Increased intravascular volume has been associated with protection from acute kidney injury (AKI), but in patients with congestive heart failure, venous congestion is associated with increased AKI. ...We tested the hypothesis that intraoperative venous congestion is associated with AKI after cardiac surgery.
In patients enrolled in the Statin AKI Cardiac Surgery trial, venous congestion was quantified as the area under the curve (AUC) of central venous pressure (CVP) >12, 16, or 20 mm Hg during surgery (mm Hg min). AKI was defined using Kidney Disease Improving Global Outcomes (KDIGO) criteria and urine concentrations of tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 (TIMP-2⋅IGFBP7), a marker of renal stress. We measured associations between venous congestion, AKI and TIMP-2⋅IGFBP7, adjusted for potential confounders. Values are reported as median (25th–75th percentile).
Based on KDIGO criteria, 104 of 425 (24.5%) patients developed AKI. The venous congestion AUCs were 273 mm Hg min (81–567) for CVP >12 mm Hg, 66 mm Hg min (12–221) for CVP >16 mm Hg, and 11 mm Hg min (1–54) for CVP >20 mm Hg. A 60 mm Hg min increase above the median venous congestion AUC above each threshold was independently associated with increased AKI (odds ratio=1.06; 95% confidence interval CI, 1.02–1.10; P=0.008; odds ratio=1.12; 95% CI, 1.02–1.23; P=0.013; and odds ratio=1.30; 95% CI, 1.06–1.59; P=0.012 for CVP>12, >16, and >20 mm Hg, respectively). Venous congestion before cardiopulmonary bypass was also associated with increased TIMP-2⋅IGFBP7 measured during cardiopulmonary bypass and after surgery, but neither venous congestion after cardiopulmonary bypass nor venous congestion throughout surgery was associated with postoperative TIMP-2⋅IGFBP7.
Intraoperative venous congestion was independently associated with increased AKI after cardiac surgery.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
To investigate the comparability of glucose levels measured with blood gas analyzers (BGAs) and by central laboratories (CLs).
Glucose measurements obtained between June 1, 2007, and March 1, 2016, ...at the Vanderbilt University Medical Center were reviewed. The agreement between CL and BGA results were assessed using Bland-Altman, consensus error grid (CEG), and surveillance error grid (SEG) analyses. We further analyzed the BGAs' performance against the US Food and Drug Administration (FDA) 2014 draft guidance and 2016 final guidance for blood glucose monitoring and the International Organization for Standardization (ISO) 15197:2013 standard.
We analyzed 2671 paired glucose measurements, including 50 pairs of hypoglycemic values (1.9%). Bland-Altman analysis yielded a mean bias of -3.1 mg/dL, with 98.1% of paired values meeting the 95% limits of agreement. In the hypoglycemic range, the mean bias was -0.8 mg/dL, with 100% of paired values meeting the 95% limits of agreement. When using CEG analysis, 99.9% of the paired values fell within the no risk zone. Similar results were found using SEG analysis. For the FDA 2014 draft guidance, our data did not meet the target compliance rate. For the FDA 2016 final guidance, our data partially met the target compliance rate. For the ISO standard, our data met the target compliance rate.
In this study, the agreement for glucose measurement between common BGAs and CL instruments met the ISO 2013 standard. However, BGA accuracy did not meet the stricter requirements of the FDA 2014 draft guidance or 2016 final guidance. Fortunately, plotting these results on either the CEG or the SEG revealed no results in either the great or extreme clinical risk zones.
Despite increasing availability and more successful interventional approaches to restore coronary reperfusion, myocardial ischemia-reperfusion injury is a substantial cause of morbidity and mortality ...worldwide. During myocardial ischemia, the myocardium becomes profoundly hypoxic, thus causing stabilization of hypoxia-inducible transcription factors (HIF). Stabilization of HIF leads to a transcriptional program that promotes adaptation to hypoxia and cellular survival. Transcriptional consequences of HIF stabilization include increases in extracellular production and signaling effects of adenosine. Extracellular adenosine functions as a signaling molecule via the activation of adenosine receptors. Several studies implicated adenosine signaling in cardioprotection, particularly through the activation of the Adora2a and Adora2b receptors. Adenosine receptor activation can lead to metabolic adaptation to enhance ischemia tolerance or dampen myocardial reperfusion injury via signaling events on immune cells. Many studies highlight that clinical strategies to target the hypoxia-adenosine link could be considered for clinical trials. This could be achieved by using pharmacologic HIF activators or by directly enhancing extracellular adenosine production or signaling as a therapy for patients with acute myocardial infarction, or undergoing cardiac surgery.
Previous studies implicate extracellular adenosine signaling in attenuating myocardial ischemia and reperfusion injury (IRI). This extracellular adenosine signaling is terminated by its uptake into ...cells by equilibrative nucleoside transporters (ENTs). Thus, we hypothesized that targeting ENTs would function to increase cardiac adenosine signaling and concomitant cardioprotection against IRI. Mice were exposed to myocardial ischemia and reperfusion injury. Myocardial injury was attenuated in mice treated with the nonspecific ENT inhibitor dipyridamole. A comparison of mice with global Ent1 or Ent2 deletion showed cardioprotection only in Ent1-/- mice. Moreover, studies with tissue-specific Ent deletion revealed that mice with myocyte-specific Ent1 deletion (Ent1loxP/loxP Myosin Cre+ mice) experienced smaller infarct sizes. Measurements of cardiac adenosine levels demonstrated that postischemic elevations of adenosine persisted during reperfusion after targeting ENTs. Finally, studies in mice with global or myeloid-specific deletion of the Adora2b adenosine receptor (Adora2bloxP/loxP LysM Cre+ mice) implied that Adora2b signaling on myeloid-inflammatory cells in cardioprotection provided by ENT inhibition. These studies reveal a previously unrecognized role for myocyte-specific ENT1 in cardioprotection by enhancing myeloid-dependent Adora2b signaling during reperfusion. Extension of these findings implicates adenosine transporter inhibitors in cardioprotection against ischemia and reperfusion injury.
Superior vena cava (SVC) syndrome, characterized by swelling of the upper torso, can result from a wide range of causes. The presence and severity of clinical symptoms depends on the degree of ...stenosis, the location of stenosis, the speed of development of stenosis, and existing collateral flow. Acute complete occlusion of the SVC frequently leads to poor neurologic outcomes such as coma or death. We report a case of a patient who had complete neurologic recovery after 26 minutes of acute total occlusion of the SVC. This report highlights the importance of meticulous management during acute SVC occlusion to improve patient outcome.
The right ventricle (RV) plays a central role in the maintenance of effective cardiac pump function. Despite overwhelming evidence that perioperative RV dysfunction (RVD) and failure (RVF) are ...associated with poor clinical outcomes, there are very few published recommendations or guidelines for comprehensive, evidence-based RV assessment on the risk of developing either during the perioperative period.
To address this gap, the Perioperative Quality Initiative-IX (POQI-IX) investigators group, comprised of clinical experts in anesthesiology, cardiovascular surgery, internal medicine, critical care medicine, and advanced practice nursing, has developed a consensus statement based on current literature, published society recommendations, and the clinical expertise of the group. Herein, the group provides recommendations and evidence-based tools related to perioperative RV assessment, functional screening, staging, and the clinical implications of each. These assessment tools are based on comprehensive patient evaluation consisting of physical examination, biomarker data, imaging, and hemodynamic assessment.
This review presents a comprehensive tool for assessing perioperative RV function. We hope that this simple, intuitive tool can be applied to all phases of perioperative care and thereby improve patient outcomes.
Anesthesiologists administer excess supplemental oxygen (hyper-oxygenation) to patients during surgery to avoid hypoxia. Hyper-oxygenation, however, may increase the generation of reactive oxygen ...species and cause oxidative damage. In cardiac surgery, increased oxidative damage has been associated with postoperative kidney and brain injury. We hypothesize that maintenance of normoxia during cardiac surgery (physiologic oxygenation) decreases kidney injury and oxidative damage compared to hyper-oxygenation.
The Risk of Oxygen during Cardiac Surgery (ROCS) trial will randomly assign 200 cardiac surgery patients to receive physiologic oxygenation, defined as the lowest fraction of inspired oxygen (FIO
) necessary to maintain an arterial hemoglobin saturation of 95 to 97%, or hyper-oxygenation (FIO
= 1.0) during surgery. The primary clinical endpoint is serum creatinine change from baseline to postoperative day 2, and the primary mechanism endpoint is change in plasma concentrations of F
-isoprostanes and isofurans. Secondary endpoints include superoxide production, clinical delirium, myocardial injury, and length of stay. An endothelial function substudy will examine the effects of oxygen treatment and oxidative stress on endothelial function, measured using flow mediated dilation, peripheral arterial tonometry, and wire tension myography of epicardial fat arterioles.
The ROCS trial will test the hypothesis that intraoperative physiologic oxygenation decreases oxidative damage and organ injury compared to hyper-oxygenation in patients undergoing cardiac surgery.
ClinicalTrials.gov, ID: NCT02361944 . Registered on the 30th of January 2015.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
1 Departments of Anesthesia and Critical Care, and 2 Respiratory Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
Submitted 1 May 2008
; accepted in final form ...29 June 2008
Upper airway unidirectional breathing, nose in and mouth out, is used by panting dogs to facilitate heat removal via water evaporation from the respiratory system. Why some humans instinctively employ the same breathing pattern during respiratory distress is still open to question. We hypothesized that 1 ) humans unconsciously perform unidirectional breathing because it improves breathing efficiency, 2 ) such an improvement is achieved by bypassing upper airway dead space, and 3 ) the magnitude of the improvement is inversely proportional to the tidal volume. Four breathing patterns were performed in random order in 10 healthy volunteers first with normal breathing effort, then with variable tidal volumes: mouth in and mouth out (MMB); nose in and nose out (NNB); nose in and mouth out (NMB); and mouth in and nose out (MNB). We found that unidirectional breathing bypasses anatomical dead space and improves breathing efficiency. At tidal volumes of 380 ml, the functional anatomical dead space during NMB (81 ± 31 ml) or MNB (101 ± 20 ml) was significantly lower than that during MMB (148 ± 15 ml) or NNB (130 ± 13 ml) (all P < 0.001), and the breathing efficiency obtained with NMB (78 ± 9%) or MNB (73 ± 6%) was significantly higher than that with MMB (61 ± 6%) or NNB (66 ± 3%) (all P < 0.001). The improvement in breathing efficiency increased as tidal volume decreased. Unidirectional breathing results in a significant reduction in functional anatomical dead space and improvement in breathing efficiency. We suggest this may be the reason that such a breathing pattern is preferred during respiratory distress.
pursed lip breathing; breathing efficiency; anatomical dead space; respiratory failure; panting
Address for reprint requests and other correspondence: R. M. Kacmarek, Dept. of Respiratory Care, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St., Ellison 401, Boston, MA 02114 (e-mail: rkacmarek{at}partners.org )
The average length of ICU stay post-op for the remaining five patients was five days and the total hospital length of stay was 7.2 days. A review of the recently published observational studies ...comparing the complication rates between the hybrid endovascular approach and open total arch repair demonstrates that in-hospital mortality and permanent stroke risk are comparable in both groups. 5 In the event of failed pacing during graft deployment, transient deliberate hypotension (systolic blood pressure < 60 mmHg) may be highly beneficial to prevent stent migration and embolization. Case Procedure Surgical access Case duration (min) Estimated blood loss (ml) Blood transfusion 1 Total percutaneous endovascular repair of aortic arch aneurysm and distal thoracic aorta using patient specific three-vessel Cook manufactured arch branch stent graft Bilateral percutaneous femoral approach using pre-closure technique with Perclose device, use of the steerable sheath system with total transfemoral axis to all 3 supraaortic trunks 230 200 No 2 Endovascular repair of thoracic aortic aneurysm using patient specific distal arch branch device with left subclavian retrograde branch and triple wide scallop for the left common carotid artery, left subclavian artery stenting, and left innominate artery stenting Bilateral percutaneous retrograde femoral approach 197 100 No 3 Percutaneous closure of pseudoaneurysm with placement of plug, selective catheterization of arch pseudoaneurysm, and aortic angiography Right percutaneous retrograde femoral access 103 100 No 4 Fenestrated endovascular repair of aortic arch aneurysm using patient specific three-vessel Cook manufactured arch branch stent graft Bilateral percutaneous retrograde femoral approach 214 300 No 5 Endovascular repair of aortic arch aneurysm using patient specific three-vessel Cook manufactured arch branch stent graft Right percutaneous transaxillary approach with further closure device and bilateral percutaneous femoral approach using pre-closure technique with Perclose device 286 200 No 6 Endovascular repair of aortic arch aneurysm using patient specific three-vessel Cook manufactured arch branch stent graft Bilateral percutaneous femoral approach using pre-closure technique with Perclose device, bilateral cervical oblique incisions for exposure, sequential clamping and access of the common carotid arteries 157 200 No
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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