Summary
Hellmut Hartert was the first person to exploit the viscoelastic properties of clotting blood to measure blood coagulation in 1948. Since then, the technology has improved, allowing these ...analyses to be performed as point‐of‐care tests with immediately‐available results. The addition of several activators and inhibitors to the original assay creates a panel of tests able to quantify the different aspects of blood clotting that can rival conventional laboratory assays. However, although much progress has been made, the standardization and validation of these tests still need improvement. Viscoelastic analyses of blood coagulation are mainly used to guide haemostatic therapy in bleeding patients and have proven superior to standard clotting tests in some circumstances. There is potential to extend their use to other areas, such as drug monitoring, and diagnosis and management of congenital bleeding disorders. The forthcoming cartridge‐based assays are expected to improve the reliability and usability of viscoelastic assays of blood coagulation but high quality clinical trials remain urgently needed to determine their exact place, benefit and cost effectiveness.
To assess the safety of “on-table” extubation after minimally-invasive heart valve surgery.
A single-center retrospective observational study.
At a tertiary referral academic hospital.
Patients who ...underwent nonemergent isolated heart valve surgery through a minithoracotomy approach between January 2016 and August 2021.
All patients were treated by 1 of the 6 cardiac anesthesiologists of the hospital. Only some of them practiced “on-table” extubation, and the outcome of patients extubated “on-table” was compared to those extubated in the intensive care unit (ICU).
The primary outcome was the occurrence of any postoperative respiratory complication during the entire hospital stay. Secondary outcomes included the use of inotropes and vasopressors, de novo atrial fibrillation, and lengths of stay in the ICU and the hospital. A total of 294 patients met inclusion criteria, of whom 186 (63%) were extubated “on-table.” Cardiopulmonary bypass duration was significantly longer, and moderate intraoperative hypothermia was significantly more frequent in patients extubated in the ICU. After adjustment for these confounders and for the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II using a multivariate logistic model, no association was found between the extubation strategy and postoperative pulmonary complications (adjusted odds ratio = 0.84; 95% CI = 0.40-1.77; p = 0.64). “On-table” extubation was associated with a lower risk of postoperative pneumonia and fewer vasopressors requirements.
“On-table” extubation was not associated with an increased incidence of respiratory complications. A randomized controlled trial is warranted to confirm these results and determine whether “on-table” extubation offers additional benefits.
Circulating cardiac biomarkers may improve the prediction of long-term outcomes after cardiac surgery. The authors sought to assess if cardiac biomarkers also help better predict short-term ...morbidity.
Prospective observational study.
Single academic hospital.
A total of 250 patients undergoing aortic or mitral valve surgery with or without associated coronary artery bypass grafts.
None
Relationships between preoperative plasma concentrations of four cardiac biomarkers (sST2, Galectin-3, GDF-15, and NT-proBNP) and postoperative outcome were assessed using logistic regressions and Cox proportional hazards models. The primary outcome was a composite of 30-day mortality, an inotropic support longer than 48 hours and an initial length of stay in the intensive care >five days. Secondary outcome measures were postoperative acute kidney injury, inotropic support duration, lengths of intensive care unit and hospital stays, and 30-day and one-year mortality. No association was observed between any of the four cardiac biomarkers and the primary outcome. The preoperative levels of Galectin-3 (hazard ratio = 1.2; p < 0.001) and sST2 (hazard ratio = 1.01, p < 0.001) were significantly associated with one-year survival, and their addition to the EuroSCORE II significantly improved the prediction of one-year mortality (p < 0.001). Similarly, Galectin-3 was associated with postoperative acute kidney injury (odds ratio = 1.15, p = 0.001) and improved the prediction of this complication when added to the EuroSCORE II (p = 0.002).
These results suggested that the ability of cardiac biomarkers to predict short-term outcome after cardiac surgery, though of interest, appears limited. Conversely, cardiac biomarkers may have the potential to refine the prediction of long-term outcome. Admittedly, all positive results were obtained on secondary outcomes and must be regarded with caution.
The authors aimed to develop a simple prediction score to help identify patients at high risk of low-cardiac-output syndrome after adult cardiac surgery.
A single-center, retrospective, observational ...study.
At a tertiary hospital.
Adult patients who underwent on-pump cardiac surgery between April 2016 and March 2021.
None.
Among the 2,806 patients retained for final analyses, 355 (12.7%) developed low-cardiac-output syndrome. Using a stepwise backward variable selection procedure applied to a multivariate logistic regression, a prediction model, including 8 risk factors, could be identified—preoperative left ventricular ejection fraction, glomerular filtration rate <60 mL/min according to the Cockcroft formula or preoperative dialysis, combined surgery, nonelective surgery, mitral valve surgery for mitral valve regurgitation, history of extracardiac arteriopathy, preoperative hemoglobin <13 g/dL, and New York Heart Association functional class III or IV. A clinical prediction score was derived from the regression coefficients. The model had a good discriminative ability, with an area under the receiver operating characteristics curve of 0.8 (95% CI: 077-0.84). Using a threshold value of 5, the score had a 68% sensitivity, 79% specificity, a positive-predictive value of 33%, and a negative-predictive value of 94%. These results were validated on a validation sample using the bootstrap resampling technique.
The authors developed a clinical score to facilitate the prediction of low- cardiac-output syndrome after adult cardiac surgery. This could help tailor patient management by contributing to the early identification of those at high risk of postoperative low cardiac output.
Bone marrow mesenchymal stem cells (MSCs) can differentiate into several types of mesenchymal cells, including osteocytes, chondrocytes, and adipocytes, but, under appropriate experimental ...conditions, can also differentiate into nonmesenchymal cells--for instance, neural cells. These observations have raised interest in the possible use of MSCs in cell therapy strategies for various neurological disorders. In the study reported here, we addressed the question of in vitro differentiation of MSCs into functional neurons. First, we demonstrate that when they are co-cultured with cerebellar granule neurons, adult MSCs can express neuronal markers. Two factors are needed for the emergence of neuronal differentiation of the MSCs: the first one is nestin expression by MSCs (nestin is a marker for the responsive character of MSCs to extrinsic signals), and the second one is a direct cell-cell interaction between neural cells and MSCs that allows the integration of these extrinsic signals. Three different approaches suggest that neural phenotypes arise from MSCs by a differentiation rather than a cell fusion process, although this last phenomenon can also coexist. The expression of several genes--including sox, pax, notch, delta, frizzled, and erbB--was analyzed by quantitative reverse transcription polymerase chain reaction (RT-PCR) in order to further characterize the nestin-positive phenotype compared to the nestin-negative one. An overexpression of sox2, sox10, pax6, fzd, erbB2, and erbB4 is found in nestin-positive MSCs. Finally, electrophysiological analyses demonstrate that MSC-derived neuron-like cells can fire single-action potentials and respond to several neurotransmitters such as GABA, glycine, and glutamate. We conclude that nestin-positive MSCs can differentiate in vitro into excitable neuron-like cells.
Peak systolic global longitudinal strain (GLS) is increasingly used to quantify left ventricular systolic function. The primary objective of this study was to assess whether GLS obtained during ...intraoperative transesophageal echocardiogram, performed before cardiopulmonary bypass, improves the prediction of postoperative low cardiac output syndrome (LCOS) after adult cardiac surgery.
GLS from 275 patients undergoing on-pump cardiac surgery was calculated retrospectively using two-dimensional- speckle tracking echocardiography (aCMQ module from Qlab software version 10.5, Philips Medical, Brussels, Belgium). LCOS was defined as the need for inotropic or mechanical circulatory support for >24 hours postoperatively. Patient and procedure characteristics associated with LCOS at the univariable level (P ≤ .05) were entered into a forward stepwise logistic regression to create a first predictive model. A second model was created by adding GLS. The 2 models were compared using the likelihood-ratio test, the area under the receiver operating characteristic (ROC) curve, and the integrated discrimination index. The optimal cutoff value of GLS associated with LCOS was determined by maximizing the Youden index of the ROC curve. Secondary outcomes included time until complete weaning from inotropes, discharge from the intensive care unit and from the hospital, and 30-day mortality.
GLS was significantly associated with LCOS (P < .001) at the univariable level. Predictors of LCOS retained in the first model were cardiopulmonary bypass duration, decreased left ventricular ejection fraction, mitral valve surgery, and New York Heart Association functional class III or IV. Adding the GLS value improved the prediction of LCOS (P = .02). However, the area under the ROC curve did not differ between the 2 models (0.83; 95% confidence interval CI, 0.77-0.99 vs 0.84; 95% CI, 0.79-0.90; P = .15). The integrated discrimination index associated with addition of GLS was 0.02 (P = .046), meaning that the difference in predicted risk between patients with and without LCOS increased by 2% after adding GLS. A GLS cutoff value of -17% (95% CI, -18.8% to -15.3%) was found to best identify LCOS. After adjusting for covariates included in model 1, a lower GLS value was significantly associated with a lower cumulative probability of weaning from inotropes postoperatively (hazard ratio, 0.90; 95% CI, 0.82-0.97; P = .01). No association was found between GLS and other secondary outcome measures.
GLS is an independent predictor of LCOS after on-pump cardiac surgery. Its incremental value over other established risk factors for postoperative LCOS is, however, limited.
Preoperative use of antidepressants and anxiolytics was reported to increase length of hospital stay (LOS) and worsen surgical outcomes. However, the surgical procedures studied were seldom performed ...with an enhanced recovery programme (ERP). This study investigated whether these medications impaired postoperative recovery after colorectal surgery with an ERP.
The data of all patients scheduled for colorectal surgery between November 2015 and December 2019 prospectively included in our database were analysed. All the patients were managed with the same ERP. Demographic data, risk factors, incidence of postoperative complications, LOS, and adherence to the ERP were compared between patients with and without preoperative antidepressant and/or anxiolytic treatment.
Of the 502 patients, 157 (31.3%) were treated with antidepressants and/or anxiolytics. They were older (65.7 vs. 59.5 years, p < 0.001), sicker (higher ASA physical status score, p = 0.001), and underwent surgery more frequently for cancer (73.9 vs. 56.8%, p < 0.001). Overall adherence to ERP (p = 0.99) and adherence to the postoperative items of ERP (p = 0.29), incidence of postoperative complications (35.7 vs. 33.2%, p = 0.61), and LOS (4 2-7 vs. 4 2-7, p = 0.99) were similar in the two groups.
Our findings suggest that preoperative treatment with antidepressants and/or anxiolytics does not worsen outcome after elective colorectal surgery with an ERP, does not impact adherence to ERP, and does not prolong LOS. ERP seems efficacious in patients treated with these medications, who should therefore not be excluded from this programme.
Intravenous magnesium deepens non-depolarising neuromuscular block.
To assess whether intravenous magnesium has the potential to re-establish paralysis in patients who have just recovered from a ...non-depolarising neuromuscular block.
Prospective randomised double-blind controlled study.
Twenty non-obese patients ranging in age from 18 to 80 years were enrolled. Exclusion criteria were a history of liver, kidney or neuromuscular disease and intake of medications interacting with neuromuscular blocking agents.
After spontaneous recovery from an intubating dose of rocuronium had been achieved (train-of-four ratio ≥0.9), patients were given either a bolus dose of magnesium 50 mg kg(-1) intravenously or an equivalent volume of isotonic saline over 5 min.
The train-of-four ratio was measured every minute until the end of surgery. The primary endpoint was the proportion of patients who experienced a decrease in train-of-four ratio following administration of magnesium or saline.
Following infusion of the study solution, the train-of-four ratio decreased in all patients in the magnesium group in contrast to none in the saline group (P<0.001). On average, magnesium-induced train-of-four ratio depression reached a nadir of 0.49 after 10 min and lasted for 45 min.
A bolus dose of intravenous magnesium 50 mg kg(-1) re-establishes a clinically relevant degree of muscle paralysis in patients who have just recovered from a non-depolarising neuromuscular block.
EudraCT.ema.europa.eu 2009-017372-24.
Background
Anemia is common before major abdominal surgery (35%). It is an independent factor for postoperative complications and longer length of stay (LOS). The aim of this study was to evaluate ...the extent to which preoperative anemia impacts on enhanced recovery programs (ERP) outcomes
.
Materials and Methods
The data for patients scheduled for colorectal surgery between 2015 and 2019, were analyzed (
n
= 494). All patients were managed with the same ERP. Demographic data, preoperative risk factors, postoperative complications, LOS and adherence to ERP were compared between anemic and non-anemic patients. Anemia was defined by a hemoglobin concentration < 13 g dL
−1
in men and < 12 g dL
−1
in women.
Results and Discussion
In total, 173 patients had preoperative anemia. They were older (
p
< 0.001) and more often male (
p
= 0.02). The following risk factors were significantly more frequent in the anemic group: renal failure (
p
= 0.04), malnutrition (
p
< 0.001), cardiac arrhythmia (
p
< 0.001), coronaropathy (
p
= 0.02) and anticoagulant treatment (
p
< 0.001). Despite more risk factors, anemic patients did not experience more postoperative complications (38.2%
vs
. 31.2%,
p
= 0.12). Overall adherence to ERP was similar (18 16–19 vs. 18 17–19,
p
= 0.06). LOS was 4 3–7 and 3 2–6.25 days in the anemic and the non-anemic groups, respectively (
p
< 0.002). Multivariate analysis showed that anemia did not affect LOS (
p
= 0.27).
Conclusion
Our study suggests that preoperative anemia does not detract from the benefits of ERP after elective colorectal surgery.
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