Adequate End-organ Perfusion Research Articles

Perioperative Left Ventricular Assist Device Use in Patients With Reduced Ejection Fraction Reduces Cardiac Surgery-Associated Acute Kidney Injury.

Background Cardiac surgery may precipitate acute kidney injury (AKI), particularly in patients with poor baseline cardiac function. This is thought to be due to intraoperative renal hypoperfusion, which results in increased morbidity and mortality. This study evaluated the perioperative use of the Impella LD (Abiomed, Danvers, MA) left ventricular assist device (LVAD) in the prevention of postoperative AKI in patients with reduced left ventricular ejection fraction (LVEF) undergoing cardiac surgery. Methods A retrospective analysis was performed at Northwest Medical Center, Tucson, AZ, USA, on patients undergoing valve surgery, coronary arterybypassgrafting(CABG), or both by a single surgeon. Those with preoperative LVEF ≤35% and preoperative serum creatinine ≥1 mg/dL were included and segregated based on intraoperative LVAD implantation. Postoperative renal functionwas assessed using serum creatinine levels and KDIGO (Kidney Disease Improving Global Outcomes) criteria to define AKI. Results Twenty-three patients were enrolled. There were no significant differences in age, demographics, baseline characteristics, or comorbidities between the treatment (n = 12) and the control group (n = 11). In the treatment group, 8% developed AKI by POD#7, while 64% of controls did. The treatment group had a significantly lower mean creatinine change from POD#0-7 (0.07 vs. 0.59, p = 0.02). However, there was no significant difference between groups in the mean creatinine change from baseline to discharge (0.46 vs. 0.42, p = 0.47). Conclusions Our study suggests that intraoperative Impella implantation may reduce the incidence of early postoperative AKI. LVAD implantation is an approach to increase and ensure adequate end-organ (renal) perfusion andcan improve postoperative recovery without dialysis requirements. Additional studies are required to understand its protective effects during the perioperative period fully.

End organ perfusion and pediatric microcirculation assessment.

Cardiovascular instability and reduced oxygenation are regular perioperative critical events associated with anesthesia requiring intervention in neonates and young infants. This review article addresses the current modalities of assessing this population's adequate end-organ perfusion in the perioperative period. Assuring adequate tissue oxygenation in critically ill infants is based on parameters that measure acceptable macrocirculatory hemodynamic parameters such as vital signs (mean arterial blood pressure, heart rate, urinary output) and chemical parameters (lactic acidosis, mixed venous oxygen saturation, base deficit). Microcirculation assessment represents a promising candidate for assessing and improving hemodynamic management strategies in perioperative and critically ill populations. Evaluation of the functional state of the microcirculation can parallel improvement in tissue perfusion, a term coined as "hemodynamic coherence". Less information is available to assess microcirculatory disturbances related to higher mortality risk in critically ill adults and pediatric patients with septic shock. Techniques for measuring microcirculation have substantially improved in the past decade and have evolved from methods that are limited in scope, such as velocity-based laser Doppler and near-infrared spectroscopy, to handheld vital microscopy (HVM), also referred to as videomicroscopy. Available technologies to assess microcirculation include sublingual incident dark field (IDF) and sublingual sidestream dark field (SDF) devices. This chapter addresses (1) the physiological basis of microcirculation and its relevance to the neonatal and pediatric populations, (2) the pathophysiology associated with altered microcirculation and endothelium, and (3) the current literature reviewing modalities to detect and quantify the presence of microcirculatory alterations.

Evaluation of Blood Lactate Concentrations as a Marker for Resuscitation and Prognosis in Patients with Major Burns

Background Severe burns require appropriate fluid management in the acute phase. A massive volume of intravenous fluid is usually required to ensure adequate end-organ perfusion. Lactate is a product of anaerobic metabolism. A high level of lactate in tissue is direct indication of tissue hypoxia. The correlation between serum lactate and clinical outcome has been well accepted in hemorrhagic and septic shock. However, studies on its use in predicting mortality and morbidity of major burn patients in particular is sparse. Early prediction of outcome in patients with major burn is very likely to aid suitable modification of management strategies. Objective To assess the role of serum lactate measurement as the predictor burn patient's outcome (survivors and non-survivors). Patients and Methods 30 patients with major burn (more than 20% of TBSA) were included. This includes operated/ non-operated patients. Of the 30 patients, 20 were males and 10 were females. All adult burned patients admitted within the first 24h post burn were included in the study. Patients admitted after 24h from the thermal injury, or those who were discharged or died 48h after admission were excluded. Results Serial blood lactate measures were better as a prognostic tool than isolated measure. Reduction or normalization of lactate levels 24 hours after admission was significantly associated with a higher probability of survival. This study confirms the prognostic value of serum lactate for mortality in patients with major burns as serial blood lactate measurements predict mortality in these patients. Conclusion Although many studies reiterate the importance of blood lactate and lactate clearance in predicting mortality in burn patients, the role of these markers in therapy titration is ambiguous. Overzealous fluid resuscitation can cause fluid overload and acute respiratory distress syndrome. little regional data are available to establish the importance of blood lactate. We have demonstrated the association of blood lactate in the first 36 hours of the burn injury with mortality. Further large multicenter prospective studies are required.

EMD-57033 Augments the Contractility in Porcine Myocardium by Promoting the Activation of Myosin in Thick Filaments.

Sufficient cardiac contractility is necessary to ensure the sufficient cardiac output to provide an adequate end-organ perfusion. Inadequate cardiac output and the diminished perfusion of vital organs from depressed myocardium contractility is a hallmark end-stage of heart failure. There are no available therapeutics that directly target contractile proteins to improve the myocardium contractility and reduce mortality. The purpose of this study is to present a proof of concept to aid in the development of muscle activators (myotropes) for augmenting the contractility in clinical heart failure. Here we use a combination of cardiomyocyte mechanics, the biochemical quantification of the ATP turnover, and small angle X-ray diffraction on a permeabilized porcine myocardium to study the mechanisms of EMD-57033 (EMD) for activating myosin. We show that EMD increases the contractility in a porcine myocardium at submaximal and systolic calcium concentrations. Biochemical assays show that EMD decreases the proportion of myosin heads in the energy sparing super-relaxed (SRX) state under relaxing conditions, which are less likely to interact with actin during contraction. Structural assays show that EMD moves the myosin heads in relaxed muscles from a structurally ordered state close to the thick filament backbone, to a disordered state closer to the actin filament, while simultaneously inducing structural changes in the troponin complex on the actin filament. The dual effects of EMD on activating myosin heads and the troponin complex provides a proof of concept for the use of small molecule muscle activators for augmenting the contractility in heart failure.

Riding The Storm: Utilizing VA-ECMO As A Bridge To Recovery In A Patient With Fulminant Necrotizing Eosinophilic Myocarditis

<h3>Background</h3> Fulminant necrotizing eosinophilic myocarditis (FNEM) is a rare form of eosinophilic myocarditis characterized by new onset heart failure often requiring inotropic and mechanical circulatory support (MCS). Early endomyocardial biopsy (EMB) and prompt immunosuppressive therapy can prevent further decompensation and death, especially in patients presenting with cardiogenic shock. <h3>Case presentation</h3> A 52-year-old female with prior history of mild asthma presented with dyspnea and chest tightness. Vital signs were significant for temperature of 100.9 F, pulse of 140 in sinus rhythm and blood pressure of 89/70. Physical exam was remarkable for crackles at the mid-lower lung fields bilaterally. Baseline EKG showed sinus tachycardia, septal Q waves with ST elevation in V1, V2 and diffuse subtle ST-depressions in the other leads (Figure 1A). Troponin T was elevated to 3.25 ng/ml, pro-BNP was 23,424 pg/ml, CRP was 26.2mg/dl and ESR to 116mm/hour . A 2D echo showed severely reduced left ventricular systolic function with left ventricular ejection fraction (LVEF) of 25-29%, normal left ventricular dimensions, and mildly reduced right ventricular systolic function. Emergent coronary angiography demonstrated no significant coronary artery disease. Right heart catheterization showed a pulmonary artery saturation of 55%, fick cardiac index 1.72, systemic vascular resistance (SVR) of 2128 dynes and elevated bi-ventricular filling pressure (mean right atrial pressure; 23, mean pulmonary capillary wedge pressure; 30mmHg). An endomyocardial biopsy was performed which was consistent with necrotizing eosinophilic myocarditis (Figure 1B). The patient was started on pulse dose steroids. During the first 24 hours she continued to be hemodynamically unstable and required two inotropes to maintain adequate end-organ perfusion. She was placed on VA-ECMO simultaneous with an IABP for left ventricular unloading. Eventually, after being on mechanical support for 7 days, her hemodynamic status improved and her biventricular function completely normalized by day 9. Mechanical and inotropic support was successfully weaned. Patient was discharged on day 23 with a goal to continue a long steroid taper for 6 months. <h3>Conclusion</h3> FNEM is an extremely rare and life threatening pathology that often presents with cardiogenic shock. It is eminently treatable if recognized early during its course. Early EMB should be performed to guide decisions for immunosuppressive therapy. We present a case of FNEM with extremis shock successfully managed with early MCS as bridge-to-recovery.

Hybrid and parallel extracorporeal membrane oxygenation circuits

Hybrid and parallel extracorporeal membrane oxygenation circuits

Abstract 17170: Does Cardiopulmonary Bypass Provide Adequate End-Organ Perfusion?

Introduction: Our clinical experience in cardiac surgery teaches us that a subset of patients show signs of unexplained end-organ hypoperfusion after an otherwise unremarkable procedure. The objective of this study is to comprehensively examine cardiopulmonary bypass (CPB) management parameters and end-organ perfusion. Hypothesis: Despite advancements in CPB management, CPB does not provide adequate end-organ perfusion. Methods: Retrospective analysis was performed using data from 1462 cardiac operations performed from 2/2019 to 4/2020, excluding circulatory arrest and non-CPB cases. CPB management parameters included cardiac index (CI), mean arterial pressure (MAP), vasopressor-phenylephrine use, lines and bladder temperatures, hemoglobin (Hgb), indexed oxygen delivery (iDO 2 ), and intravenous fluid infusion. End-organ perfusion markers included lactate levels, mixed venous oxygen saturation (SvO 2 ), oxygen consumption (VO 2 ), and arterial pH. Results were expressed as means with first standard deviation. Results: During CPB, CI, MAP, iDO 2 and Hgb were 2.2 ± 0.4 l/min/m 2 , 67 ± 16 mmHg, 270 ± 71 ml/min/m 2 , and 9.3 ± 1.6 g/dl respectively (Figure 1). Phenylephrine cumulative dose increased with CPB duration, 11 ± 9 mg at 1h and 20 ± 15 mg at 2h. Fluid administration showed similar trend. Core mean temperature was maintained with nadir being 33.5 ± 3.4°C. SvO 2 rapidly increased with institution of CPB, peaking at 85%, and then slowly declined. Inversely, VO 2 dropped and then slowly increased. Lactate continuously increased with duration of CPB. Conclusions: Our findings suggest that despite hemodynamic values being maintained at goal by continuously high vasopressor use and fluid administration during CPB, tissue perfusion was inadequate.Our study suggests that, using data-driven approaches, it may be time to revisit the assumptions regarding all aspects of managing CPB.

Transaortic or Pulmonary Artery Drainage for Left Ventricular Unloading in Venoarterial Extracorporeal Life Support: A Porcine Cardiogenic Shock Model

The peripheral venoarterial extracorporeal life support (V-A ECLS) in cardiogenic shock (CS) may lead to LV overload. The transaortic suction device (Impella, ABIOMED Inc., Danvers, MA) was compared to the pulmonary artery (PA) drainage, for LV unloading efficacy during V-A ECLS in a porcine cardiogenic shock model. A dedicated CS model included 12 swine (21 ± 1.8-week-old and weighing 54.3 ± 4.6 kg) supported with V-A ECLS and randomized to Impella or PA-related LV drainage. LV unloading and end-organ perfusion were evaluated through the PA catheter and LV pressure/volume analysis. The LV end-diastolic volume sharply dropped with Impella (143.6 ± 67.4 vs 123 ± 75.7 mL) compared to a slight decrease in the PA cannula group (134.1 ± 39.9 vs 130.1 ± 34.7 mL), resulting in an overall stroke work and pressure-volume area reductions with both techniques. However, stroke work reduction was more significant in the Impella group (V-A ECLS 3998.8 ± 2027.6 vs V-A ECLS + Impella 1796.9 ± 1033.9 mm Hg × mL, P = 0.016), leading to a more consistent pressure-volume area reduction (Impella reduction 34.7% vs PA cannula reduction 9.7%) In terms of end organ perfusion, central and mixed O2 saturation improved with V-A ECLS, and subsequently, remaining unchanged with either Impella or PA cannula as unloading strategy (SVmO2: Impella 86.0 ± 5.8 vs 87.8 ± 5.8; PA cannula 82.5 ± 10.7 vs 82.5 ± 11.3 %). Transaortic suction and PA drainage provided effective LV unloading during V-A ECLS while maintaining adequate end-organ perfusion. Impella provides a greater LV unloading effect and reduces more effectively the total LV stroke work.

Veno-arterial extracorporeal membrane oxygenation: Special reference for use in 'post-cardiotomy cardiogenic shock'-A review with an Indian perspective.

The ultimate goals of cardiovascular physiology are to ensure adequate end-organ perfusion to satisfy the local metabolic demand, to maintain homeostasis and achieve ‘milieu intérieur’. Cardiogenic shock is a state of pump failure which results in tissue hypoperfusion and its associated complications. There are a wide variety of causes which lead to this deranged physiology, and one such important and common scenario is the post-cardiotomy state which is encountered in cardiac surgical units. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an important modality of managing post-cardiotomy cardiogenic shock with variable outcomes which would otherwise be universally fatal. VA-ECMO is considered as a double-edged sword with the advantages of luxurious perfusion while providing an avenue for the failing heart to recover, but with the problems of anticoagulation, inflammatory and adverse systemic effects. Optimal outcomes after VA-ECMO are heavily reliant on a multitude of factors and require a multi-disciplinary team to handle them. This article aims to provide an insight into the pathophysiology of VA-ECMO, cannulation techniques, commonly encountered problems, monitoring, weaning strategies and ethical considerations along with a literature review of current evidence-based practices.

Vitamin C as Prevention in Burn Sepsis

Background: Burns is a severe public health problem. Its poor treatment can lead to the worst complication called sepsis. Since sepsis decreases the immune system, the critical therapy management of burn sepsis ensures adequate end-organ perfusion. According to the Surviving Sepsis Campaign Bundle, immediate identification and management in the initial hours generate a better outcome. The inflammation of burn injury is known to increase ROS production, which causes cellular damage, sepsis, and MODS. This condition initiates the importance of ROS scavenger. Methods: This literature reviewed from relevant works of literature which searched from major journal databases of WHO, Pubmed, Elsevier, JAMA, Springer, NEJM, which published from 2013 until 2018 Results: Vitamin C is a cheap but effective antioxidant, which acts as a ROS scavenger and reduces the fluid requirement in burn resuscitation for the prevention of burn sepsis Conclusion: Vitamin C could be recommended as adjuvant therapy in the prevention of burn sepsis

On-pump beating-heart coronary artery bypass grafting in high-risk patients: A systematic review and meta-analysis.

Operative technique for surgical myocardial revascularization in high-risk patients remains an argument of debate. On-pump coronary artery bypass graft (CABG) with cardioplegic arrest and off-pump CABG have intrinsic limitations. The hybrid approach of on-pump beating-heart CABG (OPBHC) has been proposed over the years with conflicting results. This systematic review and meta-analysis intends to summarize the contemporary literature. A literature search was conducted through major electronic databases. The systematic review provided a total of 279 articles, of those 17 studies were included in the present study. Compared with on-pump CABG, OPBHC patients showed a preoperative higher risk profile but had reduced early mortality (risk ratio [RR], 0.59, 95% CI, 0.36-0.97) and reduced postoperative stroke (RR, 0.60, 95% CI, 0.39-0.91). Also, interesting trends towards reduced postoperative intra-aortic balloon pump use (RR, 0.56, 95% CI, 0.31-1.01) and myocardial infarction (RR, 0.48, 95% CI, 0.22-1.07) were observed. Baseline characteristics and postoperative complications were similar between OPBHC and off-pump CABG, but limited data are available. The risk of incomplete revascularization in OPBHC is lower than off-pump CABG (RR, 0.53, 95% CI, 0.33-0.87) but higher than conventional on-pump CABG (RR, 1.71, 95% CI, 1.23-2.39). OPBHC is an effective technique to perform surgical revascularization in high-risk patients as preventing haemodynamic deterioration and guaranteeing adequate end-organ perfusion. OPBHC represents an alternative technique to on-pump and off-pump CABG, in those cases in which complications deriving from cardioplegic arrest or manipulation of the heart are more likely. For these reasons, OPBHC might be useful in patients with recent myocardial infarction or with left ventricular dysfunction.

The Obese Patient: Facts, Fables, and Best Practices.

The prevalence of obesity continues to rise worldwide, and anesthesiologists must be aware of current best practices in the perioperative management of the patient with obesity. Obesity alters anatomy and physiology, which complicates the evaluation and management of obese patients in the perioperative setting. Gastric point-of-care ultrasound (PoCUS) is a noninvasive tool that can be used to assess aspiration risk in the obese patient by evaluating the quantity and quality of gastric contents. An important perioperative goal is adequate end-organ perfusion. Standard noninvasive blood pressure (NIBP) is our best available routine surrogate measurement, but is vulnerable to greater inaccuracy in patients with obesity compared to the nonobese population. Current NIBP methodologies are discussed. Obese patients are at risk for wound and surgical site infections, but few studies conclusively guide the exact dosing of intraoperative prophylactic antibiotics for them. We review evidence for low-molecular-weight heparins and weight-based versus nonweight-based administration of vasoactive medications. Finally, intubation and extubation of the patient with obesity can be complicated, and evidence-based strategies are discussed to mitigate danger during intubation and extubation.

Staged surgical repair for infants with interrupted aortic arch

BackgroundInterrupted aortic arch (IAA) is a rare congenital cardiac anomaly, which necessitates surgical treatment. There are several surgical strategies for corrective repair of IAA, such as one-stage repair, rapid two-stage repair and two-stage repair. Here, we reported our surgical result of staged-repair policy for the patients with IAA. MethodFrom November 2003 to July 2015, there were 14 patients (8 boys, 6 girls) with IAA treated by us. Except one teenager patient, we routinely used intravenous infusion of prostaglandin E1 for all the infant patients (n = 13) to keep adequate end organ perfusion before the first surgical intervention. Surgical repair was performed after the perfusion of end organs recovered. ResultTwo patients (1 teenager and 1 infant with one-stage surgery) were excluded from this study. At the time of the first surgery, we did the first-stage surgery with anastomosis in between aortic arch and descending aorta, division of patent ductus arteriosus and banding of pulmonary trunk through left thoracotomy. The overall surgical survival rate of the first surgery was 100% (12/12). At the time of the second surgery, corrective repair was done under cardiopulmonary bypass through median sternotomy. The surgical survival rate of the corrective surgery was also 100%. There is no late death during follow-up for 9 years (range 4.2–15.0 years). ConclusionOut of several surgical strategies for the infants with IAA, staged repair still could be a treatment option to achieve satisfied surgical result.

Extracorporeal life support for severe cardiogenic shock induced by diltiazem intoxication

Introduction. Management of cardiogenic shock caused by severe drug intoxication is always challenging. In case of multidrug intoxication, a result, despite aggressive medical therapy, is often unpredictable. Utilization of extracorporeal life support devices in these cases has been suggested and reported results are promising. Case report. We presented a case of profound cardiogenic and distributive shock caused by suicidal intoxication with diltiazem and anionic surfactant ingestion in a 36-year-old woman. The patient ingested more than 90 tablets of diltiazem of 90 mg (ingested dose of 8.1 g), and 4 pieces of household toilet refresh agent containing anionic surfactant. During the admission, systemic blood pressure was 65/40 mmHg, heart rate 45 beats per minute, with signs of metabolic acidosis. The patient underwent several repeated gastric lavages. Emergent fluid resuscitation, calcium gluconate, insulin and vasopressive agents (dopamine and noradrenaline) infusions were administered with negligible effect. Due to progressive and refractory cardiogenic shock with signs of multiorgan failure, a decision was made to put the patient on venoarterial extracorporeal membrane oxygenator. Immediately after starting the extracorporeal membrane oxygenation, diuresis was established. During the next 36 h, an adequate end-organ perfusion was achieved with complete reversal of multiorgan failure. After the successful restoration of all major organ functions, the patient was successfully decannulated and discharged from the hospital after 10 days in a good condition. Conclusion. In severe cases of refractory cardiogenic and distributive shock due to diltiazem and other poison intoxication, venoarterial extracorporeal membrane oxygenation could allow additional circulatory support providing the bonus time for endogenous clearance of toxins. Venoarterial extracorporeal membrane oxygenation could be used in conjunction with the optimal medical therapy aiming to the restoration of end-organ perfusion and allowing for intrinsic drug and toxin metabolism and natural elimination.

Mechanisms, Clinical Implications, and Treatment of Intradialytic Hypotension.

Individuals with ESKD requiring maintenance hemodialysis face a unique hemodynamic challenge, typically on a thrice-weekly basis. In an effort to achieve some degree of euvolemia, ultrafiltration goals often involve removal of the equivalent of an entire plasma volume. Maintenance of adequate end-organ perfusion in this setting is dependent on the institution of a variety of complex compensatory mechanisms. Unfortunately, secondary to a myriad of patient- and dialysis-related factors, this compensation often falls short and results in intradialytic hypotension. Physicians and patients have developed a greater appreciation for the breadth of adverse outcomes associated with intradialytic hypotension, including higher cardiovascular and all-cause mortality. In this review, we summarize the evidence for adverse outcomes associated with intradialytic hypotension, explore the underlying pathophysiology, and use this as a basis to introduce potential strategies for its prevention and treatment.

No-268-The Diagnosis and Management of Ovarian Hyperstimulation Syndrome.

To review the clinical aspects of ovarian hyperstimulation syndrome and provide recommendations on its diagnosis and clinical management. These guidelines will assist in the early recognition and management of ovarian hyperstimulation. Early recognition and prompt systematic supportive care will help avert poor outcomes. Medline, Embase, and the Cochrane database were searched for relevant articles, using the key words "ovarian hyperstimulation syndrome" and "gonadotropins," and guidelines created by other professional societies were reviewed. The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report.

Did the beneficial renal outcomes with vasopressin VANISH?

Sepsis is the most common cause of infection-related death and is increasing in incidence. This disease state has a high mortality rate and is costly, with annual costs in the United States exceeding $24 billion (1). Therefore, optimal treatment of patients with septic shock is paramount. After aggressive fluid resuscitation, vasoactive agents are the mainstay of therapy to ensure adequate end organ perfusion. However, there are limited data regarding the optimal approach to the utilization of these agents beyond initial therapy. The 2012 Surviving Sepsis Campaign Guidelines (2) recommend norepinephrine (NE) as the first line vasoactive agent and epinephrine, vasopressin (AVP), or, in some circumstances, phenylephrine, as second line agents. However, data are not robust to guide the practitioner to the most appropriate second vasoactive agent to utilize and more information comparing outcomes between agents is needed.

Beneficial effects of levosimendan on survival in patients undergoing extracorporeal membrane oxygenation after cardiovascular surgery

BackgroundThe impact of levosimendan treatment on clinical outcome in patients undergoing extracorporeal membrane oxygenation (ECMO) support after cardiovascular surgery is unknown. We hypothesized that the beneficial effects of levosimendan might improve survival when adequate end-organ perfusion is ensured by concomitant ECMO therapy. We therefore studied the impact of levosimendan treatment on survival and failure of ECMO weaning in patients after cardiovascular surgery. MethodsWe enrolled a total of 240 patients undergoing veno-arterial ECMO therapy after cardiovascular surgery at a university-affiliated tertiary care centre into our observational single-centre registry. ResultsDuring a median follow-up period of 37 months (interquartile range 19–67 months), 65% of patients died. Seventy-five per cent of patients received levosimendan treatment within the first 24 h after initiation of ECMO therapy. Cox regression analysis showed an association between levosimendan treatment and successful ECMO weaning [adjusted hazard ratio (HR) 0.41; 95% confience interval (CI) 0.22–0.80; P=0.008], 30 day mortality (adjusted HR 0.52; 95% CI 0.30–0.89; P=0.016), and long-term mortality (adjusted HR 0.64; 95% CI 0.42–0.98; P=0.04). ConclusionsThese data suggest an association between levosimendan treatment and improved short- and long-term survival in patients undergoing ECMO support after cardiovascular surgery.

Ventricular tachycardia ablation: a comprehensive review for anesthesiologists.

Percutaneous catheter ablation is being increasingly performed in patients with recurrent ventricular tachycardia (VT) unresponsive to medical treatment. Optimal management of patients requires careful consideration of the severity of the underlying cardiac disease, the anesthetic drug interactions, and the procedural technique during VT mapping and ablation. The goal is to choose an anesthetic technique that has the least effect on arrhythmogenicity, allowing reproducibility of the VT in the electrophysiology laboratory. Anesthetics can alter action potential and ventricular depolarization directly through their effects on ion channels and gap junctions, as well as indirectly via their effects on the autonomic nervous system. Furthermore, maintaining hemodynamic stability and monitoring for adequate end-organ perfusion are additional challenges. In this review, we provide a comprehensive update on the currently performed VT ablation procedures and their anesthetic considerations.

The Diagnosis and Management of Ovarian Hyperstimulation Syndrome

ObjectiveTo review the clinical aspects of ovarian hyperstimulation syndrome and provide recommendations on its diagnosis and clinical management OutcomesThese guidelines will assist in the early recognition and management of ovarian hyperstimulation. Early recognition and prompt systematic supportive care will help avert poor outcomes EvidenceMedline, Embase, and the Cochrane database were searched for relevant articles, using the key words “ovarian hyperstimulation syndrome” and “gonadotropins,” and guidelines created by other professional societies were reviewed. ValuesThe quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care Recommendations for practice were ranked according to the method described in that report (Table 1). Recommandations1.Once the diagnosis of ovarian hyperstimulation syndrome is made, disease severity should be classified as mild, moderate, severe, or critical. (III-B)2.The physician prescribing gonadotropins should inform each woman of her personal risk for ovarian hyperstimulation syndrome. (III-A)3.In areas where patients do not have ready access to physicians familiar with the diagnosis and management of ovarian hyperstimulation syndrome, the physician prescribing gonadotropins should ensure that women are made aware that they should contact a physician or a member of the team within the hospital unit who has relevant experience, should the need arise. (III-B)4.Outpatient management is recommended for women with mild and moderate ovarian hyperstimulation syndrome. If outpatient management for more severe ovarian hyperstimulation syndrome is to be undertaken, the physician should ensure that the woman is capable of adhering to clinical instructions and that there is a system in place to assess her status every 1 to 2 days. (III-A)5.Paracentesis should be performed in admitted patients with tense ascites to alleviate their discomfort. (II-2B)6.Outpatient culdocentesis should be considered for the prevention of disease progression in moderate or severe ovarian hyperstimulation syndrome. (II-2B)7.Women with severe and critical ovarian hyperstimulation syndrome should be admitted to hospital for intravenous hydration and observation. (III-A)8.Intravenous hydration should be initiated with a crystalloid solution to prevent hemoconcentration and provide adequate end-organ perfusion. If end-organ perfusion is not maintained with a crystalloid solution, an alternate colloid solution should be administered. (II-2B)9.Pain relief in admitted patients should be managed with acetaminophen and/or opioid analgesics. (III-B) Non-steroidal anti-inflammatory drugs with antiplatelet properties should not be used (III-B)10.Women with severe ovarian hyperstimulation syndrome should be considered for treatment with prophylactic doses of anticoagulants. (II-2B)11.Critical ovarian hyperstimulation syndrome should be managed by a multidisciplinary team, according to the end organ affected (III-C)