Journal of cardiothoracic and vascular anesthesia
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J. Cardiothorac. Vasc. Anesth. · Apr 2011
Meta Analysis Comparative StudyPrognosis of diabetic patients undergoing coronary artery bypass surgery compared with nondiabetics: a systematic review and meta-analysis.
The influence of diabetes mellitus (DM) on mortality and morbidity in patients undergoing coronary artery bypass graft (CABG) surgery has remained uncertain due to conflicting conclusions from clinical trials measuring the association between diabetes and perioperative risk. Therefore, a quantitative meta-analysis was undertaken to evaluate the available evidence from prospective and historic cohort clinical trials. The purpose of this study was to determine the significance and magnitude of impact of DM on mortality, morbidity and resource-related outcomes for patients undergoing CABG over the past few decades and in the contemporary setting. ⋯ Current evidence suggests that patients with DM who are undergoing CABG are at increased risk of mortality, stroke, renal failure, sternal infection and blood transfusion when compared to those without DM. This increased relative risk for perioperative mortality and complications has remained, despite evolving definitions of DM and practice patterns. Future randomized studies should focus on interventions targeted toward these complications to mitigate the risk for patients with DM.
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J. Cardiothorac. Vasc. Anesth. · Apr 2011
Randomized Controlled Trial Comparative StudyHemodynamic stability during biventricular pacing after cardiopulmonary bypass.
To assess the stability of cardiac output, mean arterial pressure, and systemic vascular resistance during biventricular pacing (BiVP) optimization. ⋯ BiVP optimization may be done safely in patients after CPB. With continuous monitoring of mean arterial pressure and cardiac output, the procedure results in no harmful hemodynamic perturbation.
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Cardiac surgery, mainly in the form of coronary artery bypass graft surgery, is known to be associated with a risk of injury to the central and peripheral nervous systems. The most commonly encountered central nervous system injury associated with cardiac surgery continues to be stroke, with seizures occurring less commonly but with significant consequences. Seizures in the cardiac surgery recovery unit (CSRU) always cause great concern to the attending physicians and families of the patient. Therefore, it is of critical importance that the attending physician has an accurate and efficient approach to the differential diagnosis, investigations, and management of these patients, who represent a unique group requiring specific investigations and management. ⋯ Cardiac surgery poses a significant threat to the nervous system through various mechanisms although newer technologies and surgical techniques have led to improved outcomes in recent years. Although the incidence of seizures remains low, the causes and management are relatively unique in this setting, including a probable "toxic syndrome" related to certain antibiotics or other perioperative drugs such as tranexamic acid. A targeted approach based on recognizing focal versus generalized seizures, a careful review of history and medications, and a focused workup will lead the clinician to choosing the most effective therapy when one is required. Special concerns regarding the side effect profile of phenytoin in this setting have led to valproate and levetiracetam becoming useful alternatives, which are effective and well tolerated. The incidence of nonconvulsive seizures in the CSRU remains to be elucidated with prospective monitoring studies, as does their effect on outcome.
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J. Cardiothorac. Vasc. Anesth. · Apr 2011
ReviewRedo sternotomy for cardiac reoperations using peripheral heparin-bonded cardiopulmonary bypass circuits without systemic heparinization: technique and results.
Cardiac reoperations are challenging and time-consuming and incur a high incidence of perioperative complications because of injuries to cardiac structures, bleeding, and hemodynamic instability. Some centers are using extracorporeal circulation with heparinization at the time of resternotomy, but it leads to prolonged anticoagulation, platelet dysfunction, fibrinolysis, coagulopathy, and morbidity. The authors routinely perform resternotomy in complex surgery with the support of heparinless cardiopulmonary bypass with heparin-bonded circuits (HBCs). The authors describe their technique, indication, and results. ⋯ This study shows that HBC without systemic heparinization during resternotomy can be used safely in complex redo cardiac surgery. The heart is completely decompressed during the resternotomy, allowing easy dissection, less likely injury to vital structures, and less bleeding without compromising the hemodynamics.
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J. Cardiothorac. Vasc. Anesth. · Apr 2011
ReviewUpdate in hematology: heparin-induced thrombocytopenia and bivalirudin.
Heparin-induced thrombocytopenia (HIT) is important because it is common, and it significantly increases mortality after cardiac surgery. Although thrombocytopenia after cardiac surgery is common, it predicts serious adverse outcome when it is severe. Despite the high prevalence of heparin/platelet factor 4 antibodies in cardiac surgical patients, they typically do not indicate a higher perioperative risk. ⋯ Patients with a remote history of HIT can have cardiac surgery safely with unfractionated heparin. Patients with clinically active HIT who require cardiac surgery before the resolution of the HIT preferably should be anticoagulated with bivalirudin, dosed according to body weight and the goal-activated coagulation time. Given that bivalirudin is an established alternative to heparin as a thrombin inhibitor for cardiac surgery, it is likely that future trials will investigate which anticoagulant confers better outcomes after cardiac surgery, as is the case in percutaneous coronary intervention.