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Hemodynamic Instability (hemodynamic + instability)
Selected AbstractsA study of the extracorporeal rate of blood flow and blood pressure during hemodialysisHEMODIALYSIS INTERNATIONAL, Issue 4 2007Hariprasad S. TRIVEDI Abstract Hemodynamic instability is a common problem during hemodialysis (HD). The effect of blood flow rate (BFR) on blood pressure (BP) during HD has not been previously evaluated. Subjects receiving HD for the treatment of renal failure were enrolled (n=34). For each patient, during the last hour of 2 consecutive HD sessions the BFR was set at 200 mL/min for 30 min and at 400 mL/min for 30 min, during which period the fluid removal rate was kept constant. The order of the BFR alterations was randomized. The study procedure was repeated during the next HD session but with reversal of the order of the altered BFR. During each 30-min period, BP was recorded at baseline and subsequently every 10 min. During the BFR of 400 mL/min, subjects had a higher systolic BP by an average of 4.1 mmHg compared with the BFR of 200 mL/min (95% confidence interval [CI] 0.22,7.98; p=0.038). Similarly, during the BFR of 400 mL/min, subjects had a higher diastolic BP by an average of 3.04 mmHg compared with the BFR of 200 mL/min (95% CI 0.55,5.53; p=0.017). Likewise, during the BFR of 400 mL/min, subjects had a higher mean arterial pressure by an average of 3.44 mmHg (95% CI 0.77,6.11; p=0.012). The findings suggest that during HD, BPs are maintained higher at higher BFRs as compared with lower BFRs. [source] Numerical Simulation of Hemodynamic Changes During Beating-heart Surgery: Analysis of the Effects of Cardiac Position Alteration in an Animal ModelARTIFICIAL ORGANS, Issue 1 2007Gianfranco Ferrari Abstract:, Hemodynamic instability, mostly due to vertical lifting of the heart, is usually observed during beating-heart surgical procedures. However, some hemodynamic parameters, such as coronary blood flow, are not routinely measured. A digital computer model of the circulation able to simulate and analyze the effects of heart lifting and the Trendelenburg maneuver, and thus supply detailed hemodynamic information to the clinicians would provide a useful analytical tool. A lumped parameters model of the circulation was applied to both ,-blocked and not ,-blocked pigs. The results confirmed a drop of cardiac output and coronary flow during heart lifting and a rise of both variables after the Trendelenburg maneuver for ,-blocked animals. In not ,-blocked pigs, the analysis was more complex but the model reproduced experimental data and permitted coronary flow to be estimated. These results showed the feasibility of numerical simulation for specific circulatory conditions encountered during beating-heart surgery. [source] An Incenter Nocturnal Hemodialysis Program,Three Years ExperienceHEMODIALYSIS INTERNATIONAL, Issue 1 2003M. Gene Radford We report our experience with a program of long, slow, overnight hemodialysis (HD) performed 3 times a week in an existing dialysis facility. Beginning in April 1999, 14 chairs in one bay of our facility were replaced with beds, subdued lighting was installed, and machine alarms were decreased to minimum volume. Fresenius F60 dialyzers were selected with a QB of 220,300 ml/min and a QD of 400,500 ml/min. Patients dialyze for 7,8 hrs overnight. Staffing is with 1 nurse and 1 PCT for 10 patients. Standard dialysate is used, and heparin is dosed 100 U/kg at treatment initiation and again at mid-treatment. All access types are utilized. The program is open to all patients in our area. A total of 65 patients have participated, with a current census of 20 patients. Participants have tried nocturnal dialysis for a variety of reasons including work/school schedules, excessive interdialytic weight gains, inadequate dialysis (due to poor access function or large body mass), and hemodynamic instability with standard daytime HD. Blood pressure control has improved among the participants in the program, perhaps due to more gentle ultrafiltration and improvement in maintenance of dry weight. Among 31 patients who remained on nocturnal dialysis for over 6 months, 21 started the program on an average of 2.5 antihypertensive agents (AHA). After 6 months, 9 patients no longer needed AHA while 12 patients remain on an average of 1.3 AHA. URR also improved by an average of 4.35 among 13 patients who transferred from standard incenter HD to the nocturnal program. In all, 45 patients have left the program, for reasons which include insomnia/social (15), death (9), transfer to home HD (8), renal transplantation (6), noncompliance (3), moved away (2), and other (2). In conclusion, long overnight HD can be performed in an existing dialysis facility, providing patients with another HD option. Patients who may benefit from this modality include those with daytime jobs, patients with inadequate clearance on standard HD, patients with excessive interdialytic weight gains, and those who poorly tolerate standard HD. [source] The need for venovenous bypass in liver transplantationHPB, Issue 3 2008Hamidreza Fonouni Abstract Since introduction of the conventional liver transplantation (CLTx) by Starzl, which was based on the resection of recipient inferior vena cava (IVC) along the liver, the procedure has undergone several refinements. Successful use of venovenous bypass (VVB) was first introduced by Shaw et al., although in recent decades there has been controversy regarding the routine use of VVB during CLTx. With development of piggyback liver transplantation (PLTx), the use of caval clamping and VVB is avoided, leading to fewer complications related to VVB. However, some authors still advocate VVB in PLTx. The great diversity among centers in their use of VVB during CLTx, or even along the PLTx technique, has led to confusion regarding the indication setting for VVB. For this reason, we present an overview of the use of VVB in CLTx, the target of patients for whom VVB could be beneficial, and the needs assessment of VVB for patients undergoing PLTx. Recent studies have shown that with the advancement of surgical skills, refinement of surgical techniques, and improvements in anesthesiology, there are only limited indications for doing CLTx with VVB routinely. PLTx with preservation of IVC can be performed in almost all primary transplants and in the majority of re-transplantations without the need for VVB. Nevertheless, in a few selective cases with severe intra-operative hemodynamic instability, or with a failed test of transient IVC occlusion, the application of VVB is still justifiable. These indications should be judged intra-operatively and the decision is based on each center's preference. [source] A clinical prospective comparison of anesthetics sensitivity and hemodynamic effect among patients with or without obstructive jaundiceACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 7 2010L.-Q. YANG Background: To compare isoflurane anesthesia in patients with or without hyperbilirubinemia undergoing hepatobiliary surgery. Methods: Forty-two patients with obstructive jaundice and 40 control patients with normal liver function scheduled for hepatobiliary surgery under isoflurane anesthesia were studied. Anesthesia was induced with propofol (1.5,2 mg/kg) and remifentanil (2 ,g/kg). After tracheal intubation, anesthesia was titrated using isoflurane in oxygen-enriched air, adjusted to maintain a bispectral index (BIS) value of 46,54. Ephedrine, atropine and remifentanil were used to maintain hemodynamic parameters within 30% of the baseline. The mean arterial blood pressure (MAP), heart rate (HR), drug doses and the time taken to recover from anesthesia were recorded. Results: Demographic data, duration and BIS values were similar in both groups. Anesthesia induction and maintenance were associated with more hemodynamic instability in the patients with jaundice and they received more ephedrine and atropine and less remifentanil and isoflurane (51.1±24.2 vs. 84.6±20.3 mg/min; P for all <0.05) than control patients. Despite less anesthetic use, the time to recovery and extubation was significantly longer than that in control. Conclusion: Patients with obstructive jaundice have an increased sensitivity to isoflurane, more hypotension and bradycardia during anesthesia induction and maintenance and a prolonged recovery time compared with controls. [source] Prophylactic steroids for paediatric open-heart surgery: a systematic reviewINTERNATIONAL JOURNAL OF EVIDENCE BASED HEALTHCARE, Issue 4 2008Suzi Robertson-Malt BHSc PhD Background, The immune response to cardiopulmonary bypass in infants and children can lead to a series of post-operative morbidities and mortality, that is, hemodynamic instability, increased infection and tachyarrhythmias. Administration of prophylactic doses of corticosteroids is sometimes used to try and ameliorate this pro-inflammatory response. However, the clinical benefits and harms of this type of intervention in the paediatric patient remain unclear. Objectives, To systematically review the beneficial and harmful effects of the prophylactic administration of corticosteroids, compared with placebo, in paediatric open-heart surgery. Search strategy, The trials registry of the Cochrane Heart Group, the Cochrane Central Register of Controlled Trials in The Cochrane Library (Issue 4, 2006), MEDLINE (1966 to January 2007), EMBASE (1980 to January 2007) were searched. An additional hand-search of the EMRO database for Arabic literature was performed. Grey literature was searched, and experts in the field were contacted for any unpublished material. No language restrictions were applied. Selection criteria, All randomised and quasi-randomised controlled trials of open-heart surgery in the paediatric population that received corticosteroids pre-, peri- or post-operatively, with reported clinical outcomes in terms of morbidity and mortality. Data collection and analysis, Eligible studies were abstracted and evaluated by two independent reviewers. All meta-analyses were completed using RevMan4.2.8. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random-effects model. Main results, All cause mortality could not be assessed as the data reports were incomplete. There was weak evidence in favour of prophylactic corticosteroid administration for reducing intensive care unit stay, peak core temperature and duration of ventilation (WMD (95% confidence intervals) ,0.50 h (,1.41 to 0.41); ,0.20°C (,1.16 to 0.77) and ,0.63 h (,4.02 to 2.75) respectively). [source] Impact of chronic advanced aortic regurgitation on the perioperative outcome of noncardiac surgeryACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 5 2010H.-C. LAI Background: Whether and how chronic advanced aortic regurgitation (AR) impacts the perioperative outcome of noncardiac surgery remains unclear. Methods: From November 1999 to December 2006, all patients undergoing noncardiac operations and ever examined by echocardiography within the last 6 months were screened. Those with chronic moderate,severe or severe AR were enrolled, provided they were not already trachea-intubated or aortic valve operated, and the surgery was not performed under local anesthesia. Case-matched subjects without significant AR served as controls. The perioperative outcomes of these patients were analyzed, and independent prognostic correlates were investigated by multivariate logistic regression analysis. Results: A total of 167 patients (male 131, mean age of 75 years) complying with the enrollment criteria were studied. Compared with the other 167 case-matched control peers, patients with advanced AR risked potential hazards of serious hemodynamic instability (0.6%) and circulatory collapse (1.2%) during surgery despite the similar incidence of overall cardiac adverse events, and were further distressed with more cardiopulmonary complications (16.2% vs. 5.4%, P=0.003) and in-hospital deaths (9% vs. 1.8%, P=0.008) post-operatively. Multivariate regression analysis confirmed the correlation of advanced AR with perioperative mortality, and identified depressed left ventricular function, renal dysfunction, high surgical risk, and lack of cardiac medication as predictors of in-hospital death. Conclusion: Chronic advanced AR complicates the perioperative outcome of noncardiac surgery as reflected by frequent cardiopulmonary morbidities and in-hospital deaths, especially when coexisting with specified high-risk clinical and surgical characteristics. [source] Results of Treatment Methods in Cardiac Arrest Following Coronary Artery Bypass GraftingJOURNAL OF CARDIAC SURGERY, Issue 3 2009Mehmet R. Guney M.D. We evaluated the short- and long-term consequences of these two methods and discussed the indications for re-revascularization. Methods: Between 1998 and 2004, a total of 148 CABG patients, who were complicated with cardiac arrest, were treated with emergency re-revascularization (n = 36, group R) and ICU procedures (n = 112, group ICU). Re-revascularizations are mostly blind operations depending on clinical/hemodynamic criteria. These are: no response to resuscitation, recurrent tachycardia/fibrillation, and severe hemodynamic instability after resuscitation. Re-angiography could only be performed in 3.3% of the patients. Event-free survival of the groups was calculated by the Kaplan-Meier method. Events are: death, recurrent angina, myocardial infarction, functional capacity, and reintervention. Results: Seventy percent of patients, who were complicated with cardiac arrest, had perioperative myocardial infarction (PMI). This rate was significantly higher in group R (p = 0.013). The major finding in group R was graft occlusion (91.6%). During in-hospital period, no difference was observed in mortality rates between the two groups. However, hemodynamic stabilization time (p = 0.012), duration of hospitalization (p = 0.00006), and mechanical support use (p = 0.003) significantly decreased by re-revascularization. During the mean 37.1 ± 25.1 months of follow-up period, long-term mortality (p = 0.03) and event-free survival (p = 0.029) rates were significantly in favor of group R. Conclusion: Better short- and long-term results were observed in the re-revascularization group. [source] The Surgical Option in the Management of Acute Pulmonary EmbolismJOURNAL OF CARDIAC SURGERY, Issue 6 2008Justo Rafael Sádaba F.R.C.S. (C/Th) Traditionally this condition has been treated with thrombolysis or anticoagulation and support measures. Surgical embolectomy is carried out in situations of hemodynamic instability or contraindication for thrombolysis. We present our results of surgical embolectomy in patients with massive and submassive PE. Methods: Over a three-year period, we have carried out 20 surgical embolectomies for acute PE. The mean age was 66 years, and there were 11 males. In all cases, the diagnosis had been made by a computerized tomography (CT) pulmonary artery angiography. Nine patients (45%) arrived to the operating theater on inotropes, and two of them (10%) with ventilatory support. All patients underwent a median sternotomy, bicaval cannulation for institution of cardiopulmonary bypass (CPB), and main pulmonary arteriotomy for the removal of the thrombus. Results: The mean bypass time was 45 minutes. Two patients (12%) died after being unable to wean off CPB due to right heart failure. Among the 15 survivors, the median ventilation time in the intensive care unit was 24 hours. Twelve patients (60%) required inotropic support postoperatively for right heart failure. All but one survivor (94%) underwent an insertion of a permanent inferior vena cava filter and were anticoagulated with coumarin. The mean follow-up is 9.8 months and is 100% complete, with a survival of 94.5%. All patients were in the World Health Organization (WHO) functional class I, with no re-admissions for respiratory failure. Conclusion: In patients with acute massive or submassive PE, surgical embolectomy offers a valid therapeutic strategy. A right-sided heart failure is the main complication of this condition. [source] Left Ventricular Rhabdomyoma With Severe Left Ventricular Outflow Tract ObstructionJOURNAL OF CARDIAC SURGERY, Issue 5 2007Ali Sarigul M.D. Rhabdomyomas are the most common tumors in this group of patients. We herein report a 40-day-old male patient with left ventricular rhabdomyoma. The tumor caused syncope attack and supraventricular tachycardia. An emergency operation was planned and the life-threatening lesion was excised via left ventriculotomy. The patient was extubated on postoperative sixth hour and discharged from hospital on the sixth day of the postoperative period without any problem. This successful operation encourages us not to hesitate to perform an operation in newborns with cardiac neoplasms causing hemodynamic instability. [source] Critical Role of Inferior Vena Caval Filter Placement After Pulmonary EmbolectomyJOURNAL OF CARDIAC SURGERY, Issue 3 2005Peter Rosenberger M.D. Postoperative placement of an inferior vena caval filter (IVCF) may prevent recurrent PE. We present a patient who underwent pulmonary embolectomy in whom postoperative placement of an IVCF was postponed due to hemodynamic instability and severe hemorrhage. Recurrent PE was recognized 12 hours after the initial surgery, and required reoperative pulmonary embolectomy. This report documents that recurrent PE can occur early after pulmonary embolectomy even in the presence of coagulopathy. Therefore, concurrent IVCF placement should be considered during or immediately after pulmonary embolectomy to prevent recurrent pulmonary embolism. [source] The Role of Intra-Aortic Counterpulsation in High-Risk OPCAB Surgery:JOURNAL OF CARDIAC SURGERY, Issue 4 2003A Prospective Randomized Study This prospective and randomized study evaluates the efficacy and safety of pre- and perioperative IABC in high-risk OPCAB. Material: Group A,IABC started prior to induction of anesthesia (n = 15); group B,no preoperative IABC (n = 15). Adult high-risk coronary patients to undergo OPCAB. High risk = (minimum 2) EF < 0.30, left main stenosis, unstable angina, redo. Bailout if hemodynamic instability CPB or IABC in group B. Study endpoints (a) cardiac protection (troponin 1, cardiac index (CI), ECG), (b) inflammatory response (lactate, IL-6), (c) clinical outcome (mortality, morbidity). Emergency operations 33%, re-operation 13%, unstable angina 100%, left main 60% and EF 0.29, without group differences. Results: No bailout group A, 10 in group B, p < 0.0001. Postoperative IABC six (group A) and seven patients (group B), during 6.8 ± 5.1 hours (group A) versus 41.2 ± 25.5 hours (group B), p = 0.0110. Myocardial protection without group differences, but CI significantly better in group A. Inflammatory response significantly less in group A. Clinical outcomes: one death, one MI and two renal failure in group B, none in group A. Intensive care unit (ICU) stay 27 ± 3 hours (group A) versus 65 ± 28 hours (group B), p = 0.0017. LOS 8 ± 2 days (group A) versus 15 ± 10 (group B), p = 0.0351. No IABC related complications. Conclusions: Pre- and perioperative IABC therapy offers efficient hemodynamic support during high-risk OPCAB surgery, lowers the risk of hemodynamic instability, is safe and shortens both ICU and hospital length of stay significantly, and is a cost-effective therapy. (J Card Surg 2003; 18:286-294) [source] Evaluation of Propofol-Ketamine Anesthesia for Children Undergoing Cardiac Catheterization ProceduresJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 2 2007F.F.A. (DUBLIN), F.R.C.A. (LOND), Parthasarathi GAYATRI M.D. The aim of this study was to assess the safety and efficacy of the continuous intravenous administration of a combination of propofol and ketamine for children undergoing cardiac catheterization procedures (CCP). Thirty-two children scheduled for CCP in a university teaching hospital were included in this prospective randomized study. Patients in group 1 (n = 15) were given a combination of propofol (25 ,g/kg per minute) and ketamine (25 ,g/kg per minute), whereas patients in group 2 (n = 17) received a combination of propofol (25 ,g/kg per minute) and ketamine (12.5 ,g/kg per minute) for the maintenance of anesthesia. There were no statistically significant differences with age, weight, duration of the procedure, and the number of diagnostic and interventional procedures between the two groups. There was no hemodynamic instability, airway compromise, excessive salivation, or arterial desaturation in either of the two groups. There was more incidence of movements in patients who received less dose of ketamine; however, it did not reach to statistically significant level. The total dose of ketamine used in group 1 was 309.25 ± 90.97 ,g/min, whereas in group 2, it was 148.06 ± 34.05 ,g/min. The time to awakening was significantly less in group 2 (P < 0.05). We conclude that a combination of propofol (25 ,g/kg per minute) and two different doses of ketamine (25 and 12.5 ,g/kg per minute, respectively) are safe and efficacious for CCP in children. Although the time to awaken was more in patients receiving 25 ,g/kg per minute of ketamine compared to those receiving 12.5 ,g/kg per minute of ketamine, it was well within acceptable limits. [source] Reconstruction of the pancreatic duct after pancreaticoduodenectomy: A modification of the Whipple procedureJOURNAL OF SURGICAL ONCOLOGY, Issue 1 2001Stylianos Katsaragakis MD Abstract Background and Objectives: Pancreaticoduodenectomy is still associated with high morbidity and mortality even though there has been significant progress in the field of pancreatic surgery and postoperative follow-up. The pancreatoenteric anastomosis, regardless of the technique used, is a major cause for both morbidity and mortality after Whipple procedure. To overcome all problems resulting from anastomotic leakage, we used external drainage of the pancreatic duct. Methods: In 24 patients who underwent pancreaticoduodenectomy in our Department from 1986 to 1995, a modification to the standard Whipple procedure was performed. Instead of pancreaticoenteric anastomosis, external drainage of the pancreatic duct remnant was performed. The pancreatic duct was intubated with a silastic tube, the external end of which was sutured to the skin. All patients received substitution therapy with pancreatic enzymes. Results: Mortality in our group of patients was 4%. No complications due to the external drainage of the pancreatic duct were reported, while no patient developed diabetes mellitus after surgery. Conclusions: External drainage of the pancreatic duct remnant can be used alternatively to pancreatoenteric anastomosis after pancreatoduodenectomy. The technique is safe and simple to perform and appears to reduce overall operative time. It may be an option for patients with significant comorbidity and/or intraoperative hemodynamic instability which mandates expeditious completion of the operation. J. Surg. Oncol. 2001; 77:26,29. © 2001 Wiley-Liss, Inc. [source] Continuous spinal analgesia for labor and delivery in a parturient with hypertrophic obstructive cardiomyopathyACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 3 2002T. Okutomi Induction of labor under analgesia was planned for a 30-year-old-primiparous patient with hypertrophic obstructive cardiomyopathy (HOCM), as her fetal evaluation revealed intrauterine growth restriction at 38 weeks' gestation. However, regional analgesia during labor may present a potential risk for hemodynamic instability in patients with HOCM due to the possibility of a sympathetic block, as a result of vasodilation associated with the administration of local anesthesia. This case report demonstrates the successful management of the patient with analgesia provided by a continuous spinal catheter dosed with a continuous infusion of fentanyl and supplemental meperidine. Fetal surveillance monitoring included fetal pulse oximetry in addition to conventional cardiotocography, on the basis of which cesarean section was avoided. [source] Adenosine Induced Atrial Fibrillation Precipitating Polymorphic Ventricular TachycardiaPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 1 2000ILYA V. KAPLAN An 86-year-old female developed supraventricular tachycardia 36 hours after a myocardial infarction (MI). She developed atrial fibrillation and polymorphic ventricular tachycardia (PVT) following administration of 12 mg ofadenosine. The PVT caused hemodynamic instability with no response to cardioversion, but termination with procainamide. The heart is vulnerable to hemodynamically unstable, possibly lethal, PVT early after MI under some circumstances. This vulnerability may be exposed following administration of adenosine. Extra caution is warranted when using adenosine in the post-Mi period. [source] The PediSedate® device, a novel approach to pediatric sedation that provides distraction and inhaled nitrous oxide: clinical evaluation in a large case seriesPEDIATRIC ANESTHESIA, Issue 2 2007WILLIAM T. DENMAN MD FRCA Summary Background:, Pediatric sedation is of paramount importance but can be challenging. Fear and anticipatory anxiety before invasive procedures often lead to uncooperativeness. A novel device (PediSedate®) provides sedation through a combination of inhaled nitrous oxide and distraction (video game). We evaluated the acceptability and safety of the PediSedate® device in children. Methods:, We enrolled children between 3 and 9 years old who were scheduled to undergo surgical procedures that required general inhalational anesthesia. After the device was applied, he/she played a video game while listening to the audio portion of the game through the earphones. Nitrous oxide in oxygen was administered via the nasal piece of the headset starting at 50% and increasing to 70%, in 10% increments every 8 min. Treatment failures, vital signs, arterial oxygen saturation, depth of sedation, airway patency, side effects, acceptance of the device and parental satisfaction were all evaluated. Results:, Of 100 children included, treatment failure occurred in 18% mainly because of poor tolerance of the device. At least 96% of the children who completed the study exhibited an excellent degree of sedation, 22% had side effects, and none experienced serious airway obstruction. Nausea and vomiting were the most common side effects and no patients had hemodynamic instability. Conclusions:, The PediSedate® device combines nonpharmacologic with pharmacologic methods of sedation. Most of the children we evaluated were able to tolerate the PediSedate® device and achieved an adequate degree of sedation. [source] Low Central Venous Pressure with Milrinone During Living Donor HepatectomyAMERICAN JOURNAL OF TRANSPLANTATION, Issue 4 2010H.-G. Ryu Maintaining a low central venous pressure (CVP) has been frequently used in liver resections to reduce blood loss. However, decreased preload carries potential risks such as hemodynamic instability. We hypothesized that a low CVP with milrinone would provide a better surgical environment and hemodynamic stability during living donor hepatectomy. Thirty-eight healthy adult liver donors were randomized to receive either milrinone (milrinone group, n = 19) or normal saline (control group, n = 19) infusion during liver resection. The surgical field was assessed using a four-point scale. Intraoperative vital signs, blood loss, the use of vasopressors and diuretics and postoperative laboratory data were compared between groups. The milrinone group showed a superior surgical field (p < 0.001) and less blood loss (142 ± 129 mL vs. 378 ± 167 mL, p < 0.001). Vital signs were well maintained in both groups but the milrinone group required smaller amounts of vasopressors and less-frequent diuretics to maintain a low CVP. The milrinone group also showed a more rapid recovery pattern after surgery. Milrinone-induced low CVP improves the surgical field with less blood loss during living donor hepatectomy and also has favorable effects on intraoperative hemodynamics and postoperative recovery. [source] Routine Screening for Asymptomatic Abdominal Aortic Aneurysm in High-risk Patients Is Not Recommended in Emergency Departments That Are Frequently CrowdedACADEMIC EMERGENCY MEDICINE, Issue 11 2009Beatrice Hoffmann MD Abstract Objectives:, The objectives were to examine the feasibility of offering abdominal aortic aneurysm (AAA) screening to consecutive, asymptomatic high-risk patients in a busy emergency department (ED) and to compare the prevalence of undetected AAA among ED patients to the prevalence among similarly aged men from the general population. Methods:, A prospective cohort study was conducted at an academic community ED with an annual census of 58,000 patients. Dedicated study coordinators attempted to approach all consecutive male ED patients >50 years who presented in June,August 2007 during hours of high patient volume. To be eligible, older males had to have a smoking history or a family history of AAA. Patients were excluded if they presented with AAA symptoms, had a previous history of AAA screening or repair, had hemodynamic instability, or had an altered mental status. Study coordinators completed a brief interview with all enrolled subjects to obtain demographic and health information. A credentialed ED provider performed the ultrasound (US) screening exam and documented all findings. The US director reviewed representative images of the sonographic exam for correct visualization and measurement during quality assurance. The ED sonographers also completed a survey regarding their attitudes toward AAA screening in the ED. The primary study outcomes were the feasibility of AAA screening in the ED (screening rate, enrollment rate, US success rate, and providers' opinions) and the prevalence of AAA (aortic diameter of ,3.0 cm) in the study sample. Results:, During the 12-week study period, the study coordinators successfully approached 96% (700/729) of males > 50 years who were in the ED during study enrollment hours. Of those approached, 278 were eligible (40%), 25% were ineligible, 20% were not at high risk, and for 15% we could not determine risk factor status because of altered mental status. Of the 278 eligible, 196 (70%) underwent an US exam; 10% were not scanned because the providers were too busy, and 20% declined participation. Of those scanned, the ED sonographer was able to completely visualize and correctly measure the abdominal aortas of 71% of subjects. The prevalence rate of AAA in the study sample was 5.7% (95% confidence interval [CI] = 1.9% to 9.6%), similar to reported rates of 6 or 7% in other studies. More than half of the ED sonographers reported that US screening for AAA improved the quality of ED care (58%) and patient satisfaction (63%). However, 47% reported that AAA screening reduced ED efficiency, and 74% felt that the ED was not an appropriate setting for routine AAA screening. Conclusions:, Routine screening for asymptomatic AAA required substantial ED resources for a relatively low success rate of completed screens. The prevalence rate of AAA in our ED sample was not significantly different than prevalence estimates obtained from older men in the general population. ED sonographers reported benefits of screening in terms of improving the quality of emergency care and patient satisfaction, but also reported that it reduced operational efficiency. For EDs that have problems with crowding, we do not recommend implementing a routine screening program for AAA, even among high-risk patients. [source] Effect of a Miniaturized Cardiopulmonary Bypass System on the Inflammatory Response and Cardiac Function in Neonatal PigletsARTIFICIAL ORGANS, Issue 11 2009Ko Yoshizumi Abstract The cognitive impairment and hemodynamic instability after neonatal cardiac surgery with cardiopulmonary bypass (CPB) might be exacerbated by hemodilution. Therefore, this study investigated the impact of different bloodless prime volumes on the hemodynamics and the inflammatory response by a miniaturized CPB system in neonatal piglets. The bypass circuit consisted of a Capiox RX05 (Capiox Baby RX, Terumo Corp., Tokyo, Japan) oxygenator and 3/16 internal diameter arterial and venous polyvinyl chloride tubing lines, with a minimum 75 mL prime volume. Twelve 1-week-old piglets were placed on a mild hypothermic CPB (32°C) at 120 mL/kg/min for 2 h. The animals were divided into two groups, based on the volume of the prime solution. The priming volume was 75 mL in Group I and 175 mL in Group II. No blood transfusions were performed, and no inotropic or vasoactive drugs were used. The interleukin-6 (IL-6) and thrombin-antithrombin (TAT) complex levels, as well as right ventricular and pulmonary functions, were measured before and after CPB. Group I had low levels of IL-6 and TAT immediately after CPB (4370 ± 2346 vs. 9058 ± 2307 pg/mL, P < 0.01 and 9.9 ± 7.7 vs. 25.1 ± 8.8 ng/mL, P < 0.01, respectively). Group I had significantly improved cardiopulmonary function, cardiac index (0.22 ± 0.03 vs. 0.11 ± 0.05 L/kg/min, P < 0.001), and pulmonary vascular resistance index (7366 ± 2860 vs. 28 620 ± 15 552 dynes/cm5/kg, P < 0.01) compared with Group II. The miniaturized bloodless prime circuit for neonatal CPB demonstrated that the influence of hemodilution can reduce the subsequent inflammatory response. In addition, a low prime volume could therefore be particularly effective for attenuating pulmonary vascular resistance and right ventricular dysfunction in neonates. [source] Beneficial Effect of Preventative Intra-Aortic Balloon Pumping in High-Risk Patients Undergoing First-Time Coronary Artery Bypass Grafting,A Single Center ExperienceARTIFICIAL ORGANS, Issue 8 2009Qingcheng Gong Abstract Although intra-aortic balloon pumping (IABP) has been used widely as a routine cardiac assist device for perioperative support in coronary artery bypass grafting (CABG), the optimal timing for high-risk patients undergoing first-time CABG using IABP is unknown. The purpose of this investigation is to compare preoperative and preventative IABP insertion with intraoperative or postoperative obligatory IABP insertion in high-risk patients undergoing first-time CABG. We reviewed our IABP patients' database from 2002 to 2007; there were 311 CABG patients who received IABP treatment perioperatively. Of 311 cases, 41 high-risk patients who had first-time on-pump or off-pump CABG (presenting with three or more of the following criteria: left ventricular ejection fraction less than 0.45, unstable angina, CABG combined with aneurysmectomy, or left main stenosis greater than 70%) entered the study. We compared perioperatively the clinical results of 20 patients who underwent preoperative IABP placement (Group 1) with 21 patients who had obligatory IABP placement intraoperatively or postoperatively during CABG (Group 2). There were no differences in preoperative risk factors, except left ventricular aneurysm resection, between the two groups. There were no differences in indications for high-risk patients between the two groups. The mean number of grafts was similar. There were no significant differences in the need for inotropes, or in cerebrovascular, gastrointestinal, renal, and infective complications postoperatively. There were no IABP-related complications in either group. Major adverse cardiac event (severe hypotension and/or shock, myocardial infarction, and severe hemodynamic instability) was higher in Group 2 (14 [66.4%] vs. 1 [5%], P < 0.0001) during surgery. The time of IABP pumping in Group 1 was shorter than in Group 2 (72.5 ± 28.9 h vs. 97.5 ± 47.7 h, P < 0.05). The duration of ventilation and intensive care unit stay in Group 1 was significantly shorter than in Group 2, respectively (22.0 ± 1.6 h vs. 39.6 ± 2.1 h, P < 0.01 and 58.0 ± 1.5 h vs. 98.5 ± 1.9 h, P < 0.005). There were no differences in mortality between the two groups (n = 1 in Group 1 and n = 3 in Group 2). Preoperative and preventative insertion of IABP can be performed safely in selected high-risk patients undergoing CABG, with results comparable to those in patients who received obligatory IABP intraoperatively and postoperatively. Therefore, earlier IABP support as part of surgical strategy may help to improve the outcome in high-risk first-time CABG patients. [source] The Bradykinin Response and Early Hypotension at the Introduction of Continuous Renal Replacement Therapy in the Intensive Care UnitARTIFICIAL ORGANS, Issue 12 2001J. Stoves Abstract: We assessed the relationship of certain clinical variables (including bradykinin [BK] release and dialysis membrane) to initial mean arterial pressure (MAP) reduction in 47 patients requiring continuous renal replacement therapy (CRRT) in an intensive care unit. The pretreatment MAP was 84 ± 14 mm Hg for the group as a whole. The initial MAP reduction was 11.5 (7,20) mm Hg, occurring 4 to 8 min after connection. MAP reduction was 9 (6,15) mm Hg with polyacryonitrile (PAN) membranes versus 14 (5-19) mm Hg with polysulfone (PS) (not significant). There were positive correlations between MAP reduction and BK concentration at 3 (BK3; r = 0.58, p < 0.01) and 6 (BK6; r = 0.67, p < 0.001) min with PAN but not with PS. A greater reduction in MAP was seen in patients who were not receiving inotropic support (Mann-Whitney test, p < 0.01). BK3 and BK6 values for the PAN and PS groups were not significantly different. However, BK concentrations greater than 1,000 pg/ml were only seen with PAN (6 patients, MAP reduction 27 [17,31] mm Hg). There were positive (albumin) and negative (age; acute physiology, age, and chronic health evaluation score; C-reactive protein [CRP]; calcium) correlations with BK3/BK6 in the PAN and PS groups, some of which (albumin, CRP) reached statistical significance. In summary, MAP reduction at the start of CRRT correlates with BK concentration. The similarity of response with PAN and PS suggests an importance for other clinical factors. In this study, hemodynamic instability was more likely in patients with evidence of a less severe inflammatory or septic illness. [source] Two-stage liver transplantation: an effective procedure in urgent conditionsCLINICAL TRANSPLANTATION, Issue 1 2010Roberto Montalti Montalti R, Busani S, Masetti M, Girardis M, Di Benedetto F, Begliomini B, Rompianesi G, Rinaldi L, Ballarin R, Pasetto A, Gerunda GE. Two-stage liver transplantation: an effective procedure in urgent conditions. Clin Transplant 2010: 24: 122,126. © 2009 John Wiley & Sons A/S. Abstract:, Temporary portocaval shunt and total hepatectomy is a technique used in the presence of toxic liver syndrome because of fulminant hepatic failure, hepatic trauma, primary non-function (PNF), and eclampsia. We performed this technique on four patients. An indication for anhepatic state was severe hemodynamic instability in three of them. Etiologies of these three patients were as follows: PNF after liver transplantation, ischemic hepatitis after right hepatic artery embolization, and massive reperfusion syndrome during a liver transplantation. In the fourth patient, during the liver transplantation when hepatic artery was ligated, a kidney carcinoma in the donor graft was discovered. We decided to complete the hepatectomy and to construct a temporary portocaval shunt. Mean anhepatic phases were 19 h and 15 min. All patients survived the two-stage liver transplantation procedure without major complications. Our cases demonstrated that temporary portocaval shunt while awaiting urgent liver transplantation could be an effective "bridge" in selected patients who develop toxic liver syndrome; however, a short time between portocaval shunt and transplantation and careful intensive care managements are mandatory. [source] Is veno-venous bypass still needed during liver transplantation?CLINICAL TRANSPLANTATION, Issue 1 2009A review of the literature Abstract:, Orthotopic liver transplantation has been made feasible with intra-operative femoral-to-jugular veno-venous bypass (VVB) to redirect the blood from the lower extremities and the kidneys to the heart. This reduces hemodynamic instability and metabolic disturbances. However, complications such as thromboses with pulmonary thrombembolism or post-reperfusion syndrome were observed in up to 30% of the cases. The latter, recent developments of cava-sparing surgical techniques, shorter anhepatic times plus optimized anesthetic management have made the necessity for a routine use of VVB questionable. [source] | |||||||||||||||||||||||||