Interactive cardiovascular and thoracic surgery
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Interact Cardiovasc Thorac Surg · Jun 2011
Randomized Controlled Trial Comparative StudyComparative study of the non-dependent continuous positive pressure ventilation and high-frequency positive-pressure ventilation during one-lung ventilation for video-assisted thoracoscopic surgery.
The application of volume controlled high-frequency positive-pressure ventilation (HFPPV) to the non-dependent lung (NL) may have comparable effects to continuous positive-airway pressure (CPAP) on the surgical conditions during one-lung ventilation (OLV) for video-assisted thoracoscopic surgery (VATS). After local Ethics Committee approval and informed consent, we randomly allocated 30 patients scheduled for elective VATS after the first 15 min of OLV to ventilate the NL with CPAP of 2 cm H(2)O (NL-CPAP(2)) and HFPPV using tidal volume 2 ml/kg, inspiratory to expiratory ratio <0.3 and respiratory rate 60/min (NL-HFPPV) for 30 min, each in a randomized crossover order. ⋯ The operative field was much better during the application of NL-CPAP(2) than during NL-HFPPV (P<0.001). We concluded that the application of CPAP to the NL during OLV offers good quality of operative field and improved arterial oxygenation for VATS.
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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
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.
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Interact Cardiovasc Thorac Surg · Jun 2011
ReviewIn adult patients undergoing redo surgery for left atrioventricular valve regurgitation after atrioventricular septal defect correction, is replacement superior to repair?
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In adult patients undergoing redo surgery for left atrioventricular valve regurgitation after atrioventricular septal defect correction, is replacement superior to repair?' Altogether more than 109 papers were found using the reported search, of which eight represented 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 are tabulated. ⋯ We feel that for older patients or for those in whom long-term anticoagulation is a concern, biological prosthesis can be an option, also due to the growing and expanding experience of percutaneous/transapical valve-in-valve replacement in mitral position. Since in these patients the number of previous sternotomies is usually one or more and re-entry injuries can be a major source of perioperative mortality and morbidity, we believe that mini-thoracotomy approach can avoid potential damage; furthermore, arterial cannulation can be either central or peripheral according to the degree of visceral adhesions or surgeon's choice. Venous drainage should be provided by a percutaneous vacuum-assisted femoral double stage venous drainage, which is useful especially when concomitant tricuspid valve surgery is planned.