Duration Of Inotropic Support Research Articles

Perioperative Cannabinoids Significantly Reduce Postoperative Opioid Requirements in Patients Undergoing Coronary Artery Bypass Graft Surgery.

Background Opioids, commonly used to control pain associated with surgery, are known to prolong the duration of mechanical ventilation and length of hospital stay. A wide range of adjunctive strategies are currently utilized to reduce postoperative pain, such as local and regional nerve blocks, nerve cryoablation, and adjunctive medications. We hypothesized that dronabinol (a synthetic cannabinoid) in conjunction with standard opioid pain management will reduce opioid requirements to manage postoperative pain. Methods Sixty-eight patients who underwent isolated first-time coronary artery bypass graft surgery were randomized to either the control group, who received only standard opioid-based analgesia, or the dronabinol group, who received dronabinol (a synthetic cannabinoid) in addition to standard opioid-based analgesia. Dronabinol was given in the preoperative unit, before extubation in the ICU, and after extubation on the first postoperative day. Preoperative, intraoperative, and postoperative parameters were compared under an IRB-approved protocol. The primary endpoints were the postoperative opioid requirement, duration of mechanical ventilation, and ICU length of stay, and the secondary endpoints were the duration of inotropic support needed, left ventricular ejection fraction (LVEF), and the change in LVEF. This study was undertaken at Northwest Medical Center, Tucson, AZ, USA. Results Sixty-eight patients were randomized to either the control group (n = 37) or the dronabinol group (n = 31). Groups were similar in terms of demographic features and comorbidities. The total postoperative opioid requirement was significantly lower in the dronabinol group [39.62 vs 23.68 morphine milligram equivalents (MMEs), p = 0.0037], representing a 40% reduction. Duration of mechanical ventilation (7.03 vs 6.03h, p = 0.5004), ICU length of stay (71.43 vs 63.77h, p = 0.4227), and inotropic support requirement (0.6757 vs 0.6129 days, p = 0.7333) were similar in the control and the dronabinol groups. However, there was a trend towards lower durations in each endpoint in the dronabinol group. Interestingly, a significantly better preoperative to postoperative LVEF change was observed in the dronabinol group (3.51% vs 6.45%, p = 0.0451). Conclusions Our study found a 40% reduction in opioid use and a significantly greater improvement in LVEF in patients treated with adjunctive dronabinol. Mechanical ventilation duration, ICU length of stay, and inotropic support requirement tended to be lower in the dronabinol group, though did not reach statistical significance. The results of this study, although limited by sample size, are very encouraging and validate our ongoing investigation.

Description and outcomes of Afro-Caribbean children treated for multisystem inflammatory syndrome in the French West Indies

IntroductionSeveral studies have reported a higher frequency and greater morbidity and mortality of multisystem inflammatory syndrome in children (MIS-C) of black African descent. ObjectivesWe aimed to describe the clinical, laboratory and echocardiographic characteristics as well as outcomes of children with MIS-C requiring admission to a pediatric intensive care unit (PICU) in the French West Indies (FWI), where the majority of the population is Afro-Caribbean. MethodsAmbidirectional observational cohort study between April 1, 2020 and August 31, 2022. Children (age ≤18 years) with MIS-C and organ failure were included. Every patient was monitored and treated following the same protocol, with repeated biological tests, echocardiography, intravenous steroids and polyvalent immunoglobulins. The primary outcomes were clinical, laboratory and echocardiography characteristics. ResultsForty children (median age 7 years, range: 5–11) were included. The majority (77 %) were included prospectively. Thirty-five (87 %) had gastrointestinal symptoms, 30 (75 %) presented initial heart failure (with persisting diastolic dysfunction at day 7) and 18 (45 %) had pericarditis. Sixteen (40 %) were in cardiogenic shock and required inotropic support. Median duration of inotropic support and hospitalization in PICU were respectively 4 and 5 days. The evolution curves of the inflammatory variables matched after treatment. The clinical outcomes were favorable. The Delta variant was associated with the highest incidence of MIS-C. ConclusionThis is the first description of MIS-C course among children of Afro-Caribbean descent. The outcomes were good, without any death or cardiac sequelae. Our work does not support an ethnic susceptibility for severity of MIS-C in Afro-Caribbean population.

Abstract 13262: A Self-Administered Home Inotrope Program for Unfunded Patients With End-Stage Heart Failure

Introduction: Uninsured patients with inotrope-dependent end-stage heart failure (HF) pose a formidable challenge to the healthcare system and innovative solutions are required. We created a health system funded home program for palliative and bridge-to-funding inotrope strategies for unfunded patients. Herein, we report our updated experiences. Methods: We reviewed records of all patients enrolled in the home inotrope program since inception in 2019. Patients must have demonstrated a low cardiac index that was stabilized on a single inotrope. Advanced HF and palliative care consultations are mandatory. Next, a multidisciplinary team educates the patient via a teach-teach back method on how to self-administer intravenous inotropes via a provided continuous infusion pump. After discharge, patients attended weekly clinic appointments for assessment and dressing changes. Clinic appointments, supplies, and medications are provided by the health system at minimal cost to the patient. This project was deemed IRB exempt as a quality improvement project. Results: Thus far the program has enrolled 15 uninsured patients through April 24, 2023 (table). The median duration of inotropic support was 70 (32-143) days. Patients remained at home for 90% of the 1500 total supported days. To date, one patient has received a heart transplant and three patients have received LVAD surgery after obtaining health insurance. Three (20%) patients experienced a catheter-associated infection, with two developing bacteremia. All patients endorsed satisfaction with increased time spent outside of the hospital. This was estimated to have saved >$2,363,000 in self-pay discounted charges for a general care telemetry bed and >$586,000 in professional charges (CPT 99233, estimates via price transparency act). Conclusion: A self-administered home inotrope program for select patients is feasible, safe, and cost-effective. It may also serve as a bridge to funding for advanced therapies.

Incidence of new morbidity in children on discharge from pediatric intensive care unit of a developing country.

Objective: To determine the incidence of newly acquired morbidity, its categorization, and to identify the associated risk factors among children upon being discharged from the PICU. Study Design: Prospective Longitudinal Cohort study. Setting: Multidisciplinary PICU of Aga Khan University Hospital. Period: October 2022 to March 2023. Material & Methods: Patients who were readmitted to the PICU, deceased, or lost to follow-up during the study were excluded. The functional status was assessed using FSS at baseline, PICU discharge, and at 3 months to measure newly acquired morbidity and dysfunction. All data was collected on a structured proforma. Categorical variables were presented as absolute values and percentages, and continuous variables were expressed as means ± SD or medians with interquartile range or proportions as applicable and considered statistically significant level if p value is ≤ 0.05. Results: A total 96 patients were discharged alive from PICU and 85 of them were included in this study. The mean age was 5.27 ± 5.01 years. The major diagnostic categories were acute respiratory illnesses (25.89%), cardiovascular disorders (21.18%), and neurological disorders (16.47%). 43.53% of the patients underwent surgical intervention. The mean PRISM score at admission was 4.32 ± 5.84. The incidence of morbidity was 40% (34/85) at PICU discharge and 5.8% at 3 months. Longer duration of vasoactive medications, arterial catheterization, mechanical ventilation and PICU stay were associated with new morbidity in critically ill children on discharge from PICU. Conclusion: At PICU discharge, the incidence of new morbidity among critically ill pediatric patients was 40%, which reduced to 5.8% at 3 months. Patients with hemodynamic instability, longer duration of inotropic support and those on prolonged mechanical ventilation had longer PICU stay and exhibited increased risk for new morbidity development. The majority of patients (>82%) exhibited either good functional status or mild dysfunction upon discharge.

RETROSPECTIVE STUDY OF GLENN SHUNT WITHOUT CARDIOPULMONARY BYPASS

The bidirectional Glenn shunt improves systemic arterial oxygen saturation without increasing ventricular work or pulmonary vascular resistance (1).BDG is a commonly performed procedure for a variety of cyanotic congenital heart diseases that lead eventually to a single ventricle repair (2).It is an important intermediate palliation in patients with a structurally or functionally univentricular heart who are ultimately destined to have a Fontan-type operation (3). Avoidance of cardiopulmonary bypass (CPB) has the advantage of early extubation, less blood products, reduced requirement and duration of inotropic support (4).The end-to-side anastomosis of the superior vena cava (SVC) to the right or left pulmonary artery, which may be converted to a total cavopulmonary connection later, can effectively both increase arterial blood oxygen saturation of the patients and decrease volume overload of the ventricle (5)

THE EFFECTS OF PULMONARY HYPERTENSION ON OUTCOMES OF MITRAL VALVE SURGERY

This study aimed to assess the effect of pulmonary hypertension on the outcomes of mitral valve surgery in terms of operative mortality, dependence on inotropic agents, duration of ventilation, length of ICU, and hospital stay. This comparative study was conducted at the Department of Cardiac Surgery, Faisalabad Institute of Cardiology, from January 2018 to July 2018. A total of 138 cases (69 in each group) were included in the study. Patients with mild or moderate PHT were enrolled in group A, and patients with severe PHT were in group B. Required surgery was performed. Outcomes, including operative mortality, duration of mechanical ventilation postoperatively, dependence on inotropic agents in ICU, and length of stay in ICU as well as hospital, were noted in both groups during intensive care stay. Difference between the two groups in terms of mean duration of mechanical ventilation (10.58±2.79 vs. 10.96±3.42 hours; p-value=0.480), mean duration of inotropic support (8.55±2.75 vs. 9.45±3.92 hours, p-value=0.122), mean length of ICU stay (2.97±1.34 vs. 3.32±1.40 days, p-value=0.138) and mean length of hospital stay (12.3±3.8 vs. 12.6±4.1 days, p-value=0.684) was not statistically significant. In patients with severe pulmonary hypertension, mitral valve replacement was found equally safe compared to those with mild to moderate pulmonary hypertension.

Comparison of Single-Dose Cardioplegia in Valvular Heart Surgery: Lactated Ringer's-Based del Nido vs. Histidine-Tryptophan-Ketoglutarate Cardioplegia Solution.

This study evaluated myocardial protection and clinical outcomes when using lactated Ringer's solution as the base solution for del Nido cardioplegia compared with histidine-tryptophan-ketoglutarate (HTK) solution in valvular surgery. From January 2017 to May 2018, 71 adult patients who underwent valvular surgery with del Nido cardioplegia (n=37) or HTK cardioplegia (n=34) were retrospectively analyzed. Patients' characteristics were comparable between groups. Postoperative peak troponin T levels were similar. The del Nido group had a decreased incidence of ventricular fibrillation after aortic cross-clamp removal (13.51 vs. 55.88%; P<0.001), lower total volume of cardioplegia administered (1,000 [1,000, 1,250] vs. 1,800 [1,500, 2,000] mL; P<0.001), shorter hospital stay (6 [5, 8] vs. 7 [6, 10] days; P=0.03), and less postoperative red cell transfusion (34.29 vs. 61.11%; P=0.024). There is no difference in aortic cross-clamping time, postoperative change in left ventricular ejection fraction, intensive care unit stay, duration of inotropic support, new onset of atrial fibrillation, in-hospital mortality, complications, and three-year overall survival rate. Lactated Ringer's-based del Nido cardioplegia can be safely used for valvular surgery with acceptable clinical outcomes compared to HTK cardioplegia.

Evaluation of Postoperative Follow-ups of Children Having the Glenn Procedure

Introduction: This study aimed to evaluate the treatment results, complications, and the factors affecting mortality in cases who were followed up postoperatively in the pediatric intensive care unit (PICU) after the Glenn shunt procedure. Materials and Methods: The duration of the patients on the pump during surgery, transition times to feeding, blood gas and other laboratory parameters, complications developed during follow-up in the intensive care unit, and exitus rates were evaluated retrospectively. Results: BDG was performed due to tricuspid atresia, the most common diagnosis (30.2%). In the evaluation of the relationship between postoperative patient findings and exitus, a positive correlation was found between the duration of inotropic support, early extubation, and the duration of HFNC therapy in all patients (p&lt;0.05); and a negative correlation was found in terms of the fluid the patients received on the first day after surgery (p&lt;0.05). In patients who developed complications, a negative correlation was observed only in terms of the fluid they received on the first day after surgery (p&lt;0.05) Conclusions: In terms of all patients, it was observed that mortality increased with early extubation and prolonged duration of inotropic support and HFNC therapy, and it decreased as the fluid the patients received on the first day after surgery decreased. In patients who developed complications, it was only observed that mortality decreased as the fluid the patients received on the first day after surgery decreased.

Abstract 11576: Association Between Pre-Operative Right Heart Catheterization Parameters and Outcomes in Isolated Coronary Artery Bypass Grafting

Objective We evaluate the association between pre-operative right heart catheterization variables and outcomes in patients undergoing isolated coronary artery bypass grafting (CABG). Methods: All patients undergoing isolated CABG at our institution from 2013-2021 who also underwent pre-operative right heart catheterization &lt;14 days prior to isolated CABG were retrospectively queried. The primary outcome was operative mortality. Secondary outcomes were post-operative myocardial infarction, stroke, need for dialysis, duration of intensive care unit (ICU) stay, and duration of inotropic support. Results: Seventy-eight patients were analyzed. The incidence of operative mortality was 8(10.3%). The incidence of the secondary outcomes was 7(9.0%) for myocardial infarction, 5(6.4%) for stroke, and 4(5.1%) for need of dialysis. The median duration of ICU stay and inotropic support were 4[3.0, 7.8] and 2[1.3, 4.0] days respectively. On multivariable regression, central venous pressure was significantly associated with operative mortality (odds ratio (OR) 1.14, 95%CI 1.02-1.27, p=0.02) and duration of inotropic support (OR 1.02, 95%CI 1.00-1.03, p=0.04). Preoperative cardiac index was also significantly inversely associated with duration of ICU stay (OR 0.72, 95%CI 0.62-0.84, p&lt;0.001) and inotropic support (OR 0.76, 95%CI 0.63-0.92, p&lt;0.01). Conclusion Despite inclusion of cardiogenic shock in STS-PROM, baseline central venous pressure and cardiac index are independently associated with operative mortality, inotrope requirement and duration of ICU stay in patients undergoing isolated CABG. Assessment of pre-operative right heart function by right heart catheterization should be considered in this high-risk population to guide pre-operative optimization and intra-/post-operative decision-making.

Diagnostic significance of highly sensitive troponins in cardiac surgery

Background: The level of troponins after cardiac surgery always exceeds the reference values, however, the interpretation of these changes is difficult. Aim: To determine the relationship between the high-sensitivity cardiac troponin I and troponin T levels and the risk of heart failure (HF) development within 24 hours after the heart surgery. Methods: A prospective, observational, single-center study included 70 patients undergoing elective heart surgery. The patients were retrospectively divided into two groups based on the development of HF in the first 12 hours after the surgery. The group without HF included 57 patients, the group with HF included 13 patients. Results: The levels of highly sensitive Troponin I (HsTI) in patients who underwent elective heart surgery without complications were 61 times higher than the upper limit of the normal values, in those with the development of HF they were 111 times higher than the upper limit of the normal values. The levels of highly sensitive Troponin T (HsTT) were 25.5 times and 51 times the upper limit of the normal values, respectively. The level of HsTI at the end of the surgery can be a predictor of the HF development, regardless of the use of cardiac bypass (threshold value =1483 ng/l), as well as a predictor of the need for inotropic support for 2 days or more, regardless of the operation type (threshold value = 1573 ng/l). There was a direct moderate correlation of the HsTI level at the end of the operation and 6 hours after the operation with cumulative hemohydrobalance for 24 hours, which was 60% higher in patients with HF than that in patients without complications. Conclusion: In uncomplicated patients, the level of highly sensitive troponins T and I in the postoperative period is 2561 times higher than the upper limit of the normal values, and with the HF development it is 51111 times higher. Highly sensitive troponins can be considered as predictors of the HF development and the duration of inotropic support. The increase in the level of troponins is influenced by the duration of cardiac bypass and the volume of infusion therapy in the perioperative period.

Early Postoperative Complications in Patients with Acute Myocardial Infarction During Emergency Coronary Bypassing

Despite the success results of interventional cardiology, the indications for coronary artery bypass grafting in acute myocardial infarction, according to the recommendations, are quite limited. In recent years, the optimization of perioperative management of patients, including myocardial protection, has helped to improve the effects of treatment by emergency surgical revascularization in patients with cardiogenic shock. Thus, it is important to learn the results of emergency surgical myocardial revascularization in patients with acute myocardial infarction (AMI), which were previously considered incurable or in cases where interventional cardiology is ineffective. Therefore, the aim of the study was to conduct a prospective analysis of the immediate clinical results of the early postoperative period to determine the factors of early mortality in emergency coronary artery bypass grafting. Research methods. The research is based on the prospective investigation of 129 patients who were hospitalized in Kyiv “Heart Center” through the period from 2011 to 2015. At 100,0% the ST-elevated myocardial infarction (STEMI) of them it was verified, at 29,0 patients non- ST-elevated myocardial infarction (NSTEMI) was set. In early postoperative period, we have analyzed such events like inotropic support duration, necessity of intra-aortic balloon pump, the episodes of the development kidney injury and respiratory failure, complete atrioventricular blockade, supraventricular tachyarrhythmia episodes, encephalopathy, rethoracotomy needs. Also early postoperative mortality endpoints were evaluated. Research results. It has been proven that in the presence of STEMI type of acute myocardial injury compared with NSTEMI type, there is a higher risk of acute left ventricular failure (p &lt;0.05) followed by intra-aortic balloon pulsation (IABP)- procedure (p &lt;0,05) and inotropic support (p &lt;0,05) in the early postoperative period. In patients of the STEMI group, acute kidney injury was recorded more often with reliable indexes of absolute and relative risks (p &lt;0,05). All cases of transient atrioventricular block after emergency coronary artery bypass grafting (CABG) were registered in patients with STEMI injury with significant changes of odds ratio (p &lt;0.05). It was established that the main structure of respiratory complications was due to prolonged mechanical ventilation, but the difference in the relative risk and odds ratio between the STEMI and NSTEMI groups is insignificant (p&gt; 0.05), however the likelihood of supraventricular arrhythmia and encephalopathy in the NSTEMI group was reliably higher (p &lt;0.05). Estimates of the level of early postoperative mortality (12.4%) proved the probable relative risk (p &lt;0.05) and the odds ratio (p &lt;0.05) of mortality in the STEMI group, which was confirmed by the analysis of cumulative survival by Kaplan-Meyer method (Criterion log-rank 2,74; p = 0,006). Mortality in the STEMI group was associated with previously diagnosed acute heart failure (56,2%), the onset of cardiogenic shock (31,3%) and the development of acute mitral regurgitation (12.5%). Conclusions. STEMI type of acute myocardial damage installed reliably higher absolute and relative risk of acute left ventricle failure (p&lt;0,05) with following intra-aortic balloon pump (p&lt;0,05), inotropic support (p&lt;0,05) and acute kidney injury with glomerular rate reduction (p&lt;0,05) in the early postoperative period. The higher absolute and relative risks of encephalopathy, as well as the possibility of supraventricular arrhythmia presented at NSTEMI patients (p&lt;0,05). All cases of transient atrioventricular blockade and early hospital mortality with reliable odds ratio, absolute and relative risks changes registered at STEMI patients (p&lt;0,05). Prospects for further research are long-term prospective observation, analysis of long-term clinical results of coronary artery bypass grafting in patients with acute myocardial infarction, as well as assessment of risk factors for long-term mortality.

Early versus late parenteral nutrition in term and late preterm infants: study protocol for a randomised controlled trial

BackgroundDespite the wide use of parenteral nutrition (PN) in neonatal intensive care units (NICU), there is limited evidence regarding the optimal time to commence PN in term and late preterm infants. The recommendations from the recently published ESPGHAN/ESPEN/ESPR/CPEN and NICE guidelines are substantially different in this area, and surveys have reported variations in clinical practice. The aim of this randomised controlled trial (RCT) is to evaluate the benefits and risks of early versus late PN in term and late preterm infants.Methods/designThis study is a single-centre, non-blinded RCT in the NICU of Perth Children’s Hospital, Western Australia.A total of 60 infants born ≥34 weeks of gestation who have a high likelihood of intolerance to enteral nutrition (EN) for at least 3-5 days will be randomised to early (day 1 or day 2 of admission) or late commencement (day 6 of admission) of PN after informed parental consent. In both groups, EN will be commenced as early as clinically feasible. Primary outcomes are plasma phenylalanine and plasma F2-isoprostane levels on Day 4 and Day 8 of admission. Secondary outcomes are total and individual plasma amino acid profiles, plasma and red blood cell fatty acid profiles, in-hospital all-cause mortality, hospital-acquired infections, length of hospital/NICU stay, z scores and changes in z scores at discharge for weight, height and head circumference, time to full EN, duration of respiratory (mechanical, non-invasive) support, duration of inotropic support, the incidence of hyper and hypoglycaemia, incidence of metabolic acidosis, liver function, blood urea nitrogen, and C-reactive protein (CRP).DiscussionThis RCT will examine the effects of early versus late PN in term and late preterm infants by comparing key biochemical and clinical outcomes and has the potential to identify underlying pathways for beneficial or harmful effects related to the timing of commencement of PN in such infants.Trial registrationANZCTR; ACTRN12620000324910 (3rd March 2020)

Effect of Mild Hypothermia on Morbidity and Mortality in Post AMI Cardiogenic Shock

Background: Acute myocardial infarction (AMI) complicated with cardiogenic shock is still associated with a significant death rate. Other interventions, including intra-aortic balloon counter pulsation and medical therapy, failed to improve prognosis in large-scale randomised studies, with the exception of early revascularization. Recently, mild therapeutic hypothermia, in which patients are lowered to 33°C over the course of 24 hours, has been proposed as a therapy option for cardiogenic shock patients. The purpose of this study is to determine the impact of mild hypothermia on morbidity and mortality associated with post-AMI cardiogenic shock.&#x0D; Methods: This randomized, controlled, unblinded trial was conducted on 50 patients with AMI complicated by CS. Patients were randomly allocated into two equal groups; group I received MTH to 33°C for 24-36 h and group II (control group) did not receive MTH. Patients were subjected to full history taking, general and clinical examination, laboratory examination, echo, chest ultrasound (US), coronary angiography data and mild therapeutic hypothermia protocol.&#x0D; Results: Stroke until day 30, duration of mechanical ventilation, length of ICU stay, duration of inotropic support, mortality and pulmonary congestion by US were insignificantly different between both groups. Arterial lactate and mean arterial blood pressure (MAP) at 4h, 6h, 8h, 10h, 12h, 14h, 16h, 18h, 20h were significantly increased in group I than Group II (P value&lt;0.05). and were insignificantly different between both groups at 0h, 2h, 22h, 24h, 26h, 28h, 30h. Serum creatinine at 24h, 48h was significantly increased in group I than Group II (p value &lt;0.05) and was insignificantly different between both groups at 0h.&#x0D; Conclusions: Therapeutic hypothermia (TH) didn’t improve short term outcomes in patients with post AMI cardiogenic shock.

Comparison between Bretschneider -HTK solution and antegrade cold blood cardioplegia as a method for myocardial protection in thoracic aortic surgery

Background: Cardiac surgeons demand a cardioplegic solution providing extended durations of myocardial protection due to the increasing complexity of cardiac surgical procedures, especially thoracic aortic operations which require extended myocardial ischemic periods. The goal of this study was to assess the safety and efficacy of cold crystalloid single dosage Histidine Tryptophan Ketogultarate (Custodiol) cardioplegia to cold blood multidose cardioplegia in aortic surgery patients. Methods: Our study included 100 elective and emergency aortic surgery patients. Fifty patients received Custodiol cardioplegic solution (group A) and fifty received cold blood cardioplegia (group B). We evaluated post-operative cardiac Troponin I release, postoperative morbidities and mortality. Results: Troponin I peak release, duration of inotropic support &amp; intensive care unit stay were more in the cold blood group. Hemofiltration and intraoperative requirement of blood products transfusion were more in the Custodiol group. No differences were found regarding cross-clamp time, arrhythmias, postoperative ejection fraction and in-hospital mortality. Conclusion: In patients having thoracic aortic surgery, custodiol and cold blood cardioplegic treatments give good myocardial protection. Custodiol usage was linked to lower troponin levels, shorter inotropic support periods, and shorter ICU stays. In terms of early mortality and morbidity, there was no statistically significant difference between the two groups.

Early is superior to late plasma exchange for severe multisystem inflammatory syndrome in children.

Multisystem inflammatory syndrome in children (MIS-C) can be life threatening in severe cases because of uncontrolled inflammation and multi-organ failure. In this study, we report the effect of plasma exchange in the treatment of MIS-C and to emphasize the effect of its early application on outcome. In this retrospective observational study, the medical records of children with severe MIS-C admitted to pediatric intensive care unit (PICU) between April 2020 and January 2021 were reviewed. Severe MIS-C patients were treated according to protocol consisting of plasma exchange (PE), intravenous immune globulin, steroids, and anakinra which we called the "PISA" protocol referring to the initials. The patients were divided into two groups as early plasma exchange (E-PE) and late plasma exchange (L-PE) according to the elapse time between hospital admission and the administration of PE. Groups were compared in terms of outcome variables. Primary study outcome was 28-day mortality. Secondary outcome variables were acute phase response time, length of immunomodulatory treatment, frequency of patients requiring mechanical ventilation (MV) and inotropic support, length of inotropic support and MV, length of hospital and PICU stays. Eighteen pediatric patients with MIS-C were included in the study. Seventeen (95%) of the patients presented with decompensated shock and required inotropic support. One of the 17 patients needed extracorporeal membrane oxygenation support (ECMO) PISA protocol was used in all patients. There was no mortality in the E-PE group while the mortality rate was 20% in the L-PE group. Acute phase reactant response was faster in the E-PE group and immunomodulatory treatments could be reduced earlier; the frequency of patients requiring inotropic and mechanical ventilation (MV) support was lower in the E-PE group; the duration of inotropic support, duration of MV, and length of stay in hospital and PICU were significantly shorter in the E-PE group. We suggest that in selected cases, timely administration of PE is a beneficial rescue therapy for MIS-C related hyperinflammation presenting with severe cardiovascular collapse.

Вплив якісних та кількісних змін поповнення крововтрати на прояви синдрому поліорганної недостатності при політравмі

У роботі наведені результати аналізу 53 історій хвороб постраждалих із політравмою мирного та воєнного часу, яким проводили поповнення крововтрати за ліберальною стратегією, та обстеження 16 постраждалих, яким застосовували рестриктивну стратегію поповнення крововтрати. Обмеження інфузійно-трансфузійної терапії до 70 мл/кг не знизило її протишокового ефекту і в той же час дозволило зменшити позитивний водний баланс, скоротити тривалість вазопресорної підтримки та штучної вентиляції легень, зменшити кількість пневмоній та інших ускладнень, уникнути різких коливань гемоглобіну, гематокриту та загального білка в 1-шу добу, знизити кількість повторних трансфузій, зменшити летальність.

Comparison of effects of sevoflurane versus propofol on left ventricular longitudinal global and regional strain in patients undergoing on-pump coronary artery bypass grafting.

Background:Assessment of myocardial deformation by quantifying peak systolic longitudinal strain (PSLS) is a sensitive and robust index to detect subclinical myocardial dysfunction. We hypothesize that sevoflurane by virtue of anesthetic preconditioning preserves myocardial function better than propofol.Aims:The authors have assessed the effects of sevoflurane and propofol on global longitudinal strain (GLS) as a primary outcome in patients undergoing on-pump coronary artery bypass grafting. Our secondary aim was to assess the pattern of regional distribution of segmental PSLS between the groups.Materials and Methods:Fifty patients with normal left ventricular function undergoing coronary artery bypass grafting were analyzed in this prospective observational study. Consecutive patients received either propofol (P) or sevoflurane (S) anesthesia.Measurements:Trans-esophageal echocardiographic images (mid-esophageal four-chamber, two-chamber, and three-chamber (long-axis)) were recorded during the precardiopulmonary bypass (CPB) and post-CPB period. Strain analysis (GLS/segmental PSLS) was done offline by investigators blinded to the study. The inotropic score, duration of inotropic support, and mechanical ventilation required were recorded.Results:Following cardiopulmonary bypass and coronary revascularization, GLS reduced significantly in both the groups (P < 0.05). In the S-group, significant reduction in segmental strain was observed only in apical segments including apex, whereas in P-group significant reduction in segmental strain was seen in mid- and apical segments. The postoperative VIS, duration of inotropes/vasopressor required, and mechanical ventilation were similar in both the groups.Conclusions:There are no significant differences in global left ventricular function as assessed by GLS between patients anesthetized with sevoflurane or propofol. However, regional PSLS was better preserved in the S-group compared to P-group.

Perioperative effect of acetylsalicylic acid stoppage duration before coronary artery bypass grafting

ObjectiveTo assess the effect of timing of preoperative cessation of aspirin therapy on perioperative morbidity and mortality in patients undergoing coronary artery bypass graft (CABG) surgery.BackgroundAspirin is used for primary or secondary prevention of thrombotic complications. It inhibits platelet function and so there is an increased risk of hemorrhage among patients undergoing CABG. Aspirin discontinuation time before CABG surgery has been a controversy for years. We aimed at assessing the effect of timing of preoperative cessation of aspirin therapy on perioperative morbidity and mortality in patients undergoing CABG surgery.Patients and methodsSixty patients having coronary artery disease and indicated for CABG surgery were included. Patients were randomly allocated into two groups: group A (32 patients) patients received 100 mg (enteric coated aspirin)/day till the day of surgery and group B (28 patients) patients received aspirin 100 mg daily until 5 days before surgery. We followed postoperative hemodynamics, morbidity, and mortality for 30 days after surgery.ResultsGroup A had significantly lesser ICU stay, duration of inotropic support, and duration of mechanical ventilation than the other group. However, the need of intraoperative and postoperative blood transfusion, reopening for bleeding, postoperative myocardial infarction, and 30 days mortality were similar between the two groups.ConclusionsLate use of aspirin till the day of surgery in small doses was associated with less ICU stay and earlier weaning from mechanical ventilation and was not associated with increased risk of bleeding, increased need for blood transfusion nor increased rates of reoperation for bleeding. Hence, we can conclude that late aspirin use is recommended especially in high-risk patients

Impact of Overt Hypothyroidism on Early Outcomes of Coronary Artery Surgery.

The association between preoperative overt hypothyroidism and early outcomes after coronary artery bypass grafting (CABG) is unclear. This study aimed to evaluate the influence of overt hypothyroidism on the outcomes of CABG. The series included 189 overt hypothyroid patients, who underwent CABG at Fuwai Hospital. These patients were 1:4 matched with 737 euthyroid patients using propensity score matching. The early postoperative outcomes were compared. After propensity score matching, the incidences of impaired wound healing, reintubation, and the total complications were higher in hypothyroid patients than euthyroid patients (11.8% vs. 0.9%, P < 0.001; 2.1% vs. 0.4%, P = 0.03; 39.6% vs. 30.3%, P = 0.015, respectively). Multivariate analysis showed overt hypothyroidism was significantly associated with the occurrence of impaired wound healing (odds ratio [OR]=12.29, P < 0.001), reintubation (OR=5.71, P = 0.047), and the total complications (OR=1.31, P = 0.049). The OR of the total complications was 1.43 (P = 0.03) in hypothyroid patients with abnormal thyroid-stimulating hormone compared with euthyroid patients. The proportions of the use of dopamine, adrenaline, milrinone, and dobutamine in hypothyroid patients were higher than euthyroid patients (75.4% vs. 67.6%, P = 0.038; 10.7% vs. 6.1%, P = 0.028; 3.2% vs. 0.3%, P = 0.001; 4.8% vs. 1.2%, P = 0.004, respectively). The total duration of inotropic support and mechanical ventilation time in hypothyroid patients were longer than euthyroid patients (median duration: 4 days vs. 3 days, P = 0.003; 17 hours vs. 15 hours, P < 0.001, respectively). CABG in overt hypothyroid patients is associated with a higher incidence of postoperative complications, stronger postoperative inotropic support, and longer mechanical ventilation time.

Coronary endarterectomy in myocardial revascularization

Aim. To compare the immediate outcomes of combined coronary artery bypass grafting (CABG) with coronary endarterectomy (CE) and isolated CABG.Material and methods. This retrospective study included 192 patients with stable angina who underwent myocardial revascularization in the period from January 2016 to August 2018. The patients were divided into 2 groups. Group 1 included patients who underwent combined CABG and CE, while group 2 — patients who underwent isolated CABG. Patients in both groups did not differ in the main preoperative characteristics, with the exception of the incidence of obesity and right coronary artery disease.Results. In-hospital mortality in group 1 was 2,2% (n=2), in group 2 — 2% (n=2). The incidence of perioperative myocardial infarction in group 1 was 1% (n=1) and in group 2 — 0%. There were no significant differences between groups in the following postoperative parameters: in-hospital mortality, perioperative myocardial infarction, need and duration of inotropic support, duration of mechanical ventilation (MV) and need for long-term mechanical ventilation, stroke, arrhythmias, resternotomy for bleeding. In group 1, encephalopathy (11,8%) and respiratory failure (12,9%) were significantly more common.Conclusion. Combined CABG and CE is a safe technique for achieving complete myocardial revascularization in diffuse coronary artery disease, since, in comparison with isolated CABG, there is no increase in the incidence of death and perioperative myocardial infarction. However, in this category of patients, an increase in the incidence of non-lethal, non-disabling cerebral and pulmonary complications should be expected.