórea/métodos , Hipertensão Pulmonar/cirurgia , Complicações Pós-Operatórias/epidemiologia , Embolia Pulmonar/cirurgia , Adulto , Feminino , Humanos , Hipertensão Pulmonar/etiologia , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Ohio/epidemiologia , Embolia Pulmonar/complicações , Embolia Pulmonar/mortalidade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Resultado do Tratamento
15.
J Cardiothorac Vasc Anesth ; 33(5): 1315-1322, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30581109

RESUMO

OBJECTIVE: Myocardial strain measured by speckle-tracking echocardiography detects subtle regional and global left ventricular dysfunction. Myocardial strain is measured in the longitudinal, circumferential, and radial dimensions; however, it is unclear which dimension of strain is the best predictor of postoperative outcomes. DESIGN: A secondary analysis of prospectively collected data from a clinical trial (NCT01187329). SETTING: The cardiothoracic surgical operating rooms of an academic tertiary-care center. PARTICIPANTS: Cardiothoracic surgery patients with aortic stenosis having aortic valve replacement (AVR) with or without coronary artery bypass grafting enrolled in a clinical trial. INTERVENTIONS: Myocardial deformation analysis from standardized investigative transesophageal echocardiographic examinations performed after induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: The authors compared the ability of intraoperative global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) strain to predict adverse postoperative outcomes, including prolonged hospitalization and the need for pharmacologic hemodynamic support after cardiac surgery. The association of GLS, GCS, and GRS with prolonged hospitalization (>7 days) and the need for pharmacologic hemodynamic support, with epinephrine or norepinephrine after cardiopulmonary bypass, were assessed using separate multivariable logistic regression models with adjustment for multiple comparisons. Of 100 patients, 86 had acceptable measurements for GLS analysis, 73 for GCS, and 72 for GRS. Worse GLS was associated with prolonged hospitalization [odds ratio [OR] (98.3% confidence interval [CI]) of 1.21 (1.01-1.46) per-unit worsening in strain (p = 0.01, significance criterion <0.0167)] and the need for inotropic support with epinephrine [OR (99.2% CI) of 1.81 (1.10-2.97) per-unit worsening in strain (p = 0.002, significance criterion <0.0083)], but not norepinephrine. GCS and GRS were not associated with adverse outcomes. CONCLUSION: GLS, but not GCS or GRS, predicts prolonged hospitalization and the requirement for inotropic support with epinephrine after AVR.


Assuntos
Procedimentos Cirúrgicos Cardíacos/tendências , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Resultado do Tratamento , Disfunção Ventricular Esquerda/epidemiologia
16.
J Cardiothorac Vasc Anesth ; 33(5): 1467-1470, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30567670

RESUMO

Spectral Doppler is a part of the comprehensive echocardiographic imaging of the blood flow characteristics. Both pulsed-wave (PWD) and continuous-wave Doppler (CWD) provide valuable information about the blood flow speed and direction pattern. Evaluation of blood flow characteristics is crucially important in patients who present with thoracic aortic false aneurysm (TAFA). In the case presented, spectral Doppler interrogation, using both PWD and CWD, helped with establishing accurate mechanism for TAFA and guided surgical management.


Assuntos
Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Velocidade do Fluxo Sanguíneo/fisiologia , Ecocardiografia Doppler/métodos , Monitorização Intraoperatória/métodos , Aneurisma da Aorta Torácica/fisiopatologia , Previsões , Humanos , Masculino , Pessoa de Meia-Idade
17.
Anesth Analg ; 126(5): 1484-1493, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29200066

RESUMO

BACKGROUND: Left ventricular ejection fraction (LVEF) is often preserved in patients with aortic stenosis and thus cannot distinguish between normal myocardial contractile function and subclinical dysfunction. Global longitudinal strain and strain rate (SR), which measure myocardial deformation, are robust indicators of myocardial function and can detect subtle myocardial dysfunction that is not apparent with conventional echocardiographic measures. Strain and SR may better predict postoperative outcomes than LVEF. The primary aim of our investigation was to assess the association between global longitudinal strain and serious postoperative outcomes in patients with aortic stenosis having aortic valve replacement. Secondarily, we also assessed the associations between global longitudinal SR and LVEF and the outcomes. METHODS: In this post hoc analysis of data from a randomized clinical trial (NCT01187329), we examined the association between measures of myocardial function and the following outcomes: (1) need for postoperative inotropic/vasopressor support; (2) prolonged hospitalization (>7 days); and (3) postoperative atrial fibrillation. Standardized transesophageal echocardiographic examinations were performed after anesthetic induction. Myocardial deformation was measured using speckle-tracking echocardiography. Multivariable logistic regression was used to assess associations between measures of myocardial function and outcomes, adjusted for potential confounding factors. The predictive ability of global longitudinal strain, SR, and LVEF was assessed as area under receiver operating characteristics curves (AUCs). RESULTS: Of 100 patients enrolled in the clinical trial, 86 patients with aortic stenosis had acceptable images for global longitudinal strain analysis. Primarily, worse intraoperative global longitudinal strain was associated with prolonged hospitalization (odds ratio [98.3% confidence interval], 1.22 [1.01-1.47] per 1% decrease [absolute value] in strain; P = .012), but not with other outcomes. Secondarily, worse global longitudinal SR was associated with prolonged hospitalization (odds ratio [99.7% confidence interval], 1.68 [1.01-2.79] per 0.1 second(-1) decrease [absolute value] in SR; P = .003), but not other outcomes. LVEF was not associated with any outcomes. Global longitudinal SR was the best predictor for prolonged hospitalization (AUC, 0.72), followed by global longitudinal strain (AUC, 0.67) and LVEF (AUC, 0.62). CONCLUSIONS: Global longitudinal strain and SR are useful predictors of prolonged hospitalization in patients with aortic stenosis having an aortic valve replacement.


Assuntos
Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/tendências , Hospitalização/tendências , Função Ventricular Esquerda/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/fisiopatologia , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Volume Sistólico/fisiologia , Fatores de Tempo
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