All volatile anesthetics have cardiac depressant effects that decrease myocardial oxygen demand and may thus improve the myocardial oxygen balance during ischemia. Recent experimental evidence has ...clearly demonstrated that, in addition to these indirect effects, volatile anesthetic agents also directly protect from ischemic myocardial damage. Implementation of these effects during clinical anesthesia can provide an additional tool for treatment or prevention of ischemic cardiac dysfunction during the perioperative period. A recent meta-analysis showed that desflurane and sevoflurane reduce postoperative mortality and the incidence of myocardial infarction following cardiac surgery, with significant advantages in terms of postoperative cardiac troponin release, need for inotropic support, and time on mechanical ventilation, as well as in time spent in the intensive care unit and overall hospital stay. Multicenter, randomized clinical trials previously demonstrated that desflurane could reduce the postoperative release of cardiac troponin I, the need for inotropic support, and the number of patients requiring prolonged hospitalization following coronary artery bypass graft surgery, either with or without cardiopulmonary bypass. However, evidence in non-coronary surgical settings is contradictory and will be reviewed in this paper, together with the mechanism of cardiac protection by volatile agents.
Transcatheter aortic valve implantation (TAVI) is an emergent alternative technique to surgery in high-risk patients with aortic stenosis. Here, we describe the anesthesiological management of ...patients undergoing TAVI at our institution over an 18-month period.
After a proper assessment of surgical risk and comorbidities, 69 patients underwent TAVI with the transfemoral/subclavian approach. Both Edwards-Sapien and Corevalve prostheses were implanted. The anesthetic regimen consisted of general anesthesia or local anesthesia plus sedation.
Twenty-seven patients received general anesthesia, and 42 received local anesthesia plus sedation. Procedural complications included prosthesis embolization (2), ascending aorta dissection (1), ventricular fibrillation following rapid ventricular pacing (8), vascular access site complications (17), and the valve-in-valve procedure (1). Three patients had to be converted from local anesthesia to general anesthesia (one patient had refractory ventricular fibrillation, and two patients were restless). All patients were alive at the 30-day follow-up. Mechanical ventilation time was 8.5+/-0.03 h. Mean ICU stay was 20.1+/-2.89 h. Postoperative complications included acute renal dysfunction (11), advanced atrioventricular block (9), and stroke (1). Thirty-six out of 42 (86%) patients were alive at the 6-month follow-up.
TAVI is feasible in high-risk patients who would not be able to undergo surgical valve replacement. Hemodynamic management is the main concern of intraoperative anesthesiological management. General or local anesthesia plus sedation are both valid alternative techniques that can be titrated according to patient characteristics. Close postoperative monitoring in the ICU is required.
Critically ill patients often need catecholamines, but these agents could be associated with an increased risk of death and other adverse cardiac events. Levosimendan is a calcium sensitizer that is ...able to enhance myocardial contractility without increasing myocardial oxygen use. We conducted a meta-analysis to determine the impact of levosimendan on mortality in critically ill patients.
Four investigators independently searched BioMedCentral and PubMed to identify all randomized trials that compared levosimendan vs. control with no restriction in dose or time of administration. Exclusion criteria were duplicate publications, non-human experimental studies, and no information on the primary outcome (mortality).
Data from a total of 3,350 patients from 27 randomized controlled studies were included in the analysis. Levosimendan was associated with a significant reduction in mortality (333/1893 17.6% in the levosimendan group vs. 326/1457 22.4% in the control arm, OR=0.74 0.62-0.89, P for effect=0.001) and in the rate of myocardial infarction (3/493 0.6% in the levosimendan group vs. 14/356 3.9% in the control arm P=0.007), with a significant increase in the rate of hypotension (164/1484 11.1% in the levosimendan group vs. 106/1093 9.7% in the control arm P=0.02).
Levosimendan has cardioprotective effects that could result in a reduced mortality in critically ill patients. A large randomized controlled study is warranted in this setting.
Patients receiving implantation of ventricular assist devices (VAD) suffer a high incidence of heparin induced thrombocytopenia (HIT); the occurrence of this condition is associated with increased ...complications and worse outcomes. We report our experience in the management of patients who were diagnosed with HIT either before (HITpre) or after (HITpost) implantation of VAD with argatroban, a direct thrombin inhibitor.
This retrospective analysis assessed data of VAD patients diagnosed with HIT at Deutsches Herzzentrum Berlin between November 2005 and April 2009. Argatroban dose requirements, anticoagulation efficacy and adverse events (death, thromboembolism, bleeding) were recorded. Procedural success (discharge from the hospital, heart transplantation, or recovery of the failing heart) was also assessed.
Twenty-seven patients were identified (11 HITpre, 16 HITpost). Argatroban was effective in obtaining adequate anticoagulation with a reduced dose regimen (0.02-0.42 mcg/Kg/min starting dose; 0.02-1.5 mcg/Kg/min maintenance dose). We noted 5 thromboembolic complications (18%), 6 cases of major bleeding (22%) and 5 deaths (18%), all cause composite adverse end point occurring in 40% of patients. Procedural success was obtained in 81% of patients (92% HITpre, 69% HITpost). As compared to historical controls of patients treated with lepirudin in the period 2000-2005, results were significantly improved.
Argatroban anticoagulation is feasible in patients with HIT after VAD implantation, without increasing bleeding risk. Its impact in terms of survival should be reviewed also in the light of the technological improvements of assist devices.
There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggesting measures for ...prioritized future investigation we performed the first International Consensus Conference on this topic. The consensus was a continuous international internet‐based process with a final meeting on 28 June 2010 in Milan at the Vita‐Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons, and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting, and ranking. Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic β‐blockade, early aspirin therapy, the use of pre‐operative intra‐aortic balloon counterpulsation, and referral to high‐volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. This International Consensus Conference has identified the non‐surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra‐aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic β‐blockade, early aspirin therapy, and referral to high‐volume centers. The use of aprotinin and aged red blood cells may result in increased mortality.
Heparin-induced thrombocytopenia (HIT) is a serious, antibody-mediated complication of heparin which significantly confers risks of thrombosis and devastating outcomes. Once diagnosed, it requires ...immediate cessation of heparin and therapy with an alternative anticoagulant. No data are available in the literature on the pathophysiology and clinical implications of performing prolonged extracorporeal membrane oxygenation with a heparin-coated system in a patient with acute HIT treated with bivalirudin.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Infection during mechanical circulatory support is a frequent adverse complication. We analyzed infections occurring in this population in a national tertiary care center, and assessed the ...differences existing between the setting of extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs).
An observational study was made of patients treated with ECMO or VAD in the San Raffaele Scientific Institute (Italy) between 2009 and 2011.
None.
Thirty-nine percent of the 46 patients with ECMO and 69% of the 15 patients with VAD developed infection. We observed a mortality rate of 36.1% during mechanical circulatory support and of 55.7% during the global hospitalization period. Although Gram-negative infections were predominant overall, patients with ECMO were more prone to develop Candida infection (29%), and patients with VAD tended to suffer Staphylococcus infection (18%). Patients with infection had longer ECMO support (p=0.03), VAD support (p=0.01), stay in the intensive care unit (p=0.002), and hospital admission (p=0.03) than patients without infection. Infection (regression coefficient=3.99, 95% CI 0.93-7.05, p=0.02), body mass index (regression coefficient=0.46, 95% CI 0.09-0.83, p=0.02), fungal infection (regression coefficient=4.96, 95% CI 1.42-8.44, p=0.009) and obesity (regression coefficient=10.47, 95% CI 1.77-19.17, p=0.02) were predictors of the duration of ECMO support. Stepwise logistic regression analysis showed the SOFA score at the time of implant (OR=12.33, 95% CI 1.15-132.36, p=0.04) and VAD (OR=1.27, 95% CI 1.04-1.56, p=0.02) to be associated with infection.
Infection is a major challenge during ECMO and VAD support. Each mechanical circulatory support configuration is associated with specific pathogens; fungal infections play a major role.
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