Tracheal injury is a rare but highly morbid complication of endotracheal intubation. Recent reviews have advocated conservative management of these injuries without operative intervention. Extracorporeal membrane oxygenation may be a useful tool in non-operative management of tracheal injury in the setting of severe respiratory failure and need for prolonged intubation. We present a morbidly obese 33 year-old-female with H1N1 influenza pneumonia complicated by acute respiratory distress syndrome and bacterial super-infection who sustained a post-intubation tracheal injury. Concomitant tracheal injury and acute lung injury pose a difficult ventilation dilemma. This patient was successfully managed by venovenous extracorporeal membrane oxygenation, high frequency oscillator ventilation, proning position and tube thoracostomy. The venovenous extracorporeal membrane oxygenation and ventilator management were essential for this patient's recovery.
A 69 year old female with a history of gas-tric bypass surgery with a recent revision (12 weeks prior to presentation) was ad-mitted from a skilled nursing facility with subacute progressive dyspnea, cough and pleuritic chest pain. On initial assessment her blood pressure was 150/80 mmHg, pulse of 130 beats per minute, with a respiratory rate of 30 per minute and oxygen saturation of 85%. She had evidence of hypoxemic respira-tory failure on arterial blood gases, with a PaO2 of 46 mmHg and thus was intubated and sedated before further workup was ob -tained. A bedside echocardiogram showed pre-served left ventricular performance, with an ejection fraction of 65%, but exhibited severe right ventricular enlargement and systolic dysfunction (
There has been significant progress throughout 2014 in cardiothoracic and vascular anaesthesia and intensive care. There has been a revolution in the clinical approach to acute and chronic adult aortic diseases. Contemporary management of adult aortic disease is based on etiology, clinical presentation, extent, and integrated intervention with medical, endovascular and/or surgical measures. Further European guidelines have explored in depth the cardiovascular management in non-cardiac surgery with a thematic focus to reduce perioperative mortality from the leading offender, namely myocardial ischemia. Integrated guidelines address the management of myocardial revascularization including the percutaneous and surgical options. Despite 50 years since the first coronary artery bypass grafting procedure and impressive advances in interventional cardiology, surgical revascularization remains a gold standard for many patients with coronary artery disease. These advances in 2014 will likely further improve perioperative outcomes for our patients.
Introduction: To compare estimation of ejection fraction at the bedside by AutoEF compared with conventional methods and to assess feasibility and time consumption.Methods: A total of 102 relatively hemodynanically stable mixed medical and surgical patients were included. All patients underwent ultrasonography of the heart at the bedside performed by a novice examiner. Three assessments of ejection fraction were made: 1) Expert eyeballing by a single specialist in cardiology and expert in echocardiography; 2) Manual planimetry by an experienced examiner; 3) AutoEF by a novice examiner with limited experience in echocardiography.Results: Expert eyeballing of ejection fraction was performed in 100% of cases. Manual planimetry was possible in 89% of cases and AutoEF was possible in 83% of cases. The correlation between expert eyeballing and AutoEF was r = 0.82, p < 0.001, for manual planimetry and for AutoEF it was r= 0.82, p < 0.001; for expert eyeballing and manual planimetry it was r = 0.80, p < 0.001. The mean time consumption for manual planimetry was 98 ( 90-106) seconds; correspondingly the mean time spent for AutoEF was 41 (36-46) seconds, which was significantly less (p < 0.001).Conclusions: AutoEF seems to be a valid supplement to the clinical assessment of ejection fraction in the hands of less experienced examiners, yielding result similar to manual planimetry with less time consumption and less intra-observer variability. However, manual editing may be required and training is thus recommended before AutoEF is applicable for use by novices.
Introduction The incidence of Acute Kidney Injury is nowadays high in critically ill patients. Its etiology is multifactorial and a primary role is played by low cardiac output syndrome. Everything targeted to normalize cardiac output should increase the renal perfusion and abolish the secondary vasoconstriction. Levosimendan is a calcium sensitizer drug with inotropic properties that improves cardiac output and seems to increase renal blood flow. The aim of this meta-analysis was to evaluate the role of levosimendan in critically ill patients with or at risk of Acute Kidney Injury. Methods We performed a meta-analysis of randomized controlled trials searching for trials that compared levosimendan with any comparator. The endpoints were the number of patients receiving Renal Replacement Therapy after randomization and the number of patients developing Acute Kidney Injury. Results Final analysis included 33 trials and 3,879 patients (2,024 levosimendan and 1,855 control). The overall analysis showed that the use of levosimendan was associated with a significant reduction in the risk of Renal Replacement Therapy (17 of 492 [3.5%] in the levosimendan group versus 37 of 427 [8.7%] in the control group, relative risk =0.52 [0.32 to 0.86], p for effect =0.01) and of Acute Kidney Injury (114 of 1,598 [7.1%] in the levosimendan group versus 143 of 1,529 [9.4%] in the control arm, relative risk =0.79 [0.63 to 0.99], p for effect =0.048). Conclusions This meta-analysis suggests that the use of levosimendan is associated with a significant reduction of Renal Replacement Therapy in critically ill patients.
INTRODUCTION:Chronic mitral regurgitation is often accompanied by left atrial and ventricular remodeling and elevated natriuretic peptide levels. Our aim was to examine the relation between severe preoperative left atrial enlargement and changes in hemodynamics and natriuretic peptide levels after mitral valve surgery.METHODS:A prospective study was conducted including 40 consecutive patients in sinus rhythm, with severe degenerative mitral regurgitation. N-terminal protype-B natriuretic peptide levels and hemodynamics were measured at predefined time points. An echocardiographic evaluation was performed the day before valve surgery and six months postoperatively.RESULTS:Patients with left atrial volume index ≥60 mL/m(2), n=26, had higher baseline mean pulmonary capillary wedge pressure (17±9 mmHg vs 9±4 mmHg, p=0.010) and N-terminal protype-B natriuretic peptide (1326±2573 ng/L vs 233±221 ng/L, p=0.002) than patients with left atrial volume index <60 mL/m(2). The mean pulmonary capillary wedge pressure decreased to normal in patients with severe left atrial enlargement early after surgery, while it remained normal in patients without severe left atrial enlargement. The natriuretic peptide levels increased during the early postoperative period and decreased in both groups at 6-month follow-up.CONCLUSIONS:A severe left atrial enlargement in patients with chronic degenerative mitral regurgitation and sinus rhythm indicates higher pulmonary capillary wedge pressure and natriuretic peptide levels than in those without. These findings may support early referral to surgery and may facilitate perioperative management. The potential reversibility of left atrial enlargement after surgery may be associated with postoperative reductions in pulmonary capillary wedge pressure and natriuretic peptide levels.
Network meta-analysis provides a global estimate of comparative treatment effectiveness combining both direct and indirect evidence. In the past decade, the medical literature has witnessed a rapid increase in the possibility to combine evidence from different treatment comparisons. This opportunity is attractive for clinicians since their major concern is to identify the single best available treatment. In addition, despite the sudden increase of publications concerning network meta-analysis, only a limited number focus on methodological and statistical aspects, and many issues remain unclear. The aim of our work was to explore and emphasize the potential attractiveness of network meta-analyses. We performed a systematic and narrative review (last updated on April 15, 2014) in order to assess the scholarly diffusion of network meta-analyses. The following data were collected: author identification, year and journal of publication, PubMed index, number of treatments and studies included, characteristics of network configuration, nature of primary outcome, clinical indication, type of intervention investigated and medical area. Since 2003 there has been an exponential increase in the number of published network meta-analyses. Out of 340 articles included according to our selection criteria, encompassing 248 treatment networks, cardiovascular and pulmonary diseases were the most prevalent topics, with an average of 5 treatments being compared stemming from an average of 10 controlled trials. In conclusion, network meta-analyses are becoming increasingly attractive as they offer a comprehensive framework for decision-making. Whether they will also contribute to improvements in patient outlook remains to be proven.
Introduction Currently, a dose of protamine equal to 1 mg for each 100 units of heparin given is used to reverse the residual heparin activity following off-pump coronary artery bypass. We hypothesized that a 1:1 ratio (ratio of protamine to heparin) could be higher than necessary inducing post-operative disturbance of hemostasis. Methods Between January and March 2014 in 9 patients undergoing off-pump coronary artery bypass, we evaluated the effect of a dose of protamine equal to 1 mg per 100 units of heparin (Total Calculated Dose) on hemostasis as evaluated by means of thromboelastomery. Two data analyses were performed: the first after the administration of 2/3 of the Total Calculated Dose of protamine and the second after the administration of the Total Calculated Dose of protamine. Results We found that the administration of 2/3 of Total Calculated Dose of protamine was always able to reverse the anticoagulant effect of heparin and that a significant clotting time elongation was induced by the infusion of the second part of the Total Calculated Dose of protamine. No modification in clot firmness was observed. Conclusions The present study seems to suggest that the commonly applied ratio equal to 1:1 (ratio of protamine to heparin) could be higher than needed with potential and hazardous impacts on the efficacy of the coagulation system.
Source of Support Nil. Disclosures None declared. Cite as: Bressman M, Raad W, Levsky J, Weinstein S. Surgical therapy for complications of pneumonia on extracorporeal membrane oxygenation can improve the ability to wean patients from support. Heart, Lung and Vessels. 2015;7(4):330-331
Source of Support Nil. Disclosures None declared. Cite as: Lazzeri C, Gensini GF, Peris A. The assessment of cardiac function in veno-venous extracorporeal membrane oxygenation: the emerging role of bedside echocardiography. Heart, Lung and Vessels. 2015; 7(2): 99-100
Source of Support Nil. Disclosures None declared. Cite as: Peruzzi M, Frati G, Biondi-Zoccai G. Heart, Lung and Vessels... but brain and hands too! The case for a novel journal in the cardiovascular scholarly arena. Heart, Lung and Vessels. 2015;7 (3): 187-190
Introduction The current role of nurses in the management of critically ill patients needing continuous renal replacement therapies is clearly fundamental. The care of these complex patients is typically shared by critical care and dialysis nurses: their precise duties may vary from country to country. Methods To clarify this issue we conducted a national-level survey at a recent Italian course on nursing practices during continuous renal replacement therapies. Results A total of 119 questionnaires were analysed. The participants, who were equally divided between critical care and dialysis nurses, came from 44 different hospitals and 35 Italian cities. Overall, 23% of participants answered that “the dialysis staff” were responsible for continuous renal replacement therapies in the Intensive Care Unit, while 39% answered “the critical care nurse”, and 38% “a shared organization”. Interestingly, less than the half of participants claimed specific continuous renal replacement therapies training was provided to employees before handling an acute dialysis machine. Finally, about 60% of participants had experience of extra-corporeal membrane oxygenation machines used in conjunction with continuous renal replacement therapies. Conclusions Workload coordination and management of critically ill patients undergoing continuous renal replacement therapies in Italy is not standardized. At present, the duties of critical care and dialysis nurses vary significantly across the country. They frequently overlap or leave gaps in the assistance received by patients. The role of nurses involved in the care of continuous renal replacement therapies patients in Italy currently requires better organization, possibly starting with intensive standardized training and educational programs.
Introduction: Currently, the gold standard for donor organ preservation in clinical organ transplantation consists of 3 plastic bags and an ice box. The first plastic bag includes the organ itself immersed in preservation solution (e.g. Celsior). This bag is put in a second bag filled with saline, and then these two are put in a third bag filled with saline which is then put in the ice box. The disadvantage of this method is that the organ usually gets too cold. It has been shown that the theoretical perfect temperature for organ preservation is 4 degrees C - 8 degrees C. While higher temperatures lead to hypoxic injury of the organ because the metabolism is not decreased efficiently, lower temperatures than 4 degrees C increase the risk of cold injury with protein denaturation. In the current study, we investigated a device that keeps the organ temperature consistently in the desired range of 4 degrees C - 8 degrees C and can potentially decrease cold injury to donor organs.Methods: Three different ex vivo studies were performed with the Paragonix Sherpa Pak (TM) devices: 1) the temperature of the fluid-filled device was measured for up to 30 hours at an outside temperature set at 22 degrees C; 2) the temperature of the fluid-filled device was measured for up to 30 hours at extreme outside temperatures set at -8 degrees C and 31 degrees C; 3) the temperature of a pig heart attached to the device was measured up to 12 hours. Results: All studies showed that the Paragonix Sherpa Pak T can keep the temperature of the heart consistently between 4 degrees and 8 degrees C.Results: All studies showed that the Paragonix Sherpa Pak (TM) can keep the temperature of the heart consistently between 4 degrees and 8 degrees C.Conclusions: The Paragonix Sherpa Pak (TM) device may decrease cold injury of donor organs by maintaining the temperature consistently between 4 degrees C and 8 degrees C and therefore may decrease primary graft failure after organ transplantation.
Source of Support Nil. Disclosures None declared. Cite as: GaoY, Rowbottom RG, Landeras LA, Gilkeson RC. Improved detection of an intravascular catheter using dual energy subtraction radiography. Heart, Lung and Vessels. 2015;7(4):327
INTRODUCTION:Reconstruction of the right ventricular outflow tract is the most commonly performed valve repair/replacement procedure in congenital cardiac surgery. There is an ongoing shortage of homografts, and existing bioprosthetic options suffer from substantial rates of structural valve deterioration over time. The Medtronic Freestyle valve is used extensively in the aortic position, but little data is available on its performance in the pulmonary position.METHODS:A systematic review and meta-analysis of primary studies reporting echocardiographic and clinical outcomes, including reintervention and functional status, associated with the Freestyle valve in the pulmonary position for both Ross and congenital surgery.RESULTS:13 observational studies including 334 patients with a mean follow-up of 34 months (range 10-98 months) fulfilled the eligibility criteria and were included in the review. Structural valve deterioration occurred in 4.8% (95% confidence interval 0.8-10.6%) of patients. Reintervention was required in 1.1% (95% confidence interval 0.0-3.3%). Freedom from symptoms of heart failure occurred in 97.7% (94.6-99.7%). The results did not change substantially when analysed according to Ross or congenital surgery.CONCLUSIONS:The Freestyle valve performs well at short-term follow-up and provides a viable alternative when homografts are unavailable. Further long-term studies are required to better assess its role in right ventricular outflow tract reconstruction.
Cardiac surgery occurs at a tremendous volume worldwide and the number of cardiac surgical procedures is steadily increasing every year. Demographic change, technological advance and the growing burden of chronic disease mean that this trend is set to continue, placing further demand on limited healthcare resources. Complex interventions can be described as interventions that contain several interacting components but they have other characteristics such as range of possible outcomes and variability in the target population that evaluators should take into account. Enhanced recovery is an integrated model of care that accelerates recovery, through a series of evidence-based interventions to optimise the patient’s condition, minimise the stress response to surgery and promote return to usual function. Essentially it is a complex intervention with multiple elements and its successful implementation is likely to be influenced by numerous background factors (1). Implementation of enhanced recovery programmes varies and this variation reflects the complex ity of the programmes themselves and also issues related to implementation of changes in fundamental surgical procedures. Enhanced recovery was pioneered in Denmark in the late 1990s for patients undergoing colorectal surgery; the principles have now been applied to other surgical specialties including cardiothoracic surgery. Specific complications that influence length of stay in cardiac surgical patients are not addressed in previous studies, as the majority of trials have taken place in patients undergoing colorectal surgery (2). From our own work on enhanced recovery
Even after incomplete myocardial recovery during mechanical circulatory support, long-term survival rates after ventricular assist device (VAD) explantation can be better than those expected after heart transplantation even for patients with chronic non-ischemic cardiomyopathy as the underlying cause for VAD implantation. The elective therapeutic use of ventricular assist devices for heart failure reversal in its early stage is a future goal. It may be possible to achieve it by developing tools to predict heart failure reversibility even before ventricular assist device implantation and increasing the number of weaning candidates by improvement of adjunctive therapies to optimize unloading-promoted recovery. Special attention is focused on the long-term stability of cardiac remission after VAD removal, the clinical relevance unloading-promoted myocardial recovery and on the current knowledge about a potential prediction of myocardial recovery during long-term VAD support already before VAD implantation.
Fiberoptic bronchoscopy (for difficult intubation, bronchoalveolar lavage or biopsies), gastric endoscopies and transesophageal echocardiography (for transfemoral aortic valve replacement, MitraClip or left atrial appendage closure), are widespread diagnostic and therapeutic procedures. Non-invasive ventilation during upper endoscopies can be used to prevent or treat acute respiratory failure especially in high risk or sedated patients. We describe a novel full face mask specifically developed not only for "elective" non-invasive ventilation during upper endoscopies but also for emergent application without probe removal. The mask is formed by two halves fixed only at the upper extremity allowing opening and closure while the probe is in place. Position of the port and shape of the mask allow easy insertion (through the nose or the mouth) and handling of different sized probes. The mask, commercialized as "Janus", preserves arterial oxygenation during procedures in spontaneously breathing patients with or at risk of hypoxemia (mainly fiberoptic bronchoscopy for guided tracheal intubation or for bronchoalveolar lavage). In patients requiring a true ventilatory support (like patients with neuromuscular disease or those deeply sedated), Janus also allows effective manual or mechanical ventilation. Its use can improve safety, patient's comfort (as sedation can be titrated to the desired effect without fearing respiratory depression) and efficiency, avoiding time wasting and allowing procedure completion. Prospective trials are required to confirm its effectiveness.
INTRODUCTION:Ultra-fast track anaesthesia aims at immediate extubation of cardiac surgical patients at the end of the operation. This study compares the effect of ultrafast track anesthesia versus continued postoperative mechanical ventilation on the intensive care unit length of stay. METHODS:Fifty-two elective adult patients were randomly allocated into ultrafast track anaesthesia and conventional groups by computer-generated random numbers. Redo operations, pre-operative intubation, uncontrolled diabetes, shock/left ventricular ejection fraction < 45%, pulmonary artery systolic pressure >55mmHg, creatinine clearance -1, haemodynamic instability, or those with concerns of postoperative bleeding were excluded. Pre- and intra-operative management was similar and Logistic EuroSCORE II was calculated for all. Intra-operatively, haemodynamic parameters, urine output, oxygen saturation, arterial blood gas analysis, 5-lead electrocardiogram, operative bypass- and cross-clamp time, and opioid consumption were collected. Postoperatively, patients were compared during their intensive care unit stay. Data were analysed by χ²/Fischer exact, unpaired student's t-test, univariate two-group repeated measures with post hoc Dunnett's test, and Mann-Whitney U tests as appropriate. p < 0.05 was considered significant. RESULTS:Patients were comparable regarding their peri-operative characteristics and EuroSCORE. The intensive care unit stay was shorter in the ultrafast track anaesthesia group [57.4 (18.6) vs. 95 (33.6) h. p < 0.001], without increasing postoperative renal, respiratory complications rate or reopening rate. CONCLUSIONS:In this single center study, ultrafast track anaesthesia decreased intensive care unit stay without increasing the rate of post-operative complications.
Source of Support Nil. Disclosures None declared. Cite as: Su YJ. Hypothermic lung edema after accidental hypothermia with out of hospital cardiac arrest. Heart, Lung and Vessels. 2015;7(4):328-329
