Early detection of patients at risk of sternal complications is essential to facilitate prevention and optimize timely intervention. A systematic review and meta-analysis was conducted to identify ...risk factors associated with sternal complications. The review included 17 full-text studies, of which 10 were entered into meta-analyses. Female gender, diabetes mellitus, obesity, bilateral internal mammary artery grafts, reoperation for postoperative complications, and blood product requirement were reported as significant predictors of sternal infection. The compilation of these risk factors may help to screen and stratify patients at risk of impaired sternal healing and warrants further investigation.
Abstract Introduction The objectives of the study are to identify the most reliably imaged regions of the diaphragm, to evaluate the correlation of movement between different parts of each ...hemidiaphragm, and to assess the agreement between liver or spleen displacement and movement of the ipsilateral hemidiaphragm. Methods Images of the diaphragm, liver, and spleen were obtained using 2-dimensional ultrasound. Acceptable agreement between regions of the diaphragm, liver, and spleen was defined as an absence of fixed or proportional bias using Deming regression analysis and limits of agreement of 2 SDs of the difference less than 30% of the mean value. Results We included 90 critically ill patients. The medial (87%) and middle (73%) regions of the right hemidiaphragm, liver (87.7%), and spleen (81%) and medial (71%) and middle regions (51%) of the left hemidiaphragm were most frequently imaged. In nonintubated patients, acceptable agreement was present for comparisons of the left middle and medial, right middle and medial, and left middle regions and spleen displacement. In intubated patients and in all patients when combined, acceptable agreement was only present for comparisons of the left middle and medial and right middle and medial regions of the diaphragm. Acceptable agreement was not present for intubated and all patients for diaphragmatic and solid organ movement. Conclusion The diaphragm medial part is visualized in the majority of studied patients. The medial and middle thirds may be used interchangeably to assess hemidiaphragm movement. Acceptable agreement does not exist for diaphragm and solid organ movement, other than for the left middle region and the spleen.
The dislodgement of atheroma from the ascending aorta and proximal arch is a major cause of stroke and neurological injury following cardiac surgery. The accurate detection of atheroma prior to ...aortic manipulation is necessary to facilitate surgical strategies to reduce the risk of embolisation. The traditional method for atheroma detection is manual palpation by the surgeon. This technique misses about half the number of the atheroma lesions, as the soft (non-calcified) lesions offer little resistance to the surgeon's fingers. Trans-oesophageal echocardiography (TOE) is commonly used in cardiac surgery, but the interposition of the bronchus between the aorta and the oesophagus causes an ultrasound ‘blind spot’ in the ascending aorta and proximal arch, such that it does not offer improved detection compared to manual palpation. Accurate detection of atheroma requires direct ultrasound assessment using epiaortic scanning, with a high-frequency, linear-array probe. This allows the surgeon to correctly assess and localise any atheroma. In this article, a suggested epiaortic examination sequence is described and strategies for surgeons to avoid atheroma are discussed.
Background Radial artery harvest for coronary artery surgery leads to chronically elevated blood flow in the remaining ulnar artery. This study examined the ulnar artery for evidence of increased ...atherosclerosis compared with the contralateral ulnar artery where the radial artery had not been harvested. Methods Patients were enrolled at least seven years after unilateral radial artery harvest. Anatomical and flow data were acquired using a high-frequency ultrasound probe. Maximal forearm blood flow was measured after repeated hand grip with concurrent brachial artery occlusion to induce forearm ischemia. Results Eighty five patients, 71 males at age 71 ± 9 years (43 to 88) were assessed at 8.4 ± 1.0 years (7.2 to 11.1). There was no patient with ulnar artery atheroma on either side. Mild ulnar calcification was present in four patients bilaterally. The ulnar diameter after radial artery harvest was greater (2.8 ± 0.5 vs 2.4 ± 0.4 mm; p < 0.001), as was flow at rest (111 ± 64 vs 59 ± 41 mL/min; p < 0.001). However, the brachial artery flow was not different between the two sides at rest (169 ± 90 vs 176 ± 87 mL/min; p = 0.060) or after ischemic exercise (714 ± 294 vs 753 ± 315 mL/min; p = 0.485). Conclusions At an average of eight years after radial artery harvest, the remaining ulnar artery does not have evidence of increased atheroma and the maximal forearm blood flow is preserved.
Ultrasound in trauma Rippey, James C.R., MBBS, DCH, DDU, FACEM; Royse, Alistair G., MBBS, MD, FRACS, FCSANZ
Best practice & research. Clinical anaesthesiology,
09/2009, Letnik:
23, Številka:
3
Journal Article
Recenzirano
Point-of-care ultrasound is well suited for use in the emergency setting for assessment of the trauma patient. Currently, portable ultrasound machines with high-resolution imaging capability allow ...trauma patients to be imaged in the pre-hospital setting, emergency departments and operating theatres. In major trauma, ultrasound is used to diagnose life-threatening conditions and to prioritise and guide appropriate interventions. Assessment of the basic haemodynamic state is a very important part of ultrasound use in trauma, but is discussed in more detail elsewhere. Focussed assessment with sonography for Trauma (FAST) rapidly assesses for haemoperitoneum and haemopericardium, and the Extended FAST examination (EFAST) explores for haemothorax, pneumothorax and intravascular filling status. In regional trauma, ultrasound can be used to detect fractures, many vascular injuries, musculoskeletal injuries, testicular injuries and can assess foetal viability in pregnant trauma patients. Ultrasound can also be used at the bedside to guide procedures in trauma, including nerve blocks and vascular access. Importantly, these examinations are being performed by the treating physician in real time , allowing for immediate changes to management of the patient. Controversy remains in determining the best training to ensure competence in this user-dependent imaging modality.
Abstract Objectives This study aimed to determine the spatiotemporal stability of rotors and other atrial activation patterns over 10 min in longstanding, persistent AF, along with the relationship ...of rotors to short cycle-length (CL) activity. Background The prevalence, stability, and mechanistic importance of rotors in human atrial fibrillation (AF) remain unclear. Methods Epicardial mapping was performed in 10 patients undergoing cardiac surgery, with bipolar electrograms recorded over 10 min using a triangular plaque (area: 6.75 cm2 ; 117 bipoles; spacing: 2.5 mm) applied to the left atrial posterior wall (n = 9) and the right atrial free wall (n = 4). Activations were identified throughout 6 discrete 10-s segments of AF spanning 10 min, and dynamic activation mapping was performed. The distributions of 4,557 generated activation patterns within each mapped region were compared between the 6 segments. Results The dominant activation pattern was the simultaneous presence of multiple narrow wave fronts (26%). Twelve percent of activations represented transient rotors, seen in 85% of mapped regions with a median duration of 3 rotations. A total of 87% were centered on an area of short CL activity (<100 ms), although such activity had a positive predictive value for rotors of only 0.12. The distribution of activation patterns and wave-front directionality were highly stable over time, with a single dominant pattern within a 10-s AF segment recurring across all 6 segments in 62% of mapped regions. Conclusions In patients with longstanding, persistent AF, activation patterns are spatiotemporally stable over 10 min. Transient rotors can be demonstrated in the majority of mapped regions, are spatiotemporally associated with short CL activity, and, when recurrent, demonstrate anatomical determinism.
A 54 year-old man without prior cardiac history was involved in a motor vehicle accident. His heart rate was 100/min and blood pressure 128/78 mmHg. He complained of anterior chest pain, and on ...examination had a loud pan-systolic murmur with no clinical signs of heart failure. Three-dimensional trans-oesophageal echocardiography (3D-TOE) demonstrated partial rupture of the inferior head of the anterior papillary muscle (when 2D-TOE did not), causing severe tricuspid regurgitation. This was successfully repaired. Tricuspid valve insufficiency is a rare, but well documented, complication of blunt chest trauma. The majority of cases of tricuspid regurgitation caused by blunt trauma are diagnosed and treated late after the traumatic event. Acute diagnosis is less common but possible with a high level of vigilance, and is greatly aided by clinical indicators of cardiac injury. We describe a case of acute repair of traumatic tricuspid insufficiency, in which diagnosis and surgical planning were greatly aided by 3D-TOE.