Cardiopulmonary bypass and extracorporeal membrane oxygenation have many similarities, but there are significant differences in managing hemostasis. Cardiopulmonary bypass includes shorter mechanical ...circulatory support times, blood stasis, higher flows, and an increased blood–air interface. These factors cause differences in the risk of coagulopathy, management of anticoagulation, monitoring of the hemostatic system, and management of coagulopathy. This article aims to identify these key differences in the hemostatic system between patients on cardiopulmonary bypass and those on extracorporeal membrane oxygenation.
Lung transplantation is the definitive treatment for end-stage lung disease. The pulmonary venous anastomosis has the potential for significant obstructive complications that can lead to considerable ...morbidity and mortality. The use of intraoperative transesophageal echocardiography, including color-flow and spectral Doppler, is instrumental in evaluating the pulmonary veins after lung transplantation. In this E-challenge, a case of intraoperative pulmonary venous obstruction after bilateral lung transplantation is described, the echocardiographic principles required to evaluate the pulmonary veins and screen for complications are reviewed, and when intervention may be required is discussed.
Brachial arterial catheters better estimate aortic pressure than radial arterial catheters but are used infrequently because complications in a major artery without collateral flow are potentially ...serious. However, the extent to which brachial artery cannulation promotes complications remains unknown. The authors thus evaluated a large cohort of cardiac surgical patients to estimate the incidence of related serious complications.
The institutional Society of Thoracic Surgeons Adult Cardiac Surgery Database and Perioperative Health Documentation System Registry of the Cleveland Clinic were used to identify patients who had brachial artery cannulation between 2007 and 2015. Complications within 6 months after surgery were identified by International Classification of Diseases, Ninth Revision diagnostic and procedural codes, Current Procedural Terminology procedure codes, and Society of Thoracic Surgeons variables. The authors reviewed electronic medical records to confirm that putative complications were related plausibly to brachial arterial catheterization. Complications were categorized as (1) vascular, (2) peripheral nerve injury, or (3) infection. The authors evaluated associations between brachial arterial complications and patient comorbidities and between complications and in-hospital mortality and duration of hospitalization.
Among 21,597 qualifying patients, 777 had vascular or nerve injuries or local infections, but only 41 (incidence 0.19% 95% CI, 0.14 to 0.26%) were potentially consequent to brachial arterial cannulation. Vascular complications occurred in 33 patients (0.15% 0.10 to 0.23%). Definitely or possibly related infection occurred in 8 (0.04% 0.02 to 0.08%) patients. There were no plausibly related neurologic complications. Peripheral arterial disease was associated with increased risk of complications. Brachial catheter complications were associated with prolonged hospitalization and in-hospital mortality.
Brachial artery cannulation for hemodynamic monitoring during cardiac surgery rarely causes complications.
Hyperglycemia is associated with adverse post-surgical outcomes. We evaluated Dexcom G6 accuracy following cardiac surgery. A clinical glucose dataset included 1428 readings of 29 patients, Dexcom ...data included 45,645 measures. Clinical and Dexcom measures were restricted at least 1 hour after prior measure. Matching clinical and Dexcom measures were required within 5 min. Data were included at least 2 hr after Dexcom insertion and ICU admit. A dataset only measuring ≥24 hrs post ICU admit was created to explore device stability. Patients remained on Dexcom until discharge or 10 days postop. The population was 71% male 14% with known diabetes, 66% who went on intravenous insulin infusion. Figure 1a is Clarke error grid plot of all measures post-ICU admission: 53.5% were Zone A, 45.9% Zone B, and 0.6% (n=5) Zones D or E. Figure 1b uses restricted dataset beginning 24 hours post-ICU admission: 55.9% in Zone A, 43.9% in Zone B, and 0.2% in Zone D. MARD between clinical and Dexcom measures was 20.6% and 21.6% in post-ICU admission dataset and dataset excluding first 24 hours after ICU admission. Almost 100% of Dexcom G6 and clinical data matching points fell within areas considered as giving clinically correct decisions (Zone A) and clinically uncritical decisions (Zone B). If CGM readings are used for clinical decision-making, glucose targets or insulin dosing algorithms may need adjustment. As technology evolves, this device may limit glycemic fluctuations.
Disclosure
S.R.Insler: None. B.J.Wakefield: None. J.F.Bena: None. A.Debs: None. K.Brake: None. I.Nwosu: None. M.Lansang: Research Support; Dexcom, Inc., Abbott, Alertgy Inc.
Context: Global longitudinal strain (GLS) measured by speckle-tracking echocardiography demonstrates excellent prognostic ability in predicting major adverse cardiac events after cardiac surgery. ...However, the optimal timing of intraoperative GLS measurement that provides the best prognostic value is unclear.
Aim: Our goal was to evaluate whether GLS measured prior to cardiopulmonary bypass (pre-CPB GLS), following CPB (post-CPB GLS), or change in GLS provides the strongest association with postoperative complications.
Setting and Design: Post hoc analysis of prospectively collected data from a clinical trial (NCT01187329). 72 patients with aortic stenosis undergoing elective AVR ± coronary artery bypass grafting between January 2011 and August 2013.
Material and Methods: Myocardial deformation analysis from standardized transesophageal echocardiographic examinations were performed after anesthetic induction and chest closure. We evaluated the association between pre-CPB GLS, post-CPB GLS, and change in GLS (percent change from pre-CPB baseline) with postoperative atrial fibrillation and hospitalization >7 days. The association of post-CPB GLS with duration of mechanical ventilation, N-terminal pro-BNP (NT-proBNP) and troponin T were also assessed.
Statistical Analysis: Multivariable logistic regression.
Results: Risk-adjusted odds (OR97.5%CI of prolonged hospitalization increased an estimated 27% (1.271.01 to 1.59;Padj =0.035) per 1% decrease in absolute post-CPB GLS. Mean98.3%CI NT-proBNP increased 98.420 to 177pg/mL; Padj =0.008), per 1% decrease in post-CPB GLS. Pre-CPB GLS or change in GLS were not associated with any outcomes.
Conclusions: Post-CPB GLS provides the best prognostic value in predicting postoperative outcomes. Measuring post-CPB GLS may improve risk stratification and assist in future study design and patient outcome research.
The Angiotensin II for the Treatment of Vasodilatory Shock (ATHOS-3) trial demonstrated the vasopressor effects and catecholamine-sparing properties of angiotensin II. As a result, the Food and Drug ...Administration has approved angiotensin II for the treatment of vasodilatory shock. This review details the goals of treatment of vasodilatory shock in addition to the history, current use, and recent research regarding the use of angiotensin II. An illustrative case of the use of angiotensin II is also incorporated for understanding the clinical utility of the drug.
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