Seminars in thoracic and cardiovascular surgery
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Semin. Thorac. Cardiovasc. Surg. · Jan 2006
ReviewDiagnostic studies in patients with acute respiratory distress syndrome.
Acute respiratory distress syndrome (ARDS) is a clinical-radiological diagnosis. Clinical diagnosis comprises severe hypoxemia assessed by arterial oxygen tension/fraction of inspired oxygen ratio of less than 200 and bilateral infiltrate on a chest radiograph in the absence of left atrial hypertension. The sensitivity and specificity of the clinical diagnosis vary based on the underlying etiology for ARDS. ⋯ Diffuse alveolar damage, a pathognomic of ARDS, is seen on histopathology on transbronchial lung biopsy or open lung biopsy. Most common complications of these procedures include transient hypoxemia, respiratory acidosis, and pneumothorax with occasional persistent air leak. The potential risk of diagnostic studies should be balanced against the possible foreseeable benefits of the diagnostic studies.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2006
ReviewCurrent perspective on aortic valve repair and valve-sparing aortic root replacement.
Aortic valve repair and valve-sparing aortic root replacement are attractive concepts because they offer the possibility of valve competence without structural deterioration due to nonviability and they preclude the need for anticoagulation. Enthusiasm for aortic valve repair has waxed and waned over the past 45 years due in part to the inherent technical difficulties and poor mid-term results. ⋯ A current perspective on aortic valve repair and valve-sparing aortic root replacement is presented in the following review. Historical background, indications for repair, technical considerations, and outcomes data are discussed.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2006
ReviewPostoperative acute respiratory distress syndrome development in the thoracic surgery patient.
Acute respiratory distress syndrome (ARDS) in the thoracic surgery patient is a dreaded complication that occurs in 4% to 5% of pneumonectomies. This peculiar syndrome is indistinct from other forms of ARDS yet is associated with an exceedingly higher mortality rate. Current management parallels ARDS treatment of other etiologies.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2006
ReviewIntraoperative management of hyperglycemia in the cardiac surgical patient.
The stress response of cardiac surgery leads to hyperglycemia, and undergoing cardiopulmonary bypass magnifies this response greatly. Counter-regulatory hormones, the cytokine response, and the automatic nervous system are all part of the coordinated host response that can lead to hyperglycemia. Postoperative hyperglycemia is associated with worsened perioperative outcomes, and there are data demonstrating this to also be true for the intraoperative period. ⋯ Intraoperative glucose control has a significant impact on postoperative outcomes. No optimal intraoperative insulin regimen has been identified, but continuous intravenous infusions appear to be superior to intermittent sliding scale dosing. In addition, the technique of hyperinsulinemic glucose clamp shows the greatest promise of achieving normoglycemia while on CPB.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2006
ReviewCost considerations with tight glycemic control in the acute care setting.
Hyperglycemia is associated with increased morbidity and mortality in critically ill patients. Clinical trial data has demonstrated that controlling hyperglycemia with insulin infusions guided by frequent blood glucose monitoring can reduce this morbidity and mortality. ⋯ Based on the outcomes of cardiac surgery and intensive care unit studies, the cost per life year gained resulting from the implementation of tight glycemic control protocols is less than 6000 dollars (highly cost-effective). Benefits of implementing tight glycemic control protocols in critical or intensive care units includes not only reductions in morbidity and mortality, but reductions in hospital costs.