Interactive cardiovascular and thoracic surgery
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Interact Cardiovasc Thorac Surg · Jun 2011
Preoperative computed tomography is associated with lower risk of perioperative stroke in reoperative cardiac surgery.
Preoperative computed tomography (CT) use appears to be increasing among patients undergoing cardiac reoperations. We hypothesized that preoperative CT imaging reduces adverse outcomes and operative mortality for these patients. From July 2002 to February 2009, 373 patients underwent cardiac reoperations. ⋯ Importantly, perioperative stroke occurred only within the NCT group (5.6% vs. 0.0%, P=0.003), and emergent operative status [odds ratio (OR): 6.45, confidence interval (CI): 1.15-36.10, P=0.03] as an independent multivariate predictor of perioperative stroke. Thus, preoperative CT imaging is associated with lower rates of perioperative stroke in patients undergoing cardiac reoperations by optimizing cannulation and aortic clamping strategies. Routine use of preoperative CT should be considered for patients undergoing cardiac operations following prior sternotomy.
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Interact Cardiovasc Thorac Surg · Jun 2011
ReviewIn cardiac surgery patients does Voluven(R) impair coagulation less than other colloids?
Hydroxyethyl starch (HES) solutions are commonly used for volume replacement in cardiac surgery patients. The degree of impairment of the haemostatic system depends on the molecular weight and substitution degree of HES solutions. It is claimed that as HES 130/0.4 (Voluven(®)) exhibits a lower in vitro molecular weight and a lower degree of hydroxyethyl substitution than HES 200/0.5 (HAES-steril(®)) therefore it has less impact on haemostasis. ⋯ The in vitro studies suggest that HES 130/0.4 has no significant effect on platelet variables, shows a faster clot formation process and a better clot retraction as compared with the other HES solutions. On the other hand, current best available evidence (level 1b) from clinical studies, limited by heterogeneity predominantly in terms of dosage of HES 130/0.4 administered and the sample size of individual trials, overwhelmingly suggests that HES 130/0.4 compared with HES 200/0.5 or gelatin-based volume replacement fluid affects coagulation to the same extent resulting in similar degree of blood loss. It can be concluded that contrary to in vitro studies HES 130/0.4 in clinical practice has comparable effects on blood loss after cardiac surgery.
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Interact Cardiovasc Thorac Surg · Jun 2011
ReviewDoes use of intraoperative cell-salvage delay recovery in patients undergoing elective abdominal aortic surgery?
A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether the use of intraoperative cell-salvage (ICS) leads to negative outcomes in patients undergoing elective abdominal aortic surgery? Altogether 305 papers were found using the reported search, of which 10 were judged to represent the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. ⋯ Indeed two trials actually show a significantly shorter hospital stay after ICS use, one a shorter ITU stay and another suggests lower rates of chest sepsis. Based on these papers, we concluded that the use of ICS does not cause increased morbidity or mortality when compared to standard practise of transfusion of allogenic blood, and may actually improve some clinical outcomes. As abdominal aortic surgery inevitably causes significant intraoperative blood loss, in the range of 661-3755 ml as described in the papers detailed in this review, ICS is a useful and safe strategy to minimise use of allogenic blood.
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Interact Cardiovasc Thorac Surg · Jun 2011
ReviewShould surgeons scrub with chlorhexidine or iodine prior to surgery?
A best evidence topic was written according to a structured protocol. The question addressed was whether chlorhexidine gluconate is equivalent or superior to the use of povidone-iodine during surgical hand scrub. A total of 593 papers were found using the reported searches of which eight represented the best evidence to answer the clinical question. ⋯ Four studies went further to analyse cumulative and residual activity by testing for bacterial reduction after using a scrub solution for a number of days, an area in which chlorhexidine showed consistent advantages over povidone-iodine. These findings are given more credibility by the clinical finding of a recent meta-analysis of over 5000 patients in which chlorhexidine as an antiseptic skin preparation was associated with significantly reduced surgical site infection (SSI) in clean-contaminated surgery. Despite this, there is no evidence suggesting the use of chlorhexidine during hand scrub reduces SSI, which perhaps explains why guidelines from the World Health Organization, the Centers for Disease Control and Prevention and the Association for Perioperative Practice do not recommend one specific antimicrobial over another for hand scrub.