Patient centred outcome measures (PCOMs) are increasingly used to structure proactive symptom assessment and help centre care around the specific needs of the patient. This study aimed to review the use of PCOMs as part of the routine care of inpatients reviewed by the integrated palliative care team in a specialist cancer centre. Anonymised electronic palliative care PCOM data were retrieved for inpatients between 7/4/2021 to 31/01/2023, including Integrated Palliative Outcome Scale (IPOS), ECOG performance status, Australian Karnofsky Performance Status (AKPS) and Phase of Illness (POI). Descriptive statistics were used to define the complexity of palliative care needs based on IPOS, PS and POI. The effectiveness of the integrated palliative care service was evaluated by examining the difference between PCOM at initial and follow up assessment. Digital PCOM records for 1115 episodes of inpatient care were included, of which 391 had follow up data. On initial assessment 63% (703) patients had ECOG PS of 3 or 4 and 77% (864) had AKPS of less than 70. The most prevalent physical symptoms were weakness (84%, 1265), pain (80.7%, 1215), and poor mobility (72.3%, 1089). The most prevalent psychosocial symptom was family or friends feeling anxious or worried (85.8%, 1292). 83% (1250) had at least one palliative care need of severe or overwhelming intensity on initial assessment. 67.5% (753) were in an unstable POI on initial assessment, requiring urgent input. On follow up 92% (328) patients were in a stable, deteriorating or dying POI with no change to the care plan required. In patients with initial moderate to overwhelming symptoms, pain improved in 74%, nausea improved in 84%, vomiting improved in 93%, and constipation improved in 68% at follow up. The high prevalence of physical and psychosocial symptoms demonstrates the complexity of needs and provides evidence of the requirement for integration of specialist palliative care services in cancer centres. The improvement in symptom scores between initial and follow up assessment demonstrates the effectiveness of integrated palliative care for cancer centre inpatients.

Rigid bronchoscopy under general anesthesia enables performing diagnostic and/or therapeutic procedures in the tracheobronchial tree. This technique is characterized by specific technical problems, insofar as the anesthesiologist and the operators share the same space, namely the airway. Several potential complications (hemorrhage inside the airway, threat to ventilation ...) may arise. These challenges render the ability to use the variable available techniques essential, as well as knowledge of the complications they could entail, and the ability to rapidly solve them. General anesthesia is usually total intravenous anesthesia, using short acting agents. Ventilation can be spontaneous, but more often insured using high-frequency jet ventilation. The hospital infrastructure and staff must have the expertise to perform this particular procedure, in order to limit the complication rate.

Objectives. - Videolaryngoscope techniques are more and more in use and tend to modify our approach for patients difficult to intubate. We compared two techniques, Airtraq (TM) and Glidescope (TM) with direct laryngoscopy, with special emphasis on ease of access to airway (Intubation Difficulty Score - IDS score, duration and success of intubation) and the impact on hemodynamic variables among patients with a BMI of more than 30.Study design. - Prospective study randomised with minimisation technique. Material and methods. - Eighty patients have been allocated by minimisation to four groups: two groups being intubated with Airtraq (TM), each one with a different investigator, and two with Glidescope (TM) videolaryngoscope technique. Induction of anesthesia was standardly performed with total intravenous anesthesia with remifentanil, propofol in TCI mode and rocuronium in bolus. Following parameters were recorded : intubation success based on intubation time and desaturation level, its duration, its impact on hemodynamic variables, IDS score and possible dental lesions.Results. - Intubation success was 100% for Glidescope (TM) and 80.6% for Airtraq (TM) (P = 0.009). Airtraq (TM) allowed a better visualisation of the vocal cords (lower Cormack and Lehane score) than Glidescope (TM). In contrast, alternative intubation techniques were significantly more often used in the Airtraq (TM) group. No difference could be detected between both systems on hemodynamic parameters.Conclusions. - In obese patients, Glidescope (TM) allows intubation relatively easily without rescue techniques. (C) 2012 Societe francaise d'anesthesie et de reanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

Purpose : Report a case of a patient, who benefitted from the I-gel, during an elective urological surgery and who presented severe laryngeal hemorrhage at the time of its withdrawal.Clinical features : A 71-year-old male patient had been admitted in the operating room for the insertion of a ureteral stent. He had a history of usual interstitial pneumonia (UIP) requiring corticosteroids and oxygen therapy and a severe obstructive sleep apnea syndrome treated with nasal continuous positive airway pressure (NCPAP). After intravenous induction of anesthesia, a size 5 I-gel (Intersurgical, Wokhingam, UK) was easily inserted in the fast attempt. Anesthesia was maintained with sevoflurane. As soon as the procedure ended, the I-Gel was removed. After two minutes, the patient presented a respiratory distress and started spitting significant quantity of blood. Oropharyngeal fiberscopy was performed in emergency and highlighted active bleeding of the left aryepiglottic fold. Hemostasis was obtained by local compression. The patient was transferred to the intensive care unit. lie was extubated the following day without complications. No additional procedure was necessary to stop the bleeding.Conclusion : Authors reported the first severe complication associated with the use of size 5 I-gel. Additional studies have to be carried out to specify the advantages and risks associated with the use of this recent material.

Gourdin, M.; Dransart, C.; Lameir, M.; Evans, A.; Jamart, J.; Collard, E. Author Information

Background. To assess the influence on myocardial protection of the rate of infusion (continuous vs intermittent) of cold blood cardioplegia administered retrogradely during prolonged aortic cross-clamping. The end-points were ventricular performance and biochemical markers of ischemia.Methods. Seventy patients undergoing myocardial re-vascularization for three-vessel disease were prospectively randomized to receive intermittent or continuous retrograde cold blood cardioplegia. Hemodynamic measurements were obtained using a rapid-response thermodilution catheter and included right ventricular ejection fraction, cardiac output, left and right ventricular stroke work index, and systemic and pulmonary vascular resistance. Blood samples were obtained from the coronary sinus before cross-clamp application and immediately after cross-clamp removal for determinations of lactate and hypoxanthine.Results. The left ventricular stroke work index trend was significantly superior (p = 0.038) by repeated-measures analysis in continuous cardioplegia. Other hemodynamic measurements revealed a similar trend. The need for postoperative inotropic drugs support was reduced in continuous cardioplegia. The release of lactate in the coronary sinus after unclamping was 2.30 +/- 0.12 mmol/L after intermittent cardioplegia and 1.97 +/- 0.09 mmol/L after continuous cardioplegia (p = 0.036). The release of hypoxanthine was 20.47 +/- 2.74 mumol/L in intermittent cardioplegia and 11.77 +/- 0.69 mumol/L in continuous cardioplegia (p = 0.002).Conclusions. Continuous cold blood cardioplegia results in improved ventricular performance and reduced myocardial ischemia in comparison with intermittent administration. (C) 2004 by The Society of Thoracic Surgeons.

Pulmonary artery catheter (PAC) entrapment in cardiac sutures has been described.1Kodavatiganti R Hearn CJ Insler SR Bleeding from a pulmonary artery catheter temperature connection port.J Cardiothorac Vasc Anesth. 1999; 13: 75-77Abstract Full Text PDF PubMed Scopus (10) Google Scholar Recognition is usually delayed after surgery when resistance to PAC withdrawal is encountered in the intensive care unit (ICU). Return to the operating room for surgical liberation under possible cardiopulmonary bypass (CPB) is mandatory and may increase patient morbidity after an initial successful operation. We describe how a case of PAC entrapment was confirmed by transesophageal echocardiography (TEE) before the end of the procedure. A 64-year-old man presented for aortic valve replacement, mitral valvuloplasty, and coronary artery bypass graft surgery. Hemodynamic monitoring consisted of radial and pulmonary artery catheters, and a TEE probe. CPB was uneventful, and the patient was weaned from CPB easily. A few minutes later, it became impossible to measure the cardiac output, while fresh blood oozed from the temperature connection port of the PAC. PAC entrapment was suspected and quickly confirmed by TEE (Fig 1).We visualized the catheter passing through the running suture closing the left atriotomy. Consequently, a second short CPB was initiated for surgical PAC liberation. The suture passed through the PAC and dislodged the thermistor wire nestled in the core of the catheter (Fig 2).Fig. 2The suture passed through the PAC and dislodged the thermistor wire nestled in the core of the catheter.View Large Image Figure ViewerDownload Hi-res image Download (PPT)The patient was safely separated from CPB, and transported to the ICU. No further complication occurred. This case is remarkable because TEE allowed the precise diagnosis of PAC entrapment intraoperatively. Similar to Kodavatiganti's conclusions,1Kodavatiganti R Hearn CJ Insler SR Bleeding from a pulmonary artery catheter temperature connection port.J Cardiothorac Vasc Anesth. 1999; 13: 75-77Abstract Full Text PDF PubMed Scopus (10) Google Scholar we recommend free manipulation of the PAC after CPB and protamine administration, and a close look via TEE at every suture site alongside the PAC before chest closure. doi: 10.1053/jcan.2003.31

Objective: The objective of this study was to assess improved myocardial protection by performing coronary artery bypass grafting (CABG) on the beating heart. A case-snatched study was conducted among patients who underwent CABG either on-pump (group 1), or off-pump (group 2). Methods: Forty-five pairs of patients, having a similar clinical profile, were selected on the basis of five variables: age, gender, body surface area, ejection fraction, extent of coronary disease. Operative risk predicted by the The Society of Thoracic Surgeons national database was 1.80 +/- 0.35% in group 1, and 1.89 +/- 0.37% in group 2 (NS). Cold blood cardioplegia and 28degreesC cardiopulmonary bypass were used in group 1. In group 2, beating heart coronary grafting was achieved with the Octopus(TM) and 2 stabilizers. The average number of distal anastomoses was 2.8 +/- 0.1 in group 1 and 2.3 +/- 0.1 in group 2 (P = 0.015). Results: There was no significant difference among the groups regarding the trend in cardiac index, left and right ventricular stroke work indexes, and systemic and pulmonary vascular resistance indexes. However, heart rate trend was slower in group 2 (P = 0.05). Pharmacological support was required in 65% of the patients in group 1, and in 33% in group 2 (P < 0.001). The total amount of Dobutamine and/or Dopamine administered during the first 48 h was 3914 +/- 1306, gamma/kg in group 1 and 1645 +/- 697 gamma/kg in group 2 (P = 0.049). Release of creatine kinase MB mass isoenzyme (CK-MB mass) was markedly reduced in group 2 (P < 10(-4)). Conclusions: Hemodynamic outcome following off-pump CABG is similar to on-pump CABG but the need for inotropic support is significantly reduced and CPK-MB mass release is markedly lower. (C) 2002 Elsevier Science B.V. All rights reserved.

IR EMBOLISM during cardiac surgery is a common occurrence and may be responsible for neurologlc and cardiac complications. This case report illustrates how transesophageal echocardiography (TEE) showed the regional increment in myocardial reflectlvity secondary to coronary air embolism and how TEE momtoring aided in detecting the efficacy of maneuvers to remove the air. CASE REPORT A 56-year-old man was scheduled for an aortic valve replacement. He had a history of severe aortic valvular stenosis with a mean transaortlc gradient of 56 mmHg and an aortic valve area of 0.63 cm 2. Coronary angiogram was normal with a left ventricular ejection fraction of 60%. After induction of anesthesia, a multiplane TEE probe, operating at 5 mHz, connected to an echocardiographlc system (Hewlett Packard SONOS 1000; Andover, MA), was inserted in a routine manner. After cross-clamping of the ascending aorta, anterograde cold hyperkalemic cardioplegia was administered, followed by intermittent retrograde cold hyperkalemic cardioplegia. Cardiopulmonary bypass (CPB) was performed under mild systemic hypothermia (34.8°C). The aortic valve was replaced by a mechanical prosthetic valve (St Jude 23 ram). Before unclamping of the aorta, passive filling of the left ventricle (LV), venting through a needle inserted in the ascending aorta and manual inflation of the lungs were performed with the patient head down. The passive filling was still low, and the accumulated air in the heart was not detected by TEE at that time. Immediately after unclamping of the aorta, the TEE detected microbubbles coming from the left atrium and massively from the right pulmonary veins. Although the venting was maintained, with the heart beating, an abrupt increase in myocardial reflectivity was observed (Fig 1). This myocardial opacification involved right ventricular and septal walls and was followed by significant ST-segment elevation in inferior leads on the electrocardiogram (ECG) (Fig 2). Severe depression of the regional LV function occurred, followed by severe distention of the LV cavity and by refractory ventricular fibrillation. It was decided to clamp the ascending aorta again in order to avoid systemic air embolism and to administer crystalloid retrograde cardioplegia (300 mL) to eliminate the intracoronary air, while the heart was manipulated in

OBJECTIVE:To compare intraoperative hemodynamics profiles and recovery characteristics of propofol-alfentanil with fentanyl-midazolam anesthesia in elective coronary artery surgery. DESIGN:Prospective, randomized study. SETTING:University hospital. PARTICIPANTS:Fifty patients with impaired or good left ventricular function. INTERVENTIONS:In group 1, (n = 25) anesthesia was induced with an infusion of propofol, 3 to 4 mg/kg/h, alfentanil, 500 micrograms, and pancuronium 0.1 mg/kg, and maintained with propofol, 3 to 6 mg/kg/h (variable rate), and alfentanil infusions, 30 micrograms/kg/h (fixed rate). Additional boluses of alfentanil, 1 mg, were administered before noxious stimuli; group 2 (n = 25) received a loading dose of fentanyl, 25 micrograms/kg, midazolam, 1.5 to 3 mg, and pancuronium, 0.1 mg/kg for induction, followed by an infusion of fentanyl, 7 micrograms/kg/h, for maintenance. Additional boluses of midazolam (1.5 to 3 mg) and fentanyl (250 micrograms) were administered before noxious stimuli. MEASUREMENTS AND MAIN RESULTS. Cardiovascular parameters at eight intraoperative time points as well as time to extubation, morphine consumption, and pain scores were recorded. Induction of anesthesia was associated in both groups with a small but significant decrease in mean arterial pressure (1: 15 mmHg (15%); 2: 8 mmHg (8%) with significant decreases in cardiac index (1: 8%; 2: 8%) and left ventricular stroke work index (1: 24%; 2: 21%). Throughout surgery, hemodynamic profiles were comparable between groups except after intubation when the MAP was significantly lower in group 1 (75 +/- 12 mmHg) than in group 2 (89 +/- 17 mmHg). Group 1 required less inotropic support. Extubation was performed faster in group 1 (7.6 h) than in group 2 (18.0 h). Morphine requirements and pain scores were comparable between groups. CONCLUSIONS:Propofol-alfentanil anesthesia provides good intraoperative hemodynamics and allows early extubation after coronary artery surgery.

Coronary artery bypass grafting for the treatment of unstable angina is still associated with increased operative risk and postoperative morbidity. The impact of the extended use of arterial grafts on early results is incompletely defined. In a 7-year period (1986 to 1993), 474 patients (average age, 65 years; range, 34 to 85 years) underwent coronary artery bypass grafting for the treatment of unstable angina. Sixty-eight patients were operated on emergently and 406 urgently. They received an average of 3.0 distal anastomoses (range, 1 to 6). Seventy-nine patients had exclusively venous grafts, 316 had one internal thoracic artery graft, 79 had bilateral internal thoracic artery grafts, and 20 had inferior epigastric artery grafts. Sequential internal thoracic artery grafting was performed in 70 patients. Redo operations were performed in 26 patients. Thirty-four patients (7.2%) experienced a new myocardial infarction. Eighty-nine patients (18.8%) had an intraaortic balloon pump inserted preoperatively, intraoperatively, or postoperatively. Eight patients (1.7%) died intraoperatively and 24 patients (5.1%) died postoperatively. Seventy-seven patients (16.2%) had an adverse outcome, as shown by the need for an intraaortic balloon pump (intraoperatively or postoperatively) or hospital death, or by both. Forty variables were examined by multivariate analysis for their influence on the occurrence of an adverse outcome. Aortic cross-clamp time (p = 0.0004), transfer from the intensive care unit (p = 0.0023), female sex (p = 0.0023), operation performed in early years (p = 0.0041), left ventricular aneurysm (p = 0.0068), the number of diseased coronary vessels (p = 0.0312), and reoperation (p = 0.0318) were all found to be significant independent predictors of increased risk.(ABSTRACT TRUNCATED AT 250 WORDS)

We postulated that patients with an internal locus of control, i.e. those who like to control their health problems themselves, would adapt more adequately to the 'patient-controlled analgesia' technique as compared to patients with an external health locus of control, who do not believe in their own control. Since contradicting studies have been published on this matter, we investigated relations between the demand for analgesics, perceived pain in the postoperative phase, and the health locus of control in the postoperative context of cardiac surgery. Findings demonstrate distinct utilization patterns between subjects with internal or external locus of control concerning total morphine consumption, number of unsatisfied demands and reduction of perceived pain.

We read with great interest the excellent article by Foster and associates on the post-cardiopulmonary bypass use of atriobiventricular pacing [1].Concerning the hemodynamic benefit reported, we wish to stress the major importance of the variation of left atrioventricular delay (LAVD) on cardiac performance, particularly in situations characterized by poor diastolic function, like the post-cardiopulmonary bypass period.It is obvious that the effective LAVD during their investigation was quite different during each pacemaker setting.The LAVD during AAI pacing was unavoidably different for each patient due to the variation in their native atrioventricular delay.The LAVD during atrio-right ventricular pacing was certainly longer than during atrio-left ventricular pacing, due to the addition of the interventricular conduction time.Finally, it seems difficult to assume that atrio-biventricular pacing did not interfere further with LAVD, in comparison with the atrio-left ventricular pacing mode.The small magnitude of the hemodynamic modifications observed by Foster and associates is to be balanced against the well-known greater benefit described when solely adjusting atrioventricular delay [2].More investigations are needed to precisely define the hemodynamic improvement provided by atrio-biventricular pacing, apart from any LAVD modification, before drawing any conclusions about this important topic.