Postoperative Mechanical Ventilation Time Research Articles

Retrospective Evaluation of Fascial Plane Blocks in Cardiac Surgery With Median Sternotomy in a Tertiary Hospital.

Cardiac surgery typically causes moderate to severe postoperative pain and discomfort. Inadequate pain management in the early postoperative period leads to pulmonary complications. The length of intensive care unit (ICU) stay and the hospital is typically prolonged. As a component of multimodal analgesia regimens, fascial plane blocks have become more popular. In our clinic, serratus anterior plane blocks (SAPB), pectoral nerve blocks (PECS I-II), and pectointercostal nerve fascial plane blocks (PIFB) are performed by ultrasonography. We wished to evaluate the postoperative visual pain scale, initial additional analgesic agent requirement time, extubation time, morbidity and mortality in patients who underwent open heart surgery with fascial plane blocks. Forty-eight patients over 18 yearswho underwent open heart surgery with sternotomy between 01 September 2021 and 15 June 2022 were evaluated retrospectively. Only patients with chest wall blocks placed at the end of surgery were included in the study. In Group 1, the PECS II block was placed on the chest tube side and bilateral PIFBs were placed at the end of surgery in the operating room. In Group 2, SAPB was placed on the chest tube side and bilateral PIFBs were placed at the end of surgery. Data regarding patient demographics, anesthesia method applied, amount of opioid used intraoperatively, cardiopulmonary bypass time, anesthesia and surgery time, postoperative extubation time, mechanical ventilation time, Visual Analogue Scale (VAS) of patients at rest and movement at 6th, 12th, 18th, 24th, 48th hours post-extubation, time to and type of first postoperative analgesic, postoperative complications, length of cardiac intensive care unit (CICU) stay and hospital length of stay were recorded from hospital records. The data of a total of 46 patients (Group 1: PECS II block + PIFB, n=20; Group 2: SAPB+ PIFB, n=26) were analyzed retrospectively. There was no difference in demographic variables between the groups. Intraoperative opioid usage, operation time, Cardiopulmonary bypass time, postoperative mechanical ventilation time, extubation time, ICU discharge time, and length of hospital stay were not statistically different between the groups. The first rescue analgesic requirement time was longer in group 2 than in group 1 but not statistically significant (18.76±15.36 h vs 12.62±10.61 h, p=0.162). The post-extubation VAS scores at rest and movement at the 6th hour were significantly lower in group 2 than in group 1 (1.73±1.28 vs 3.15±2.10, respectively, p=0.02). In our study, the VAS scores at the 6th hour were lower in SAPB + PIFB group than in PECS II + PIFB group. As these blocks can be easy to apply, we thought these combinations could be an alternative for pain relief in cardiac surgery. Prospective randomized studies are needed with a large number of patients.

Thoracic paravertebral versus interpleural catheter for post-thoracotomy pain control in minimally invasive cardiac surgery.

The aim of this study was to compare efficacy and safety of paravertebral block (PVB) and interpleural analgesia (IPA) after minimally invasive cardiac surgery through thoracotomy in terms of quality of analgesia, post-operative mechanical ventilation time, intensive care unit (ICU) and hospital length of stay (LOS) and complications. A randomized, prospective study. A total of 50 adult patients (18-50 years old) undergoing minimally invasive cardiac surgery via thoracotomy. Patients were randomized for group A: paravertebral epidural catheter (n = 25), group B: interpleural catheter (n = 25). All patients were given Inj. Bupivacaine 0.125%, 8 ml and Inj. Tramadol 100 mg as an adjuvant, total volume 10 ml. After obtaining institutional review board approval, data collected and analysed - visual analogue score (VAS) at rest and on coughing, haemodynamic and respiratory parameters, time to extubation, supplementary analgesia requirement, LOS and complications. VAS was recorded at 0, 2, 3, 4, 8, 12 and 24 h post-extubation, while blood gases at-after shifting, 4, 8, 12 and 24 h. There were no significant differences in haemodynamic or respiratory parameters, VAS at rest and on coughing, ventilation duration, ICU and hospital LOS between two groups. The requirement of rescue analgesia was in one patient of mini coronary artery bypass in group B, while one patient in group A required reintubation due to respiratory acidosis and got successfully extubated on next day morning. PVB and IPA both are safe and effective techniques for minimally invasive cardiac surgery with thoracotomy. It allows optimal pain control and safe ICU fast-track post-operative course.

A comparison of total thoracoscopic versus robotic approach for cardiac myxoma resection: a single-center retrospective study

Advances in instrumentation and technique have facilitated minimally invasive surgeries for cardiac myxoma treatment. This study aims to compare the clinical outcomes between the thoracoscopic and robotic approaches for myxoma resection. Intraoperative data and postoperative data of 46 patients who underwent either thoracoscopic (n = 15) or robotic (n = 31) cardiac myxoma resection in our center between July 2013 and September 2022 were retrospectively compared. There was no in-hospital death in either group. Meanwhile, the operative time and cardiopulmonary bypass time were significantly shorter in the robotic group than in thoracoscopic group (P = 0.015 and P = 0.035, respectively). Furthermore, shorter ICU stays (P = 0.006), shorter postoperative mechanical ventilation time (P = 0.035) and less thoracic drainage (P = 0.040) were observed in the robotic group. However, the operating room costs and total hospital costs were both significantly lower in thoracoscopic group (P = 0.004 and P = 0.007, respectively). There was no significant difference between two groups regarding the incidence of postoperative complications (P > 0.05). Lastly, a faster return to exercise was noted in robotic group than in thoracoscopic group (Log-Rank χ2 = 4.094, P = 0.043). Both approaches can be safe and feasible for myxoma resection. However, regardless of higher expenses, the robotic myxoma resection approach provides shorter operation time, less postoperative thoracic drainage, and faster recovery than total thoracoscopic technique.

A simple-to-use nomogram for predicting prolonged mechanical ventilation for children after Ebstein anomaly corrective surgery: a retrospective cohort study

BackgroundProlonged mechanical ventilation (PMV) after pediatric cardiac surgery imposes a great burden on patients in terms of morbidity, mortality as well as financial costs. Ebstein anomaly (EA) is a rare congenital heart disease, and few studies have been conducted about PMV in this condition. This study aimed to establish a simple-to-use nomogram to predict the risk of PMV for EA children.MethodsThe retrospective study included patients under 18 years who underwent corrective surgeries for EA from January 2009 to November 2021. PMV was defined as postoperative mechanical ventilation time longer than 24 hours. Through multivariable logistic regression, we identified and integrated the risk factors to develop a simple-to-use nomogram of PMV for EA children and internally validated it by bootstrapping. The calibration and discriminative ability of the nomogram were determined by calibration curve, Hosmer-Lemeshow goodness-of-fit test and receiver operating characteristic (ROC) curve.ResultsTwo hundred seventeen children were included in our study of which 44 (20.3%) were in the PMV group. After multivariable regression, we obtained five risk factors of PMV. The odds ratios and 95% confidence intervals (CI) were as follows: preoperative blood oxygen saturation, 0.876(0.805,0.953); cardiothoracic ratio, 3.007(1.107,8.169); Carpentier type, 4.644(2.065,10.445); cardiopulmonary bypass time, 1.014(1.005,1.023) and postoperative central venous pressure, 1.166(1.016,1.339). We integrated the five risk factors into a nomogram to predict the risk of PMV. The area under ROC curve of nomogram was 0.805 (95% CI, 0.725,0.885) and it also provided a good discriminative information with the corresponding Hosmer-Lemeshow p values > 0.05.ConclusionsWe developed a nomogram by integrating five independent risk factors. The nomogram is a practical tool to early identify children at high-risk for PMV after EA corrective surgery.

Surgical treatment of congenital diaphragmatic hernia in a single institution

BackgroundThis study aimed to evaluate the effectiveness of video-assisted thoracic surgery for the treatment of congenital diaphragmatic hernia (CDH) in a larger series compared with conventional open surgery. Additionally, we summarized the experience of thoracoscopic surgery in the treatment of CDH in infants.MethodsWe retrospectively analysed the clinical data of 109 children with CDH who underwent surgical treatment at the Department of Cardiothoracic Surgery of Children’s Hospital of Chongqing Medical University from January 2011 to January 2021. According to the surgical method, the children were divided into an open group (62 cases) and a thoracoscopy group (47 cases).Patients who underwent surgical correction had the diaphragmatic defect size graded (A–D) using a standardized system. We compared the operation time, intraoperative blood loss, postoperative mechanical ventilation time, postoperative hospital stay, postoperative CCU admission time and other surgical indicators as well as the recurrence rate, mortality rate and complication rate of the two groups of children.ResultsThe index data on the operation time, intraoperative blood loss, postoperative mechanical ventilation time, postoperative hospital stay and postoperative CCU admission time were better in the thoracoscopy group than in the open group. The difference between the two groups was statistically significant (P < 0.05). We compared the number of incision infections, lung infections, atelectasis, pleural effusion, and chylothorax between the two groups. There were more children in the open group than in the thoracoscopy group. The overall incidence of postoperative complications in the open group (51.61%) was higher than that in the thoracoscopy group (44.68%).The recurrence rate of the thoracoscopy group (8.51%) was higher than that of the open group (3.23%). In the open group, 7 patients died of respiratory distress after surgery, and no patients died in the thoracoscopy group.ConclusionsThoracoscopic surgery and open surgery can effectively treat CDH. Compared with conventional open surgery, thoracoscopy has the advantages of shorter operation time, less trauma, faster recovery and fewer complications. We believe that thoracoscopic surgery for type A/B diaphragmatic defect has certain advantages, but there is a risk of recurrence.

Exploration of the thoracoscopic treatment of esophageal atresia under high-frequency ventilation.

Explore the feasibility and safety of thoracoscopy in the treatment of esophageal atresia under high-frequency oscillatory ventilation (HFOV) mode. This was a single-center retrospective analysis. A total of 24 children were divided into the HFOV and the No-HFOV group. The demographic information, surgical results and relevant experience were analyzed. All patients in the HFOV group underwent thoracoscopic esophageal atreplasty with a mean operation duration of 165.8 ± 33.9 min. Two patients had postoperative anastomotic leakage, which was cured after conservative treatment. One child had a recurrent tracheoesophageal fistula, which was closed after endoscopic cauterization. The mean postoperative mechanical ventilation time was 8.83 ± 8.02 days. There was no return of anastomotic leakage or r-TEF after oral feeding. Furthermore, there was no significant difference between the NO-HFOV and the HFOV groups except for the operation time where the HFOV group was shorter than that of the NO-HFOV group. Thoracoscopic esophageal atresia anastomosis under HFOV ventilation is feasible for patients with severe pulmonary infection, heart malformation, such as patent ductus arteriosus, ventricular septal defect, and poor anesthesia tolerance, but the long-term prognosis still needs further study in a large sample size.

The effect of perioperative use of dexmedetomidine on time to extubation and ICU stay after coronary artery bypass graft surgery: a single-center retrospective cohort study

Background: Dexmedetomidine plays an important role in postoperative respiratory weaning after cardiac surgery due to its sedative and analgesic properties without causing respiratory depression. Objectives: To evaluate if dexmedetomidine could shorten postoperative ventilation time, ICU stay (primary outcomes) and total hospital stay (secondary outcome). Methods: All patients who underwent elective CABG surgery between January 1st 2019 and March 3rd 2021 in AZ Sint-Jan, Bruges, Belgium were included in this retrospective single-center study. 175 of them received dexmedetomidine perioperative, opposed to 248 patients who did not. Results: When looking at the postoperative length of ICU stay, no significant difference could be detected between the dexmedetomidine and non-dexmedetomidine group (median of 2 days, CI95% [2 - 3] vs 2 days CI95% [2-3] respectively; p= 0,5462). No difference in postoperative hospital stay could be detected between the dexmedetomidine and non-dexmedetomidine group either (median of 7 days, CI95% [7 - 8] vs 7 days, CI95% [7 - 7] respectively; p=0,4731). Time to extubation was significantly lower in the group with perioperative dexmedetomidine administration in comparison to those who did not receive dexmedetomidine during surgery (mean of 375 minutes; CI95% [332 - 418] vs 487 minutes; CI95% [420 - 555] respectively; p=0,0059). Conclusion: Dexmedetomidine can play an important role in postoperative respiratory weaning after elective CABG surgery by reducing the postoperative mechanical ventilation time. No effect on ICU stay and total length of hospital stay could be detected.

Correlation between cerebral oxygen saturation monitored by near-infrared spectroscopy during operation and risk of stroke after acute type A aortic dissection surgery

Objective: Near-infrared spectroscopy (NIRS) is widely used for intraoperative cerebral oxygen saturation monitoring in patients with acute type A aortic dissection. This study aimed to investigate the correlation between NIRS-derived oxygen saturation and risk of postoperative stroke. Methods: This study included 193 patients with acute type A aortic dissection undergoing emergency surgery and elective unilateral cerebral perfusion via the right axillary artery at the Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, China, from 2018 to 2020. NIRS was used for intraoperative cerebral oxygen saturation monitoring, and the basal values and the lowest values of cerebral oxygen saturation during deep hypothermic circulatory arrest (DHCA) were recorded. The patients were divided into no-stroke group (n=178, 92.2%) and stroke group (n=15, 7.8%) according to the absence or presence of postoperative stroke. The differences in preoperative, operative and postoperative clinical differences between the two groups were compared, and the relationship between the lowest cerebral oxygen saturation value and the change in cerebral oxygen saturation value ((base-lowest)/basal) and postoperative stroke were analyzed. Results: The proportion of preoperative atrial fibrillation (6.7% vs. 0.6%, P=0.026), and the proportion of preoperative hypotension (26.7% vs. 9.0%, P=0.031) were significantly higher in the stroke group than no-stroke group. There were no differences in the surgical approach between the two groups. Cardiopulmonary bypass (CPB) time ((256.1±84.8) h vs.(217.8±58.4) h, P=0.020), postoperative mechanical ventilation time ((139.3±172.8) h vs. (35.6±45.6) h, P<0.001) were significantly longer in stroke group as compared to no-stroke group. Incidence of postoperative tracheotomy (20.0% vs. 1.1%, P<0.001), acute kidney injury (73.3% vs. 30.3%, P=0.001) and continuous renal replacement therapy (46.7% vs. 11.8%, P<0.001) as well as mortality (20.0% vs. 5.1%, P=0.022) were significantly higher in the stroke group than in non-stroke group. There was no significant difference in the basal NIRS value and the lowest NIRS value during DHCA between the two groups. Patients in the stroke group had a significantly greater intraoperative change rate of right NIRS as compared to no-stroke group (15.2%±15.7% vs. 9.2%±7.0%, P=0.006). Conclusions: NIRS is valuable for monitoring cerebral oxygen saturation during acute type A aortic dissection surgery, and the rate change of NIRS during operation correlates significantly with postoperative stroke.

Effect of preoperative pulse oximeter oxygen saturation on postoperative prolonged mechanical ventilation in patients with tetralogy of Fallot.

BackgroundAs an easily accessible and intervened clinical indicator, preoperative pulse oximeter oxygen saturation (SpO2) is an important factor affecting the prognosis of patients with tetralogy of Fallot (TOF). However, whether SpO2 is associated with postoperative mechanical ventilation (MV) time remains unknown. Therefore, this study aimed to investigate the impact of preoperative SpO2 on postoperative prolonged mechanical ventilation (PMV) in children with TOF.Materials and methodsThe study included children younger than 18 years who underwent corrective operations for TOF between January 2016 and December 2018 in Fuwai Hospital, China. Univariate and multivariate logistic regression analyses were used to evaluate the influence of preoperative SpO2 on postoperative PMV. After identifying SpO2 as an independent risk factor for PMV, patients were further divided into two groups according to the cutoff value of SpO2, and propensity score matching (PSM) analysis was used to eliminate the effect of confounding factors. The logistic regression was used to compare the outcomes between the two groups after PSM.ResultsA total of 617 patients were finally enrolled in this study. By the univariable and multivariate logistic analysis, four independent risk factors for PMV were determined, namely, SpO2, surgical technique, aortic cross-clamp time, and intraoperative minimum temperature. According to the outcomes of 219 paired patients after PSM, the incidence of PMV was significantly higher in patients with lower preoperative SpO2 (P = 0.022). Also, there was significant increase in mechanical ventilation time (P = 0.019), length of intensive care unit stay (P = 0.044), postoperative hospital stay (P = 0.006), hospital stay (P = 0.039), and hospitalization cost (P = 0.019) at the lower preoperative SpO2 level.ConclusionLow preoperative SpO2 represents an independent risk factor of postoperative PMV in children with TOF.

Clinical Evaluation of on-Table Extubation in Patients Aged Over 60 Years Undergoing Minimally Invasive Mitral or Aortic Valve Replacement Surgery.

AimsTo evaluate the clinical efficiency of on-table extubation (OTE) versus delayed extubation in patients aged over 60 years that underwent minimally invasive mitral or aortic valve replacement surgery and evaluate the factors associated with successful OTE implementation.MaterialsPatients over 60 years with mitral or aortic valve disease who received minimally invasive mitral or aortic valve replacement surgery from October 2020 to October 2021 were selected retrospectively. We divided patients into the on-table extubated (OTE) group (n = 71) and the delayed extubation (DE) group (n = 22). Preoperative, intraoperative, and postoperative clinical variables were compared between the two groups.ResultsPatients in the DE group underwent longer surgery time, longer aortic occlusion clamping time and longer cardiopulmonary bypass time than those in the OTE group(217.48 ± 27.83 vs 275.91 ± 77.22, p = 0.002; 76.49 ± 16.00 vs 126.55 ± 54.85, p = 0.001; 112.87 ± 18.91 vs 160.77 ± 52.17, p = 0.001). Patients in the OTE group had shorter postoperative mechanical ventilation time (min), shorter ICU time, shorter postoperative hospital length of stay and lower total cost and medication cost (p < 0.05). The AUC for aortic occlusion clamping time was 0.81 (p < 0.01), making it the most significant predictor of on-table extubation success.ConclusionsOn-table extubation following mitral or aortic valve cardiac surgery was associated with a superior clinical outcome and high cost-effectiveness.

Early Serum Metabolism Profile of Post-operative Delirium in Elderly Patients Following Cardiac Surgery With Cardiopulmonary Bypass

BackgroundCardiac surgery with cardiopulmonary bypass (CPB) is considered to be one of the surgical types with the highest incidence of post-operative delirium (POD). POD has been associated with a prolonged intensive care and hospital stay, long-term neurocognitive deterioration, and increased mortality. However, the specific pathogenesis of POD is still unclear. Untargeted metabolomics techniques can be used to understand the changes of serum metabolites in early POD to discover the relationship between serum metabolites and disease.Materials and MethodsThe present study recruited 58 elderly patients undergoing cardiac surgery with CPB. Serum was collected within the first 24 h after surgery. The Confusion Assessment Method (CAM) and ICU-CAM assessments were used to identify patients who experienced POD. All patients with normal post-operative cognitive assessment were included in the non-POD groups. Moreover, we collected serum from 20 healthy adult volunteers. We performed untargeted analyses of post-operative serum metabolites in all surgical groups, as well as serum metabolites in healthy non-surgical adults by using liquid chromatography mass spectrometry (LC/MS) and analyzed metabolic profiles and related metabolites.ResultsThe probability of POD after cardiac surgery were 31%. There were statistically significant differences in post-operative mechanical ventilation time, ICU stay time and post-operative hospital stay between POD and non-POD group (P < 0.05). And ICU stay time was an independent risk factor for POD. The analysis revealed that a total of 51 differentially expressed metabolites (DEMs) were identified by comparing the POD and non-POD group, mostly lipids and lipid-like molecules. Three phosphatidylinositol (PI) were down-regulated in POD group, i.e., PI [18:0/18:2 (9Z, 12Z)], PI [20:4 (8Z, 11Z, 14Z, 17Z)/18:0], and PI [18:1 (9Z)/20:3 (8Z, 11Z, 14Z)]. The receiver operating characteristic (ROC) curve analysis showed that three kinds of PI metabolites had the highest area under the curve (AUC), which were 0.789, 0.781, and 0.715, respectively. Correlation analysis showed that the expression of three PIs was negatively correlated with the incidence of POD.ConclusionOur findings suggest that lipid metabolism plays an important role in the serum metabolic profile of elderly patients with POD in the early post-operative period. Low serum lipid metabolic PI was associated with incidence of POD in elderly following cardiac bypass surgery, which may provide new insights into the pathogenesis of POD.

Blood Transfusion Predicts Prolonged Mechanical Ventilation in Acute Stanford Type A Aortic Dissection Undergoing Total Aortic Arch Replacement.

BackgroundThis research aimed to evaluate the impacts of transfusing packed red blood cells (pRBCs), fresh frozen plasma (FFP), or platelet concentrate (PC) on postoperative mechanical ventilation time (MVT) in patients with acute Stanford type A aortic dissection (ATAAD) undergoing after total arch replacement (TAR).MethodsThe clinical data of 384 patients with ATAAD after TAR were retrospectively collected from December 2015 to October 2017 to verify whether pRBCs, FFP, or PC transfusion volumes were associated with postoperative MVT. The logistic regression was used to assess whether blood products were risk factors for prolonged mechanical ventilation (PMV) in all three endpoints (PMV ≥24 h, ≥48 h, and ≥72 h).ResultsThe mean age of 384 patients was 47.6 ± 10.689 years, and 301 (78.39%) patients were men. Median MVT was 29.5 (4–574) h (h), and 213 (55.47%), 136 (35.42%), and 96 (25.00%) patients had PMV ≥24 h, ≥48 h, and ≥72 h, respectively. A total of 36 (9.38%) patients did not have any blood product transfusion, the number of patients with transfusion of pRBCs, FFP, and PC were 334 (86.98%), 286 (74.48%), and 189 (49.22%), respectively. According to the multivariate logistic regression of three PMV time-endpoints, age was a risk factor [PMV ≥ 24 h odds ratio (ORPMV≥24) = 1.045, p = 0.005; ORPMV≥48 = 1.060, p = 0.002; ORPMV≥72 = 1.051, p = 0.011]. pRBC transfusion (ORPMV≥24 = 1.156, p = 0.001; ORPMV≥48 = 1.156, p < 0.001; ORPMV≥72 = 1.135, p ≤ 0.001) and PC transfusion (ORPMV≥24 = 1.366, p = 0.029; ORPMV≥48 = 1.226, p = 0.030; ORPMV≥72 = 1.229, p = 0.011) were independent risk factors for PMV. FFP had no noticeable effect on PMV [ORPMV≥48 = 0.999, 95% confidence interval (CI) 0.998–1.000, p = 0.039; ORPMV≥72 = 0.999, 95% CI: 0.998–1.000, p = 0.025].ConclusionsIn patients with ATAAD after TAR, the incidence of PMV was very high. Blood products transfusion was closely related to postoperative mechanical ventilation time. pRBC and PC transfusions and age increased the incidence of PMV at all three endpoints.

Hepatic dysfunction in patients who received acute DeBakey type I aortic dissection repair surgery: incidence, risk factors, and long-term outcomes

BackgroundHepatic dysfunction (HD) increases the morbidity and mortality rates after cardiac surgery. However, few studies have investigated the association between HD and acute DeBakey type I aortic dissection (ADIAD) surgery. This retrospective study aimed to identify risk factors for developing HD in patients who received acute type I aortic dissection repair and its consequences.MethodsA total of 830 consecutive patients who received ADIAD surgery from January 2014 to December 2019 at our center were screened for this study. The End-Stage Liver Disease (MELD) score more than 14 was applied to identify postoperative HD. Logistic regression model was applied to identify risk factors for postoperative HD, Kaplan–Meier survival analysis and Cox proportional hazards regression assay were conducted to analyze the association between HD and postoperative long-term survival.ResultsAmong 634 patients who eventually enrolled in this study, 401 (63.2%) experienced postoperative HD with a 30-Day mortality of 15.5%. Preoperative plasma fibrinogen level (PFL) [odds ratio (OR): 0.581, 95% confidence interval (CI): 0.362–0.933, P = 0.025], serum creatinine (sCr) on admission (OR: 1.050, 95% CI 1.022–1.079, P < 0.001), cardiopulmonary bypass (CPB) time (OR: 1.017, 95% CI 1.010–1.033, P = 0.039), and postoperative mechanical ventilation (MV) duration (OR: 1.019, 95% CI 1.003–1.035, P = 0.020) were identified as independent risk factors for developing postoperative HD by multivariate analyses. In addition, the Kaplan–Meier analysis indicated that the long-term survival rate was significantly different between patients with or without postoperative HD. However, the hazard ratios of long-term survival for these two groups were not significantly different.ConclusionsHD was a common complication after ADIAD surgery and associated with an increasing 30-Day mortality rate. Decreased PFL, elevated sCr, prolonged CPB duration, and longer postoperative MV time were independent risk factors for postoperative HD.

Temporary Diaphragm Pacing for Patients at Risk of Prolonged Mechanical Ventilation After Extensive Open Aortic Surgery

Respiratory failure after extensive aortic surgery (EAS), such as thoracoabdominal aortic aneurysm (TAAA) repair, is the most prevalent complication. It starts with the initiation of mechanical ventilation (MV), which results in diaphragm atrophy and contractile dysfunction, termed ventilator-dependent diaphragmatic dysfunction (VIDD), with attendant increases in morbidity and mortality. VIDD has been reported in ≤53% of patients after 24 hours of MV. Diaphragm pacing (DP) has been used for patients with VIDD, such as quadriplegia and diaphragm paralysis. We evaluated the feasibility of DP for patients with a high risk of prolonged MV after EAS. A retrospective review of prospectively collected data was conducted of patients who had undergone implantation of a Food and Drug Administration–approved DP system after EAS from June 2020 to March 2021. The DP electrodes were placed in the left diaphragm after diaphragm closure after TAAA repair or bilaterally after transperitoneal exposure. DP was instituted on arrival to the intensive care unit to prevent diaphragm atrophy and VIDD. The diaphragm electromyogram was analyzed before DP and daily. The key clinical outcome variables were recorded. Seven patients (four men; mean age, 70.1 years) had undergone DP implantation after TAAA repair (n = 6) or transperitoneal renal/visceral debranching (n = 1). The risk factors for respiratory failure and outcomes are listed in the Table. Pulmonary function could not be assessed in three patients owing to emergency nature of the operation. No patient died intraoperatively. No DP-related complications occurred. In all patients, significant improvement in the diaphragm electromyogram was noted with DP (Fig). The median total MV time, including operating time, was 32 hours (range, 16-73 hours). The median postoperative MV time was 22.1 hours (range, 8-63 hours). One patient had required reintubation because of pulmonary edema 29 hours after initial extubation, requiring 44 hours of additional MV. No patient had required prolonged MV (>3 days) or developed VIDD. The median intensive care unit length of stay was 5 days. DP was used for 2 to 6 days (median, 3.8 days). DP increased diaphragm muscular contractions and might mitigate prolonged MV and the development of VIDD after EAS. A further comparative study is warranted.TableRisk factors and outcomesPt. No.Age; sexRisk factorProcedureMV duration, hoursICU, daysFEV1, %EMG: right; leftPostoperativeTotalBaselineFollow-up160; MFormer smokerTAAA repair17.530.54NANA; weakNA; good276; MFormer smoker; sleep studies with poor oxygen saturationRuptured TAAA repair12206NANA; weakNA; good381; MFormer smoker; COPDMycotic TAAA repair16.525.52NANA; weakNA; good475; FFormer smoker; COPDRuptured TAAA repair816101.68NA; weakNA; good561; FActive smoker; COPDTAAA repair243651.55NA; nearly absentNA; good666; MActive smoker; COPDRVD19 + 4423 + 4462.38Nearly absent; nearly absentGood; good779; FFormer smokerTAAA repair637351.29NA; absentNA; weakCOPD, Chronic obstructive pulmonary disease; EMG, electromyogram; F, female; FEV1, forced expiratory volume in 1 second; ICU, intensive care unit; M, male; MV, mechanical ventilation; NA, not applicable; Pt. No., patient number; RVD, renal/visceral debranching; TAAA, thoracoabdominal aortic aneurysm. Open table in a new tab

Comparison of the clinical effect between the lower sternal incision and the left parasternal fourth intercostal incision in the transthoracic closure of ventricular septal defect

BackgroundTo analyze the clinical effect of two different ways of minimally invasive transthoracic closure in children with ventricular septal defect (VSD).MethodsFrom January 2015 to July 2019, 294 children with VSD were enrolled in the Fujian Medical University Union Hospital. Patients were divided into two groups – those who underwent VSD closure through the left sternal fourth intercostal incision (group A: n = 95) and the lower sternal incision (group B: n = 129).ResultsThe operation time, bleeding volume, postoperative mechanical ventilation time, postoperative intensive care unit (ICU) monitoring time, postoperative hospitalization time and complication rate in group A were significantly lower than those in group B (P < 0.05). There was no significant difference between the two groups in the operation success rate, mechanical ventilation time and total hospitalization cost (P > 0.05).ConclusionThe transthoracic closure of ventricular septal defect through the left sternal fourth intercostal incision is feasible, safe, cosmetic, and worth popularizing.

Application of Left Axillary Incision in Patent Ductus Arteriosus Ligation

Left posterolateral incision has been a conventional incision for patent ductus arteriosus ligation. This study aimed to evaluate the efficacy and safety of left axillary thoracotomy for patent ductus arteriosus ligation. Between January 2013 and December 2019, the clinical data of 76 patients who underwent left axillary thoracotomy for patent ductus arteriosus ligation were compared with the data of a paired group of 101 patients who underwent left posterolateral thoracotomy. Compared with the left posterolateral group, the left axillary group showed less drainage (P < 0.05). Operation time, postoperative mechanical ventilation time, and postoperative hospitalization duration were similar between the groups. Complications were rare in both groups with no mortality during follow up. In total, 72 patient families (95%) in the left axillary group and 81 patient families (80%) in the left posterolateral group were satisfied with their cosmetic results (P < 0.01). A left axillary thoracotomy is as safe and effective as a left posterolateral thoracotomy for patent ductus arteriosus ligation. With lower trauma and better cosmetic results, this procedure provides a good alternative to the standard left posterolateral thoracotomy.

Protective effect of sevoflurane on vascular endothelial glycocalyx in patients undergoing heart valve surgery: A randomised controlled trial.

The glycocalyx plays an important physiological role and may be damaged during cardiopulmonary bypass. Sevoflurane can protect the glycocalyx; however, its relevance in a clinical setting is unknown. Glycocalyx degradation during cardiopulmonary bypass in patients was investigated. On the basis of the available experimental data, we hypothesised that sevoflurane-based anaesthesia would confer additional protection against cardiopulmonary bypass-induced glycocalyx damage. Randomised controlled study. Clinical study at The First Affiliated Hospital of Wenzhou Medical University between June 2018 and March 2019. Fifty-one patients. After intubation and mechanical ventilation, patients undergoing elective heart valve surgery were maintained under general anaesthesia with either propofol or sevoflurane during surgery. Glycocalyx markers (such as syndecan-1, heparan sulphate and hyaluronan), sheddases responsible for the degradation of the endothelial glycocalyx (such as matrix metalloproteinase-9 and cathepsin-B), urine albumin-to-creatinine ratio and levels of lactic acid and myocardial enzymes were all measured. Postoperative mechanical ventilation time and length of stay in the cardiac care unit and hospital were also measured. Morbidity and mortality after 30 days and 1 year were evaluated. The vascular endothelial glycocalyx was damaged during cardiopulmonary bypass. The glycocalyx damage in the sevoflurane group was less extensive than that in the propofol group. The urine albumin-to-creatinine ratio increased in both groups but was lower in the sevoflurane group. Enzymes including matrix metalloproteinase-9 and cathepsin-B were positively correlated with glycocalyx marker concentrations. After operation, the sevoflurane group showed lower levels of lactic acid and myocardial enzyme, as well as shorter duration of postoperative mechanical ventilation than the propofol group. Sevoflurane can decrease glycocalyx degradation in patients undergoing heart valve surgery under cardiopulmonary bypass. Chinese Clinical Trial Registry, chictr.org.cn, identifier: ChiCTR1800016367.

Clinical outcome of right ventricle outflow tract management for repair of Tetralogy of Fallot with three contemporary surgical strategies.

Objective:To compare the early operative outcome of TOF repair with three contemporary repair strategies of RVOTO repair i.e. TAP, Mono-cusp construction (MC) in TAP and pulmonary valve repair.Methods:Study is performed at Punjab Institute of Cardiology, Lahore from May 2016 to April 2020. Retrospective analysis of data was performed for patient who underwent TOF repair by three different strategies of RVOT repairs during TOF surgery based on z scoring for pulmonary valve annulus. Group-I underwent trans-annular patch repair, while Group-II and III underwent Mono-cusp repair with autologous pericardium and pulmonary valve repair respectively. Analysis of Variance (ANOVA) and Pearson Chi-Square (PCS) statistics were used to compare the three groups for numeric and categorical variables respectively. Post-hoc t-test and Bonferroni correction were performed for numeric data to compare two groups with each other. Chi-square test was used to perform comparison between groups for categorial variables.Results:ANOVA for aortic cross clamp time, total CPB time, Post-operative mechanical ventilation time, ICU stay and hospital stay showed statistical difference among all three group with p-value less than 0.05 however post hoc T-test showed this variation is limited to post-operative mechanical ventilation only when groups compared with each other. PCS showed there was difference for incidence of difficult weaning from CPB when all three groups compared while there was no difference in operative mortality with p-value of 0.15. However, Group-II comparison with Group-I showed that weaning from CPB was superior in-Group-II with p-value of 0.016. Group-III showed the best statistics for all operative outcome variables among all three groups. Comparison of incidence of post-operative moderate pulmonary regurgitation before discharge between Group-II and Group-III showed significant difference with p-value of 0.0052.Conclusion:PV repair strategy should be employed for RVOT repair of TOF whenever feasible. MC repair showed fewer hours of postoperative mechanical ventilation and higher incidence of easy weaning from CPB when compared to TAP, however its impacts over ICU stay, Hospital stay and operative mortality is not profound in our TOF repair population.

Early Outcome of Minimally Invasive Versus Median Sternotomy Mitral Valve Replacement In Patients With Severe Chronic Obstructive Pulmonary Disease

Background: Minimally invasive valve surgery is considered much more beneficial than routine median sternotomy in patients undergoing open heart surgery with sever chronic obstructive pulmonary disease (COPD). Objective: To compare between early outcomes of minimally invasive versus routine median sternotomy in patients with severe COPD undergoing isolated mitral valve replacement (MVR). Patients and Methods: 100 patients with severe COPD between October 2016 and September 2019 underwent isolated MVR. Patients were divided into 2 groups: Group (A): 50 patients underwent surgery via minimally invasive approach and group (B): 50 patients underwent surgery via median sternotomy. Early postoperative complications, Intensive Care Unit stay and total hospital stay were compared in both groups. Results: The mean age was 60 ± 9 years for Group (A) and 61 ± 10 years for Group (B), (P = 0.29). Combined postoperative complications were significantly lower in Group (A) [8 (16%) versus 12 (24%), P < 0.05]. The median postoperative mechanical ventilation time was 10 hours in group (A) versus 22 hours in group (B) (P < 0.05). The median ICU stay in group (A) was 1.5 days versus 3 days in group (B) (P < 0.05). The median length of total hospital stay was 7 days in group (A) versus 13 days in group (B) (P < 0.05). The overall hospital mortality was 2 patients (4%) in group (A) versus 1 patient (2%) in group (B) P < 0.05. Conclusion: Minimally invasive had better early outcome than routine median sternotomy in patients with severe COPD undergoing MVR and should be considered as a good option in these patients.

Effects of Isovolumic Hemodilution and Platelet-Rich Plasma Separation on Platelet Activation State and Function, Complications, and Inflammation in Patients Undergoing Cardiac Surgery.

To explore the effects of isovolumic hemodilution and platelet-rich plasma separation on platelet activation state and function, complications, and inflammation in patients undergoing cardiac surgery. A total of 80 patients who needed cardiac surgery under extracorporeal circulation from February 2018 to December 2019 in our hospital were selected as research subjects and divided into observation group (n = 40) and control group (n = 40) according to the random number table method. The patients in the observation group underwent platelet-rich plasma separation, while those in control group received acute isovolumic hemodilution. Then the platelet activation state and functional indexes, hemorheological indexes, and the coagulation functional indexes were compared between the two groups of patients before operation. Next, the changes in the levels of hemoglobin and high-sensitivity C-reactive protein (hs-CRP), an inflammatory factor, during blood protection (before and at 6 hours and 12 hours after intervention) were analyzed. Moreover, the dosage of blood products during operation was compared between the two groups, and postoperative complications and recovery in the two groups were statistically assessed. Before operation, the platelet adherence rate and aggregation rate in the observation group were significantly higher than those in control group (p < 0.05), while R and K values in thromboelastograms in the former were notably smaller than those in the latter (p < 0.05). Meanwhile, the whole blood low-shear viscosity, whole blood high-shear viscosity, and plasma viscosity in observation group were remarkably lower than those in control group (p < 0.05). In addition, the observation group exhibited shorter prothrombin time (PT), thrombin time (TT), and activated partial thromboplastin time (APTT) (p < 0.05) and a higher fibrinogen (Fib) level (p < 0.05) than the control group. At 6 hours and 12 hours after intervention and before operation, the hemoglobin level in observation group was markedly higher than that in control group (p < 0.05). In addition, the dosages of red blood cells, fresh frozen plasma, and platelets among blood products during operation in the observation group were evidently lower than those in the control group (p < 0.05), and the number of cases of hemorrhage, pulmonary infection, coagulation dysfunction, and paraplegia after operation in the former was distinctly smaller than that in the latter (p < 0.05). Furthermore, the observation group had an obviously smaller postoperative 24 hours drainage volume (p < 0.05) as well as shorter postoperative mechanical ventilation time and ICU treatment time than control group (p < 0.05). For patients undergoing cardiac surgery under extracorporeal circulation, platelet-rich plasma separation and reinfusion technology can effectively ensure platelet activation state and function, reduce blood viscosity, ensure stable coagulation function, elevate hemoglobin level and decrease inflammatory reaction, and perioperative allogeneic blood infusion, with fewer adverse reactions in treatment, thus efficaciously facilitating the post-operative recovery of patients.