The Annals of thoracic surgery
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Clinical Trial
Postthoracotomy pain management using continuous epidural analgesia in 1,324 patients.
Continuous epidural analgesia consisting of an opioid with or without a local anesthetic agent is a commonly employed technique for pain relief after thoracotomy. In this study, we prospectively evaluated the use of continuous epidural analgesia in 1,324 patients undergoing elective thoracotomy between 1987 and 1993. Epidural pain management was continued for 1 to 3 postoperative days. ⋯ The incidence of inadequate analgesia (a visual analog pain score of 7 or more persisting for 1 to 2 hours after an epidurally administered bolus) was 3.8%. The results from this study support the use of standard protocols for dosing guidelines, the treatment of inadequate analgesia, and the management of side effects. Daily evaluation by a team member of the postoperative analgesia services section of the Department of Anesthesiology enhances patient care and minimizes adverse effects.
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Review Case Reports
Carcinoid heart disease: early failure of an allograft valve replacement.
A woman who had carcinoid syndrome and carcinoid heart disease underwent tricuspid and pulmonary valve replacements with a xenograft and a cryopreserved allograft, respectively. Within 3 months of the operation severe pulmonary regurgitation and pulmonary hypertension refractory to medical therapy developed. Autopsy found the biomechanical tricuspid valve to be free of disease but the allograft in the pulmonary position was involved by carcinoid heart disease in a fashion similar to the excised native pulmonary valve.
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Randomized Controlled Trial Clinical Trial
Aprotinin preserves hemostasis in aspirin-treated patients undergoing cardiopulmonary bypass.
Various clinical trials have shown that hemostasis is improved by the administration of aprotinin during cardiopulmonary bypass. However, this effect has not been proved for those patients treated preoperatively with aspirin. Therefore, a double-blind, placebo-controlled study was conducted to test the efficacy of low-dose aprotinin (2 x 10(6) KIU in the pump prime solution) in preserving hemostasis in 40 aspirin-treated (325 mg) patients undergoing coronary artery bypass grafting. ⋯ The inhibitory effects of aspirin on collagen-induced platelet aggregation and thromboxane production were not influenced by aprotinin treatment. The findings from the present study indicate that aprotinin preserves hemostasis in aspirin-treated patients during cardiopulmonary bypass, but aspirin's effect on platelets is maintained. Therefore, aprotinin seems to be a useful adjunct treatment in aspirin-treated patients undergoing coronary artery bypass grafting.
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Although low systemic vascular resistance occurs during normothermic and hypothermic cardiopulmonary bypass, the determinants of depressed systemic vascular resistance and its effect on outcomes are unknown. To assess the predictors and clinical effects of low systemic vascular resistance, 555 patients undergoing isolated coronary artery bypass grafting were evaluated prospectively. The extent of low systemic vascular resistance during bypass was estimated by the amount of the vasoconstrictor phenylephrine administered: group 1, 0 to 160 micrograms; group 2, 161 to 800 micrograms; group 3, more than 800 micrograms. ⋯ Patients in group 3 had a higher cardiac index and lower-mean arterial pressure and systemic vascular resistance postoperatively. In those patients who received a left internal mammary artery graft, the incidences of the low-output syndrome (group 1, 4.9%; group 3, 2.7%; p = not significant) and myocardial infarction (group 1, 1.4%; group 3, 1.8%; p = not significant) were not influenced by the amount of phenylephrine infused during cardiopulmonary bypass. In those patients who were at high risk of suffering a stroke preoperatively, the hypotension induced by the low systemic vascular resistance and its treatment with phenylephrine was not associated with an increased incidence of stroke (group 1, 5.8%; group 3, 2.8%; p = not significant).
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We report the case of a 24-year-old man in whom a clinical syndrome developed while he was on active military duty in Saudi Arabia that was subsequently diagnosed as constrictive pericarditis. Phrenic nerve to phrenic nerve pericardiectomy and posterior pericardial release successfully relieved the ventricular constriction with a resultant increase in the cardiac index from 1.9 to 3.8 L.min-1.m-2. Transesophageal echocardiographic monitoring during the operation disclosed trace mitral regurgitation before median sternotomy. ⋯ This echocardiographic finding had improved 1 week later, but the regurgitation still was greater than baseline. Mitral valve function had returned to baseline by 4 weeks after the operation. Possible mechanisms of this evolving pattern of perioperative mitral valve dysfunction are discussed.