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1.
Crit Care ; 25(1): 295, 2021 Aug 17.
Artigo em Inglês | MEDLINE | ID: mdl-34404458

RESUMO

BACKGROUND: Intensive Care Resources are heavily utilized during the COVID-19 pandemic. However, risk stratification and prediction of SARS-CoV-2 patient clinical outcomes upon ICU admission remain inadequate. This study aimed to develop a machine learning model, based on retrospective & prospective clinical data, to stratify patient risk and predict ICU survival and outcomes. METHODS: A Germany-wide electronic registry was established to pseudonymously collect admission, therapeutic and discharge information of SARS-CoV-2 ICU patients retrospectively and prospectively. Machine learning approaches were evaluated for the accuracy and interpretability of predictions. The Explainable Boosting Machine approach was selected as the most suitable method. Individual, non-linear shape functions for predictive parameters and parameter interactions are reported. RESULTS: 1039 patients were included in the Explainable Boosting Machine model, 596 patients retrospectively collected, and 443 patients prospectively collected. The model for prediction of general ICU outcome was shown to be more reliable to predict "survival". Age, inflammatory and thrombotic activity, and severity of ARDS at ICU admission were shown to be predictive of ICU survival. Patients' age, pulmonary dysfunction and transfer from an external institution were predictors for ECMO therapy. The interaction of patient age with D-dimer levels on admission and creatinine levels with SOFA score without GCS were predictors for renal replacement therapy. CONCLUSIONS: Using Explainable Boosting Machine analysis, we confirmed and weighed previously reported and identified novel predictors for outcome in critically ill COVID-19 patients. Using this strategy, predictive modeling of COVID-19 ICU patient outcomes can be performed overcoming the limitations of linear regression models. Trial registration "ClinicalTrials" (clinicaltrials.gov) under NCT04455451.


Assuntos
COVID-19/epidemiologia , Estado Terminal/epidemiologia , Registros Eletrônicos de Saúde/estatística & dados numéricos , Unidades de Terapia Intensiva , Aprendizado de Máquina , Adulto , Idoso , COVID-19/terapia , Estudos de Coortes , Estado Terminal/terapia , Serviço Hospitalar de Emergência , Feminino , Alemanha , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde
2.
Artigo em Alemão | MEDLINE | ID: mdl-34187073

RESUMO

Vasopressors are widely used in anaesthesiology and critical care medicine, to treat harmless (e.g. anaesthesia-induced hypotension) as well as life-threatening conditions (e.g. septic shock). Some clinically used vasopressors resemble endogenous substances - such as norepinephrine - while others have been artificially synthesized (e.g. phenylephrine). Most of the substances used in different clinical scenarios have various effects except for vasoconstriction alone. Therefore, a thorough understanding of the pharmacology and clinical profile of every single substance is of highest importance prior to practical usage. Furthermore, the fundamentals of vascular physiology and vasotonic regulation are mandatory to safely provide vasopressor-based therapies. This article covers the essentials of physiology and pharmacology of vasopressors, and the clinical settings they are used in (e.g. septic shock, vasoplegic shock after cardiac surgery, trauma-induced hypotension).


Assuntos
Choque Séptico , Choque , Humanos , Norepinefrina , Fenilefrina , Choque Séptico/tratamento farmacológico , Vasoconstritores/uso terapêutico
3.
J Intensive Care Med ; 36(6): 681-688, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33663244

RESUMO

BACKGROUND: The COVID-19 pandemic reached Germany in spring 2020. No proven treatment for SARS-CoV-2 was available at that time, especially for severe COVID-19-induced ARDS. We determined whether the infusion of mesenchymal stromal cells (MSCs) would help to improve pulmonary function and overall outcome in patients with severe COVID-19 ARDS. We offered MSC infusion as an extended indication to all critically ill COVID-19 patients with a Horovitz index <100. We treated 5 out of 23 patients with severe COVID-19 ARDS with an infusion of MSCs. One million MSCs/kg body weight was infused over 30 minutes, and the process was repeated in 3 patients twice and in 2 patients 3 times. RESULT: Four out of 5 MSC-treated patients compared to 50% of control patients (9 out of 18) received ECMO support (80%). The MSC group showed a higher Murray score on admission than control patients, reflecting more severe pulmonary compromise (3.5 ± 0.2 versus 2.8 ± 0.3). MSC infusion was safe and well tolerated. The MSC group had a significantly higher Horovitz score on discharge than the control group. Compared to controls, patients with MSC treatment showed a significantly lower Murray score upon discharge than controls. In the MSC group, 4 out of 5 patients (80%) survived to discharge and exhibited good pulmonary function, whereas only 8 out of 18 patients (45%) in the control group survived to discharge. CONCLUSION: MSC infusion is a safe treatment for COVID-19 ARDS that improves pulmonary function and overall outcome in this patient population.


Assuntos
COVID-19/complicações , COVID-19/terapia , Cuidados Críticos , Transplante de Células-Tronco Mesenquimais , Síndrome do Desconforto Respiratório/terapia , Síndrome do Desconforto Respiratório/virologia , Adulto , Idoso , COVID-19/mortalidade , Estudos de Coortes , Feminino , Alemanha , Humanos , Masculino , Pessoa de Meia-Idade , Respiração Artificial , Síndrome do Desconforto Respiratório/mortalidade , Taxa de Sobrevida , Resultado do Tratamento
4.
J Intensive Care Med ; 36(7): 783-792, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32274961

RESUMO

BACKGROUND: Temporary extracorporeal life support (ECLS) by venoarterial extracorporeal membrane oxygenation is an emerging therapy for patients with severe, ongoing cardiogenic shock. After stabilization of the hemodynamic status and end-organ function, sedation weaning, extubation, and noninvasive ventilation (NIV) can be attempted. The goal of this study was to analyze the feasibility of extubation and NIV during versus after ECLS for cardiogenic shock. METHODS: Single-center retrospective observational study of 132 patients undergoing ECLS due to severe cardiogenic shock between January 2015 and December 2016 at a tertiary care university hospital. RESULTS: Patients received ECLS due to acute myocardial infarction (20.6%), ongoing cardiogenic shock (15.2%), postoperative low-cardiac-output syndrome (24.2%), and extracorporeal cardiopulmonary resuscitation (40.2%). Overall, intensive care unit survival was 44.7%. Sixty-nine (52.3%) patients could never be extubated. Forty-three (32.6%) were extubated while on ECLS support (group 1) and 20 (15.1%) were extubated after weaning from ECLS (group 2). Patients extubated during ECLS had a significantly shorter total time on ventilator (P = .003, mean difference: -284 hours [95% confidence limits: -83 to -484]) and more invasive ventilation free days (P = .0018; mean difference 8 days [95%CL: 2-14]). Mortality and NIV failure rates were similar between groups. CONCLUSIONS: Extubation and NIV are feasible in patients who stabilize during ECLS therapy. Further studies need to address whether extubation has the potential to improve patients outcome or if the feasibility to extubate is a surrogate for disease severeness.

5.
Artif Organs ; 45(5): 524-527, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33184841

RESUMO

We report the case of a 12-year old female patient with Friedreich's ataxia and diabetes mellitus. Due to a progressive multiorgan failure, a veno-arterial extracorporeal membrane oxygenation was implanted through the axillary vessels. However, due to a lack of ejection and severe dilatation of the left ventricle, an Impella 2.5 was implanted. Due to the small diameter of the femoral arteries, we performed a trans-aortic implantation through a median sternotomy via a Dacron tube graft. We report on the procedure and perioperative outcome.

6.
Platelets ; : 1-9, 2020 Dec 21.
Artigo em Inglês | MEDLINE | ID: mdl-33347335

RESUMO

Blood flow through left ventricular assist devices (LVAD) may induce activation and dysfunction of platelets. Dysfunctional platelets cause coagulation disturbances and form platelet-neutrophil conjugates (PNC), which contribute to inflammatory tissue damage. This prospective observational cohort study investigated patients, who underwent implantation of a LVAD (either HeartMate II (HM II) (n = 7) or HeartMate 3 (HM 3) (n = 6)) and as control patients undergoing coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) (n = 10). We performed platelet and leukocyte flow cytometry, analysis of platelet activation markers, and platelet aggregometry. Platelet CD42b expression was reduced at baseline and perioperatively in HM II/3 compared to CABG/AVR patients. After surgery the platelet activation marker ß-thromboglobulin and platelet microparticles increased in all groups while platelet aggregation decreased. Platelet aggregation was more significantly impaired in LVAD compared to CABG/AVR patients. PNC were higher in HM II compared to HM 3 patients. We conclude that LVAD implantation is associated with platelet dysfunction and proinflammatory platelet-leukocyte binding. These changes are less pronounced in patients treated with the newer generation LVAD HM 3. Future research should identify device-specific LVAD features, which are associated with the least amount of platelet activation to further improve LVAD therapy.

7.
Blood Coagul Fibrinolysis ; 31(8): 551-557, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33141779

RESUMO

: Bleeding after cardiac surgery is associated with significant morbidity and mortality. Hypofibrinogenemia is a crucial factor for bleeding in this setting and may be rapidly detected using point-of-care viscoelastic tests (POC-VET). However, the correlation of POC-VET with conventional coagulation assays is still unclear. The current study aimed to correlate resonance-based POC-VET assays (Haemonetics TEG 6s) with the traditional nonrapid Clauss method. Another aim was to identify a cut-off value for the detection of hypofibrinogenemia (fibrinogen plasma level below 150 mg/dl) focusing on the maximum amplitude of the TEG 6s citrated functional fibrinogen (CFF) assay. Adult patients undergoing cardiac surgery were screened for inclusion in this single-centre retrospective cohort study. Inclusion criteria were the availability of a TEG assay and timely corresponding laboratory results. Calculation of a CFF-maximum amplitude (CFF-MA) cut-off value was performed using receiver operating curve analysis in the baseline cohort and validated in the control cohort. The best correlation with the Clauss method was observed for the CFF-MA (r = 0.77; P < 0.0001) compared with the citrate kaolin maximum amplitude assay (r = 0.57; P < 0.0001) and the citrate kaolin heparinase maximum amplitude assay (r = 0.67; P < 0.0001). A cut-off value of 19.9 mm for the CFF-MA was calculated [area under the curve 0.87 (95% confidence interval: 0.82-0.92; P < 0.0001)]. This cut-off value had a sensitivity of 81.8% and a specificity of 71.1% for identification of hypofibrinogenemia in the control cohort. The resonance-based thrombelastography analyser can identify hypofibrinogenemia. Future clinical studies should investigate whether cut-off value guided coagulation therapy with POC-VET may improve patient outcomes in patients who suffer from bleeding complications.


Assuntos
Afibrinogenemia/sangue , Fibrinogênio/análise , Afibrinogenemia/diagnóstico , Idoso , Coagulação Sanguínea , Testes de Coagulação Sanguínea , Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Humanos , Pessoa de Meia-Idade , Monitorização Intraoperatória , Testes Imediatos , Estudos Retrospectivos , Tromboelastografia
9.
Eur J Vasc Endovasc Surg ; 60(5): 647-654, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32819817

RESUMO

OBJECTIVE: The aim was to evaluate the potential of near infrared spectrometry (NIRS) monitoring enhanced by autoregulation parameters to detect clamp ischaemia during awake carotid endarterectomy (CEA). METHODS: This was a prospective, hypothesis generating, single centre observational study. Fifty-nine consecutive patients with carotid artery stenosis, of whom 15 (25%) were symptomatic, were enrolled. The patients underwent awake CEA with NIRS monitoring. Regional oxygen saturation (rSO2), relative tissue haemoglobin concentration (rTHb), and mean arterial blood pressure were captured by ICM + software (University of Cambridge Enterprise, Cambridge, UK). The cerebral oxygenation index (COx) and haemoglobin volume index (HVx) were calculated continuously. Two groups were formed depending on neurological symptoms: a symptomatic group with shunt insertion (shunt) and an asymptomatic group (no shunt). RESULTS: Eight patients (14%) became symptomatic and needed intra-operative shunting. The decrease in ipsilateral rSO2 was higher in the shunt group (13.5% vs. 5.3%) and rTHB increased on the non-operated side (+0.05 ± 0.01; p = .016). In symptomatic patients no significant change in rTHB was found during clamping, whereas in asymptomatic patients there was a bilateral increase (ipsilateral: + 0.06 [p = .022]; contralateral: + 0.06 [p = .010]). In asymptomatic patients, ipsilateral COx decreased after clamping (-0.06 ± 0.02; p = .024), indicating functional autoregulation. In symptomatic patients, ipsilateral COx increased to 0.32 (+0.19 ± 0.05; p = .048), indicating loss of autoregulation. Accordingly, pooled ipsilateral and contralateral data showed increasing HVx and COx in symptomatic patients (HVx, p < .001; COx, p = .039). CONCLUSION: In addition to a drop in rSO2, the loss of autoregulatory capacity may be useful in identifying clinically significant clamping ischaemia during CEA under general anaesthesia and may allow optimisation of blood pressure management during awake CEA.


Assuntos
Isquemia Encefálica/diagnóstico , Estenose das Carótidas/cirurgia , Circulação Cerebrovascular/fisiologia , Endarterectomia das Carótidas/efeitos adversos , Complicações Intraoperatórias/diagnóstico , Monitorização Intraoperatória/métodos , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/efeitos adversos , Pressão Arterial/fisiologia , Isquemia Encefálica/etiologia , Isquemia Encefálica/fisiopatologia , Isquemia Encefálica/prevenção & controle , Circulação Colateral/fisiologia , Estudos de Viabilidade , Feminino , Homeostase/fisiologia , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/fisiopatologia , Complicações Intraoperatórias/prevenção & controle , Masculino , Oximetria/métodos , Oxigênio/sangue , Estudos Prospectivos , Espectroscopia de Luz Próxima ao Infravermelho , Vigília/fisiologia
10.
Cardiovasc Ultrasound ; 18(1): 32, 2020 Aug 12.
Artigo em Inglês | MEDLINE | ID: mdl-32787878

RESUMO

BACKGROUND: Right ventricular (RV) function is an important prognostic indicator. The acute effects of cardiac interventions or cardiac surgery on global and longitudinal RV function are not entirely understood. In this study, acute changes of RV function during mitral valve surgery (MVS), percutaneous mitral valve repair (PMVR) and off-pump coronary artery bypass surgery (OPCAB) were investigated employing 3D echocardiography. METHODS: Twenty patients scheduled for MVS, 23 patients scheduled for PMVR and 25 patients scheduled for OPCAB were included retrospectively if patients had received 3D transesophageal echocardiography before and immediately after MVS, PMVR or OPCAB, respectively. RV global and longitudinal function was assessed using a 3D multiparameter set consisting of global right ventricular ejection fraction (RVEF), tricuspid annular plane systolic excursion (TAPSE), longitudinal contribution to RVEF (RVEFlong) and free wall longitudinal strain (FWLS). RESULTS: Longitudinal RV function was significantly depressed immediately after MVS, as reflected by all parameters (RVEFlong: 20 ± 5% vs. 13 ± 6%, p <  0.001, TAPSE: 13.1 ± 5.1 mm vs. 11.0 ± 3.5 mm, p = 0.04 and FWLS: -20.1 ± 7.1% vs. -15.4 ± 5.1%, p <  0.001, respectively). The global RVEF was slightly impaired, but the difference did not reach significance (37 ± 13% vs. 32 ± 9%, p = 0.15). In the PMVR group, both global and longitudinal RV function parameters were unaltered, whereas the OPCAB group showed a slight reduction of RVEFlong only (18 ± 7% vs. 14 ± 5%, p <  0.01). RVEFlong yielded moderate case-to-case but good overall reproducibility. CONCLUSIONS: TAPSE, FWLS and RVEFlong reflect the depression of longitudinal compared to global RV function initially after MVS. PMVR alone had no impact, while OPCAB had a slight impact on longitudinal RV function. The prognostic implications of these phenomena remain unclear and require further investigation.

11.
Crit Care Res Pract ; 2020: 6958152, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32257436

RESUMO

Background: Extracorporeal membrane oxygenation (ECMO) serves as a rescue therapy when systemic hypoxia persists despite conventional care for severe acute respiratory distress syndrome (ARDS). Due to the extracorporeal gas exchange, the p aO2/F iO2 ratio cannot be used as the primary marker for disease severity and progression. Therefore, we performed a propensity score-matched analysis to identify other potential predictors of outcomes in patients supported by ECMO therapy. Results: Between December 2014 and May 2018, 105 patients underwent venovenous ECMO in our institution. From these patients, we identified 28 who died during ECMO therapy and assigned 28 control patients using propensity score matching based on the following criteria: age, ARDS severity, and SAPSII score at admission. A statistical evaluation of the patient characteristics, intensive care data, morbidities, respiratory system variables, and outcomes was performed. The baseline patient characteristics did not differ between groups and ECMO was placed on day 1 in all patients. The analyzed variables of respiratory mechanics, such as the plateau pressure, positive end-expiratory pressure, and tidal volume, did not differ between groups. The driving pressure before ECMO was equal between the nonsurvivors and the controls. Twelve hours after initiation of ECMO therapy, the driving pressure decreased by 40.8% in the survivors but by only 20.1% in the nonsurvivors. Conclusions: We report that very early driving pressure changes can serve as an indicator of disease severity and predict patient survival following ECMO therapy.

13.
Perfusion ; 35(7): 621-625, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-31960747

RESUMO

INTRODUCTION: Aortic arch reconstruction surgery represents a challenge for the medical personnel involved in treatment. Along the years, the perfusion strategies for aortic arch reconstruction have evolved from deep hypothermic cardiac arrest to antegrade cerebral perfusion with moderate hypothermia, and recently to a combined cerebral and lower body perfusion with moderate hypothermia. To achieve a lower body perfusion, several cannulation strategies have been described. In this study, we investigated the feasibility of utilizing an arterial sheath introduced in the femoral artery to achieve an effective lower body perfusion. METHODS: We included patients who underwent an aortic arch reconstruction surgery with a lower body perfusion, from January 2017 to June 2019. To achieve a lower body perfusion, a three-way stopcock was connected to the arterial line, where one end was connected to the central cannulation for cerebral perfusion and the other to an arterial sheath that was introduced through the femoral artery. A total of 25 patients were included. Peri- and postoperative lactate and creatinine levels and signs of malperfusion were recorded. RESULTS: During the reperfusion phase, after selective perfusion ended none of the patients showed a significant increase in lactate, creatinine, and liver enzyme levels. After 24 hours, there were no signs of an acute kidney injury, femoral vessel injury, or limb malperfusion. CONCLUSION: These findings show that a sufficient lower body perfusion through an arterial sheath placed in the femoral artery for aortic arch reconstruction can be achieved. This approach caused no complications related to the arterial sheath during the early postoperative period and is an easy way to maintain perfusion of systemic organs.

14.
BMC Anesthesiol ; 19(1): 199, 2019 11 04.
Artigo em Inglês | MEDLINE | ID: mdl-31684877

RESUMO

BACKGROUND: General anesthesia induction with the initiation of positive pressure ventilation creates a vulnerable phase for patients. The impact of positive intrathoracic pressure on cardiac performance has been studied but remains controversial. 3D echocardiography is a valid and MRI-validated bed-side tool to evaluate the right ventricle (RV). The aim of this study was to assess the impact of anesthesia induction (using midazolam, sufentanil and rocuronium, followed by sevoflurane) with positive pressure ventilation (PEEP 5, tidal volume 6-8 ml/kg) on 2D and 3D echocardiography derived parameters of RV function. METHODS: A prospective observational study on fifty-three patients undergoing elective cardiac surgery in a tertiary care university hospital was designed. Transthoracic echocardiography exams were performed before and immediately after anesthesia induction and were recorded together with hemodynamic parameters and ventilator settings. RESULTS: After anesthesia induction TAPSE (mean difference - 1.6 mm (95% CI - 2.6 mm to - 0.7 mm; p = 0.0013) as well as the Tissue Doppler derived tricuspid annulus peak velocity (TDITVs') were significantly reduced (mean difference - 1.9% (95% CI: - 2.6 to - 1.2; p < 0.0001), but global right ventricular ejection fraction (RVEF; p = 0.1607) and right ventricular stroke volume (RVSV; p = 0.1838) did not change. CONCLUSIONS: This data shows a preserved right ventricular ejection fraction and right ventricular stroke volume after anesthesia induction and initiation of positive pressure ventilation. However, the baso-apical right ventricular function is significantly reduced. Larger studies are needed in order to determine the clinical impact of these findings especially in patients presenting with impaired right ventricular function before anesthesia induction. TRIAL REGISTRATION: Retrospecitvely registered, 6th June 2016, ClinicalTrials.gov Identifier NCT02820727 .


Assuntos
Anestesia Geral/métodos , Ecocardiografia/métodos , Respiração com Pressão Positiva/métodos , Disfunção Ventricular Direita/diagnóstico por imagem , Idoso , Ecocardiografia Tridimensional/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Volume Sistólico/fisiologia , Volume de Ventilação Pulmonar/fisiologia , Função Ventricular Direita/fisiologia
15.
Int J Cardiol Heart Vasc ; 24: 100413, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31508480

RESUMO

Introduction: In this study, we evaluated right ventricular (RV) function before and after percutaneous mitral valve repair (PMVR) using conventional echocardiographic parameters and novel 3DE data sets acquired prior to and directly after the procedure. Patients and methods: Observational study on 45 patients undergoing PMVR at an university hospital. Results: In the overall collective, the 3D RV-EF before and after PMVR showed no significant change (p = 0.16). While there was a significant increase of the fractional area change (FAC, from 23 [19-29] % to 28 [24-33] %, p = 0.001), no significant change of the tricuspid annular plane systolic excursion (TAPSE, from 17 ±â€¯6 mm to 18 ±â€¯5 mm (standard deviation), p = 0.33) was observed. Regarding patients with a reduced RV-EF (< 35%), a significant RV-EF improvement was observed (from 27 [23-34] % to 32.5 [30-39] % (p = 0.001). 71.4% of patients had an improved clinical outcome (improvement in 6-minute walk test and/or improvement in NYHA class of more than one grade), whereas clinical outcome did not improve in 28.6% of patients. Using univariate logistic regression analysis, the post-PMVR RV-EF (OR 1.15: 95% CI 1.02-1.29; p = 0.02) and the change in RV-EF (OR 1.13: 95% CI 1.02-1.25; p = 0.02) were significant predictors for improved clinical outcome at 6 months follow up. Conclusion: Thus, RV function may be an important non-invasive parameter to add to the predictive parameters indicating a potential clinical benefit from treatment of severe mitral regurgitation using PMVR.

16.
Thromb Res ; 182: 33-38, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31445451

RESUMO

BACKGROUND: The monitoring of unfractionated heparin (UFH) reversal with protamine plays a crucial role for bleeding management after cardio-pulmonary bypass (CPB) in congenital cardiac surgery. The current standard for the monitoring of UFH and its reversal is the activated clotting time (ACT). While the ACT is affected by other CPB-associated pathologies a bedside technique with more specific heparin-related results would be very helpful. The new point-of-care viscoelastic test Haemonetics TEG® 6s, which is based on small blood samples may fulfill these requirements. This study aimed to compare the new TEG with laboratory assays. METHODS: A retrospective observational study was performed on 40 children with a median age of 130 days (interquartile range 13 to 310 days) undergoing congenital cardiac surgery. After separation of CPB, test results of the TEG® 6s, ACT, anti-Xa for UFH and PTT were compared and correlated with each other. RESULTS: No clinically relevant correlation was found for heparin specific TEG-derived parameters (CK/CKH R-time ratio) with ACT, PTT and anti-Xa measurements. After grouping in dependence to the CK/CKH R-time in patients with and without successful heparin reversal again no significant difference of anti-Xa-UFH-levels, post-/pre-CPB ratio of the PTT and ACT was observed. CONCLUSIONS: In pediatric patients undergoing cardiac surgery using CPB there is no association of conventional coagulation tests and TEG-derived results. While bedside viscoelastic tests deliver rapid results, further studies are needed to compare whether the TEG based management of incomplete heparin reversal is sufficient to monitor heparin reversal and to reduce blood loss.


Assuntos
Anticoagulantes/uso terapêutico , Cardiopatias Congênitas/cirurgia , Antagonistas de Heparina/uso terapêutico , Heparina/uso terapêutico , Protaminas/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Testes de Coagulação Sanguínea , Ponte Cardiopulmonar/métodos , Feminino , Cardiopatias Congênitas/sangue , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos
18.
Int J Cardiovasc Imaging ; 35(12): 2177-2188, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31321655

RESUMO

Longitudinal right ventricular (RV) function is substantial and might be reflected by free wall longitudinal strain (FWLS). Software solutions for FWLS analysis by two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) are available, but data on validation are sparse. In this study, a novel method for FWLS analysis on 3D meshes ("mesh surface", MS-FWLS,) was tested for feasibility and compared to available parameters. 80 patients undergoing left-sided cardiac valve surgery with intraoperative TEE were included retrospectively. 2D-FWLS, 3D-derived (3Dd)-FWLS (assessed in optimized four-chamber views after volume analysis) and MS-FWLS were measured and compared to conventional parameters (3Dd-TAPSE, FAC and RVEF). The mean FWLS values did not differ significantly between methods (- 19.0 ± 6.1%, - 20.0 ± 7.3%, - 19.5 ± 7.3% for 2D-, 3Dd- and MS-FWLS, respectively). No significant differences in the mean FWLS between patients with normal or increased pulmonary artery pressures as well as normal or reduced left ventricular ejection fraction were observed. Agreement was best between 3Dd- and MS-FWLS (r = 0.89, bias = - 1.0%, LOA ± 6.9%). Conventional echocardiographic parameters yielded poorer intermodality agreement. In patients with discrepant results between 2D- and 3Dd-FWLS, 3Dd-FWLS and MS-FWLS yielded similar results (r = 0.82, bias = - 0.3%, LOA ± 8.6%), while 2D-FWLS and MS-FWLS did not. Intra- and interobserver variabilities of strain analyses were low. MS-FWLS might represent a promising method to overcome artefacts associated with 2D analysis. Its prognostic relevance needs to be investigated in prospective studies.


Assuntos
Ecocardiografia Tridimensional , Ecocardiografia Transesofagiana , Contração Miocárdica , Disfunção Ventricular Direita/diagnóstico por imagem , Função Ventricular Direita , Adulto , Idoso , Estudos de Viabilidade , Feminino , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Disfunção Ventricular Direita/fisiopatologia
19.
Pediatr Crit Care Med ; 20(10): 923-930, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31232848

RESUMO

OBJECTIVES: The transition from single-ventricle lesions with surgically placed systemic-to-pulmonary artery shunt to the circulation following a bidirectional cavopulmonary connection results in higher pressure in the superior vena cava when compared with the preceding circulation. The aim of this study was to evaluate the impact of this transition on the perioperative cerebral oxygen metabolism. DESIGN: Prospective observational cohort study. SETTING: Pediatric critical care unit of a tertiary referral center. PATIENTS: Sixteen infants after bidirectional cavopulmonary connection. INTERVENTION: Cardiac surgery (bidirectional cavopulmonary connection). MEASUREMENTS AND MAIN RESULTS: We measured regional cerebral oxygen saturation, amount of hemoglobin, blood flow velocity, and microperfusion immediately before, 12-24 hours, and 36-48 hours following bidirectional cavopulmonary connection. Based on these measurements, we calculated cerebral fractional tissue oxygen extraction and approximated cerebral metabolic rate of oxygen. Mean pressure in the superior vena cava increased significantly (8 vs 17 mm Hg; p < 0.001) following bidirectional cavopulmonary connection. Mean cerebral oxygen saturation increased from 49.0% (27.4-61.0) to 56.9% (39.5-64.0) (p = 0.008), whereas mean cerebral blood flow velocity decreased from 80.0 arbitrary units (61.9-93.0) to 67.3 arbitrary units (59.0-83.3) (p < 0.001). No change was found in the cerebral amount of hemoglobin and in the cerebral microperfusion. Mean cerebral fractional tissue oxygen extraction (0.48 [0.17-0.63] vs 0.30 [0.19-0.56]; p = 0.006) and approximated cerebral metabolic rate of oxygen (5.82 arbitrary units [2.70-8.78] vs 2.27 arbitrary units [1.19-7.35]; p < 0.001) decreased significantly. CONCLUSIONS: Establishment of bidirectional cavopulmonary connection is associated with postoperative improvement in cerebral oxygen metabolism. Cerebral amount of hemoglobin did not increase, although creation of the bidirectional cavopulmonary connection results in significant elevation in superior vena cava pressure. Improvement in cerebral oxygen metabolism was due to lower cerebral blood flow velocity and stable microperfusion, which may indicate intact cerebral autoregulation.


Assuntos
Circulação Cerebrovascular , Técnica de Fontan/métodos , Consumo de Oxigênio , Coração Univentricular/cirurgia , Veia Cava Superior/fisiopatologia , Velocidade do Fluxo Sanguíneo , Feminino , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica , Masculino , Oxigênio/sangue , Assistência Perioperatória , Estudos Prospectivos , Pressão Venosa
20.
Artigo em Alemão | MEDLINE | ID: mdl-31212330

RESUMO

Perioperative bleeding disorders leading to major blood losses have a severe impact on patient morbidity and mortality. Despite efficient communication with the surgical team, a profound knowledge concerning the underlying mechanisms, diagnostic possibilities and available therapeutic strategies is essential for the anesthesiologist in charge. This clinical review summarizes the preoperative assessment of the most common preexisting bleeding disorders, as well as intraoperative diagnostics and management. A special focus is set on novel point-of-care tests, such as viscoelastic coagulation assays that allow rapid and precise bedside analysis of different blood clotting components. As anticoagulants and antiplatelet drugs are broadly established in everyday clinical practice, pharmacological profiles of the most common substances are highly relevant in order to provide the patient with a safe perioperative setting - including novel oral anticoagulants. Structured checklists, as introduced in this article, may help to facilitate clinical decision making during perioperative bleedings.


Assuntos
Anticoagulantes , Transtornos da Coagulação Sanguínea , Assistência Perioperatória , Anticoagulantes/uso terapêutico , Transtornos da Coagulação Sanguínea/diagnóstico , Transtornos da Coagulação Sanguínea/tratamento farmacológico , Hemorragia , Humanos , Inibidores da Agregação Plaquetária/uso terapêutico
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