Seminars in thoracic and cardiovascular surgery
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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.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2006
ReviewMechanical ventilation and acute respiratory distress syndrome.
Acute respiratory distress syndrome continues to be a high-mortality condition. The role of mechanical ventilation remains primarily a supportive modality. ⋯ Animal and human investigations that culminated in the Acute Respiratory Distress Syndrome Network low tidal volume study are reviewed. Current controversies in the application of mechanical ventilation including the use of positive end-expiratory pressure, recruitment maneuvers, and high frequency oscillatory ventilation are also addressed.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2006
Glycemic control, diabetic status, and mortality in a heterogeneous population of critically ill patients before and during the era of intensive glycemic management: six and one-half years experience at a university-affiliated community hospital.
Hyperglycemia occurs commonly in acutely and critically ill patients and has been associated with adverse clinical consequences. An emerging body of literature describes the beneficial effects of intensive glycemic monitoring and treatment (tight glycemic control, or "TGC"). ⋯ Non-diabetics who sustained hyperglycemia had an especially high risk of mortality, and benefited greatly from treatment. Further investigations will be needed to identify the most appropriate glycemic targets for different populations of patients.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2005
Review Comparative StudyAntifibrinolytic agents in cardiac surgery: current controversies.
Antifibrinolytic agents play a prominent role in adult cardiac surgery. This article is a review of the modern published experience of antifibrinolytic agent use in adult cardiac surgery. The use of tranexamic acid, epsilon-aminocaproic acid, and aprotinin is examined during primary cardiac surgery, deep hypothermic circulatory arrest, reoperative cardiac surgery, and off-pump coronary artery bypass surgery. In addition, the issues of vein graft patency and hypersensitivity reaction in the presence of antifibrinolytic agents are examined.