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1.
JAMA ; : 1-11, 2019 Oct 21.
Artigo em Inglês | MEDLINE | ID: mdl-31634905

RESUMO

Importance: Excessive bleeding is a common complication of cardiac surgery. An important cause of bleeding is acquired hypofibrinogenemia (fibrinogen level <1.5-2.0 g/L), for which guidelines recommend fibrinogen replacement with cryoprecipitate or fibrinogen concentrate. The 2 products have important differences, but comparative clinical data are lacking. Objective: To determine if fibrinogen concentrate is noninferior to cryoprecipitate for treatment of bleeding related to hypofibrinogenemia after cardiac surgery. Design, Setting, and Participants: Randomized clinical trial at 11 Canadian hospitals enrolling adult patients experiencing clinically significant bleeding and hypofibrinogenemia after cardiac surgery (from February 10, 2017, to November 1, 2018). Final 28-day follow-up visit was completed on November 28, 2018. Interventions: Fibrinogen concentrate (4 g; n = 415) or cryoprecipitate (10 units; n = 412) for each ordered dose within 24 hours after cardiopulmonary bypass. Main Outcomes and Measures: Primary outcome was blood components (red blood cells, platelets, plasma) administered during 24 hours post bypass. A 2-sample, 1-sided test for the ratio of the mean number of units was conducted to evaluate noninferiority (threshold for noninferiority ratio, <1.2). Results: Of 827 randomized patients, 735 (372 fibrinogen concentrate, 363 cryoprecipitate) were treated and included in the primary analysis (median age, 64 [interquartile range, 53-72] years; 30% women; 72% underwent complex operations; 95% moderate to severe bleeding; and pretreatment fibrinogen level, 1.6 [interquartile range, 1.3-1.9] g/L). The trial met the a priori stopping criterion for noninferiority at the interim analysis after 827 of planned 1200 patients were randomized. Mean 24-hour postbypass allogeneic transfusions were 16.3 (95% CI, 14.9 to 17.8) units in the fibrinogen concentrate group and 17.0 (95% CI, 15.6 to 18.6) units in the cryoprecipitate group (ratio, 0.96 [1-sided 97.5% CI, -∞ to 1.09; P < .001 for noninferiority] [2-sided 95% CI, 0.84 to 1.09; P = .50 for superiority]). Thromboembolic events occurred in 26 patients (7.0%) in the fibrinogen concentrate group and 35 patients (9.6%) in the cryoprecipitate group. Conclusions and Relevance: In patients undergoing cardiac surgery who develop clinically significant bleeding and hypofibrinogenemia after cardiopulmonary bypass, fibrinogen concentrate is noninferior to cryoprecipitate with regard to number of blood components transfused in a 24-hour period post bypass. Use of fibrinogen concentrate may be considered for management of bleeding in patients with acquired hypofibrinogenemia in cardiac surgery. Trial Registration: ClinicalTrials.gov Identifier: NCT03037424.

2.
CMAJ ; 191(9): E247-E256, 2019 Mar 04.
Artigo em Inglês | MEDLINE | ID: mdl-30833491

RESUMO

BACKGROUND: Perioperative corticosteroid use may reduce acute kidney injury. We sought to test whether methylprednisolone reduces the risk of acute kidney injury after cardiac surgery. METHODS: We conducted a prespecified substudy of a randomized controlled trial involving patients undergoing cardiac surgery with cardiopulmonary bypass (2007-2014); patients were recruited from 79 centres in 18 countries. Eligibility criteria included a moderate-to-high risk of perioperative death based on a preoperative score of 6 or greater on the European System for Cardiac Operative Risk Evaluation I. Patients (n = 7286) were randomly assigned (1:1) to receive intravenous methylprednisolone (250 mg at anesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients, caregivers, data collectors and outcome adjudicators were unaware of the assigned intervention. The primary outcome was postoperative acute kidney injury, defined as an increase in the serum creatinine concentration (from the preoperative value) of 0.3 mg/dL or greater (≥ 26.5 µmol/L) or 50% or greater in the 14-day period after surgery, or use of dialysis within 30 days after surgery. RESULTS: Acute kidney injury occurred in 1479/3647 patients (40.6%) in the methylprednisolone group and in 1426/3639 patients (39.2%) in the placebo group (adjusted relative risk 1.04, 95% confidence interval 0.96 to 1.11). Results were consistent across several definitions of acute kidney injury and in patients with preoperative chronic kidney disease. INTERPRETATION: Intraoperative corticosteroid use did not reduce the risk of acute kidney injury in patients with a moderate-to-high risk of perioperative death who had cardiac surgery with cardiopulmonary bypass. Our results do not support the prophylactic use of steroids during cardiopulmonary bypass surgery. Trial registration: ClinicalTrials.gov, no. NCT00427388.

3.
J Cardiothorac Vasc Anesth ; 33(5): 1197-1204, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30655202

RESUMO

OBJECTIVE: To compare myocardial protection with retrograde cardioplegia alone with antegrade and retrograde cardioplegia in minimally invasive mitral valve surgery (MIMS). DESIGN: Retrospective study. SETTING: Tertiary care university hospital. PARTICIPANTS: The authors studied 97 MIMS patients using retrograde cardioplegia alone and 118 MIMS patients using antegrade and retrograde cardioplegia. INTERVENTIONS: The data from patients admitted for MIMS using retrograde cardioplegia (MIMS retro) between 2009 to 2012 were compared with the data from patients undergoing MIMS with antegrade and retrograde cardioplegia (MIMS ante-retro) between 2006 and 2010 (control group). Cardioplegia in the MIMS retro group was delivered solely through an endovascular coronary sinus (CS) catheter positioned under echographic and fluoroscopic guidance. Antegrade and retrograde cardioplegia was used in the MIMS ante-retro group. Data regarding myocardial infarction (MI; creatine kinase Mb, troponin T, electrocardiogram), myocardial function, and hemodynamic stability were collected for comparison. MEASUREMENTS AND MAIN RESULTS: Adequate cardioplegia administration (CS pressure >30 mmHg and asystole) was attained in 74.2% of the patients with retrograde cardioplegia alone. In 23.7% of the patients, the addition of an antegrade cardioplegia was necessary. No difference was observed in the incidence of MI (0 MIMS retro v 1 for MIMS ante-retro, p = 0.3623), difficult separation from cardiopulmonary bypass, and postoperative malignant arrhythmia. No difference was found for maximal creatine kinase Mb (39.1 [28.0-49.1] v 37.9 [28.6-50.9]; p = 0.8299) and for maximal troponin T levels (0.39 [0.27-0.70] v 0.47 [0.32-0.79]; p = 0.1231) for MIMS retro and MIMS ante-retro, respectively. However, lactate levels in the MIMS retro group were significantly lower than in the MIMS ante-retro group (2.1 [1.4-3.05] v 2.4 [1.8-3.3], respectively; p = 0.0453). No difference was observed in duration of intensive care unit stay and death. MIMS retro patients had a shorter hospital stay (7.0 [6.0-8.0] v 8.0 [7.0-9.0] days; p = 0.0003). CONCLUSION: Retrograde cardioplegia administration alone provided comparable myocardial protection to antegrade and retrograde cardioplegia during MIMS, but was not sufficient to achieve asystole in one-fifth of patients.


Assuntos
Cateterismo Cardíaco/métodos , Seio Coronário/cirurgia , Procedimentos Endovasculares/métodos , Parada Cardíaca Induzida/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Valva Mitral/cirurgia , Adulto , Idoso , Cateterismo Cardíaco/normas , Soluções Cardioplégicas/administração & dosagem , Terapia Combinada/métodos , Terapia Combinada/normas , Procedimentos Endovasculares/normas , Feminino , Parada Cardíaca Induzida/normas , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/normas , Estudos Retrospectivos
4.
J Cardiothorac Vasc Anesth ; 33(3): 651-660, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30683595

RESUMO

OBJECTIVE: To report the authors' 12 years of experience with intratracheal milrinone administration and to assess the efficacy and limitations of intratracheal milrinone bolus administration for the treatment of unexpected acute right ventricular (RV) failure in patients undergoing cardiac surgery. DESIGN: Retrospective analysis. SETTING: Single-center university hospital. PARTICIPANTS: One hundred seventy-six patients (4.6%) undergoing on-pump cardiac surgery. INTERVENTIONS: Endotracheal tube administration of milrinone (5-mg bolus) after unexpected acute RV failure during separation from cardiopulmonary bypass (CPB) weaning. RV failure was defined as the simultaneous presence of all of the following criteria: (1) hemodynamic instability or difficult separation from CPB with associated elevated central venous pressure or abnormal RV pressure waveform, (2) >20% reduction of RV fractional area change from baseline evaluated by transesophageal echocardiography, and (3) anatomical visualization of impaired or absent RV wall motion by direct intraoperative visual inspection. MEASUREMENTS AND MAIN RESULTS: Intratracheal milrinone administration was found to improve RV failure in 109 patients (61.9%) whereas RV failure persisted in 67 patients (38.1%). Using a multiple logistic regression model, severely decreased left ventricular ejection fraction (<35% v >50%) (adjusted odds ratio [OR] 3.72; 95% confidence interval [CI] 1.2-11.3; p = 0.012), longer CPB time (adjusted OR 1.014; CI 1.01-1.02; p = 0.001) and elevated postoperative fluid balance (adjusted OR 1.39; CI 1.1-1.8; p = 0.02) were found to be significant predictors of persistent RV failure. CONCLUSION: Intratracheal instillation of milrinone was associated with clinical improvement of RV failure occurring during separation from CPB in almost two-thirds of patients. Factors limiting its therapeutic efficacy include severe left ventricular dysfunction, increased fluid balance, and long CPB time.


Assuntos
Ponte Cardiopulmonar/tendências , Cardiotônicos/administração & dosagem , Intubação Intratraqueal/tendências , Milrinona/administração & dosagem , Disfunção Ventricular Direita/tratamento farmacológico , Disfunção Ventricular Direita/cirurgia , Doença Aguda , Idoso , Ecocardiografia Transesofagiana/tendências , Feminino , Insuficiência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Disfunção Ventricular Direita/diagnóstico por imagem
5.
Artigo em Inglês | MEDLINE | ID: mdl-30269893

RESUMO

Right ventricular (RV) dysfunction is a cause of increased morbidity and mortality in both cardiac surgery and noncardiac surgery and in the intensive care unit. Early diagnosis of this condition still poses a challenge. The diagnosis of RV dysfunction traditionally is based on a combination of echocardiography, hemodynamic measurements, and clinical symptoms. This review describes the method of using RV pressure waveform analysis to diagnose and grade the severity of RV dysfunction. The authors describe the technique, optimal use, and pitfalls of this method, which has been used at the Montreal Heart Institute since 2002, and review the current literature on this method. The RV pressure waveform is obtained using a pulmonary artery catheter with the capability of measuring RV pressure by connecting a pressure transducer to the pacemaker port. The authors describe how RV pressure waveform analysis can facilitate the diagnosis of systolic and diastolic RV dysfunction, the evaluation of RV-arterial coupling, and help diagnose RV outflow tract obstruction. RV pressure waveform analysis also can be used to guide pharmacologic treatment and fluid resuscitation strategies for RV dysfunction.

6.
Artigo em Inglês | MEDLINE | ID: mdl-30195598

RESUMO

BACKGROUND: Complex aortic procedures are potentially associated with important blood loss and coagulopathy. The aim of this study was to assess the impact of rotational thromboelastometry (ROTEM, Tem International GmBH, Munich, Germany) on transfusion requirements after proximal aortic operations in a real-world setting. METHODS: This single-center retrospective analysis based on 385 consecutive patients undergoing cardiac surgeries involving the aortic root, ascending aorta, or aortic arch compared 197 controls managed according to routine transfusion protocol before the introduction of the ROTEM in 2012 with 188 patients operated afterward. With the use of a 1:1 propensity score match, 224 patients were included in paired analysis (112 in each group). The primary end point was erythrocytes transfusion rate. The secondary end points comprised the transfusion of other allogeneic blood products, number of units transfused, postoperative blood loss, massive transfusion rate, and use of other hemostatic products. RESULTS: ROTEM implementation was associated with a trend toward reduction in the rate of erythrocytes transfusion (57% vs 46%, P = .08) and a decreased median number of units transfused for erythrocytes (1.0 [0.0-4.0] unit vs 0.0 [0.0-2.0] unit, P = .03) and plasma (0.0 [0.0-4.0] unit vs 0.0 [0.0-2.0] unit, P = .04). After sensitivity analysis, ROTEM displayed a comparable rate of erythrocytes transfusion (58% vs 47%, P = .15). CONCLUSIONS: In a real-world setting, ROTEM-based algorithm implementation could help reduce excess erythrocytes transfusion for complex aortic procedures. We advocate for a strict adherence and concerted team effort to maximize the benefits of such addition to patients' management.

7.
Artigo em Inglês | MEDLINE | ID: mdl-30122614

RESUMO

OBJECTIVE: To assess a novel hypothesis to explain delirium after cardiac surgery through the relationship between cumulative fluid balance and delirium. This hypothesis involved an inflammatory process combined with a hypervolemic state, which could lead to venous congestion reaching the brain. DESIGN: Retrospective case-control (1:1) cohort study. SETTING: University-affiliated tertiary cardiology center. PARTICIPANTS: Cardiac surgery intensive care unit (ICU) patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Cumulative fluid balance was evaluated at 3 times: (1) upon arrival at the ICU after surgery, (2) 24 hours post-ICU arrival, and (3) 48 hours post-ICU arrival. A generalized estimated equation was used to model the association between cumulative fluid balance and delirium occurrence 24 hours later. Covariates were selected based on the statistical differences between cases and controls on delirium risk factors and clinical characteristics. The cohort included 346 patients, of which 39 (11%), 104 (30%), and 142 patients (41%) presented delirium at 24, 48, and 72 hours post-ICU arrival, respectively. The effect of time had an odds ratio (OR) of 2.14, 95% confidence interval (CI) 1.603 to 2.851, and a p value < 0.001. The cumulative fluid balance was associated with delirium occurrence (OR 1.20, 95% CI: 1.066-1.355, p = .003). History of neurological disorder, having both hearing and visual impairment, type of procedure, perioperative cerebral oximetry, mean pulmonary artery pressure pre-cardiopulmonary bypass (CPB), and mean arterial pressure post-CPB also contributed to delirium in the model. CONCLUSION: Delirium is associated with a cumulative fluid balance, but the extent through which this plays an etiologic role remains to be determined.

8.
J Cardiothorac Vasc Anesth ; 32(2): 656-663, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29217241

RESUMO

OBJECTIVE: To compare antegrade and retrograde cardioplegia administration in minimally invasive mitral valve surgery (MIMS) and open mitral valve surgery (OMS) for myocardial protection. DESIGN: Retrospective study. SETTING: Tertiary care university hospital. PARTICIPANTS: The study comprised 118 patients undergoing MIMS and 118 patients undergoing OMS. INTERVENTIONS: The data of patients admitted for MIMS from 2006 to 2010 were reviewed. Patients undergoing isolated elective OMS from 2004 to 2006 were used as a control group. Cardioplegia in the MIMS group was delivered via the distal port of the endoaortic clamp and an endovascular coronary sinus catheter positioned using echographic and fluoroscopic guidance. Antegrade and retrograde cardioplegia were used in OMS. Data regarding myocardial infarction (MI) (creatine kinase [CK]-MB, troponin T, electrocardiography); myocardial function; and hemodynamic stability were collected. MEASUREMENTS AND MAIN RESULTS: There was no difference in the perioperative MI incidence between both groups (1 in each group, p = 0.96). No statistically significant difference was found for maximal CK-MB (35.9 µg/L [25.1-50.1] v 37.9 µg/L [28.6-50.9]; p = 0.31) or the number of patients with CK-MB levels >50 µg/L (29 v 33; p = 0.55) or CK-MB >100 µg/L (3 v 4; p = 0.70) between the OMS and MIMS groups. However, maximum troponin T levels in the MIMS group were significantly lower (0.47 µg/L [0.32-0.79] v 0.65 µg/L [0.45-0.94]; p = 0.0007). No difference in the incidence of difficult weaning from bypass and intra-aortic balloon pump use between the MIMS and OMS groups was found. CONCLUSIONS: Antegrade and retrograde cardioplegia administration during MIMS and OMS provided comparable myocardial protection.


Assuntos
Cateterismo Cardíaco/métodos , Parada Cardíaca Induzida/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Insuficiência da Valva Mitral/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Esternotomia/métodos , Adulto , Cateterismo Cardíaco/tendências , Feminino , Parada Cardíaca Induzida/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/tendências , Insuficiência da Valva Mitral/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Estudos Retrospectivos , Esternotomia/tendências
9.
J Cardiothorac Vasc Anesth ; 31(5): 1611-1617, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28803773

RESUMO

OBJECTIVE: The incidence of postoperative nonischemic seizures associated with the use of tranexamic acid (TXA) and the possibility of prevention with a low-dose regimen of TXA were evaluated. DESIGN: Retrospective study. SETTING: Tertiary care university hospital. PARTICIPANTS: A total of 12,195 patients who underwent cardiac surgical procedures under cardiopulmonary bypass (CPB) were evaluated. INTERVENTIONS: The files of every clinical seizure case diagnosed in the surgical intensive care unit between April 2006 and April 2014 were reviewed. Patients who experienced a postoperative seizure underwent a cerebral computed tomography scan to exclude an ischemic lesion. Dosage and type of antifibrinolytic used and surgery characteristics were retrieved from perfusion files. Low-dose TXA was defined as 1,000-mg bolus, 400-mg/h infusion, and 500 mg in CPB priming. High-dose TXA was defined as 30-mg/kg bolus, 15 mg/kg/h, and 2 mg/kg in CPB priming. RESULTS: No seizure was observed in the 886 patients who did not receive antifibrinolytics. A total of 98 clinical seizures (0.8%) were recorded in the intensive care unit, and ischemic cause was excluded in the majority of them after computed tomography scan results were reviewed (91 patients [93%]). Low-dose TXA was associated with fewer seizures than was high-dose TXA (46 of 7,452 cases [0.70%] v 34 of 2,190 cases [1.55%], respectively; p < 0.0001). Open-chamber cardiac surgery also was linked to a higher incidence of seizures compared with revascularization (80 of 6,662 [1.20%] and 11 of 5,533 [0.20%], respectively; p < 0.0001). CONCLUSIONS: Lower doses of TXA were associated with a lower incidence of nonischemic seizures compared with higher doses of the drug.


Assuntos
Antifibrinolíticos/administração & dosagem , Procedimentos Cirúrgicos Cardíacos/tendências , Ponte Cardiopulmonar/tendências , Convulsões/prevenção & controle , Ácido Tranexâmico/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Relação Dose-Resposta a Droga , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Convulsões/diagnóstico por imagem , Convulsões/etiologia
12.
Anesthesiology ; 123(6): 1404-10, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26501386

RESUMO

BACKGROUND: Persistent incisional pain is common after cardiac surgery and is believed to be in part related to inflammation and poorly controlled acute pain. Methylprednisolone is a corticosteroid with substantial antiinflammatory and analgesic properties and is thus likely to ameliorate persistent surgical pain. Therefore, the authors tested the primary hypothesis that patients randomized to methylprednisolone have less persistent incisional pain than those given placebo. METHODS: One thousand forty-three patients having cardiopulmonary bypass for cardiac surgery via a median sternotomy were included in this substudy of Steroids in Cardiac Surgery (SIRS) trial. Patients were randomized to 500 mg intraoperative methylprednisolone or placebo. Incisional pain was assessed at 30 days and 6 months after surgery, and the potential risk factors were also evaluated. RESULTS: Methylprednisolone administration did not reduce pain at 30 days or persistent incisional pain at 6 months, which occurred in 78 of 520 patients (15.7%) in the methylprednisolone group and in 88 of 523 patients (17.8%) in the placebo group. The odds ratio for methylprednisolone was 0.93 (95% CI, 0.79 to 1.09, P = 0.37). Furthermore, there was no difference in worst pain and average pain in the last 24 h, pain interference with daily life, or use of pain medicine at 6 months. Younger age, female sex, and surgical infections were associated with the development of persistent incisional pain. CONCLUSIONS: Intraoperative methylprednisolone administration does not reduce persistent incisional pain at 6 months in patients recovering from cardiac surgery.


Assuntos
Anti-Inflamatórios/uso terapêutico , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Metilprednisolona/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Fatores Etários , Idoso , Ponte Cardiopulmonar , Feminino , Seguimentos , Humanos , Masculino , Fatores de Risco , Fatores Sexuais , Resultado do Tratamento
13.
Can J Anaesth ; 62(4): 377-84, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25537735

RESUMO

PURPOSE: Acute kidney injury (AKI) is a potentially serious complication of cardiac surgery. Anemia and red blood cell (RBC) transfusion have individually been identified as potentially modifiable risk factors, but their interrelationship with AKI has not been clearly defined. The purpose of this study was to explore the interrelationship of preoperative anemia, intraoperative anemia, and RBC transfusion on the day of surgery with AKI in cardiac surgery. METHODS: This historical cohort study included 16 hospitals, each contributing data on approximately 100 consecutive patients who underwent cardiac surgery with cardiopulmonary bypass. Acute kidney injury was defined as a > 50% increase in creatinine levels during the first postoperative week. Multivariable regression was used to identify the interrelationship between preoperative anemia (hemoglobin < 130 g·L(-1) in males and < 120 g·L(-1) in females), intraoperative anemia (hemoglobin < 80 g·L(-1) during cardiopulmonary bypass), RBC transfusion on the day of surgery, and their interaction terms, after adjusting for site and baseline AKI risk. RESULTS: Of the 1,444 patients included in the study, 541 (37%) had preoperative anemia, 501 (35%) developed intraoperative anemia, 619 (43%) received RBC transfusions, and 238 (16%) developed AKI. After risk-adjustment, an individual with the combination of these three risk factors had a 2.6-fold (95% confidence interval 2.0 to 3.3) increase in the relative risk of AKI over an individual with none of these risk factors. CONCLUSIONS: Preoperative anemia, intraoperative anemia, and RBC transfusion on the day of surgery are interrelated risk factors for AKI after cardiac surgery. Targeting these risk factors may reduce the burden of AKI.


Assuntos
Lesão Renal Aguda/etiologia , Anemia/complicações , Ponte Cardiopulmonar/métodos , Transfusão de Eritrócitos/métodos , Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/prevenção & controle , Idoso , Anemia/epidemiologia , Ponte Cardiopulmonar/efeitos adversos , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Análise de Regressão , Estudos Retrospectivos , Fatores de Risco
14.
Can J Cardiol ; 30(12 Suppl): S459-77, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25432139

RESUMO

Perioperative care for cardiac surgery is undergoing rapid evolution. Many of the changes involve the application of novel technologies to tackle common challenges in optimizing perioperative management. Herein, we illustrate recent advances in perioperative management by focusing on a number of novel components that we judge to be particularly important. These include: the introduction of brain and somatic oximetry; transesophageal echocardiographic hemodynamic monitoring and bedside focused ultrasound; ultrasound-guided vascular access; point-of-care coagulation surveillance; right ventricular pressure monitoring; novel inhaled treatment for right ventricular failure; new approaches for postoperative pain management; novel approaches in specialized care procedures to ensure quality control; and specific approaches to optimize the management for postoperative cardiac arrest. Herein, we discuss the reasons that each of these components are particularly important in improving perioperative care, describe how they can be addressed, and their impact in the care of patients who undergo cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Cardiopatias/cirurgia , Coração/fisiopatologia , Unidades de Terapia Intensiva , Assistência Perioperatória/métodos , Cardiopatias/fisiopatologia , Humanos , Monitorização Fisiológica , Salas Cirúrgicas
15.
Can J Anaesth ; 61(8): 727-35, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24890696

RESUMO

PURPOSE: Recombinant activated factor VII (rFVIIa) is a pro-hemostatic drug that is approved for treatment of bleeding in hemophilia patients, but it is frequently used off-label in non-hemophiliacs. The purpose of this study was to determine if the off-label use of rFVIIa is expanding and whether this poses a net harm to patients. METHODS: For this historical cohort study, data were collected on all non-hemophilia patients who received rFVIIa from 2007 to 2010 at 16 Canadian centres, and the pattern of use was examined. Logistic regression was used to determine the prognostic importance of severity of bleeding and the presence of an rFVIIa dose-effect relationship with major adverse events. RESULTS: One thousand three hundred seventy-eight patients received rFVIIa off-label, and 987 (72%) of these patients underwent cardiac surgery. The median [interquartile range] dose was 57 [36-85] µg·kg(-1). Usage increased from 2007 to 2008 (n = 341 and 380, respectively) but decreased in 2009 and 2010 (n = 350 and 307, respectively). Dose of rFVIIa and bleeding severity were associated with measured adverse events (P < 0.05). After adjusting for bleeding severity, dose was not associated with any of the adverse events. CONCLUSIONS: The off-label use of rFVIIa in Canada remains stable. Since severity of bleeding is prognostically important, the benefits of rapidly gaining control of bleeding that is non-responsive to conventional therapies may at times warrant the use of potent hemostatic drugs with established risk profiles, such as rFVIIa.


Assuntos
Fator VIIa/uso terapêutico , Hemorragia/tratamento farmacológico , Hospitais/estatística & dados numéricos , Uso Off-Label/estatística & dados numéricos , Idoso , Canadá , Estudos de Coortes , Feminino , Hemostáticos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Proteínas Recombinantes/uso terapêutico , Sistema de Registros
16.
BMJ Open ; 4(3): e004842, 2014 Mar 05.
Artigo em Inglês | MEDLINE | ID: mdl-24598306

RESUMO

INTRODUCTION: Steroids In caRdiac Surgery trial (SIRS) is a large international randomised controlled trial of methylprednisolone or placebo in patients undergoing cardiac surgery with the use of a cardiopulmonary bypass pump. At the time of surgery, compared with placebo, methylprednisolone divided into two intravenous doses of 250 mg each may reduce the risk of postoperative acute kidney injury (AKI). METHODS AND ANALYSIS: With respect to the study schedule, over 7000 substudy eligible patients from 81 centres in 18 countries were randomised in December 2013. The authors will use a logistic regression to estimate the adjusted OR of methylprednisolone versus placebo on the primary outcome of AKI in the 14 days following surgery (a postoperative increase in serum creatinine of ≥50%, or ≥26.5 µmol/L, from the preoperative value). The stage of AKI will also be considered, as will the outcome of AKI in those with and without preoperative chronic kidney disease. After receipt of grant funding, the authors began to record additional perioperative serum creatinine measurements in consecutive patients enrolled at substudy participating centres, and patients were invited to enroll in a 6-month serum creatinine collection. In these trial subpopulations, the authors will consider the outcome of AKI defined in alternate ways, and the outcome of a 6-month change in kidney function from the preoperative value. ETHICS AND DISSEMINATION: The authors were competitively awarded a grant from the Canadian Institutes of Health Research for this SIRS AKI substudy. Ethics approval was obtained for additional serum creatinine recordings in consecutive patients enrolled at participating centres. The additional kidney data collection first began for patients enrolled after 1 March 2012. In patients who provided consent, the last 6-month kidney outcome data will be collected in 2014. The results will be reported no later than 2015. CLINICAL TRIAL REGISTRATION: Number NCT00427388.


Assuntos
Lesão Renal Aguda/prevenção & controle , Anti-Inflamatórios/uso terapêutico , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Metilprednisolona/uso terapêutico , Biomarcadores/sangue , Canadá , Procedimentos Cirúrgicos Cardíacos/métodos , Protocolos Clínicos , Creatinina/sangue , Humanos , Projetos de Pesquisa , Fatores de Risco
17.
Can J Cardiol ; 29(11): 1532.e9-10, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23751148

RESUMO

A woman aged 79 years with a history of stroke was admitted to undergo surgical treatment of a severe mitral regurgitation caused by active endocarditis. A preoperative computed tomography scan showed the presence of a porcelain aorta. The mitral valve was successfully repaired with an endovascular cardiopulmonary bypass system. The patient was discharged on postoperative day 10 with no complication. Endoaortic clamping is thought to be a useful technique in patients with a severely calcified aorta.


Assuntos
Doenças da Aorta/diagnóstico por imagem , Procedimentos Endovasculares , Insuficiência da Valva Mitral/cirurgia , Calcificação Vascular/diagnóstico por imagem , Idoso , Ponte Cardiopulmonar , Feminino , Humanos , Toracotomia , Tomografia Computadorizada por Raios X
18.
J Cardiothorac Vasc Anesth ; 27(6): 1260-6, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-23791498

RESUMO

OBJECTIVES: To measure the incidence of cerebral desaturation during high-risk cardiac surgery and to evaluate strategies to reverse cerebral desaturation. DESIGN: Prospective observational study followed by a randomized controlled study with 1 intervention group and 1 control group. SETTING: Tertiary care center specialized in cardiac surgery. PARTICIPANTS: All patients were scheduled for high-risk cardiac surgery, 279 consecutive patients in the prospective study and 48 patients in the randomized study. INTERVENTIONS: An algorithmic approach of strategies to reverse cerebral desaturation. In the control group, no attempts were made to reverse cerebral desaturation. MEASUREMENTS AND MAIN RESULTS: Cerebral saturation was measured using near-infrared reflectance spectroscopy. A decrease of 20% from baseline for 15 seconds defined cerebral desaturation. The success or failure of the interventions was noted. Demographic data were collected. Models for predicting the probability and the reversal of cerebral desaturation were based on multiple logistic regressions. In the randomized study, 12 hours of measurements were continued in the intensive care unit without interventions. Differences in desaturation load (% desaturation × time) were compared between groups. Half of the high-risk patients had cerebral desaturation that could be reversed 88% of the time. Interventions resulted in smaller desaturation loads in the operating room and in the intensive care unit. CONCLUSIONS: Cerebral desaturation in high-risk cardiac surgery is frequent but can be reversed most of the time resulting in a smaller desaturation load. A large randomized study will be needed to measure the impact of reversing cerebral desaturation on patient's outcome.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Consumo de Oxigênio/fisiologia , Idoso , Algoritmos , Química Encefálica/fisiologia , Cuidados Críticos , Feminino , Humanos , Hipóxia/terapia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Oximetria/métodos , Oxigênio/sangue , Projetos Piloto , Valor Preditivo dos Testes , Estudos Prospectivos , Risco , Espectroscopia de Luz Próxima ao Infravermelho , Resultado do Tratamento
19.
J Cardiothorac Vasc Anesth ; 27(3): 485-93, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23036623

RESUMO

OBJECTIVE: Autonomic nervous system dysfunction is a well-recognized but rarely evaluated risk factor for patients undergoing cardiac surgery. By measuring autonomic reserves in patients scheduled for cardiac surgery, the authors aimed to identify those with autonomic dysfunction and to evaluate their risk of perioperative complications. DESIGN: This was a prospective, observational study. SETTING: The study was conducted in a single academic center. PARTICIPANTS: Sixty-seven patients completed the study. INTERVENTIONS: Autonomic reserves were evaluated using analysis of heart rate variability (HRV) and blood pressure variability (BPV) after a Valsalva maneuver. MEASUREMENTS AND MAIN RESULTS: The patients were divided into 2 groups depending on their response to the autonomic challenge, a group with autonomic reserves (AR, n = 38) and a group with negligible autonomic reserves (NAR, n = 29). The groups were compared for baseline psychologic distress, demographic and medical profiles, autonomic response to morphine premedication and the induction of anesthesia, hemodynamic instability, the occurrence of decreases in cerebral oxygen saturation, and postoperative complications. Patients in the NAR group had significantly higher psychologic distress scores (p < 0.001), a higher baseline parasympathetic tone (p = 0.003), were unable to increase parasympathetic tone with morphine premedication, had more severe hypotension at the induction of anesthesia (p < 0.001), more episodes of decreases in cerebral saturation (p = 0.0485), and a higher overall complication rate (p = 0.0388) independent of other variables studied. CONCLUSIONS: Patients with diminished autonomic reserves can be identified before cardiac surgery using analysis of HRV and BPV of the response to the Valsalva maneuver, and some evidence suggests that they may be at increased risk of perioperative complications.


Assuntos
Sistema Nervoso Autônomo/fisiologia , Procedimentos Cirúrgicos Cardíacos/métodos , Idoso , Pressão Sanguínea/fisiologia , Química Encefálica/fisiologia , Eletrocardiografia , Feminino , Frequência Cardíaca/fisiologia , Hemodinâmica/fisiologia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Pré-Medicação , Escalas de Graduação Psiquiátrica , Manobra de Valsalva
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