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Groenewoud R, Gunning D, Fava C, Sharpe R, Valchanov K, Shayan H. Successful thrombolysis of early bioprosthetic mitral valve thrombosis following extracorporeal membrane oxygenation: Case report. Perfusion 2024; 39:640-642. [PMID: 36796035 DOI: 10.1177/02676591231157200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Introduction: Bioprosthetic mitral valve thrombosis (BPMVT) following post-operative extracorporeal membrane oxygenation (ECMO) is a rare complication with high mortality.Case Report: A 75-year-old man with a flail posterior mitral leaflet underwent a bioprosthetic mitral valve replacement and was subsequently placed on central veno-arterial high flow ECMO following intractable shock after protamine administration. He developed BPMVT over the following 48 hr, which did not resolve with 3 weeks of systemic heparin. He was then treated successfully with 3 days of continuous low dose (1 mg/hr) Tissue Plasminogen Activator (TPA). He suffered no bleeding consequences and had a complete cardiac and end-organ recovery.Discussion: Slow TPA infusion may be an acceptable treatment strategy for alleviating thrombotic burden from a bioprosthetic valve, even in the post-operative setting.
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Affiliation(s)
- Rosalind Groenewoud
- Undergraduate Medical Education, University of British Columbia, Vancouver, BC, Canada
| | - Derek Gunning
- Royal Columbian Hospital, New Westminster, BC, Canada
- Division of Cardiac Surgery, University of British Columbia, Vancouver, BC, Canada
- Division of Critical Care, University of British Columbia, Vancouver, BC, Canada
| | - Craig Fava
- Royal Columbian Hospital, New Westminster, BC, Canada
- Division of Critical Care, University of British Columbia, Vancouver, BC, Canada
| | - Rob Sharpe
- Royal Columbian Hospital, New Westminster, BC, Canada
- Division of Critical Care, University of British Columbia, Vancouver, BC, Canada
| | - Kamen Valchanov
- Royal Columbian Hospital, New Westminster, BC, Canada
- Department of Anesthesia, University of British Columbia, Vancouver, BC, Canada
- Department of Anaesthesia and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Hossein Shayan
- Royal Columbian Hospital, New Westminster, BC, Canada
- Division of Cardiac Surgery, University of British Columbia, Vancouver, BC, Canada
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2
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Chia AXF, Valchanov K, Ng C, Tsui S, Taghavi J, Vuylsteke A, Fowles JA, Jenkins DP. Perioperative extracorporeal membrane oxygenation support for pulmonary endarterectomy: A 17-year experience from the UK national cohort. J Heart Lung Transplant 2024; 43:241-250. [PMID: 37730188 DOI: 10.1016/j.healun.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 08/30/2023] [Accepted: 09/14/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Pulmonary endarterectomy (PEA) is the guideline-recommended treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, some patients develop severe cardiopulmonary compromise before surgery, intraoperatively, or early postoperatively. This may result from advanced CTEPH, reperfusion pulmonary edema, massive endobronchial bleeding, or right ventricular (RV) failure secondary to residual pulmonary hypertension. Conventional cardiorespiratory support is ineffective when these complications are severe. Since 2005, we used extracorporeal membrane oxygenation (ECMO) as a rescue therapy for this group. We review our experience with ECMO support in these patients. METHODS This study was a retrospective analysis of patients who received perioperative ECMO for PEA from a single national center from August 2005 to July 2022. Data were prospectively collected. RESULTS One hundred and ten patients (4.7%) had extreme cardiorespiratory compromise requiring perioperative ECMO. Nine were established on ECMO before PEA. Of those who received ECMO postoperatively, 39 were for refractory reperfusion lung injury, 20 for RV failure, 31 for endobronchial bleeding, and the remaining 11 were for "other" reasons, such as cardiopulmonary resuscitation following late tamponade and aspiration pneumonitis. Sixty-two (56.4%) were successfully weaned from ECMO. Fifty-seven patients left the hospital alive, giving a salvage rate of 51.8%. Distal disease (Jamieson Type III) and significant residual pulmonary hypertension were also predictors of mortality on ECMO support. Overall, 5- and 10-year survival in patients who were discharged alive following ECMO support was 73.9% (SE: 6.1%) and 58.2% (SE: 9.5%), respectively. CONCLUSIONS Perioperative ECMO support has an appropriate role as rescue therapy for this group. Over 50% survived to hospital discharge. These patients had satisfactory longer-term survival.
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Affiliation(s)
- Alicia X F Chia
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Kamen Valchanov
- Department of Anaesthesia, Singapore General Hospital, Singapore, Singapore
| | - Choo Ng
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Steven Tsui
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - John Taghavi
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Alain Vuylsteke
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Jo-Anne Fowles
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom.
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Yusuff H, Chawla S, Sato R, Dugar S, Bangash MN, Antonini MV, Shelley B, Valchanov K, Roscoe A, Scott J, Akhtar W, Rosenberg A, Dimarakis I, Khorsandi M, Zochios V. Mechanisms of Acute Right Ventricular Injury in Cardiothoracic Surgical and Critical Care Settings: Part 2. J Cardiothorac Vasc Anesth 2023; 37:2318-2326. [PMID: 37625918 DOI: 10.1053/j.jvca.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 07/05/2023] [Accepted: 07/17/2023] [Indexed: 08/27/2023]
Abstract
The right ventricle (RV) is intricately linked in the clinical presentation of critical illness; however, the basis of this is not well-understood and has not been studied as extensively as the left ventricle. There has been an increased awareness of the need to understand how the RV is affected in different critical illness states. In addition, the increased use of point-of-care echocardiography in the critical care setting has allowed for earlier identification and monitoring of the RV in a patient who is critically ill. The first part of this review describes and characterizes the RV in different perioperative states. This second part of the review discusses and analyzes the complex pathophysiologic relationships between the RV and different critical care states. There is a lack of a universal RV injury definition because it represents a range of abnormal RV biomechanics and phenotypes. The term "RV injury" (RVI) has been used to describe a spectrum of presentations, which includes diastolic dysfunction (early injury), when the RV retains the ability to compensate, to RV failure (late or advanced injury). Understanding the mechanisms leading to functional 'uncoupling' between the RV and the pulmonary circulation may enable perioperative physicians, intensivists, and researchers to identify clinical phenotypes of RVI. This, consequently, may provide the opportunity to test RV-centric hypotheses and potentially individualize therapies.
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Affiliation(s)
- Hakeem Yusuff
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom.
| | - Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH
| | - Mansoor N Bangash
- Liver Intensive Care Unit, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, United Kingdom; Birmingham Liver Failure Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Benjamin Shelley
- Department of Cardiothoracic Anesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, United Kingdom; Anesthesia, Perioperative Medicine and Critical Care research group, University of Glasgow, Glasgow, United Kingdom
| | - Kamen Valchanov
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Outram Road, Singapore
| | - Andrew Roscoe
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Outram Road, Singapore; Department of Anesthesiology, Singapore General Hospital, National Heart Centre Singapore, Singapore
| | - Jeffrey Scott
- Jackson Health System / Miami Transplant Institute, Miami, FL
| | - Waqas Akhtar
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Alex Rosenberg
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Ioannis Dimarakis
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Vasileios Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
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4
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Zochios V, Shelley B, Antonini MV, Chawla S, Sato R, Dugar S, Valchanov K, Roscoe A, Scott J, Bangash MN, Akhtar W, Rosenberg A, Dimarakis I, Khorsandi M, Yusuff H. Mechanisms of Acute Right Ventricular Injury in Cardiothoracic Surgical and Critical Care Settings: Part 1. J Cardiothorac Vasc Anesth 2023; 37:2073-2086. [PMID: 37393133 DOI: 10.1053/j.jvca.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/21/2023] [Accepted: 06/07/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Vasileios Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.
| | - Benjamin Shelley
- Department of Cardiothoracic Anesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, United Kingdom; Anesthesia, Perioperative Medicine and Critical Care research group, University of Glasgow, Glasgow, United Kingdom
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH
| | - Kamen Valchanov
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Andrew Roscoe
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Singapore; Department of Anesthesiology, Singapore General Hospital, National Heart Center, Singapore
| | - Jeffrey Scott
- Jackson Health System, Miami Transplant Institute, Miami, FL
| | - Mansoor N Bangash
- Liver Intensive Care Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Birmingham Liver Failure Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom
| | - Waqas Akhtar
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Alex Rosenberg
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Ioannis Dimarakis
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Hakeem Yusuff
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
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Ruiz J, Foglia J, Valchanov K, Gill N. A CASE OF INTRA-OPERATIVE ANAPHYLAXIS TO LATEX IN A PULMONARY ARTERY CATHETER. Ann Allergy Asthma Immunol 2022. [DOI: 10.1016/j.anai.2022.08.777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Long E, Ruiz JC, Foglia J, Valchanov K, Meikle A. Recognition, treatment, and prevention of perioperative anaphylaxis: a narrative review. AIMSMEDS 2022. [DOI: 10.3934/medsci.2022005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
<abstract>
<p>Perioperative anaphylaxis events are allergic reactions which occur in the perioperative period when patients are exposed to a multitude of agents, received anesthesia, and undergo a procedure. These reactions are rare and can be life-threatening, with the common signs being hypotension, hypoxia, elevated airway pressures and urticaria. Perioperative anaphylaxis can be mediated by immunoglobulin E (IgE) or non-IgE mechanisms. Globally, the incidence of reactions and frequency of specific triggers varies considerably. Perioperative anaphylaxis events often result in discontinuation of surgery, extended hospital stays, unanticipated intensive care admissions and increased morbidity and mortality. Common causative agents include neuromuscular blocking agents (NMBA's), beta-lactam antibiotics, chlorhexidine, and latex. The primary treatment of perioperative anaphylaxis is removal of the offending agent, epinephrine, and adequate fluid resuscitation. Post-operative workup involves serial serum tryptase measurements, skin testing, in-vitro testing and challenges to determine the culprit agent. Several countries including the UK, Spain, France, Australia, and New Zealand have established guidelines, reporting systems, and specialized clinics dedicated to perioperative hypersensitivity reactions. Future efforts should address diagnostic challenges as well as increasing awareness of other perioperative anaphylaxis triggers. This narrative review will provide an overview of the epidemiology, diagnosis, management, and prevention of perioperative anaphylaxis events.</p>
</abstract>
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7
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Alvarez-Villegas D, Giménez-Milà M, Sbraga F, Camprubí I, Gil A, Valchanov K, Shayan H, Castillo J, Weiner MM. Dealing With the Right Side: Carcinoid Heart Disease. J Cardiothorac Vasc Anesth 2021; 36:2793-2802. [PMID: 34863651 DOI: 10.1053/j.jvca.2021.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 11/11/2022]
Affiliation(s)
- David Alvarez-Villegas
- Department of Anesthesia and Critical Care,Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Marc Giménez-Milà
- Department of Anesthesia and Critical Care,Hospital Clínic Barcelona, Universitat de Barcelona, Barcelona, Spain.
| | - Fabrizio Sbraga
- Department of Cardiovascular Surgery and Transplantation, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Immaculada Camprubí
- Department of Anesthesia and Critical Care,Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Albert Gil
- Department of Anesthesia and Critical Care,Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Kamen Valchanov
- Department of Anesthesia,Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Hossain Shayan
- Department of Cardiac Surgery, Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Javier Castillo
- Heart & Lung Institute, Bayamon Medical Center, Bayamon, Puerto Rico
| | - Menachem M Weiner
- Department of Anesthesiology, The Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY
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8
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Protopapas AD, Valchanov K, Catarino P, Zochios V. Neuroprotection and the Aorta: One System, One Artery, One Expectation, One Team. J Cardiothorac Vasc Anesth 2020; 35:1189-1191. [PMID: 33431269 DOI: 10.1053/j.jvca.2020.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 11/11/2022]
Affiliation(s)
| | - Kamen Valchanov
- Royal Columbian Hospital, Vancouver, British Columbia, Canada
| | - Pedro Catarino
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Vasileios Zochios
- Department of Critical Care Medicine, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK; Birmingham Acute Care Research, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK.
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9
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Valchanov K, Krishnan U, Hoole SP, Davies WR, Pettit S, Jones N, Parmar J, Catarino P, Osman M, Berman M. COVID-19 patient with coronary thrombosis supported with ECMO and Impella 5.0 ventricular assist device: a case report. Eur Heart J Case Rep 2020; 4:1-6. [PMID: 33442588 PMCID: PMC7717226 DOI: 10.1093/ehjcr/ytaa342] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/02/2020] [Accepted: 09/02/2020] [Indexed: 12/26/2022]
Abstract
Background COVID-19 can present with cardiovascular complications. Case summary We present a case report of a 43-year-old previously fit patient who suffered from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection with thrombosis of the coronary arteries causing acute myocardial infarction. These were treated with coronary stenting during which the patient suffered cardiac arrest. He was supported with automated chest compressions followed by peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO). No immediate recovery of the myocardial function was observed and, after insufficient venting of the left ventricle was diagnosed, an Impella 5 pump was implanted. The cardiovascular function recovered sufficiently and ECMO was explanted and inotropic infusions discontinued. Due to SARS-CoV-2 pulmonary infection, hypoxia became resistant to conventional mechanical ventilation and the patient was nursed prone overnight. After initial recovery of respiratory function, the patient received a tracheostomy and was allowed to wake up. Following a short period of agitation his neurological function recovered completely. During the third week of recovery, progressive multisystem dysfunction, possibly related to COVID-19, developed into multiorgan failure, and the patient died. Discussion We believe that this is the first case report of coronary thrombosis related to COVID-19. Despite the negative outcome in this patient, we suggest that complex patients may in the future benefit from advanced cardiovascular support, and may even be nursed safely in the prone position with Impella devices.
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Affiliation(s)
| | | | | | | | | | | | - Jas Parmar
- Royal Papworth Hospital, Cambridge CB2 0AY, UK
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10
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Giménez-Milà M, Videla S, Pallarés N, Sabaté A, Parmar J, Catarino P, Tosh W, Rafiq MU, Nalpon J, Valchanov K. Impact of surgical technique and analgesia on clinical outcomes after lung transplantation: A STROBE-compliant cohort study. Medicine (Baltimore) 2020; 99:e22427. [PMID: 33181640 PMCID: PMC7668481 DOI: 10.1097/md.0000000000022427] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
There is paucity of data on the impact of surgical incision and analgesia on relevant outcomes.A retrospective STROBE-compliant cohort study was performed between July 2007 and August 2017 of patients undergoing lung transplantation. Gender, age, indication for lung transplantation, and the 3 types of surgical access (Thoracotomy (T), Sternotomy (S), and Clamshell (C)) were used, as well as 2 analgesic techniques: epidural and intravenous opioids. Outcome variables were: pain scores; postoperative hemorrhage in the first 24 hours, duration of mechanical ventilation, and length of stay at intensive care unit (ICU).Three hundred forty-one patients were identified. Thoracotomy was associated with higher pain scores than Sternotomy (OR 1.66, 95% CI: 1.01; 2.74, P: .045) and no differences were found between Clamshell and Sternotomy incision. The median blood loss was 800 mL [interquartile range (IQR): 500; 1238], thoracotomy patients had 500 mL [325; 818] (P < .001). Median durations of mechanical ventilation in Thoracotomy, Sternotomy, and Clamshell groups were 19 [11; 37] hours, 34 [IQR 16; 57.5] hours, and 27 [IQR 15; 50.5] hours respectively. Thoracotomy group were discharged earlier from ICU (P < .001).Thoracotomy access produces less postoperative hemorrhage, duration of mechanical ventilation, and lower length of stay in ICU, but higher pain scores and need for epidural analgesia.
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Affiliation(s)
- Marc Giménez-Milà
- Department of Anaesthesia and Critical Care, Bellvitge University Hospital, Bellvitge Biomedical
| | - Sebastián Videla
- Clinical Research Support Unit, Clinical Pharmacology Department, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, L’Hospitalet de Llobregat
| | - Natalia Pallarés
- Biostatistics Unit, Bellvitge Biomedical Research Institute, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Antoni Sabaté
- Department of Anaesthesia and Critical Care, Bellvitge University Hospital, Bellvitge Biomedical
| | | | - Pedro Catarino
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge
| | - Will Tosh
- Department of Anaesthesia and Intensive Care, University Hospital Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham
| | | | | | - Kamen Valchanov
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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11
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Rafiq MU, Valchanov K, Vuylsteke A, Taghavi FJ, Iyer SB, Sudarshan CD, Fowles JA, Anderson S, Govender P, Holmes M, White A, Mishra A, Mwaura L, Jenkins DP. Regional extracorporeal membrane oxygenation retrieval service during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic: an interdisciplinary team approach to maintain service provision despite increased demand. Eur J Cardiothorac Surg 2020; 58:875-880. [PMID: 32964930 PMCID: PMC7543471 DOI: 10.1093/ejcts/ezaa327] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/17/2020] [Accepted: 07/28/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Coronavirus disease 2019 is a new contagious disease that has spread rapidly across the world. It is associated with high mortality in those who develop respiratory complications and require admission to intensive care. Extracorporeal membrane oxygenation (ECMO) is a supportive therapy option for selected severely ill patients who deteriorate despite the best supportive care. During the coronavirus disease 2019 pandemic, extra demand led to staff reorganization; hence, cardiac surgery consultants joined the ECMO retrieval team. This article describes how we increased service provisions to adapt to the changes in activity and staffing. METHODS The data were collected from 16 March 2020 to 8 May 2020. The patients were referred through a dedicated Web-based referral portal to cope with increasing demand. The retrieval team attended the referring hospital, reviewed the patients and made the final decision to proceed with ECMO. RESULTS We reported 41 ECMO retrieval runs during this study period. Apart from staffing changes, other retrieval protocols were maintained. The preferred cannulation method for veno-venous ECMO was drainage via the femoral vein and return to the right internal jugular vein. There were no complications reported during cannulation or transport. CONCLUSIONS Staff reorganization in a crisis is of paramount importance. For those with precise transferrable skills, experience can be gained quickly with appropriate supervision. Therefore, the team members were selected based on skill mix rather than on roles that are more traditional. We have demonstrated that an ECMO retrieval service can be reorganized swiftly and successfully to cope with the sudden increase in demand by spending cardiac surgeons services to supplement the anaesthetic-intensivist roles.
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Affiliation(s)
- Muhammad U Rafiq
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Kamen Valchanov
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Alain Vuylsteke
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Fouad J Taghavi
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Swetha B Iyer
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Catherine D Sudarshan
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Jo-Anne Fowles
- Department of Nursing and Critical Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Simon Anderson
- Cambridge Perfusion Services, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Pooveshni Govender
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Miranda Holmes
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Alexander White
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Abhi Mishra
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Lucy Mwaura
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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12
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Valchanov K. Perioperative management of patients with undergoing mechanical circulatory support. Ann Transl Med 2020; 8:826. [PMID: 32793671 PMCID: PMC7396246 DOI: 10.21037/atm-2020-pm-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Kamen Valchanov
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK.
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Valchanov K, Salaunkey K, Parmar J. Percutaneous Dilatational Tracheostomy in Coronavirus Disease 2019 Extracorporeal Membrane Oxygenation Patients: A Case Series. J Cardiothorac Vasc Anesth 2020; 35:348-350. [PMID: 32620486 PMCID: PMC7289737 DOI: 10.1053/j.jvca.2020.06.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 06/05/2020] [Indexed: 01/30/2023]
Affiliation(s)
- Kamen Valchanov
- Department of Anesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Kiran Salaunkey
- Department of Anesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Jas Parmar
- Department of Anesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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14
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Pieterse J, Valchanov K, Abu-Omar Y, Falter F. Thrombotic risk in central venoarterial extracorporeal membrane oxygenation post cardiac surgery. Perfusion 2020; 36:50-56. [DOI: 10.1177/0267659120922016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Post-cardiotomy cardiogenic shock is an accepted indication for venoarterial extracorporeal membrane oxygenation. The true incidence and risk factors for the development of thrombosis in this setting remain unclear. Methods: Patients supported with central venoarterial extracorporeal membrane oxygenation due to ventricular dysfunction precluding weaning from cardiopulmonary bypass were retrospectively identified. Electronic records from a single institution spanning a 4-year period from January 2015 to December 2018 were interrogated to assess the incidence of thrombosis. The relationship to exposures including intracardiac stasis and procoagulant usage was explored. Results: Twenty-four patients met the inclusion criteria and six suffered major intracardiac thrombosis. All cases of thrombosis occurred early, and none survived to hospital discharge. The lack of left ventricular ejection conferred a 46% risk of developing thrombosis compared to 0% if ejection was maintained (p = 0.0093). Aprotinin use was also associated with thrombus formation (p = 0.035). There were no significant differences between numbers of patients receiving other procoagulants when grouped by thrombosis versus no thrombosis. Conclusion: Stasis is the predominant risk factor for intracardiac thrombosis. This occurs rapidly and the outcome is poor. As a result, we suggest early left ventricular decompression. Conventional management of post-bypass coagulopathy seems safe if the aortic valve is opening.
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Affiliation(s)
- John Pieterse
- Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Kamen Valchanov
- Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Yasir Abu-Omar
- Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Florian Falter
- Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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Patterson CM, Valchanov K, Barker A, Goddard M, Yang H, Butchart AG. Severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation support: a consequence of vaping. ERJ Open Res 2020; 6:00013-2020. [PMID: 32440517 PMCID: PMC7231114 DOI: 10.1183/23120541.00013-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/17/2020] [Indexed: 01/16/2023] Open
Abstract
Since the emergence of electronic cigarette products on the retail market just over a decade ago, there has been an exponential rise in their use, particularly amongst young adults [1] and the global market is now estimated by Euromonitor International to be worth $19.3 billion, up from $6.9 billion 5 years ago [1]. Despite being marketed as a safer alternative to traditional cigarettes, “vaping” generates aerosols containing a heterogenous mix of potentially harmful substances and pulmonary disease related to vaping has been identified in recent case clusters [3–5]. In the past decade, vaping has become more prevalent globally. Since mid-2019, reports have linked the use of vaping devices to lung injury (EVALI). This is the first reported adult case outside the USA to require ECMO for a severe vaping complication.https://bit.ly/39hf2ZY
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Affiliation(s)
| | - Kamen Valchanov
- Royal Papworth Hospital NHS Foundation Trust, Cambridge , UK
| | - Allanah Barker
- Royal Papworth Hospital NHS Foundation Trust, Cambridge , UK
| | - Martin Goddard
- Royal Papworth Hospital NHS Foundation Trust, Cambridge , UK
| | - Huina Yang
- Royal Papworth Hospital NHS Foundation Trust, Cambridge , UK
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16
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Tan Z, Nalpon J, Valchanov K. Case Series of Left Stellate Ganglion Blocks for Refractory Angina Pectoris: 14 Years Later and Still Efficacious. J Pain Symptom Manage 2019; 58:e11-e14. [PMID: 31181247 DOI: 10.1016/j.jpainsymman.2019.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 11/23/2022]
Affiliation(s)
- Zihui Tan
- Department of Anaesthesia and Intensive Care, Singapore General Hospital, Singapore, Singapore
| | - Jacinta Nalpon
- Department of Nursing, Royal Papworth Hospital, Cambridge, UK
| | - Kamen Valchanov
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK.
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Tan Z, Ng CY, Jenkins D, Barrow L, Valchanov K. Deprescribing practices for anticonvulsants after benign seizures secondary to high-dose tranexamic acid in a single, large UK cardiothoracic centre. Eur J Hosp Pharm 2019; 27:337-340. [PMID: 33097616 DOI: 10.1136/ejhpharm-2018-001844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/28/2019] [Accepted: 03/05/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE High-dose tranexamic acid (TXA) can cause seizures in patients who have undergone pulmonary endarterectomy (PTE). Seizures secondary to TXA will resolve once the drug is excreted from the body, and the patients do not have to be on long-term anticonvulsants. The aim of the study is to find out if medication review in the hospital has led to deprescribing of anticonvulsants for TXA-associated seizures on discharge from the critical care unit (CCU) and hospital. METHODS This is a single-centre retrospective study conducted at a tertiary cardiothoracic hospital between 2012 and 2017. The inclusion criteria consisted of all adult patients who have undergone PTE surgery. Patients who were started on anticonvulsants preoperatively or postoperatively for seizures secondary to organic causes were excluded. RESULTS A total of 933 patients underwent PTE from January 2012 to August 2017. 25 patients had TXA-related seizures postoperatively and were started on anticonvulsant therapy, giving an incidence of 2.7%. 15 patients were discharged from the CCU without anticonvulsants. A further three patients had their anticonvulsants deprescribed in the ward before being discharged from the hospital. CONCLUSION Deprescribing of anticonvulsants after benign seizures secondary to high-dose TXA is facilitated by verbal and written handover, which can be improved in our hospital. A detailed handover summary, as well as a discharge letter with clearly defined instructions for drug review, is needed to make deprescribing a more robust process.
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Affiliation(s)
- Zihui Tan
- Anaesthetics and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Choo Yen Ng
- Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - David Jenkins
- Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Linda Barrow
- Pharmacy, Royal Papworth Hospital, Cambridge, UK
| | - Kamen Valchanov
- Anaesthetics and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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18
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Oscier C, Patvardhan C, Falter F, Tosh W, Dunning J, Catarino P, DeSilva R, Besser M, Valchanov K. Three consecutive cases of fatal intraoperative intracardiac thrombosis associated with the initiation of venoarterial extracorporeal membrane oxygenation in the presence of aprotinin. Perfusion 2019; 34:417-421. [PMID: 30712494 DOI: 10.1177/0267659119826822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Central venoarterial extracorporeal membrane oxygenation has been used since the 1970s to support patients with cardiogenic shock following cardiac surgery. Despite this, in-hospital mortality is still high, and although rare, thrombus within the cardiac chambers or within the extracorporeal membrane oxygenation circuit is often fatal. Aprotinin is an antifibrinolytic available in Europe and Canada, though not currently in the United States. Due to historical safety concerns, use of aprotinin is generally limited and is commonly reserved for patients with the highest bleeding risk. Given the limited availability of aprotinin over the last decade, it is not surprising to find a complete absence of literature describing the use of venoarterial extracorporeal membrane oxygenation in the presence of aprotinin. We present three consecutive cases of rapid fatal intraoperative intracardiac thrombosis associated with post-cardiotomy central venoarterial extracorporeal membrane oxygenation in patients receiving aprotinin.
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Affiliation(s)
- Chris Oscier
- 1 Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Chinmay Patvardhan
- 1 Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Florian Falter
- 1 Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Will Tosh
- 1 Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - John Dunning
- 2 Department of Cardiac Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Pedro Catarino
- 2 Department of Cardiac Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Ravi DeSilva
- 2 Department of Cardiac Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Martin Besser
- 3 Department of Haematology, Royal Papworth Hospital, Cambridge, UK
| | - Kamen Valchanov
- 1 Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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Valchanov K, Falter F, George S, Burt C, Roscoe A, Ng C, Besser M, Nasser S. Three Cases of Anaphylaxis to Protamine: Management of Anticoagulation Reversal. J Cardiothorac Vasc Anesth 2019; 33:482-486. [DOI: 10.1053/j.jvca.2018.03.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Indexed: 01/12/2023]
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20
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Nair SK, Sudarshan CD, Thorpe BS, Singh J, Pillay T, Catarino P, Valchanov K, Codispoti M, Dunning J, Abu-Omar Y, Moorjani N, Matthews C, Freeman CJ, Fox-Rushby JA, Sharples LD. Mini-Stern Trial: A randomized trial comparing mini-sternotomy to full median sternotomy for aortic valve replacement. J Thorac Cardiovasc Surg 2018; 156:2124-2132.e31. [DOI: 10.1016/j.jtcvs.2018.05.057] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 04/23/2018] [Accepted: 05/15/2018] [Indexed: 11/24/2022]
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21
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Tan Z, Valchanov K, Klein A. Complications in aortic surgery: are CSF drains to be blamed? Comment on Br J Anaesth 2018; 120: 904-913. Br J Anaesth 2018; 121:987. [PMID: 30236274 DOI: 10.1016/j.bja.2018.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 07/13/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022] Open
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22
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Oscier C, Tosh W, Patvardhan C, Falter F, Besser M, Desilva R, Valchanov K. 3 consecutive cases of fatal intracardiac thrombosis associated with VA ECMO and aprotinin. J Cardiothorac Vasc Anesth 2018. [DOI: 10.1053/j.jvca.2018.08.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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23
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Rubino A, Costanzo D, Stanszus D, Valchanov K, Jenkins D, Sertic F, Fowles JA, Vuylsteke A. Central Veno-Arterial Extracorporeal Membrane Oxygenation (C-VA-ECMO) After Cardiothoracic Surgery: A Single-Center Experience. J Cardiothorac Vasc Anesth 2018; 32:1169-1174. [DOI: 10.1053/j.jvca.2017.12.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Indexed: 12/31/2022]
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24
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Aneman A, Brechot N, Brodie D, Colreavy F, Fraser J, Gomersall C, McCanny P, Moller-Sorensen PH, Takala J, Valchanov K, Vallely M. Advances in critical care management of patients undergoing cardiac surgery. Intensive Care Med 2018; 44:799-810. [DOI: 10.1007/s00134-018-5182-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/12/2018] [Indexed: 12/23/2022]
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25
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Valchanov K, Sturgess J. Complications: an anaesthetist's rather than a surgeon's notes (with apologies to Atul Gwande). Anaesthesia 2018; 73 Suppl 1:3-6. [PMID: 29313913 DOI: 10.1111/anae.14134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 12/31/2022]
Affiliation(s)
- K Valchanov
- Department of Anaesthesia, Papworth Hospital, Cambridge, UK
| | - J Sturgess
- Department of Anaesthesia, West Suffolk Hospital, Suffolk, UK
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26
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Messer S, Page A, Axell R, Berman M, Hernández-Sánchez J, Colah S, Parizkova B, Valchanov K, Dunning J, Pavlushkov E, Balasubramanian SK, Parameshwar J, Omar YA, Goddard M, Pettit S, Lewis C, Kydd A, Jenkins D, Watson CJ, Sudarshan C, Catarino P, Findlay M, Ali A, Tsui S, Large SR. Outcome after heart transplantation from donation after circulatory-determined death donors. J Heart Lung Transplant 2017; 36:1311-1318. [DOI: 10.1016/j.healun.2017.10.021] [Citation(s) in RCA: 162] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 10/20/2017] [Accepted: 10/21/2017] [Indexed: 11/26/2022] Open
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27
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Prabhu M, Valchanov K. Pre-anaesthetic evaluation of the patient with end-stage lung disease. Best Pract Res Clin Anaesthesiol 2017; 31:249-260. [PMID: 29110797 DOI: 10.1016/j.bpa.2017.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/10/2017] [Indexed: 11/29/2022]
Abstract
Lung transplantation is a viable alternative for end-stage lung diseases, which offers good quality of life and survival outcomes for recipients. The aims of pre-assessment for potential lung transplant recipients are to assess fitness for surgery, optimise co-morbidities, commence interventions or investigations, weigh risk-benefit ratio, plan appropriate analgesia and obtain informed consent. The assessment information is gathered from the medical record, patient interview, physical examination and pre-operative tests. A comprehensive workup includes cardiopulmonary evaluation, haematological, biochemical, microbiological and immunological investigations. Most of the evidence regarding lung transplantation is gleaned from retrospective data from single, multi-centre or multinational registries. The lack of good quality evidence means that the guidelines are based on expert consensus.
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Affiliation(s)
- Mahesh Prabhu
- Cardiothoracic Anaesthesia and Intensive Care, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne NE7 7DN, UK.
| | - Kamen Valchanov
- Anaesthesia and Intensive Care, Papworth Hospital, Cambridge CB23 3RE, UK.
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28
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Blaudszun G, Vuylsteke A, Gerrard C, Zochios V, Jenkins D, Valchanov K. Patients Discharged From the Intensive Care Unit on a Dopamine Infusion-A Retrospective, Observational Study. J Cardiothorac Vasc Anesth 2017; 31:1676-1680. [PMID: 28843607 DOI: 10.1053/j.jvca.2017.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess the safety of discharging cardiac surgical patients from the intensive care unit (ICU) to wards while the patients are still receiving a dopamine infusion. DESIGN Retrospective, observational study. SETTING Cardiothoracic ICU of a tertiary academic hospital in the United Kingdom. PARTICIPANTS The study comprised all cardiac surgical patients older than 18 years and admitted between September 1, 2015 and September 16, 2016 to the ICU and subsequently discharged to a surgical ward. Patients were divided in the following 2 groups: a dopamine group with patients discharged with a dopamine infusion and a control group with patients discharged without any dopamine infusion. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The hospital mortality rate was comparable in both groups (0.7% in the dopamine group v 0.2% in the control group [p = 0.11]), despite that the median logistic EuroSCORE was significantly higher in the dopamine group (7.0 v 3.8 [p < 0.01]). The ICU readmission rate was higher in the dopamine group (6.6% v 2.4%; p < 0.01). ICU and hospital lengths of stay were longer in the dopamine group (1.7 v 0.9 days [p < 0.01] and 11.4 v 8.0 days [p < 0.01], respectively). CONCLUSIONS Despite a higher ICU readmission rate, ICU discharge of patients on dopamine infusion was not associated with increased mortality.
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Affiliation(s)
- Grégoire Blaudszun
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK.
| | - Alain Vuylsteke
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Caroline Gerrard
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Vasileios Zochios
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham College of Medical and Dental Sciences, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - David Jenkins
- Department of Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Kamen Valchanov
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK
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29
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Kruit N, Valchanov K, Blaudszun G, Fowles JA, Vuylsteke A. Bleeding Complications Associated With Percutaneous Tracheostomy Insertion in Patients Supported With Venovenous Extracorporeal Membrane Oxygen Support: A 10-Year Institutional Experience. J Cardiothorac Vasc Anesth 2017; 32:1162-1166. [PMID: 29129346 DOI: 10.1053/j.jvca.2017.08.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To evaluate the bleeding complications associated with percutaneous tracheostomy while a patient is receiving venovenous extracorporeal membrane oxygen (VV ECMO) support. DESIGN Retrospective, observational analysis. SETTING Single-center, tertiary, academic institution. PARTICIPANTS All consecutive patients on VV ECMO over a 10 year-period undergoing percutaneous tracheostomy. INTERVENTIONS Percutaneous tracheostomy. MEASUREMENTS AND MAIN RESULTS Fifty percutaneous tracheostomies were performed in patients requiring VV ECMO support over the 10-year period. The authors observed a 40% incidence of bleeding, with 32% of these incidences characterized as minor (self-limiting, localized stomal ooze) and 8% characterized as significant (necessitating surgical control and frequent packing or accompanied by a decrease in hemoglobin >20%). CONCLUSIONS Bleeding is associated with percutaneous tracheostomy and is self-limiting in the majority of patients.
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Affiliation(s)
- Natalie Kruit
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK.
| | - Kamen Valchanov
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Gregoire Blaudszun
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Jo-Anne Fowles
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Alain Vuylsteke
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK
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30
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31
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Messer S, Page A, Axell R, Colah S, Hernandez-Sanchez J, Parizkova B, Valchanov K, Dunning J, Parameshwar J, Lewis C, Omar Y, Pettit S, Kydd A, Jenkins D, Sudarshan C, Catarino P, Berman M, Findlay M, Ali A, Tsui S, Large S. Excellent Early Outcomes Following Heart Transplantation from Circulatory Dead Donors. J Heart Lung Transplant 2017. [DOI: 10.1016/j.healun.2017.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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32
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Abstract
The article reviews cannulation strategy for different modes of extracorporeal life support. Technical aspects, pitfalls and complications are discussed for central and peripheral extracorporeal membrane oxygenation (VA, VV, VAV, VVA), biventricular assist device support and extracorporeal CO2 removal.
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Affiliation(s)
| | - Marius Berman
- Papworth Hospital, Papworth Everard, Cambridge, CB23 3RE, UK
| | - Kamen Valchanov
- Papworth Hospital, Papworth Everard, Cambridge, CB23 3RE, UK
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33
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Abdelaziz MM, Fowles J, Vulysteke A, Valchanov K, Sulankey K, Parmar J. P197 Medium term impacts of ecmo on adult survivors. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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34
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Blaskovics I, Valchanov K. Anaesthesia for patients with arrhythmogenic right ventricular dysplasia. World J Anesthesiol 2016; 5:44-53. [DOI: 10.5313/wja.v5.i3.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 09/14/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023] Open
Abstract
Arrhythmogenic right ventricular dysplasia (ARVD) is an inherited heart muscle disease. Myocyte apoptosis and fibro-fatty scar tissue predisposes patients to malignant ventricular arrhythmias. Patients may present to variety of surgical procedures with diagnosed ARVD. Surgical insult, catecholamine surge and physiological disturbance can be hazardous on the vulnerable myocardium and may result in life-threatening ventricular tachycardia or sudden cardiac death in the perioperative period. Anaesthetists have particular role in perioperative management of this patient population, meticulous perioperative planning, close haemodynamic monitoring and maintenance of physiological stability throughout helps to avoid devastating perioperative loss.
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35
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Messer SJ, Axell RG, Colah S, White PA, Ryan M, Page AA, Parizkova B, Valchanov K, White CW, Freed DH, Ashley E, Dunning J, Goddard M, Parameshwar J, Watson CJ, Krieg T, Ali A, Tsui S, Large SR. Functional assessment and transplantation of the donor heart after circulatory death. J Heart Lung Transplant 2016; 35:1443-1452. [PMID: 27916176 DOI: 10.1016/j.healun.2016.07.004] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 06/06/2016] [Accepted: 07/13/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND After a severe shortage of brain-dead donors, the demand for heart transplantation has never been greater. In an attempt to increase organ supply, abdominal and lung transplant programs have turned to the donation after circulatory-determined death (DCD) donor. However, because heart function cannot be assessed after circulatory death, DCD heart transplantation was deemed high risk and never adopted routinely. We report a novel method of functional assessment of the DCD heart resulting in a successful clinical program. METHODS Normothermic regional perfusion (NRP) was used to restore function to the arrested DCD heart within the donor after exclusion of the cerebral circulation. After weaning from support, DCD hearts underwent functional assessment with cardiac-output studies, echocardiography, and pressure-volume loops. In the feasibility phase, hearts were transported perfused before evaluation of function in modified working mode extracorporeally. After the establishment of a reliable assessment technique, hearts with demonstrable good function were then selected for clinical transplantation. RESULTS NRP was instituted in 13 adult DCD donors, median age of 33 years (interquartile range [IQR], 28-38 years), after a median ischemic time from withdrawal to perfusion of 24 minutes (IQR, 21-29; range, 17-146 minutes). Two of 4 hearts in the feasibility phase were unsuitable for transplantation after functional assessment. Nine DCD hearts were transplanted in the clinical phase, with 100% survival. The median intensive care duration was 5 days (IQR, 4-5 days), with 2 patients requiring mechanical support. There were no episodes of rejection (total, 1,436 patient-days; range, 48-297). During the same period, we performed 20 standard heart transplants using brain-dead donors. CONCLUSIONS NRP allows rapid reperfusion and functional assessment of the DCD donor heart, ensuring only viable hearts are selected for transplantation. This technique minimizes the risk of primary graft dysfunction and maximizes confidence in DCD heart transplantation, realizing a 45% increase in our heart transplant activity.
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Affiliation(s)
- Simon J Messer
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Richard G Axell
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Simon Colah
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Paul A White
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Marian Ryan
- Eastern Region Specialist Nurses in Organ Donation, NHS Blood and Transplant, Cambridge, United Kingdom
| | - Aravinda A Page
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Barbora Parizkova
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Kamen Valchanov
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Christopher W White
- Division of Cardiac Surgery, University of Alberta Hospital, Manankowiski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Darren H Freed
- Division of Cardiac Surgery, University of Alberta Hospital, Manankowiski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Euan Ashley
- Falk Cardiovascular Research Center, Stanford University School of Medicine, Palo Alto, California
| | - John Dunning
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Martin Goddard
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Jayan Parameshwar
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Christopher J Watson
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Thomas Krieg
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Ayyaz Ali
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Steven Tsui
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Stephen R Large
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom.
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Messer S, Axell R, Colah S, White P, Page A, Parizkova B, Valchanov K, Dunning J, Parameshwar J, Ali A, Tsui S, Large S. Functional Assessment of the Donor Heart Following Circulatory Death and Clinical Transplantation. J Heart Lung Transplant 2016. [DOI: 10.1016/j.healun.2016.01.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Giménez-Milà M, Videla S, Jenkins D, Klein AA, Gerrard C, Nalpon J, Valchanov K. Acute Pain and Analgesic Requirements After Pulmonary Endarterectomy With Deep Hypothermic Circulatory Arrest. J Cardiothorac Vasc Anesth 2015; 30:993-6. [PMID: 26948465 DOI: 10.1053/j.jvca.2015.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To assess postoperative pain intensity and the analgesic requirements in the postoperative period in patients undergoing sternotomy for pulmonary endarterectomy involving deep hypothermic circulatory arrest. DESIGN Retrospective cohort study. SETTING Single-center hospital study. PARTICIPANTS Patients 18 years and older undergoing sternotomy for cardiac surgery between August 2012 and August 2014. INTERVENTIONS No modification to usual clinical practice. MEASUREMENTS AND MAIN RESULTS Intraoperative opioid and steroid administration, referral to the chronic pain unit, intensive care unit pain scores, and analgesic administration in the first 48 hours after the admission to the intensive care unit were recorded. Postoperative pain was evaluated by means of a categoric verbal scale from no pain (0) to severe pain (3); this is the routine analgesic scale used in the authors' intensive care unit. A total of 200 consecutive patients undergoing pulmonary endarterectomy (PEA group) were included in the study. No patient in the PEA group received morphine during surgery. The mean (standard deviation) postoperative pain intensity score at 24 hours was 0.30 (0.54) in the PEA group. Postoperative morphine was administered in 39% of patients. No PEA patient was referred to the chronic pain unit after hospital discharge. CONCLUSION The total analgesic requirements and pain score of patients undergoing sternotomy for pulmonary endarterectomy with deep hypothermic circulatory arrest seemed to be low.
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Affiliation(s)
- Marc Giménez-Milà
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, United Kingdom;.
| | - Sebastian Videla
- Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Catalonia, Spain
| | - David Jenkins
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, United Kingdom
| | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, United Kingdom
| | - Caroline Gerrard
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, United Kingdom
| | - Jacinta Nalpon
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, United Kingdom
| | - Kamen Valchanov
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, United Kingdom
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Zochios V, Protopapas AD, Valchanov K. Stridor in adult patients presenting from the community: An alarming clinical sign. J Intensive Care Soc 2015; 16:272-273. [PMID: 28979428 DOI: 10.1177/1751143714568773] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Parhar K, Parizkova B, Jones N, Valchanov K, Fowles JA, Besser M, Telfer P, Kaya B, Vuylsteke A, Rubino A. Extracorporeal membrane oxygenation for the treatment of adult sickle cell acute chest syndrome. Perfusion 2015; 31:262-5. [DOI: 10.1177/0267659115593172] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Sickle cell disease (SCD) is a hereditary haemoglobinopathy that results in polymerization of haemoglobin molecules and subsequent vaso-occlusion. A common cause of death in adults is acute chest syndrome (AChS) with resulting hypoxemic respiratory failure. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been used successfully in acutely reversible respiratory failure when conventional mechanical ventilation has been unable to adequately oxygenate and ventilate in a lung-protective fashion. We present an adult SCD patient with severe respiratory failure due to AChS, successfully treated with VV-ECMO. We also discuss some of the technical challenges and considerations when using ECMO in the SCD patient.
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Affiliation(s)
- Ken Parhar
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Barbora Parizkova
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Nicola Jones
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Kamen Valchanov
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Jo-Anne Fowles
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Martin Besser
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Paul Telfer
- Department of Haematology, Barts Health NHS Trust, London, UK
| | - Banu Kaya
- Department of Haematology, Barts Health NHS Trust, London, UK
| | - Alain Vuylsteke
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Antonio Rubino
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
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Zochios V, Valchanov K. Raised cardiac troponin in intensive care patients with sepsis, in the absence of angiographically documented coronary artery disease: A systematic review. J Intensive Care Soc 2014; 16:52-57. [PMID: 28979375 DOI: 10.1177/1751143714555303] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Elevated cardiac troponin in the critically ill has been associated with increased hospital mortality. However, in critically ill patients with sepsis the results are heterogeneous and less easy to interpret. The objectives of this systematic review were to describe the pathophysiology, clinical relevance and prognostic significance of raised troponin in intensive care patients with sepsis. Articles were identified through a detailed MEDLINE search and additional references were retrieved from the selected studies. A growing body of clinical evidence suggests that although troponins are sensitive biomarkers with prognostic value, they are not independent predictors of mortality. However, vigilance for objective evidence of coronary artery disease is required and patients with atherosclerotic risk factors and elevated troponins may benefit from cardiac imaging. In patients with low pre-test probability for coronary artery disease and elevated troponins, therapy should target management of sepsis and optimisation of myocardial oxygen demand/supply balance.
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Affiliation(s)
- Vasileios Zochios
- Cardiothoracic Intensive Care Unit, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Kamen Valchanov
- Cardiothoracic Intensive Care Unit, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
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Valchanov K, Goddard M, Ghosh S. Anesthesia for heart transplantation in patients with arrhythmogenic right ventricular dysplasia. J Cardiothorac Vasc Anesth 2013; 28:355-7. [PMID: 23994174 DOI: 10.1053/j.jvca.2013.02.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Kamen Valchanov
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, United Kingdom.
| | - Martin Goddard
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, United Kingdom
| | - Sunit Ghosh
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, United Kingdom
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Abstract
Critically ill patients at extremes of physiology may benefit from mechanical support for heart failure and intensive care practitioners should be knowledgeable about these options. In this article we will discuss the mechanical support for critically ill patients in heart failure. Referral to a specialist centre should be considered early for maximal patient benefit.
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Affiliation(s)
- Kiran Salaunkey
- Clinical Fellow, Department of Anaesthesia
- Papworth Hospital, Cambridge
| | - Jayan Parameshwar
- Consultant Cardiologist, Deputy Director, Transplant Services
- Papworth Hospital, Cambridge
| | - Kamen Valchanov
- Consultant Anaesthetist and Intensivist, Department of Anaesthesia
- Papworth Hospital, Cambridge
| | - Alain Vuylsteke
- Consultant Anaesthetist and Intensivist, Department of Anaesthesia
- Papworth Hospital, Cambridge
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Berman M, Tsui S, Vuylsteke A, Dunning J, Fowles J, Ng C, Valchanov K, Webb S, Falter F, Jones N, Treacy C, Jenkins D. Successful Extracorporeal Membrane Oxygenation Support Following Pulmonary Endarterectomy. J Heart Lung Transplant 2013. [DOI: 10.1016/j.healun.2013.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Abstract
This paper reviews the basic fluid dynamics underlying extracorporeal membrane oxygenation (ECMO) cannula design. General cannula features and their effect on flow are discussed and the specific requirements of different ECMO circuits are explained. The current commercially available cannula options for veno-arterial and veno-venous circuits are reviewed and the main characteristics presented.
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Affiliation(s)
- K Kohler
- Department of Anaesthesia, West Suffolk Hospital, Bury St Edmunds, UK
| | - K Valchanov
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Papworth Everard, Cambridgeshire, UK
| | - G Nias
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Papworth Everard, Cambridgeshire, UK
| | - A Vuylsteke
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Papworth Everard, Cambridgeshire, UK
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Valchanov K. Atlas of Implantable Therapies for Pain Management. Anaesthesia 2012. [DOI: 10.1111/j.1365-2044.2011.06892.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Extra-corporeal membrane oxygenation has come of age after publication of the CESAR trial and the experience of its use during the 2009 H1N1 influenza pandemic, showing its increasing benefit for the treatment of hypoxaemic respiratory failure and combined cardiovascular and respiratory failure, including post-cardiac arrest. The article reviews the evidence for this technology and its indications, modes, methods, complications and recent advances. The authors suggest that ECMO will be used increasingly, even in non-cardiac specialist centres.
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Affiliation(s)
- Matthew Hung
- Locum Consultant in Anaesthesia and Intensive Care
- Papworth Hospital, Cambridge
| | - Alain Vuylsteke
- Consultant in Anaesthesia and Intensive Care
- Papworth Hospital, Cambridge
| | - Kamen Valchanov
- Consultant in Anaesthesia and Intensive Care
- Papworth Hospital, Cambridge
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Veenith T, Sharples L, Gerrard C, Valchanov K, Vuylsteke A. Survival and length of stay following blood transfusion in octogenarians following cardiac surgery. Anaesthesia 2010; 65:331-6. [PMID: 20148816 DOI: 10.1111/j.1365-2044.2009.06225.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Our aim was to assess if peri-operative blood transfusion is an independent risk factor for mortality and morbidity in the elderly. We report the results of a cohort study of all patients aged 80 or more on the day of their emergency or elective cardiac surgery (n = 874), using routinely collected data from January 2003 to November 2007. The primary outcome was all-cause mortality in hospital. The secondary outcomes were duration of stay in the intensive care unit (ICU) and overall hospital stay. Confounding variables were used to build up a risk model using a multivariable logistic regression analysis, and blood transfusion was added to assess whether it had additional predictive value for hospital mortality. Patients were divided into three groups: (i) transfusion of 0-2 units of red blood cells; (ii) transfusion of > 2 units of red blood cells and (iii) transfusion of red blood cells plus other clotting products. The strongest independent predictors of hospital death were logistic EuroSCORE and body mass index. After inclusion of these two variables, the odds ratio for transfusion remained significant. Relative to 0-2 units, the odds ratio for > 2 units was 6.80 (95% CI 2.46-18.8), and for other additional blood products was 14.4 (95% CI 5.34-37.3), with a p value of < 0.001. Duration of stay in the ICU was significantly associated with the amount of blood products administered (median (IQR [range]) ICU stay 1 (1-2 [0-15]) day if transfused 0-2 units of red blood cells, 2 (1-6 [0-128]) days if transfused > 2 units of red blood cells and 3 (1-76 [0-114]) days if other clotting products were used; p value < 0.001). Hospital stay was also associated with the amount of red cells used (p < 0.001).
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Affiliation(s)
- T Veenith
- Department of Intensive Care Medicine, Papworth Hospital NHS Foundation Trust, Cambridge University Teaching Hospital, Papworth Everard, UK.
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Saravanan P, Exley AR, Valchanov K, Casey ND, Falter F. Impact of xenon anaesthesia in isolated cardiopulmonary bypass on very early leucocyte and platelet activation and clearance: a randomized, controlled study. Br J Anaesth 2009; 103:805-10. [PMID: 19918023 DOI: 10.1093/bja/aep297] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) is associated with leucocyte and platelet activation and also organ dysfunction. Xenon has been found to have organ-protective effects. We therefore investigated the effect of isolated CPB on leucocyte and platelet activation and the efficacy of xenon in inhibiting these changes. METHODS Isolated CPB was conducted according to strict standardized clinical criteria using blood from healthy volunteers. They were randomized to an air-oxygen mixture (control group) vs xenon-oxygen mixture (xenon group). Blood samples were drawn at 5, 15, 30, 60, and 90 min from commencement of circuits and analysed for haemoglobin concentrations, white cell, neutrophil, monocyte, lymphocyte, and platelet counts. Leucocyte and platelet activation and also complex formation were determined by measuring levels of CD14++ monocytes, CD16+ monocytes, platelet-monocyte complexes, and platelet-neutrophil complexes (PNC). Differences between and within the groups were analysed with Student's t-test. RESULTS Biomarker levels were not different between the groups. The data were pooled to identify the effects of isolated bypass. The neutrophils, monocytes, platelets, CD14++ monocytes, and CD16+ monocytes decreased within 5 min of the bypass experiments, whereas the percentage of platelet-CD++ monocyte complexes and PNC increased. CONCLUSIONS Isolated CPB elicited rapid, substantial leucocyte and platelet activation, and xenon had no impact on inhibiting these changes.
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Affiliation(s)
- P Saravanan
- Department of Anaesthetics, Blackpool Fylde and Wyre Hospitals NHS Foundation Trust, Blackpool, UK.
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Hallward G, Valchanov K. An unexpected pre-operative diagnosis. Eur Heart J Cardiovasc Imaging 2009; 11:89-90. [PMID: 19939813 DOI: 10.1093/ejechocard/jep162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This is a case report of a patient presenting with breathlessness who was thought to have suspected systemic lupus erythematosus, but was actually diagnosed with an atrial myxoma. It shows how cardiac pathology can be easily misdiagnosed as suspected pulmonary pathology and serves as a reminder to clinicians when investigating a patient with breathlessness. It also raises the question as to which patients should undergo routine pre-operative echocardiography before thoracic surgery.
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