Feasibility of On-table Extubation After Cardiac Surgery with Cardiopulmonary Bypass: A Randomized Clinical Trial

Clinical Evaluation of on-Table Extubation in Patients Aged Over 60 Years Undergoing Minimally Invasive Mitral or Aortic Valve Replacement Surgery

Aims

To evaluate the clinical efficiency of on-table extubation (OTE) versus delayed extubation in patients aged over 60 years that underwent minimally invasive mitral or aortic valve replacement surgery and evaluate the factors associated with successful OTE implementation.

Materials

Patients over 60 years with mitral or aortic valve disease who received minimally invasive mitral or aortic valve replacement surgery from October 2020 to October 2021 were selected retrospectively. We divided patients into the on-table extubated (OTE) group (n = 71) and the delayed extubation (DE) group (n = 22). Preoperative, intraoperative, and postoperative clinical variables were compared between the two groups.

Results

Patients in the DE group underwent longer surgery time, longer aortic occlusion clamping time and longer cardiopulmonary bypass time than those in the OTE group(217.48 ± 27.83 vs 275.91 ± 77.22, p = 0.002; 76.49 ± 16.00 vs 126.55 ± 54.85, p = 0.001; 112.87 ± 18.91 vs 160.77 ± 52.17, p = 0.001). Patients in the OTE group had shorter postoperative mechanical ventilation time (min), shorter ICU time, shorter postoperative hospital length of stay and lower total cost and medication cost (p < 0.05). The AUC for aortic occlusion clamping time was 0.81 (p < 0.01), making it the most significant predictor of on-table extubation success.

Conclusions

On-table extubation following mitral or aortic valve cardiac surgery was associated with a superior clinical outcome and high cost-effectiveness.

Effect of Nebulized Heparin on Weaning off Intubated Patients with Acute Respiratory Distress Syndrome (ARDS) Admitted to Intensive Care Unit (ICU): A Randomized Clinical Trial

Background: Acute respiratory distress syndrome (ARDS) treatment is based on supportive care such as mechanical ventilation, prophylaxis of stress ulcer, prophylaxis of deep vein thrombosis (DVT), nutritional support, and treatment of underlying disease. Objectives: We aimed to investigate the effects of nebulized heparin on weaning off intubated ARDS patients admitted to the intensive care unit (ICU). Methods: In this double-blind clinical trial study, 60 patients with ARDS receiving routine care according to the ARDS protocol were randomly assigned into two groups: intervention group (receiving nebulized heparin 5000 u/BD for one week) and control group (receiving nebulized sterile water 2 cc/BD for one week). The respiratory index (PaO2/FiO2), pulmonary shunt percentage (measured by ABG), tidal volume, minute ventilation, admission duration in the ICU, and days of mechanical ventilation required were recorded for each patient for one week. Results: There was no significant difference in demographic data between the two groups. Inhaled heparin in patients with ARDS could significantly increase the respiratory index (PaO2/FiO2) and decrease pulmonary shunt percentage, minute ventilation, and tidal volume. It also significantly reduced the number of admission days in the ICU and the need for mechanical ventilation. Conclusions: The result of the present study showed that inhaled heparin in intubated ARDS patients admitted to the ICU improved respiratory and pulmonary status and reduced the need for mechanical ventilation and admission days in the ICU. Nebulizing heparin, as an anti-inflammatory and anti-coagulant agent, is an effective and safe medication for ARDS patients on mechanical ventilation.

Reliable and Rapid Smooth Extubation After "Ketamine-Propfol Mixture" for Induction of General Anesthesia in Laparoscopic Drilling of Polycystic Ovary: A Randomized, Double-blind, Comparative Study

Background

Ketofol's effect on hemodynamics and the airway response during inducing general anesthesia has been studied previously. However, ketofol's effect on the smoothness of extubation has not been studied yet.

Objectives

We aimed to assess ketofol’s effect on the smoothness of extubation and compare it with propofol for inducing general anesthesia.

Methods

This double-blind, randomized, and controlled study was conducted on 106 class I and II female patients with the “American Society of Anesthesiologists Physical Status (ASAPS),” aged 18 - 40 years, scheduled for laparoscopic drilling for polycystic ovary disease under general anesthesia. The patients were assigned to two groups of 53 patients each: Group KP = ketofol and Group P = propofol.

Results

There was an excellent sedation score during suction and extubation in the ketofol group. The airway response and smoothness of extubation were better in the ketofol group than in the propofol group.

Conclusions

Ketofol as an induction anesthetic agent more effectively attenuated the airway response during extubation than only propofol.

Establishment of an enhanced recovery after surgery protocol in minimally invasive heart valve surgery

Protocols for “Enhanced recovery after surgery (ERAS)” are on the rise in different surgical disciplines and represent one of the most important recent advancements in perioperative medical care. In cardiac surgery, only few ERAS protocols have been described in the past. At University Heart Center Hamburg, Germany, we invented an ERAS protocol for patients undergoing minimally invasive cardiac valve surgery. In this retrospective single center study, we aimed to describe the implementation of our ERAS program and to evaluate the results of the first 50 consecutive patients. Our ERAS protocol was developed according to a modified Kern cycle by an expert group, literature search, protocol creation and pilot implementation in the clinical practice. Data of the first 50 consecutive patients undergoing minimally invasive cardiac valve surgery were analysed retrospectively. The key features of our multidisciplinary ERAS protocol are physiotherapeutic prehabilitation, minimally invasive valve surgery techniques, modified cardiopulmonary bypass management, fast-track anaesthesia with on- table extubation and early mobilisation. A total of 50 consecutive patients (mean age of 51.9±11.9 years, mean STS score of 0.6±0.3) underwent minimally-invasive mitral or aortic valve surgery. The adherence to the ERAS protocol was high and neither protocol related complications nor in-hospital mortality occurred. 12% of the patients developed postoperative atrial fibrillation, postoperative delirium emerged in two patients and reintubation was required in one patient. Intensive care unit stay was 14.0±7.4 hours and total hospital stay 6.2±2.9 days. Our ERAS protocol is feasible and safe in minimally-invasive cardiac surgery setting and has a clear potential to improve patients outcome.