Texas Heart Institute journal
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There is an interest in the use of high thoracic epidural anesthesia in cardiac surgery, because experimental and clinical studies have suggested that central neuroaxial blockade attenuates the response to surgical stress and improves myocardial metabolism and perioperative analgesia-thus enabling earlier extubation and a smoother postoperative course. Matters of major concern in the adoption of high thoracic epidural anesthesia in cardiac surgery are neurologic injury secondary to neuroaxial hematoma and hypotension secondary to sympatholysis. The risk associated with possible neuraxial hematoma caused by high thoracic epidural anesthesia has been thoroughly investigated and largely discounted, but scant attention has been devoted to the onset of hypotensive episodes in the same setting. ⋯ Among the patient variables that we tested in a multivariate logistic-regression model, only female sex was found to be significantly correlated with hypotension. In order to decrease the incidence and severity of hypotensive episodes resulting from anesthetic blockade, anesthesiologists need to monitor, with special care, women patients who are under high thoracic epidural anesthesia. Further studies are needed in order to determine why women undergoing open heart surgery under high thoracic epidural anesthesia are at a relatively greater risk of hypotension.
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In order to determine the temporal pattern of weaning from mechanical ventilation for patients undergoing prolonged mechanical ventilation after cardiac surgery, we performed a retrospective review of 21 patients' weaning courses at our long-term acute care hospital. Using multiple regression analysis of an estimate of individual patients' percentage of mechanical ventilator support per day (%MVSD), we determined that 14 of 21 patients (67%) showed a statistically significant quadratic or cubic relationship between time and % MVSD. These patients showed little or no improvement in their ventilator dependence until a point in time when, abruptly, they began to make rapid progress (a "wean turning point"), after which they progressed to discontinuation of mechanical ventilation in a relatively short period of time. ⋯ Most patients in the study group weaned from the ventilator through a specific temporal pattern that is newly described herein. Data analysis suggested that the mechanism for the development of a wean turning point was improvement of pulmonary mechanics rather than improvement in gas exchange or respiratory load. Although these observations need to be confirmed by a prospective trial, they may have implications for weaning cardiac surgery patients from prolonged mechanical ventilation, and possibly for weaning a broader group of patients who require prolonged mechanical ventilation.
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Early mobilization and aggressive physical therapy are essential in patients who receive left ventricular assist devices (LVADs) due to long-term, end-stage heart failure. Some of these patients remain ventilator dependent for quite some time after device implantation. We report our regimen of mobilization with the aid of a portable ventilator, in patients with cardiac cachexia and LVAD implantation. ⋯ There were significant functional gains during the period of prolonged mechanical ventilation. The patient was able to walk up to 600 feet by the time he was weaned from the ventilator and transferred out of the intensive care unit. He underwent successful heart transplantation 6 weeks after being weaned from the ventilator We believe that improving the mobility of LVAD patients who require mechanical ventilation has the potential both to facilitate ventilator weaning and to improve the outcomes of transplantation.
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Few reported cases document injury to the circumflex coronary artery secondary to repair of the mitral valve annulus. This potentially life-threatening sequela must be considered during mitral valve repair. In an effort to increase awareness of this sequela, we present the case of a patient who experienced a perioperative myocardial infarction secondary to injury of the circumflex coronary artery after mitral valve repair.
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Comparative Study
Topical versus systemic vancomycin for deep sternal wound infection caused by methicillin-resistant Staphylococcus aureus in a rodent experimental model.
In 37 Wistar albino rats, we investigated the effects of topical vancomycin on deep sternal wound infection caused by methicillin-resistant Staphylococcus aureus. Partial median sternotomy was performed under sterile conditions. Group I (n=6) was the sham, and group II (n=7) was the control. ⋯ We found 5.00 +/- 0 CFU/mL microorganisms in the mediastinum in group II, 1.90 +/- 1.70 in group III, 3.33 +/- 0.48 in group IV and 1.70 +/- 1.08 in group V. The quantity of microorganisms per gram of tissue in the sternum was 736 +/- 0.23 in group II, 6.01 +/- 0.33 in group III, 5.81 +/- 0.81 in group IV and 3.99 +/- 2.47 in group V The quantity of microorganisms was less in the 3 treatment groups than in the control group (P < 0.05). We conclude that topical plus systemic vancomycin treatment might be more effective in patients with deep sternal wound infections caused by methicillin-resistant S. aureus.