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David N, Lakha S, Walsh S, Fried E, DeMaria S. Novel inhaled pulmonary vasodilators in adult cardiac surgery: a scoping review. Can J Anaesth 2024; 71:1154-1162. [PMID: 38782851 DOI: 10.1007/s12630-024-02770-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/08/2024] [Accepted: 02/18/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE Pulmonary hypertension (PH) is a common cause of postoperative mortality in cardiac surgery that is commonly treated with conventional inhaled therapies, specifically nitric oxide and prostacyclin. Alternative therapies include inhaled milrinone and levosimendan, which are receiving more research interest and are increasing in clinical use as they may cut costs while allowing for easier administration. We sought to conduct a scoping review to appraise the evidence base for the use of these two novel inhaled vasodilators as an intervention for PH in cardiac surgery. SOURCE We searched Embase and MEDLINE for relevant articles from 1947 to 2022. PRINCIPAL FINDINGS We identified 17 studies including 969 patients. The included studies show that inhaled milrinone and levosimendan are selective pulmonary vasodilators with potential benefits ranging from ease of weaning from cardiopulmonary bypass to reduction in ventricular dysfunction. Nevertheless, high-quality data are limited, and study design and comparators are extremely heterogeneous, limiting the potential validity and generalizability of findings. CONCLUSION The findings of this scoping review suggest that milrinone and levosimendan may be effective alternatives to current inhaled therapies for cardiac dysfunction in the setting of PH. Nevertheless, randomized trials have focused on specific agents and consistent outcome measures are needed to better validate the early-stage promise of these agents. STUDY REGISTRATION Open Science Framework ( https://osf.io/z3k6f/ ); first posted 21 July 2022.
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Affiliation(s)
- Navindra David
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA.
| | - Sameer Lakha
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samantha Walsh
- Hunter College, City University of New York, New York, NY, USA
| | - Eric Fried
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel DeMaria
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Oláh A, Barta BA, Ruppert M, Sayour AA, Nagy D, Bálint T, Nagy GV, Puskás I, Szente L, Szőcs L, Sohajda T, Zima E, Merkely B, Radovits T. A Comparative Investigation of the Pulmonary Vasodilating Effects of Inhaled NO Gas Therapy and Inhalation of a New Drug Formulation Containing a NO Donor Metabolite (SIN-1A). Int J Mol Sci 2024; 25:7981. [PMID: 39063223 PMCID: PMC11277253 DOI: 10.3390/ijms25147981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 07/15/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Numerous research projects focused on the management of acute pulmonary hypertension as Coronavirus Disease 2019 (COVID-19) might lead to hypoxia-induced pulmonary vasoconstriction related to acute respiratory distress syndrome. For that reason, inhalative therapeutic options have been the subject of several clinical trials. In this experimental study, we aimed to examine the hemodynamic impact of the inhalation of the SIN-1A formulation (N-nitroso-N-morpholino-amino-acetonitrile, the unstable active metabolite of molsidomine, stabilized by a cyclodextrin derivative) in a porcine model of acute pulmonary hypertension. Landrace pigs were divided into the following experimental groups: iNO (inhaled nitric oxide, n = 3), SIN-1A-5 (5 mg, n = 3), and SIN-1A-10 (10 mg, n = 3). Parallel insertion of a PiCCO system and a pulmonary artery catheter (Swan-Ganz) was performed for continuous hemodynamic monitoring. The impact of iNO (15 min) and SIN-1A inhalation (30 min) was investigated under physiologic conditions and U46619-induced acute pulmonary hypertension. Mean pulmonary arterial pressure (PAP) was reduced transiently by both substances. SIN-1A-10 had a comparable impact compared to iNO after U46619-induced pulmonary hypertension. PAP and PVR decreased significantly (changes in PAP: -30.1% iNO, -22.1% SIN-1A-5, -31.2% SIN-1A-10). While iNO therapy did not alter the mean arterial pressure (MAP) and systemic vascular resistance (SVR), SIN-1A administration resulted in decreased MAP and SVR values. Consequently, the PVR/SVR ratio was markedly reduced in the iNO group, while SIN-1A did not alter this parameter. The pulmonary vasodilatory impact of inhaled SIN-1A was shown to be dose-dependent. A larger dose of SIN-1A (10 mg) resulted in decreased PAP and PVR in a similar manner to the gold standard iNO therapy. Inhalation of the nebulized solution of the new SIN-1A formulation (stabilized by a cyclodextrin derivative) might be a valuable, effective option where iNO therapy is not available due to dosing difficulties or availability.
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Affiliation(s)
- Attila Oláh
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Bálint András Barta
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Mihály Ruppert
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Alex Ali Sayour
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Dávid Nagy
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Tímea Bálint
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Georgina Viktória Nagy
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | | | | | | | | | - Endre Zima
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Tamás Radovits
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
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Zhao Y, Wang H, Cheng Y, Zhang J, Zhao L. Factors Influencing Successful Weaning From Venoarterial Extracorporeal Membrane Oxygenation: A Systematic Review. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00328-8. [PMID: 38969612 DOI: 10.1053/j.jvca.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 05/01/2024] [Accepted: 05/11/2024] [Indexed: 07/07/2024]
Abstract
With advancements in extracorporeal life support (ECLS) technologies, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as a crucial cardiopulmonary support mechanism. This review explores the significance of VA-ECMO system configuration, cannulation strategies, and timing of initiation. Through an analysis of medication management strategies, complication management, and comprehensive preweaning assessments, it aims to establish a multidimensional evaluation framework to assist clinicians in making informed decisions regarding weaning from VA-ECMO, thereby ensuring the safe and effective transition of patients.
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Affiliation(s)
- Yanlong Zhao
- Department of Cardiology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Heru Wang
- Department of Cardiology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Yihao Cheng
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jifeng Zhang
- School of Pharmaceutical Sciences, Jilin University, Changchun, Jilin, China
| | - Lei Zhao
- Department of Cardiology, The Second Hospital of Jilin University, Changchun, Jilin, China.
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Arora RC, Brown JK, Chatterjee S, Gan TJ, Singh G, Tong MZ. Perioperative management of the vulnerable and failing right ventricle. Perioper Med (Lond) 2024; 13:40. [PMID: 38750602 PMCID: PMC11097429 DOI: 10.1186/s13741-024-00397-5] [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: 01/17/2024] [Accepted: 05/05/2024] [Indexed: 05/18/2024] Open
Abstract
Under recognition combined with suboptimal management of right ventricular (RV) dysfunction and failure is associated with significant perioperative morbidity and mortality. The contemporary perioperative team must be prepared with an approach for early recognition and prompt treatment. In this review, a consensus-proposed scoring system is described to provide a pragmatic approach for expeditious decision-making for these complex patients with a vulnerable RV. Importantly, this proposed scoring system incorporates the context of the planned surgical intervention. Further, as the operating room (OR) represents a unique environment where patients are susceptible to numerous insults, a practical approach to anesthetic management and monitoring both in the OR and in the intensive care unit is detailed. Lastly, an escalating approach to the management of RV failure and options for mechanical circulatory support is provided.
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Affiliation(s)
- R C Arora
- Harrington Heart and Vascular Institute - University Hospitals, Cleveland, OH, USA.
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA.
| | - J K Brown
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S Chatterjee
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - T J Gan
- Division of Anesthesiology and Perioperative Medicine, Critical Care and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Singh
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
- Departments of Critical Care Medicine and Surgery, University of Alberta, Edmonton, AB, Canada
| | - M Z Tong
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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Ostasevicius V, Jurenas V, Venslauskas M, Kizauskiene L, Zigmantaite V, Stankevicius E, Bubulis A, Vezys J, Mikuckyte S. Low-frequency ultrasound for pulmonary hypertension therapy. Respir Res 2024; 25:70. [PMID: 38317182 PMCID: PMC10840147 DOI: 10.1186/s12931-024-02713-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 01/28/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Currently, there are no reliable clinical tools that allow non-invasive therapeutic support for patients with pulmonary arterial hypertension. This study aims to propose a low-frequency ultrasound device for pulmonary hypertension therapy and to demonstrate its potential. METHODS A novel low-frequency ultrasound transducer has been developed. Due to its structural properties, it is excited by higher vibrational modes, which generate a signal capable of deeply penetrating biological tissues. A methodology for the artificial induction of pulmonary hypertension in sheep and for the assessment of lung physiological parameters such as blood oxygen concentration, pulse rate, and pulmonary blood pressure has been proposed. RESULTS The results showed that exposure of the lungs to low-frequency ultrasound changed physiological parameters such as blood oxygen concentration, pulse rate and blood pressure. These parameters are most closely related to indicators of pulmonary hypertension (PH). The ultrasound exposure increased blood oxygen concentration over a 7-min period, while pulse rate and pulmonary blood pressure decreased over the same period. In anaesthetised sheep exposed to low-frequency ultrasound, a 10% increase in SpO2, a 10% decrease in pulse rate and an approximate 13% decrease in blood pressure were observed within 7 min. CONCLUSIONS The research findings demonstrate the therapeutic efficiency of low-frequency ultrasound on hypertensive lungs, while also revealing insights into the physiological aspects of gas exchange within the pulmonary system.
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Affiliation(s)
- Vytautas Ostasevicius
- Institute of Mechatronics, Kaunas University of Technology, Studentu Street 56, 51424, Kaunas, Lithuania.
| | - Vytautas Jurenas
- Institute of Mechatronics, Kaunas University of Technology, Studentu Street 56, 51424, Kaunas, Lithuania
| | - Mantas Venslauskas
- Institute of Mechatronics, Kaunas University of Technology, Studentu Street 56, 51424, Kaunas, Lithuania
| | - Laura Kizauskiene
- Department of Computer Sciences, Kaunas University of Technology, Studentu Street 50, 51368, Kaunas, Lithuania
| | - Vilma Zigmantaite
- Biological Research Center Lithuanian, University of Health Sciences, Tilžės Street 18, 47181, Kaunas, Lithuania
- Laboratory of Membrane Biophysics, Cardiology Department, Lithuanian University of Health Sciences, Sukilėlių Street 15, 50103, Kaunas, Lithuania
| | - Edgaras Stankevicius
- Institute of Physiology and Pharmacology, Lithuanian University of Health Sciences, A. Mickevicius Street 9, 44307, Kaunas, Lithuania
| | - Algimantas Bubulis
- Institute of Mechatronics, Kaunas University of Technology, Studentu Street 56, 51424, Kaunas, Lithuania
| | - Joris Vezys
- Department of Mechanical Engineering, Kaunas University of Technology, Kaunas University of Technology, Studentu Street 56, 51424, Kaunas, Lithuania
| | - Sandra Mikuckyte
- Institute of Mechatronics, Kaunas University of Technology, Studentu Street 56, 51424, Kaunas, Lithuania
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Benedetto M, Piccone G, Gottin L, Castelli A, Baiocchi M. Inhaled Pulmonary Vasodilators for the Treatment of Right Ventricular Failure in Cardio-Thoracic Surgery: Is One Better than the Others? J Clin Med 2024; 13:564. [PMID: 38256697 PMCID: PMC10816998 DOI: 10.3390/jcm13020564] [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: 11/20/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
Right ventricular failure (RFV) is a potential complication following cardio-thoracic surgery, with an incidence ranging from 0.1% to 30%. The increase in pulmonary vascular resistance (PVR) is one of the main triggers of perioperative RVF. Inhaled pulmonary vasodilators (IPVs) can reduce PVR and improve right ventricular function with minimal systemic effects. This narrative review aims to assess the efficacy of inhaled nitric oxide and inhaled prostacyclins for the treatment of perioperative RVF. The literature, although statistically limited, supports the clinical similarity between them. However, it failed to demonstrate a clear benefit from the pre-emptive use of inhaled nitric oxide in patients undergoing left ventricular assist device implantation or early administration during heart-lung transplants. Additional concerns are related to cost safety and IPV use in pathologies associated with pulmonary venous congestion. The largest ongoing randomized controlled trial on adults (INSPIRE-FLO) is addressing whether inhaled Epoprostenol and inhaled nitric oxide are similar in preventing RVF after heart transplants and left ventricular assist device placement, and whether they are similar in preventing primary graft dysfunction after lung transplants. The preliminary analysis supports their equivalence. Several key points may be achieved by the present narrative review. When RVF occurs in the setting of elevated PVR, IPV should be the preferred initial treatment and they should be preventively used in patients at high risk of postoperative RVF. If severe refractory postoperative RVF occurs, IPVs should be combined with complementary pharmacology (inotropes and inodilators). If unsuccessful, right ventricular mechanical support should be established.
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Affiliation(s)
- Maria Benedetto
- Cardio-Thoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (M.B.)
| | - Giulia Piccone
- Cardiothoracic and Vascular Intensive Care Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37124 Verona, Italy; (G.P.); (L.G.)
| | - Leonardo Gottin
- Cardiothoracic and Vascular Intensive Care Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37124 Verona, Italy; (G.P.); (L.G.)
| | - Andrea Castelli
- Cardio-Thoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (M.B.)
| | - Massimo Baiocchi
- Cardio-Thoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (M.B.)
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Bhatt HV, Fritz AV, Feinman JW, Subramani S, Malhotra AK, Townsley MM, Weiner MM, Sharma A, Teixeira MT, Lee J, Linganna RE, Waldron NH, Shapiro AB, Mckeon J, Hanada S, Ramakrishna H, Martin AK. The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2023. J Cardiothorac Vasc Anesth 2024; 38:16-28. [PMID: 38040533 DOI: 10.1053/j.jvca.2023.10.030] [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: 10/19/2023] [Accepted: 10/21/2023] [Indexed: 12/03/2023]
Abstract
This special article is the 16th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. The major themes selected for 2023 are outlined in this introduction, and each highlight is reviewed in detail in the main article. The literature highlights in the specialty for 2023 begin with an update on perioperative rehabilitation in cardiothoracic surgery, with a focus on novel methods to best assess patients in the preoperative and postoperative periods, and the impact of rehabilitation on outcomes. The second major theme is focused on cardiac surgery, with the authors discussing new insights into inhaled pulmonary vasodilators, coronary revascularization surgery, and discussion of causes of coronary graft failure after surgery. The third theme is focused on cardiothoracic transplantation, with discussions focusing on bridge-to-transplantation strategies. The fourth theme is focused on mechanical circulatory support, with discussions focusing on both temporary and durable support. The fifth and final theme is an update on medical cardiology, with a focus on outcomes of invasive approaches to heart disease. The themes selected for this article are only a few of the diverse advances in the specialty during 2023. These highlights will inform the reader of key updates on various topics, leading to improved perioperative outcomes for patients with cardiothoracic and vascular disease.
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Affiliation(s)
- Himani V Bhatt
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Jared W Feinman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Anita K Malhotra
- Division of Cardiothoracic Anesthesiology and Critical Care, Penn State Hershey Medical Center, Hershey, PA
| | - Matthew M Townsley
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham School of Medicine, Birmingham, AL; Bruno Pediatric Heart Center, Children's of Alabama, Birmingham, AL
| | - Menachem M Weiner
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Archit Sharma
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Miguel T Teixeira
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Jennifer Lee
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Regina E Linganna
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nathan H Waldron
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Anna Bovill Shapiro
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - John Mckeon
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Satoshi Hanada
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL.
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Giorgino F, Battelino T, Bergenstal RM, Forst T, Green JB, Mathieu C, Rodbard HW, Schnell O, Wilmot EG. The Role of Ultra-Rapid-Acting Insulin Analogs in Diabetes: An Expert Consensus. J Diabetes Sci Technol 2023:19322968231204584. [PMID: 37937585 DOI: 10.1177/19322968231204584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Ultra-rapid-acting insulin analogs (URAA) are a further development and refinement of rapid-acting insulin analogs. Because of their adapted formulation, URAA provide an even faster pharmacokinetics and thus an accelerated onset of insulin action than conventional rapid-acting insulin analogs, allowing for a more physiologic delivery of exogenously applied insulin. Clinical trials have confirmed the superiority of URAA in controlling postprandial glucose excursions, with a safety profile that is comparable to the rapid-acting insulins. Consequently, many individuals with diabetes mellitus may benefit from URAA in terms of prandial glycemic control. Unfortunately, there are only few available recommendations from authoritative sources for use of URAA in clinical practice. Therefore, this expert consensus report aims to define populations of people with diabetes mellitus for whom URAA may be beneficial and to provide health care professionals with concrete, practical recommendations on how best to use URAA in this context.
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Affiliation(s)
- Francesco Giorgino
- Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | - Tadej Battelino
- Department of Endocrinology, Diabetes and Metabolism, UCH-University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Thomas Forst
- Department of Endocrinology and Metabolic Diseases, Johannes Gutenberg University Medical Center, Mainz, Germany
- Clinical Research Services, Mannheim, Germany
| | - Jennifer B Green
- Division of Endocrinology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
| | | | - Oliver Schnell
- Forschergruppe Diabetes eV at the Helmholtz Centre, Munich-Neuherberg, Germany
| | - Emma G Wilmot
- Department of Diabetes & Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
- Academic Unit for Translational Medical Sciences, University of Nottingham, Nottingham, England, UK
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9
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Roeschl T, Hinrichs N, Hommel M, Pfahringer B, Balzer F, Falk V, O'Brien B, Ott SC, Potapov E, Schoenrath F, Meyer A. Systematic Assessment of Shock Severity in Postoperative Cardiac Surgery Patients. J Am Coll Cardiol 2023; 82:1691-1706. [PMID: 37852698 DOI: 10.1016/j.jacc.2023.08.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/05/2023] [Accepted: 08/15/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The Society for Cardiovascular Angiography and Interventions (SCAI) shock classification has been shown to provide robust mortality risk stratification in a variety of cardiovascular patients. OBJECTIVES This study sought to evaluate the SCAI shock classification in postoperative cardiac surgery intensive care unit (CSICU) patients. METHODS This study retrospectively analyzed 26,792 postoperative CSICU admissions at a heart center between 2012 and 2022. Patients were classified into SCAI shock stages A to E using electronic health record data. Moreover, the impact of late deterioration (LD) as an additional risk modifier was investigated. RESULTS The proportions of patients in SCAI shock stages A to E were 24.4%, 18.8%, 8.4%, 35.5%, and 12.9%, and crude hospital mortality rates were 0.4%, 0.6%, 3.3%, 4.9%, and 30.2%, respectively. Similarly, the prevalence of postoperative complications and organ dysfunction increased across SCAI shock stages. After multivariable adjustment, each higher SCAI shock stage was associated with increased hospital mortality (adjusted OR: 1.26-16.59) compared with SCAI shock stage A, as was LD (adjusted OR: 8.2). The SCAI shock classification demonstrated a strong diagnostic performance for hospital mortality (area under the receiver operating characteristic: 0.84), which noticeably increased when LD was incorporated into the model (area under the receiver operating characteristic: 0.90). CONCLUSIONS The SCAI shock classification effectively risk-stratifies postoperative CSICU patients for mortality, postoperative complications, and organ dysfunction. Its application could, therefore, be extended to the field of cardiac surgery as a triage tool in postoperative care and as a selection criterion in research.
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Affiliation(s)
- Tobias Roeschl
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Charité-Universitätsmedizin Berlin, Institute of Medical Informatics, Berlin, Germany.
| | - Nils Hinrichs
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Charité-Universitätsmedizin Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Matthias Hommel
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Deutsches Herzzentrum der Charité (DHZC), Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Boris Pfahringer
- Deutsches Herzzentrum der Charité (DHZC), Centre for Cardiovascular Telemedicine, Berlin, Germany
| | - Felix Balzer
- Charité-Universitätsmedizin Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Volkmar Falk
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany; Translational Cardiovascular Technologies, Institute of Translational Medicine, Department of Health Sciences and Technology, Swiss Federal Institute of Technology, Zürich, Switzerland
| | - Benjamin O'Brien
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Deutsches Herzzentrum der Charité (DHZC), Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany; St Bartholomew's Hospital and Barts Heart Centre, Department of Perioperative Medicine, London, United Kingdom
| | - Sascha Christoph Ott
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Deutsches Herzzentrum der Charité (DHZC), Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Evgenij Potapov
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Felix Schoenrath
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Alexander Meyer
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Charité-Universitätsmedizin Berlin, Institute of Medical Informatics, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
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10
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Foster EM, Sullinger D, Coons JC. Management Considerations for Pulmonary Arterial Hypertension Pharmacotherapy in the Intensive Care Unit. PHARMACY 2023; 11:145. [PMID: 37736917 PMCID: PMC10514794 DOI: 10.3390/pharmacy11050145] [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: 07/27/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023] Open
Abstract
Pulmonary arterial hypertension is a rare and progressive disease with significant morbidity and mortality risk. Several medications targeting three major disease pathways are approved for treatment. However, the management of pulmonary arterial hypertension pharmacotherapies in a patient admitted to an intensive care unit poses unique challenges. Factors such as intubation and altered mental status may prevent the continuation of home oral and/or inhaled therapy, and the progression of the disease may require escalation of therapy. This review will focus on practical management strategies for the continuation of home pulmonary arterial hypertension pharmacotherapy and escalation of therapy.
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Affiliation(s)
| | - Danine Sullinger
- UPMC Presbyterian Shadyside Hospital, 200 Lothrop Street, Pittsburgh, PA 15213, USA; (E.M.F.); (J.C.C.)
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11
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Shehzad I, Banker A, Das B, Humayun A, Wills H, Raju M, Vora N. Successful Weaning From Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) After Initiation of Inhaled Epoprostenol in a Neonate With Refractory Persistent Pulmonary Hypertension of the Newborn (PPHN). Cureus 2023; 15:e45595. [PMID: 37868379 PMCID: PMC10588285 DOI: 10.7759/cureus.45595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/20/2023] [Indexed: 10/24/2023] Open
Abstract
Despite improvements in the medical management of persistent pulmonary hypertension of the newborn (PPHN), a significant number of patients persist with inadequate gas exchange and are treated with extracorporeal membrane oxygenation (ECMO). Prolonged time to weaning ECMO can increase mortality risk. Therefore, multiple therapies are utilized for pulmonary hypertension treatment, including pharmacotherapy with pulmonary vasodilators, to improve the prognosis of these critical patients. We report a case of a 37 2/7-week neonate with severe PPHN refractory to triple pulmonary vasodilator therapy (inhaled nitric oxide (iNO), sildenafil, and milrinone) and required veno-venous (VV)-ECMO support to improve oxygenation. Our patient was successfully weaned from ECMO after the addition of inhaled epoprostenol (iEPO) therapy. This report indicates that inhaled prostacyclin therapy effectively helps refractory PPHN patients off extracorporeal life support (ECLS) and should be considered a valuable treatment.
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Affiliation(s)
- Irfan Shehzad
- Neonatology, Baylor Scott & White Health, Austin, USA
| | - Ashish Banker
- Pediatric Cardiology, Baylor Scott & White Health, Temple, USA
| | - Bibhuti Das
- Pediatric Cardiology, Baylor Scott & White Health, Temple, USA
| | - Adil Humayun
- Neonatology, Baylor Scott & White Health, Temple, USA
| | - Hale Wills
- Pediatric Surgery, Baylor Scott & White Health, Temple, USA
| | - Muppala Raju
- Neonatology, Baylor Scott & White Health, Temple, USA
| | - Niraj Vora
- Neonatology, Baylor Scott & White Health, Temple, USA
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12
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Kamenshchikov NO, Duong N, Berra L. Nitric Oxide in Cardiac Surgery: A Review Article. Biomedicines 2023; 11:biomedicines11041085. [PMID: 37189703 DOI: 10.3390/biomedicines11041085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/26/2023] [Accepted: 03/29/2023] [Indexed: 05/17/2023] Open
Abstract
Perioperative organ injury remains a medical, social and economic problem in cardiac surgery. Patients with postoperative organ dysfunction have increases in morbidity, length of stay, long-term mortality, treatment costs and rehabilitation time. Currently, there are no pharmaceutical technologies or non-pharmacological interventions that can mitigate the continuum of multiple organ dysfunction and improve the outcomes of cardiac surgery. It is essential to identify agents that trigger or mediate an organ-protective phenotype during cardiac surgery. The authors highlight nitric oxide (NO) ability to act as an agent for perioperative protection of organs and tissues, especially in the heart-kidney axis. NO has been delivered in clinical practice at an acceptable cost, and the side effects of its use are known, predictable, reversible and relatively rare. This review presents basic data, physiological research and literature on the clinical application of NO in cardiac surgery. Results support the use of NO as a safe and promising approach in perioperative patient management. Further clinical research is required to define the role of NO as an adjunct therapy that can improve outcomes in cardiac surgery. Clinicians also have to identify cohorts of responders for perioperative NO therapy and the optimal modes for this technology.
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Affiliation(s)
- Nikolay O Kamenshchikov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 634012 Tomsk, Russia
| | - Nicolette Duong
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
- Respiratory Care Service, Patient Care Services, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Lorenzo Berra
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
- Respiratory Care Service, Patient Care Services, Massachusetts General Hospital, Boston, MA 02114, USA
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13
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Randhawa VK, Spataru A, Jory L, Moussa F, Bhardwaj A, Rajapreyar I. Effects of Inhaled Pulmonary Vasodilators on Perioperative Right Ventricular Hemodynamics: Are These "Nebs" Simply Nebulous? Can J Cardiol 2023; 39:483-486. [PMID: 36746371 DOI: 10.1016/j.cjca.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Affiliation(s)
- Varinder K Randhawa
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Ana Spataru
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lindsay Jory
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Fuad Moussa
- Department of Cardiac Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anju Bhardwaj
- Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas/McGovern Medical School, Houston, Texas, USA
| | - Indranee Rajapreyar
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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14
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VARDAR G, AKSOY OKAN M, TOPÇUOĞLU S, KARADAĞ N, ÖZALKAYA E, OZGUN KARATEPE H, KARATEKİN G. Controversies in neonatology: The efficacy of inhaled nitric oxide in preterm infants with persistent pulmonary hypertension. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1104799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: There is limited and conflicting information in literature regarding use of inhaled nitric oxide (iNO) in preterm infants. In this study we examined the characteristics of preterm infants with persistent pulmonary hypertension (PHT) who responded and did not respond to iNO therapy .
Material and Method: We retrospectively reviewed data of infants
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Affiliation(s)
- Gonca VARDAR
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL ZEYNEP KAMİL HEALTH RESEARCH CENTER FOR GYNAECOLOGY AND PEDIATRICS
| | - Meliha AKSOY OKAN
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL ZEYNEP KAMİL HEALTH RESEARCH CENTER FOR GYNAECOLOGY AND PEDIATRICS
| | - Sevilay TOPÇUOĞLU
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL ZEYNEP KAMİL HEALTH RESEARCH CENTER FOR GYNAECOLOGY AND PEDIATRICS
| | - Nilgün KARADAĞ
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL ZEYNEP KAMİL HEALTH RESEARCH CENTER FOR GYNAECOLOGY AND PEDIATRICS
| | - Elif ÖZALKAYA
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL ZEYNEP KAMİL HEALTH RESEARCH CENTER FOR GYNAECOLOGY AND PEDIATRICS
| | - Hande OZGUN KARATEPE
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL ZEYNEP KAMİL HEALTH RESEARCH CENTER FOR GYNAECOLOGY AND PEDIATRICS
| | - Güner KARATEKİN
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL ZEYNEP KAMİL HEALTH RESEARCH CENTER FOR GYNAECOLOGY AND PEDIATRICS
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15
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Bansal N, Magoon R, Kalaiselvan J, Shri I, Kohli JK, Kashav RC. Inhaled Milrinone via HFNC as a Postextubation Cardiopulmonary Elixir: Case Series and Review of Literature. JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0042-1757366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
AbstractPulmonary hypertension (PH) often complicates perioperative course following pediatric cardiac surgery, often presenting unique challenges to the attending cardiac anesthesiologist. Apart from difficult weaning from cardiopulmonary bypass, PH can often compound weaning from mechanical ventilation in this postoperative subset. From pathophysiological standpoint, the former can be attributed to concurrent detrimental cardiopulmonary consequences of PH as a multisystemic syndrome. Therefore, with an objective to address the affected systems, that is, cardiac and pulmonary simultaneously, we report combined use of inhaled milrinone (a pulmonary vasodilator) through high-frequency nasal cannula (oxygen reservoir and continuous positive airway pressure delivery device), purported to complement each other's mechanism of action in the management of PH, thereby hastening postoperative recovery. This article additionally presents a nuanced perspective on the advantages of combining the aforementioned therapies and hence proposing the same as a possible “postoperative cardiopulmonary elixir.”
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Affiliation(s)
- Noopur Bansal
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia (RML) Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Rohan Magoon
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia (RML) Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Jaffrey Kalaiselvan
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia (RML) Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Iti Shri
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia (RML) Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Jasvinder Kaur Kohli
- Department of Cardiac Anaesthesia, Dr. Ram Manohar Lohia (RML) Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Ramesh Chand Kashav
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia (RML) Hospital, Baba Kharak Singh Marg, New Delhi, India
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16
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Bansal N, Magoon R, Kalaiselvan J, ItiShri I, Kohli JK, Kashav RC. Inhaled Milrinone via HFNC as a Postextubation Cardiopulmonary Elixir: Case Series and Review of Literature. JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0042-1759823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
AbstractPulmonary hypertension (PH) often complicates perioperative course following pediatric cardiac surgery, often presenting unique challenges to the attending cardiac anesthesiologist. Apart from difficult weaning from cardiopulmonary bypass, PH can often compound weaning from mechanical ventilation in this postoperative subset. From pathophysiological standpoint, the former can be attributed to concurrent detrimental cardiopulmonary consequences of PH as a multisystemic syndrome. Therefore, with an objective to address the affected systems, that is, cardiac and pulmonary simultaneously, we report combined use of inhaled milrinone (a pulmonary vasodilator) through high-frequency nasal cannula (oxygen reservoir and continuous positive airway pressure delivery device), purported to complement each other's mechanism of action in the management of PH, thereby hastening postoperative recovery. The article additionally presents a nuanced perspective on the advantages of combining the aforementioned therapies and hence proposing the same as a possible “postoperative cardiopulmonary elixir.”
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Affiliation(s)
- Noopur Bansal
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Rohan Magoon
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Jaffrey Kalaiselvan
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - ItiShri ItiShri
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Jasvinder Kaur Kohli
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Ramesh Chand Kashav
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India
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17
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Lee K, Kim M, Kim N, Kang SJ, Oh YJ. Effects of Iloprost on Arterial Oxygenation and Lung Mechanics during One-Lung Ventilation in Supine-Positioned Patients: A Randomized Controlled Study. J Pers Med 2022; 12:jpm12071054. [PMID: 35887551 PMCID: PMC9323331 DOI: 10.3390/jpm12071054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 06/23/2022] [Accepted: 06/26/2022] [Indexed: 11/24/2022] Open
Abstract
Patients undergoing one-lung ventilation (OLV) in the supine position face an increased risk of intraoperative hypoxia compared with those in the lateral decubitus position. We hypothesized that iloprost (ILO) inhalation improves arterial oxygenation and lung mechanics. Sixty-four patients were enrolled and allocated to either the ILO or control group (n = 32 each), to whom ILO or normal saline was administered. The partial pressure of the arterial oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio, dynamic compliance, alveolar dead space, and hemodynamic variables were assessed 20 min after anesthesia induction with both lungs ventilated (T1) and 20 min after drug nebulization in OLV (T2). A linear mixed model adjusted for group and time was used to analyze repeated variables. While the alveolar dead space remained unchanged in the ILO group, it increased at T2 in the control group (n = 30 each) (p = 0.002). No significant differences were observed in the heart rate, mean blood pressure, PaO2/FiO2 ratio, or dynamic compliance in either group. Selective ILO nebulization was inadequate to enhance oxygenation parameters during OLV in the supine position. However, it favorably affected alveolar ventilation during OLV in supine-positioned patients without adverse hemodynamic effects.
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Affiliation(s)
- Kyuho Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Korea; (K.L.); (N.K.); (S.J.K.)
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Mina Kim
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang-si 10326, Gyeonggi-do, Korea;
| | - Namo Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Korea; (K.L.); (N.K.); (S.J.K.)
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Su Jeong Kang
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Korea; (K.L.); (N.K.); (S.J.K.)
| | - Young Jun Oh
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Korea; (K.L.); (N.K.); (S.J.K.)
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul 03722, Korea
- Correspondence: ; Tel.: +82-2-2228-2428
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18
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Neder JA, Kirby M, Santyr G, Pourafkari M, Smyth R, Phillips DB, Crinion S, de-Torres JP, O’Donnell DE. V̇/Q̇ Mismatch. Chest 2022; 162:1030-1047. [DOI: 10.1016/j.chest.2022.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/14/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022] Open
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19
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Brown CJ, Rubel N, Lai J, Ward C, McLean J, Wheelock M, Steuerwald M, Cathers A. Initiation of Inhaled Nitric Oxide by Air Transport Team in Adult COVID-19 Respiratory Failure. Air Med J 2022; 41:406-410. [PMID: 35750450 PMCID: PMC8907015 DOI: 10.1016/j.amj.2022.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/28/2022] [Accepted: 03/02/2022] [Indexed: 11/19/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has caused a significant increase in the volume of critical care flight transports between outlying referral hospitals and tertiary care facilities. Because of the tropism of severe acute respiratory syndrome coronavirus 2, flight crews are often asked to transport mechanically ventilated patients in refractory hypoxemic respiratory failure. The authors present a case series of 5 patients with COVID-19 acute respiratory distress syndrome (ARDS) who were initiated on inhaled nitric oxide (iNO) by the transport team before rotor wing transport and survived the journey in stable or improved condition upon arrival. Previously, no case reports have described adults with COVID-19 ARDS transported after iNO initiation by the transport team. This case series shows the feasibility of iNO initiation by trained air medical transport teams and suggests a short-term stabilizing effect of iNO in patients with ARDS from COVID-19.
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Affiliation(s)
- Connor J Brown
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI.
| | - Nicolas Rubel
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Jason Lai
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Christen Ward
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Justin McLean
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Martin Wheelock
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Michael Steuerwald
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
| | - Andrew Cathers
- BerbeeWalsh University of Wisconsin Department of Emergency Medicine, Madison, WI; University of Wisconsin MedFlight, BerbeeWalsh Department of Emergency Medicine, Madison, WI
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20
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Li P, Gu L, Tan J, Song Z, Bian Q, Jiao D, Xu Z, Wang L. A randomised controlled trial on roles of prostaglandin E1 nebulization among patients undergoing one lung ventilation. BMC Pulm Med 2022; 22:37. [PMID: 35027012 PMCID: PMC8759228 DOI: 10.1186/s12890-022-01831-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 01/06/2022] [Indexed: 12/24/2022] Open
Abstract
Background Prostaglandin E1 (PGE1) has been reported to maintain adequate oxygenation among patients under 60% FiO2 one-lung ventilation (OLV). This research aimed to explore whether PGE1 is safe in pulmonary shunt and oxygenation under 40% FiO2 OLV and provide a reference concentration of PGE1. Methods Totally 90 esophageal cancer patients treated with thoracotomy were enrolled in this study, randomly divided into three groups (n = 30/group): Group A (60% FiO2 and 0.1 µg/kg PGE1), Group B (40% FiO2 and 0.1 µg/kg PGE1), and Group C (40% FiO2, 0.2 µg/kg PGE1). Primary outcomes were oxygenation and pulmonary shunt during OLV. Secondary outcomes included oxidative stress after OLV. Results During OLV, patients in Group C and B had lower levels of PaO2, SaO2, SpO2, MAP, and Qs/Qt than those in Group A (P < 0.05). At T2 (OLV 10 min), patients in Group C and B exhibited a lower level of PaO2/FiO2 than those in Group A, without any statistical difference at other time points. The IL-6 levels of patients in different groups were different at T8 (F = 3.431, P = 0.038), with IL-6 in Group C being lower than that in Group B and A. MDA levels among the three groups differed at T5 (F = 4.692, P = 0.012) and T7 (F = 5.906, P = 0.004), with the MDA level of Group C being lower than that of Group B and A at T5, and the MDA level of Group C and B being lower than that of Group A at T7. In terms of TNF-α level, patients in Group C had a lower level than those in Group B and A at T8 (F = 3.598, P = 0.033). Compared with patients who did not use PGE1, patients in Group C had comparable complications and lung infection scores. Conclusion The concentration of FiO2 could be reduced from 60 to 40% to maintain oxygenation. 40% FiO2 + 0.2 µg/kg PGE1 is recommended as a better combination on account of its effects on the inflammatory factors. Trial registration: Chictr.org.cn identifier: ChiCTR1800018288, 09/09/2018.
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