Extravascular Lung Water and Effect on Oxygenation Assessed by Lung Ultrasound in Adult Cardiac Surgery

Intraoperative Goal-Directed Perfusion in Cardiac Surgery with Cardiopulmonary Bypass: The Roles of Delivery Oxygen Index and Cardiac Index

PURPOSE

Goal-directed perfusion (GDP) refers to individualized goal-directed therapy using comprehensive monitoring and optimizing the delivery of oxygen during cardiopulmonary bypass (CPB). This study aims to determine whether the intraoperative GDP protocol method has better outcomes compared to conventional methods.

METHODS

We searched the PubMed, Central, and Scopus databases up to October 12, 2023. We primarily examined the GDP protocol in adult cardiac surgery, using CPB with oxygen delivery index (DO2I) and cardiac index (CI) as the main parameters.

RESULTS

In all, 1128 participants from seven studies were included in our analysis. The results showed significant differences in the duration of intensive care unit (ICU) stays (p = 0.01), with a mean difference of -0.33 (-0.59 to 0.07), and hospital length of stay (LOS) (p = 0.0002), with a mean difference of -0.84 (-1.29 to -0.39). There was also a notable reduction in postoperative complications (p <0.00001), odds ratio (OR) of 0.43 (0.32-0.60). However, there was no significant decrease in mortality rate (p = 0.54), OR of 0.77 (0.34-1.77).

CONCLUSION

Postoperative acute kidney injury and ICU and hospital LOS are significantly reduced when GDP protocols with indicators of flow management, oxygen delivery index, and CI are used in intraoperative cardiac surgery using CPB.

Difficult Respiratory Weaning after Cardiac Surgery: A Narrative Review

Respiratory weaning after cardiac surgery can be difficult or prolonged in up to 22.7% of patients. The inability to wean from a ventilator within the first 48 h after surgery is related to increased short- and long-term morbidity and mortality. Risk factors are mainly non-modifiable and include preoperative renal failure, New York Heart Association, and Canadian Cardiac Society classes as well as surgery and cardio-pulmonary bypass time. The positive effects of pressure ventilation on the cardiovascular system progressively fade during the progression of weaning, possibly leading to pulmonary oedema and failure of spontaneous breathing trials. To prevent this scenario, some parameters such as pulmonary artery occlusion pressure, echography-assessed diastolic function, brain-derived natriuretic peptide, and extravascular lung water can be monitored during weaning to early detect hemodynamic decompensation. Tracheostomy is considered for patients with difficult and prolonged weaning. In such cases, optimal patient selection, timing, and technique may be important to try to reduce morbidity and mortality in this high-risk population.

New onset atrial fibrillation during orthotopic liver transplantation induced by iced saline injection for transpulmonary thermodilution: a case report

Transpulmonary thermodilution is often used to measure extravascular lung water during liver transplantation. Here, the case of new onset atrial fibrillation during orthotopic liver transplantation, which may have been induced by iced saline injection for transpulmonary thermodilution measurement, is described. A 52-year-old male patient underwent orthotopic liver transplantation due to alcoholic cirrhosis combined with portal hypertension. During dissection of the recipient liver, transpulmonary thermodilution was performed. At 3 minutes following iced saline injected, atrial fibrillation occurred, the ventricular rate increased to more than 120 beats per min, and blood pressure dropped to 75/50 mmHg. Massive haemorrhage, inferior vena cava clamping, electrolyte disorder, acid-base balance disorder, and hypothermia were all ruled out, and iced saline injection was suspended. Hemodynamic stability was maintained with phenylephrine and lanatocide C (cedilanid), and chemical cardioversion was performed using amiodarone. During the reperfusion phase, transient hemodynamic instability was managed by norepinephrine. The neohepatic phase was uneventful. Atrial fibrillation lasted for 5 days and reversed to sinus rhythm automatically. The patient was hemodynamically stable during this period, and recovery was smooth with no thromboembolic events. In conclusion, atrial fibrillation may be induced by iced saline injection for transpulmonary thermodilution measurement during orthotopic liver transplantation.