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Rybar D. Deep Hypothermic Circulatory Arrest: A Brief History and Where It Is Going. J Cardiothorac Vasc Anesth 2024; 38:560-562. [PMID: 38228425 DOI: 10.1053/j.jvca.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/03/2023] [Indexed: 01/18/2024]
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2
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Ghia S, Savadjian A, Shin D, Diluozzo G, Weiner MM, Bhatt HV. Hypothermic Circulatory Arrest in Adult Aortic Arch Surgery: A Review of Hypothermic Circulatory Arrest and its Anesthetic Implications. J Cardiothorac Vasc Anesth 2023; 37:2634-2645. [PMID: 37723023 DOI: 10.1053/j.jvca.2023.08.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 09/20/2023]
Abstract
Diseases affecting the aortic arch often require surgical intervention. Hypothermic circulatory arrest (HCA) enables a safe approach during open aortic arch surgeries. Additionally, HCA provides neuroprotection by reducing cerebral metabolism and oxygen requirements. However, HCA comes with significant risks (eg, neurologic dysfunction, stroke, and coagulopathy), and the cardiac anesthesiologist must completely understand the surgical techniques, possible complications, and management strategies.
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Affiliation(s)
- Samit Ghia
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andre Savadjian
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC
| | - DaWi Shin
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gabriele Diluozzo
- Department of Cardiovascular Surgery, Yale School of Medicine, Bridgeport, CT
| | - Menachem M Weiner
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Himani V Bhatt
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Gilbey T, Milne B, de Somer F, Kunst G. Neurologic complications after cardiopulmonary bypass - A narrative review. Perfusion 2023; 38:1545-1559. [PMID: 35986553 PMCID: PMC10612382 DOI: 10.1177/02676591221119312] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
Neurologic complications, associated with cardiac surgery and cardiopulmonary bypass (CPB) in adults, are common and can be devastating in some cases. This comprehensive review will not only consider the broad categories of stroke and neurocognitive dysfunction, but it also summarises other neurological complications associated with CPB, and it provides an update about risks, prevention and treatment. Where appropriate, we consider the impact of off-pump techniques upon our understanding of the contribution of CPB to adverse outcomes.
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Affiliation(s)
- Tom Gilbey
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Benjamin Milne
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Filip de Somer
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Gudrun Kunst
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, Faculty of Life Sciences and Medicine, King’s College London British Heart Foundation Centre of Excellence, London, UK
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Salomon JD, Qiu H, Feng D, Owens J, Khailova L, Osorio Lujan S, Iguidbashian J, Chhonker YS, Murry DJ, Riethoven JJ, Lindsey ML, Singh AB, Davidson JA. Piglet cardiopulmonary bypass induces intestinal dysbiosis and barrier dysfunction associated with systemic inflammation. Dis Model Mech 2023; 16:dmm049742. [PMID: 36426663 PMCID: PMC9844230 DOI: 10.1242/dmm.049742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/14/2022] [Indexed: 11/26/2022] Open
Abstract
The intestinal microbiome is essential to human health and homeostasis, and is implicated in the pathophysiology of disease, including congenital heart disease and cardiac surgery. Improving the microbiome and reducing inflammatory metabolites may reduce systemic inflammation following cardiac surgery with cardiopulmonary bypass (CPB) to expedite recovery post-operatively. Limited research exists in this area and identifying animal models that can replicate changes in the human intestinal microbiome after CPB is necessary. We used a piglet model of CPB with two groups, CPB (n=5) and a control group with mechanical ventilation (n=7), to evaluate changes to the microbiome, intestinal barrier dysfunction and intestinal metabolites with inflammation after CPB. We identified significant changes to the microbiome, barrier dysfunction, intestinal short-chain fatty acids and eicosanoids, and elevated cytokines in the CPB/deep hypothermic circulatory arrest group compared to the control group at just 4 h after intervention. This piglet model of CPB replicates known human changes to intestinal flora and metabolite profiles, and can be used to evaluate gut interventions aimed at reducing downstream inflammation after cardiac surgery with CPB.
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Affiliation(s)
- Jeffrey D. Salomon
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE 68102, USA
- Department of Cellular & Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68102, USA
| | - Haowen Qiu
- Center for Biotechnology, University of Nebraska Lincoln, Lincoln, NE 68588, USA
| | - Dan Feng
- Department of Hematology/Oncology, University of Nebraska Medical Center, Omaha, NE 68102, USA
| | - Jacob Owens
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE 68102, USA
| | - Ludmila Khailova
- Department of Pediatrics, University of Colorado, Aurora, CO 80045, USA
| | | | - John Iguidbashian
- Department of Pediatrics, University of Colorado, Aurora, CO 80045, USA
| | - Yashpal S. Chhonker
- Department of Pharmacy Practice, University of Nebraska Medical Center College of Pharmacy, Omaha, NE 68102, USA
| | - Daryl J. Murry
- Department of Pharmacy Practice, University of Nebraska Medical Center College of Pharmacy, Omaha, NE 68102, USA
| | - Jean-Jack Riethoven
- Center for Biotechnology, University of Nebraska Lincoln, Lincoln, NE 68588, USA
| | - Merry L. Lindsey
- School of Graduate Studies and Research, Meharry Medical College, Nashville, TN 37208, USA
- Research Service, Nebraska-Western Iowa Health Care System, Omaha, NE 68105, USA
| | - Amar B. Singh
- Research Service, Nebraska-Western Iowa Health Care System, Omaha, NE 68105, USA
- Department of Biochemistry & Molecular Biology, University of Nebraska Medical Center, Omaha, NE 68102, USA
| | - Jesse A. Davidson
- Department of Pediatrics, University of Colorado, Aurora, CO 80045, USA
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Sultan I, Bianco V, Aranda-Michel E, Kilic A, Serna-Gallegos D, Navid F, Wang Y, Gleason TG. The use of blood and blood products in aortic surgery is associated with adverse outcomes. J Thorac Cardiovasc Surg 2023; 165:544-551.e3. [PMID: 33838909 DOI: 10.1016/j.jtcvs.2021.02.096] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 02/08/2021] [Accepted: 02/23/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To report long-term outcomes after deep hypothermic circulatory arrest (DHCA) with or without perioperative blood or blood products. METHODS All patients who underwent proximal aortic surgery with DHCA from 2011 to 2018 were propensity matched according to baseline characteristics. Primary outcomes included short- and long-term mortality. Stratified Cox regression analysis was performed for significant associations with survival. RESULTS A total of 824 patients underwent aortic replacement requiring circulatory arrest. After matching, there were 224 patients in each arm (transfusion and no transfusion). All baseline characteristics were well matched, with a standardized mean difference (SMD) <0.1. Preoperative hematocrit (41.0 vs 40.6; SMD = 0.05) and ejection fraction (57.5% vs 57.0%; SMD = 0.08) were similar between the no transfusion and blood product transfusion cohorts. Rate of aortic dissection (42.9% vs 45.1%; SMD = 0.05), hemiarch replacement (70.1% vs 70.1%; SMD = 0.00), and total arch replacement (21.9% vs 23.2%; SMD = 0.03) were not statistically different. Cardiopulmonary bypass and cross-clamp time were higher in the blood product transfusion cohort (P < .001). Operative mortality (9.4% vs 2.7%; P = .003), stroke (7.6% vs 1.3%; P = .001), reoperation rate, pneumonia, prolonged ventilation, and dialysis requirements were significantly higher in the transfusion cohort (P < .001). In stratified Cox regression, transfusion was an independent predictor of mortality (hazard ratio, 2.62 [confidence interval, 1.47-4.67]; P = .001). One- and 5-year survival were significantly reduced for the transfusion cohort (P < .001). CONCLUSIONS In patients who underwent aortic surgery with DHCA, perioperative transfusions were associated with poor outcomes despite matching for preoperative baseline characteristics.
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Affiliation(s)
- Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
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Sato H, Iba Y, Kawaharada N, Fukada J, Iwashiro Y, Tsushima S, Hosaka I, Okawa A, Shibata T, Nakazawa J, Nakajima T, Hasegawa T, Tamiya Y. Temperature analysis of aortic repair with hypothermic circulatory arrest to quantify the injury by cooling. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 36:6976074. [PMID: 36802248 PMCID: PMC9931076 DOI: 10.1093/icvts/ivac282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/14/2022] [Accepted: 12/07/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES We analyzed the temperature in proximal aortic repair with moderate hypothermic circulatory arrest (HCA) and evaluated the effect of the cooling status on postoperative outcomes. METHODS A total of 340 patients who underwent elective ascending aortic replacement or total arch replacement with moderate HCA from December 2006 to January 2021 were studied. The change in body temperature trends recorded during surgery was shown graphically. Several parameters, such as the nadir temperature, cooling speed and the degree of cooling (cooling area), which was the area under curve of inverted temperature trends from cooling to rewarming as calculated by the integral method, were analyzed. The relationships between these variables and a major adverse outcome (MAO) postoperatively defined as prolonged ventilation (>72 h), acute renal failure, stroke, reoperation for bleeding, deep sternal wound infection or in-hospital death were evaluated. RESULTS An MAO was observed in 68 patients (20%). The cooling area was larger in the MAO group than in the non-MAO group (1668.7 vs 1383.2°C min; P < 0.0001). A multivariate logistic model showed that old myocardial infarction, peripheral vascular disease, chronic renal dysfunction, cardiopulmonary bypass time and the cooling area were independent risk factors for an MAO (odds ratio = 1.1 per 100°C min; P < 0.001). CONCLUSIONS The cooling area, which indicates the degree of cooling, shows a significant relationship with an MAO after aortic repair. This finding indicates that the cooling status with HCA can affect clinical outcomes.
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Affiliation(s)
- Hiroshi Sato
- Corresponding author. Department of Cardiovascular Surgery, Otaru General Hospital, 1-1-1 Wakamatsu, Otaru 047-8550, Japan. Tel: +81-0134-25-1211; fax: +81-0134-25-1600; e-mail: (H. Sato)
| | - Yutaka Iba
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Joji Fukada
- Department of Cardiovascular Surgery, Otaru General Hospital, Otaru, Japan
| | - Yuu Iwashiro
- Department of Cardiovascular Surgery, Otaru General Hospital, Otaru, Japan
| | - Shingo Tsushima
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Itaru Hosaka
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Akihito Okawa
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tsuyoshi Shibata
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Jyunji Nakazawa
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tomohiro Nakajima
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Takeo Hasegawa
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yukihiko Tamiya
- Department of Cardiovascular Surgery, Otaru General Hospital, Otaru, Japan
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Tyrrell‐Marsh I, Stanley S. Neurological injury after cardiac arrest - setting a case of prolonged re-warming into a developing research context. Anaesth Rep 2023; 11:e12234. [PMID: 37323807 PMCID: PMC10267611 DOI: 10.1002/anr3.12234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 06/17/2023] Open
Affiliation(s)
- I. Tyrrell‐Marsh
- Department of Critical CareManchester Royal InfirmaryManchesterUK
| | - S. Stanley
- North West School of AnaesthesiaManchesterUK
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Tan SZ, Singh S, Austin NJ, Alfonso Palanca J, Jubouri M, Girardi LN, Chen EP, Bashir M. Duration of deep hypothermic circulatory arrest for aortic arch surgery: is it a myth, fiction, or scientific leap? THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:243-253. [PMID: 35238523 DOI: 10.23736/s0021-9509.22.12275-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The use of deep hypothermic circulatory arrest (DHCA) to provide aortic surgeons with a bloodless operative field while simultaneously protecting the brain and peripheries from ischemic damage revolutionized cardiac and aortic surgery, and is currently used in specialist centers across the globe. However, it is associated with manifold adverse outcomes, including neurocognitive dysfunction and mortality. This review seeks to analyze the relationship between DHCA duration and clinical outcome, and evaluate the controversies and limitations surrounding its use. EVIDENCE ACQUISITION We performed a review of available literature with statistical analysis to evaluate the relationship between DHCA duration (<40 min and >40 min) and key clinical outcomes, including mortality, permanent and temporary neurological deficit, renal damage, admission length, and reintervention rate. The controversies surrounding DHCA use and future directions for care are also explored. EVIDENCE SYNTHESIS Statistical analysis revealed no significant association (P>0.05) between DHCA duration and clinical outcomes (early and late mortality rates, neurological deficit, admission length, and reintervention rate), both with and without adjunctive perfusion techniques. CONCLUSIONS Available literature suggests that the relationships between DHCA duration (with and without adjunctive perfusion) and clinical outcomes are unclear, and at present not statistically significant. Alternative surgical and endovascular techniques have been identified as promising novel approaches not requiring DHCA, as have the use of biomarkers to enable early diagnosis and intervention for aortic pathologies.
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Affiliation(s)
- Sven Z Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sidhant Singh
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Natasha J Austin
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Joaquin Alfonso Palanca
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Health and Education Improvement Wales, Nantgarw, UK -
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9
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Patel PM, Chen EPC. Optimal brain protection in aortic arch surgery. Indian J Thorac Cardiovasc Surg 2022; 38:36-43. [PMID: 35463699 PMCID: PMC8980966 DOI: 10.1007/s12055-021-01212-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 10/20/2022] Open
Abstract
There is considerable debate with regard to the optimal cerebral protection strategy during aortic arch surgery. There are three contemporary techniques in use which include straight deep hypothermic circulatory arrest (DHCA), DHCA with retrograde cerebral perfusion (DHCA + RCP), and moderate hypothermic circulatory arrest with antegrade cerebral perfusion (MHCA + ACP). Appropriate application of these methods ensures appropriate cerebral, myocardial, and visceral protection. Each of these techniques has benefits and drawbacks and ensuring coordinated circulation management strategy is critical to safe performance of aortic arch surgery. In this report, we will review various cannulation strategies, review logistics of hypothermia, and review the relevant literature to outline the strengths and weaknesses of these various cerebral protection strategies.
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Ishiyama Y, Kondo T, Yoshida K, Takagi T, Iizuka J, Tanabe K. Surgery for renal cell carcinoma extending to the right atrium in Japanese institutions: Focusing on cardiopulmonary bypass with or without deep hypothermic circulatory arrest. Int J Urol 2021; 28:1001-1007. [PMID: 34156120 DOI: 10.1111/iju.14627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 05/28/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the outcomes of Japanese patients with renal cell carcinoma undergoing surgery for tumor thrombus invading the right atrium. METHODS We retrospectively evaluated 23 patients who underwent extracorporeal circulation-assisted surgery at two institutions. Perioperative outcomes and survival rates were evaluated and compared between two groups of patients, which were set according to the use or not of deep hypothermic circulatory arrest. Data on systemic treatments were assessed. RESULTS The median age was 64 years; the majority of patients were fit according to the Charlson Comorbidity Index. Five (21.7%) patients had at least one distant metastasis, and 17 (73.9%) received systemic therapy. A total of 16 (69.6%) patients underwent deep hypothermic circulatory arrest. Baseline characteristics were comparable between groups. Patients who underwent deep hypothermic circulatory arrest had a non-significant reduction in blood loss compared with those who did not undergo this procedure (1866.0 vs 3513.0 mL, P = 0.102). The complication rate, both of any grade (43.8% vs 71.4%, P = 0.215) and grade ≥3 (6.3% vs 28.6%, P = 0.162), tended to be lower in patients who underwent deep hypothermic circulatory arrest. The mean 90-day mortality rate was 8.7%, with no difference among groups (6.3% vs 14.3%, respectively; P = 0.545). The overall median cancer-specific and overall survival were both 64.4 months, and did not differ between groups. CONCLUSIONS Renal cell carcinoma patients undergoing extracorporeal circulation-assisted surgery and systemic therapy for right atrial tumor thrombus have acceptable long-term survival rates. Outcomes are comparable regardless of the use of deep hypothermic circulatory arrest.
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Affiliation(s)
- Yudai Ishiyama
- Department of Urology, Tokyo Women's Medical University Medical Center East, Tokyo, Japan.,Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tsunenori Kondo
- Department of Urology, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Kazuhiko Yoshida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Junpei Iizuka
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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Elhelali A, Hynes N, Devane D, Sultan S, Kavanagh EP, Morris L, Veerasingam D, Jordan F. Hybrid repair versus conventional open repair for thoracic aortic arch aneurysms. Cochrane Database Syst Rev 2021; 6:CD012923. [PMID: 34085713 PMCID: PMC8407084 DOI: 10.1002/14651858.cd012923.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Thoracic aortic arch aneurysms (TAAs) can be a life-threatening condition due to the potential risk of rupture. Treatment is recommended when the risk of rupture is greater than the risk of surgical complications. Depending on the cause, size and growth rate of the TAA, treatment may vary from close observation to emergency surgery. Aneurysms of the thoracic aorta can be managed by a number of surgical techniques. Open surgical repair (OSR) of aneurysms involves either partial or total replacement of the aorta, which is dependent on the extent of the diseased segment of the aorta. During OSR, the aneurysm is replaced with a synthetic graft. Hybrid repair (HR) involves a combination of open surgery with endovascular aortic stent graft placement. Hybrid repair requires varying degrees of invasiveness, depending on the number of supra-aortic branches that require debranching. The hybrid technique that combines supra-aortic vascular debranching with stent grafting of the aortic arch has been introduced as a therapeutic alternative. However, the short- and long-term outcomes of HR remain unclear, due to technical difficulties and complications as a result of the angulation of the aortic arch as well as handling of the arch during surgery. OBJECTIVES To assess the effectiveness and safety of HR versus conventional OSR for the treatment of TAAs. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 22 March 2021. We also searched references of relevant articles retrieved from the electronic search for additional citations. SELECTION CRITERIA We considered for inclusion in the review all published and unpublished randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing HR to OSR for TAAs. DATA COLLECTION AND ANALYSIS Two review authors independently screened all titles and abstracts obtained from the literature search to identify those that met the inclusion criteria. We retrieved the full text of studies deemed as potentially relevant by at least one review author. The same review authors screened the full-text articles independently for inclusion or exclusion. MAIN RESULTS No RCTs or CCTs met the inclusion criteria for this review. AUTHORS' CONCLUSIONS Due to the lack of RCTs or CCTs, we were unable to determine the safety and effectiveness of HR compared to OSR in people with TAAs, and we are unable to provide high-certainty evidence on the optimal surgical intervention for this cohort of patients. High-quality RCTs or CCTs are necessary, addressing the objective of this review.
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Affiliation(s)
- Ala Elhelali
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular and Endovascular Surgery, The Galway Clinic, Galway, Ireland
| | - Declan Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Sherif Sultan
- Vascular Surgery, Galway University Hospital, Galway, Ireland
| | - Edel P Kavanagh
- Department of Vascular and Endovascular Surgery, The Galway Clinic, Galway, Ireland
| | - Liam Morris
- Mechanical and Industrial Engineering, Galway-Mayo Institute of Technology, Galway, Ireland
| | - Dave Veerasingam
- Cardiothoracic Surgery, Galway University Hospital, Galway, Ireland
| | - Fionnuala Jordan
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
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Emerging hemorrhage control and resuscitation strategies in trauma: Endovascular to extracorporeal. J Trauma Acute Care Surg 2021; 89:S50-S58. [PMID: 32345902 DOI: 10.1097/ta.0000000000002747] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article reviews four emerging endovascular hemorrhage control and extracorporeal perfusion techniques for management of trauma patients with profound hemorrhagic shock including hemorrhage-induced traumatic cardiac arrest: resuscitative endovascular balloon occlusion of the aorta, selective aortic arch perfusion, extracorporeal life support, and emergency preservation and resuscitation. The preclinical and clinical studies underpinning each of these techniques are summarized. We also present an integrated conceptual framework for how these emerging technologies may be used in the future care of trauma patients in both resource-rich and austere environments.
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13
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Das D, Dutta N, Roy Chowdhuri K. Total circulatory arrest as a support modality in congenital heart surgery: review and current evidence. Indian J Thorac Cardiovasc Surg 2021; 37:165-173. [PMID: 33584032 PMCID: PMC7859125 DOI: 10.1007/s12055-020-00930-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/21/2020] [Accepted: 01/27/2020] [Indexed: 11/24/2022] Open
Abstract
The use of total circulatory arrest (TCA)/deep hypothermic circulatory arrest (DHCA) as a support modality in congenital heart surgery is a time-tested strategy. However, with technological advances, the widespread use of this technique has decreased. Adjunctive cerebral perfusion with continuous cardiopulmonary bypass (CPB) gradually has become more popular with a view to reduce the complications related to DHCA. In addition, better neuromonitoring and neuroprotective strategies have made DHCA much safer. However, the level of evidence to support the best way to protect the brain during congenital heart surgery is insufficient. This review analyzes the history, physiology, techniques of DHCA, as well as other alternative strategies like selective cerebral perfusion and presents the current available evidence.
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Affiliation(s)
- Debasis Das
- Department of Cardiac Surgery, Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah, 711103 India
| | - Nilanjan Dutta
- Department of Cardiac Surgery, Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah, 711103 India
| | - Kuntal Roy Chowdhuri
- Department of Cardiac Surgery, BM Birla Heart Research Centre, 1, National Library Avenue, Alipore, Kolkata, 700027 India
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14
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de Wolf A, Phaedra C, Perry RM, Maire M. Ultrastructural Characterization of Prolonged Normothermic and Cold Cerebral Ischemia in the Adult Rat. Rejuvenation Res 2020; 23:193-206. [DOI: 10.1089/rej.2019.2225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
| | - Chana Phaedra
- Advanced Neural Biosciences (ANB), Portland, Oregon, USA
| | | | - Michael Maire
- Department of Computer Science, The University of Chicago, Chicago, Illinois, USA
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Ma O, Crepeau AZ, Dutta A, Bliss DW. Anticipating Postoperative Delirium During Burst Suppression Using Electroencephalography. IEEE Trans Biomed Eng 2020; 67:2659-2668. [PMID: 32031924 DOI: 10.1109/tbme.2020.2967693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This study develops an electro-encephalography-based method for predicting postoperative delirium early during cardiac surgeries involving deep hypothermia circulatory arrest (DHCA), potentially providing an opportunity to intervene and minimize poor surgical outcome. DHCA is a surgical technique used during cardiac surgeries to facilitate repairs. Deep hypothermia is induced and supplemented by perfusion techniques to protect the brain during circulatory arrest, but concern for cerebral injury still remains. METHODS This research studies whether or not monitoring burst suppression, an electrophysiological phenomenon observed during patient cooling and warming, helps in predicting postoperative delirium, a correlate of poor prognosis. A metric called the burst suppression duty cycle (BSDC), akin to burst suppression ratio, is formulated to characterize this electrophysiological activity. RESULTS Assuming no complications occur prior to circulatory arrest, delirium diagnoses are correlated with the time elapsed until suppression activity ceases since resuming cardiopulmonary bypass. By comparing against a benchmark the times when BSDC reaches 100%, 15 of 16 cases can be correctly predicted. Similar accuracy can be achieved when querying BSDC progress earlier during warming. CONCLUSION Our results show that our BSDC metric is a promising candidate for early detection of postoperative delirium, and motivates further analysis of the causal relationship between postoperative delirium and the procedure transitioning out of circulatory arrest. SIGNIFICANCE The developed methodology anticipates incidences of postoperative delirium during rewarming, which potentially provides an opportunity to intervene and avert it.
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16
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Tisel SM, Ahlskog JE, Duffy JR, Matsumoto JY, Josephs KA. PSP-like syndrome after aortic surgery in adults (Mokri syndrome). Neurol Clin Pract 2019; 10:245-254. [PMID: 32642326 DOI: 10.1212/cpj.0000000000000708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/13/2019] [Indexed: 11/15/2022]
Abstract
Background A rare progressive supranuclear palsy-like syndrome seemingly triggered by aortic surgery was first described in 2004. This largest case series to date describes the features of this syndrome. Methods We searched the Mayo Clinic electronic medical records using the advanced cohort explorer search engine for patients evaluated for neurologic symptoms after cardiac-aortic surgery in the past 30 years. Data were extracted to Microsoft Excel from the identified patients and included clinical and neuroimaging features and outcomes. Results Twenty-five patients met the inclusion criteria. All surgeries were performed under thoracic aortic bypass and deep hypothermia. Surgery included aortic aneurysm, aortic valve repair, and/or aortic dissection repair. Surgical records were unavailable, although surgery was documented in the Mayo record as uncomplicated in 60% of cases. In the remaining cases, no particular intraoperative or postoperative complications were documented at a high frequency. A typical triad was documented: supranuclear gaze palsy (SNGP; 100%), gait imbalance (80%), and dysarthria (96%). Part or all of the triad was observed before hospital discharge and stabilized over the course of days-weeks. A second phase of symptom worsening plus new symptoms developed up to a year later; this decline continued for up to several years before stabilization. Delayed epileptic seizures occurred in 32% of patients. Brain MRI revealed only nonspecific findings. Conclusion This syndrome following adult thoracic aortic bypass surgery with deep hypothermia remains unexplained. It follows a biphasic course and is characterized by the triad of SNGP, unsteady gait, and a predominantly ataxic dysarthria.
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Affiliation(s)
- Sarah M Tisel
- Department of Neurology (SMT, JEA, JRD, KAJ), Mayo Clinic, Rochester, MN; and Department of Neurology (JYM), University of Minnesota, Minneapolis, MN
| | - J Eric Ahlskog
- Department of Neurology (SMT, JEA, JRD, KAJ), Mayo Clinic, Rochester, MN; and Department of Neurology (JYM), University of Minnesota, Minneapolis, MN
| | - Joseph R Duffy
- Department of Neurology (SMT, JEA, JRD, KAJ), Mayo Clinic, Rochester, MN; and Department of Neurology (JYM), University of Minnesota, Minneapolis, MN
| | - Joseph Y Matsumoto
- Department of Neurology (SMT, JEA, JRD, KAJ), Mayo Clinic, Rochester, MN; and Department of Neurology (JYM), University of Minnesota, Minneapolis, MN
| | - Keith A Josephs
- Department of Neurology (SMT, JEA, JRD, KAJ), Mayo Clinic, Rochester, MN; and Department of Neurology (JYM), University of Minnesota, Minneapolis, MN
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Urits I, Jones MR, Orhurhu V, Sikorsky A, Seifert D, Flores C, Kaye AD, Viswanath O. A Comprehensive Update of Current Anesthesia Perspectives on Therapeutic Hypothermia. Adv Ther 2019; 36:2223-2232. [PMID: 31301055 PMCID: PMC6822844 DOI: 10.1007/s12325-019-01019-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Indexed: 12/16/2022]
Abstract
Normal thermal regulation is a result of the integration of afferent sensory, central control, and efferent responses to temperature change. Therapeutic hypothermia (TH) is a technique utilized during surgery to protect vital organs from ischemia; however, in doing so leads to other physiological changes. Indications for inducing hypothermia have been described for neuroprotection, coronary artery bypass graft (CABG) surgery, surgical repair of thoracoabdominal and intracranial aneurysms, pulmonary thromboendarterectomy, and arterial switch operations in neonates. Initially it was thought that induced hypothermia worked exclusively by a temperature-dependent reduction in metabolism causing a decreased demand for oxygen and glucose. Induced hypothermia exerts its neuroprotective effects through multiple underlying mechanisms including preservation of the integrity and survival of neurons through a reduction of extracellular levels of excitatory neurotransmitters dopamine and glutamate, therefore reducing central nervous system hyperexcitability. Risks of hypothermia include increased infection risk, altered drug pharmacokinetics, and systemic cardiovascular changes. Indications for TH include ischemia-inducing surgeries and diseases. Two commonly used methods are used to induce TH, surface cooling and endovascular cooling. Core body temperature monitoring is essential during induction of TH and rewarming, with central venous temperature as the gold standard. The aim of this review is to highlight current literature discussing perioperative considerations of TH including risks, benefits, indications, methods, and monitoring.
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Affiliation(s)
- Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Mark R Jones
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Vwaire Orhurhu
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Andrew Sikorsky
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Danica Seifert
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Catalina Flores
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Creighton University School of Medicine, Omaha, NE, USA
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18
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Kratzert WB, Boyd EK, Saggar R, Channick R. Critical Care of Patients After Pulmonary Thromboendarterectomy. J Cardiothorac Vasc Anesth 2019; 33:3110-3126. [PMID: 30948200 DOI: 10.1053/j.jvca.2019.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/19/2019] [Accepted: 03/01/2019] [Indexed: 12/16/2022]
Abstract
Pulmonary thromboendarterectomy (PTE) remains the only curative surgery for patients with chronic thromboembolic pulmonary hypertension (CTEPH). Postoperative intensive care unit care challenges providers with unique disease physiology, operative sequelae, and the potential for detrimental complications. Central concerns in patients with CTEPH immediately after PTE relate to neurologic, pulmonary, hemodynamic, and hematologic aspects. Institutional experience in critical care for the CTEPH population, a multidisciplinary team approach, patient risk assessment, and integration of current concepts in critical care determine outcomes after PTE surgery. In this review, the authors will focus on specific aspects unique to this population, with integration of current available evidence and future directions. The goal of this review is to provide the cardiac anesthesiologist and intensivist with a comprehensive understanding of postoperative physiology, potential complications, and contemporary intensive care unit management immediately after pulmonary endarterectomy.
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Affiliation(s)
- Wolf B Kratzert
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Eva K Boyd
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Rajan Saggar
- Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Richard Channick
- Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Jovin DG, Katlaps KG, Ellis BK, Dharmaraj B. Neuroprotection against stroke and encephalopathy after cardiac surgery. Interv Med Appl Sci 2019; 11:27-37. [PMID: 32148901 PMCID: PMC7044570 DOI: 10.1556/1646.11.2019.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Cerebral ischemia in the perioperative period is a major risk factor for stroke, encephalopathy, and cognitive decline after cardiothoracic surgery. After coronary artery bypass grafting, both stroke and encephalopathy can result in poor patient outcomes and increased mortality. Neuroprotection aims to lessen the severity and occurrence of further injury mediated by stroke and encephalopathy and to aid the recovery of conditions already present. Several pharmacological and non-pharmacological methods of neuroprotection have been investigated in experimental studies and in animal models, and, although some have shown effectiveness in protection of the central nervous system, for most, clinical research is lacking or did not show the expected results. This review summarizes the value and need for neuroprotection in the context of cardiothoracic surgery and examines the use and effectiveness of several agents and methods with an emphasis on clinical trials and clinically relevant neuroprotectants.
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Affiliation(s)
- Daniel G Jovin
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Karl G Katlaps
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Ben K Ellis
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Benita Dharmaraj
- Cardiothoracic Research, Department of Surgery, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
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Medikonda R, Ong CS, Wadia R, Goswami D, Schwartz J, Wolff L, Hibino N, Vricella L, Barodka V, Steppan J. A Review of Goal-Directed Cardiopulmonary Bypass Management in Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2018; 9:565-572. [PMID: 30157729 DOI: 10.1177/2150135118775964] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cardiopulmonary bypass perfusion management significantly affects postoperative outcomes. In recent years, the principles of goal-directed therapy have been applied to the field of cardiothoracic surgery to improve patient outcomes. Goal-directed therapy involves continuous peri- and postoperative monitoring of vital clinical parameters to tailor perfusion to each patient's specific needs. Closely measured parameters include fibrinogen, platelet count, lactate, venous oxygen saturation, central venous oxygen saturation, mean arterial pressure, perfusion flow rate, and perfusion pulsatility. These parameters have been shown to influence postoperative fresh frozen plasma transfusion rate, coagulation state, end-organ perfusion, and mortality. In this review, we discuss the recent paradigm shift in pediatric perfusion management toward goal-directed perfusion.
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Affiliation(s)
| | - Chin Siang Ong
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Rajeev Wadia
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Dheeraj Goswami
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jamie Schwartz
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Larry Wolff
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Narutoshi Hibino
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Luca Vricella
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Viachaslau Barodka
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jochen Steppan
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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Miles LF, Giraud K, Ferris R, Klein AA, Martinez GC, Jenkins DP, Saulankey K. Evaluation of a novel in-line point-of-care blood gas analyser. Anaesthesia 2018; 71:1044-52. [PMID: 27523052 DOI: 10.1111/anae.13548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2016] [Indexed: 11/27/2022]
Abstract
Point-of-care testing is becoming increasingly relevant to the practice of anaesthesia and critical care medicine, especially in terms of minimisation of sample volumes and decreased time to decision making. We performed a prospective observational study to evaluate a novel, in-line blood gas analysis device against a conventional benchtop model, and assessed it while placing the enrolled patients under extreme physiological conditions, specifically deep hypothermic circulatory arrest. Eight patients were studied, and had between seven and 11 samples analysed for seven variables (pH, pCO2 , pO2 , HCO3 (-) , base excess [BE], K(+) and haematocrit [Hct]), using the device during the process of cooling to 20 °C on cardiopulmonary bypass, and subsequent rewarming to normothermia. After Passing-Bablok analysis, the variables were evaluated for bias, limits of agreement and percentage error at above and below 30 °C. Of the measured variables, only pH (percentage error 2.4%) and potassium (19.8%) demonstrated acceptable (< 30%) percentage error over the full range of temperatures measured. Carbon dioxide, when stratified by temperature, was acceptable (< 30 °C percentage error 24.6%, > 30 °C percentage error 9.9%), but the overall percentage error of the dataset (45.8%) was excessively high. Bicarbonate and haematocrit both had an acceptable percentage error above 30 °C (25.2% and 18.5%, respectively), but similar to carbon dioxide, percentage error for the full range of temperatures exceeded 30%. These data differ from previous work examining this device, and highlights the difference between derived measures using different apparatuses when exposed to extreme physiological conditions.
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Affiliation(s)
- L F Miles
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - K Giraud
- Department of Research and Development, Papworth Hospital, Cambridge, UK
| | - R Ferris
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - G C Martinez
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - D P Jenkins
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - K Saulankey
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
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Gupta P, Harky A, Jahangeer S, Adams B, Bashir M. Varying Evidence on Deep Hypothermic Circulatory Arrest in Thoracic Aortic Aneurysm Surgery. Tex Heart Inst J 2018; 45:70-75. [PMID: 29844738 DOI: 10.14503/thij-17-6364] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Cardiovascular surgeons have long debated the safe duration of deep hypothermic circulatory arrest during thoracic aortic aneurysm surgery. The rationale for using adjunctive cerebral perfusion (or not) is to achieve the best technical aortic repair with the lowest risk of morbidity and death. In this literature review, we highlight the debates surrounding these issues, evaluate the disparate findings on deep hypothermic circulatory arrest durations and temperatures, and consider the usefulness of adjunctive perfusion.
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23
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Cerebral Glucose Metabolism and Sedation in Brain-injured Patients: A Microdialysis Study. J Neurosurg Anesthesiol 2016; 27:187-93. [PMID: 25144502 DOI: 10.1097/ana.0000000000000107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Disturbed brain metabolism is a signature of primary damage and/or precipitates secondary injury processes after severe brain injury. Sedatives and analgesics target electrophysiological functioning and are as such well-known modulators of brain energy metabolism. Still unclear, however, is how sedatives impact glucose metabolism and whether they differentially influence brain metabolism in normally active, healthy brain and critically impaired, injured brain. We therefore examined and compared the effects of anesthetic drugs under both critical (<1 mmol/L) and noncritical (>1 mmol/L) extracellular brain glucose levels. METHODS We performed an explorative, retrospective analysis of anesthetic drug administration and brain glucose concentrations, obtained by bedside microdialysis, in 19 brain-injured patients. RESULT Our investigations revealed an inverse linear correlation between brain glucose and both the concentration of extracellular glutamate (Pearson r=-0.58, P=0.01) and the lactate/glucose ratio (Pearson r=-0.55, P=0.01). For noncritical brain glucose levels, we observed a positive linear correlation between midazolam dose and brain glucose (P<0.05). For critical brain glucose levels, extracellular brain glucose was unaffected by any type of sedative. CONCLUSIONS These findings suggest that the use of anesthetic drugs may be of limited value in attempts to influence brain glucose metabolism in injured brain tissue.
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Silva C, Pinheiro F, Chieira D, Marques S, Órfão MR. Anesthetic Management of an Acute Bleeding Ventriculo-Cutaneous Fistula. J Cardiothorac Vasc Anesth 2016; 30:1324-8. [PMID: 27039109 DOI: 10.1053/j.jvca.2015.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Carla Silva
- Anesthesiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Filipe Pinheiro
- Anesthesiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Diana Chieira
- Anesthesiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Sofia Marques
- Anesthesiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Maria Rosário Órfão
- Anesthesiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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25
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Otto KA. Therapeutic hypothermia applicable to cardiac surgery. Vet Anaesth Analg 2015; 42:559-69. [PMID: 26361886 DOI: 10.1111/vaa.12299] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 03/19/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To review the beneficial and adverse effects of therapeutic hypothermia (TH) applicable to cardiac surgery with cardiopulmonary bypass (CPB) in the contexts of various temperature levels and techniques for achieving TH. DATABASES USED Multiple electronic literature searches were performed using PubMed and Google for articles published from June 2012 to December 2014. Relevant terms (e.g. 'hypothermia', 'cardiopulmonary bypass', 'cardiac surgery', 'neuroprotection') were used to search for original articles, letters and reviews without species limitation. Reviews were included despite potential publication bias. References from the studies identified were also searched to find other potentially relevant citations. Abstracts, case reports, conference presentations, editorials and expert opinions were excluded. CONCLUSIONS Therapeutic hypothermia is an essential measure of neuroprotection during cardiac surgery that may be achieved most effectively by intravascular cooling using hypothermic CPB. For most cardiac surgical procedures, mild to modest (32-36 °C) TH will be sufficient to assure neuroprotection and will avoid most of the adverse effects of hypothermia that occur at lower body core temperatures.
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Affiliation(s)
- Klaus A Otto
- Central Laboratory Animal Facility, Hannover Medical School, Hannover, Germany
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