Postoperative Oxygen Saturation Research Articles

Clinical characteristics of severe infant laryngomalacia diagnosed by flexible bronchoscopy and the curative effect of laser therapy

Objective To explore the clinical characteristics of severe infant laryngomalacia diagnosed by fle-xible bronchoscopy, and to investigate the effectiveness and safety of treatment on it. Methods Data of 29 severe laryngomalacia patients from Gansu Provincial Maternity and Child-Care Hospital diagnosed by flexible bronchoscopy were analyzed from March 2013 to July 2015, retrospectively. Twelve cases of them received laser therapy under balanced intravenous anesthesia. Preoperative and postoperative pulse oxygen saturation(SpO2), pulmonary function, and dyspnea index were analyzed statistically. Results After supraglottoplasty with laser, the findings were as follows: SpO2 (94.26±1.30)%, tidal volume(6.11±0.77) mL/kg, time to peak tidal expiratory flow/expiratory time 27.42±3.51, volume at time of peak expiratory flow/expiratory volume 30.95±5.46, and dyspnea index 1.95±1.05; while preoperative findings were SpO2 (82.45±1.35)%, tidal volume(5.30±1.03) mL/kg, time to peak tidal expiratory flow/expiratory time 27.42±3.51, volume at time of peak expiratory flow/expiratory volume 21.93±7.23, and dyspnea index 2.75±0.84, respectively, and there were significant differences between the preoperative and postoperative therapy(all P<0.05). Complications were not observed over the next 6 months after operations. Conclusions Severe infant laryngomalacia has influence on living quality of patients, which can be diagnosed by flexible bronchoscopy. Laser therapy is a safe effective cure for it. Key words: Infants; Laryngomalacia; Flexible bronchoscopy; Laser therapy

Maxillomandibular Advancement for Treatment of Obstructive Sleep Apnea

Maxillomandibular advancement (MMA) is an invasive yet effective surgical option for obstructive sleep apnea (OSA) that achieves enlargement of the upper airway by physically expanding the facial skeletal framework. To identify criteria associated with surgical outcomes of MMA using aggregated individual patient data from multiple studies. The Cochrane Library, Scopus, Web of Science, and MEDLINE from June 1, 2014, to March 16, 2015, using the Medical Subject Heading keywords maxillomandibular advancement, orthognathic surgery, maxillary osteotomy, mandibular advancement, sleep apnea, surgical, surgery, sleep apnea syndrome, and obstructive sleep apnea. Inclusion criteria consisted of studies in all languages of (1) adult patients who underwent MMA as treatment for OSA; (2) report of preoperative and postoperative quantitative outcomes for the apnea-hypopnea index (AHI) and/or respiratory disturbance index (RDI); and (3) report of individual patient data. Studies of patients who underwent adjunctive procedures at the time of MMA (including tonsillectomy, uvulopalatopharyngoplasty, and partial glossectomy) were excluded. Three coauthors systematically reviewed the articles and updated the review through March 16, 2015. The PRISMA statement was followed. Data were pooled using a random-effects model and analyzed from July 1, 2014, to September 23, 2015. The primary outcomes were changes in the AHI and RDI after MMA for each patient. Secondary outcomes included surgical success, defined as the percentage of patients with more than 50% reduction of the AHI to fewer than 20 events/h, and OSA cure, defined as a post-MMA AHI of fewer than 5 events/h. Forty-five studies with individual data from 518 unique patients/interventions were included. Among patients for whom data were available, 197 of 268 (73.5%) had undergone prior surgery for OSA. Mean (SD) postoperative changes in the AHI and RDI after MMA were -47.8 (25.0) and -44.4 (33.0), respectively; mean (SE) reductions of AHI and RDI outcomes were 80.1% (1.8%) and 64.6% (4.0%), respectively; and 512 of 518 patients (98.8%) showed improvement. Significant improvements were also seen in the mean (SD) postoperative oxygen saturation nadir (70.1% [15.6%] to 87.0% [5.2%]; P < .001) and Epworth Sleepiness Scale score (13.5 [5.2] to 3.2 [3.2]; P < .001). Rates of surgical success and cure were 389 (85.5%) and 175 (38.5%), respectively, among 455 patients with AHI data and 44 (64.7%) and 13 (19.1%), respectively, among 68 patients with RDI data. Preoperative AHI of fewer than 60 events/h was the factor most strongly associated with the highest incidence of surgical cure. Nevertheless, patients with a preoperative AHI of more than 60 events/h experienced large and substantial net improvements despite modest surgical cure rates. Maxillomandibular advancement is an effective treatment for OSA. Most patients with high residual AHI and RDI after other unsuccessful surgical procedures for OSA are likely to benefit from MMA.

Risk factors for delirium after on-pump cardiac surgery: a systematic review.

IntroductionAs evidence-based effective treatment protocols for delirium after cardiac surgery are lacking, efforts should be made to identify risk factors for preventive interventions. Moreover, knowledge of these risk factors could increase validity of etiological studies in which adjustments need to be made for confounding variables. This review aims to systematically identify risk factors for delirium after cardiac surgery and to grade the evidence supporting these associations.MethodA prior registered systematic review was performed using EMBASE, CINAHL, MEDLINE and Cochrane from 1990 till January 2015 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014007371). All studies evaluating patients for delirium after cardiac surgery with cardiopulmonary bypass (CPB) using either randomization or multivariable data analyses were included. Data was extracted and quality was scored in duplicate. Heterogeneity impaired pooling of the data; instead a semi-quantitative approach was used in which the strength of the evidence was graded based on the number of investigations, the quality of studies, and the consistency of the association reported across studies.ResultsIn total 1462 unique references were screened and 34 were included in this review, of which 16 (47 %) were graded as high quality. A strong level of evidence for an association with the occurrence of postoperative delirium was found for age, previous psychiatric conditions, cerebrovascular disease, pre-existent cognitive impairment, type of surgery, peri-operative blood product transfusion, administration of risperidone, postoperative atrial fibrillation and mechanical ventilation time. Postoperative oxygen saturation and renal insufficiency were supported by a moderate level of evidence, and there is no evidence that gender, education, CPB duration, pre-existent cardiac disease or heart failure are risk factors.ConclusionOf many potential risk factors for delirium after cardiac surgery, for only 11 there is a strong or moderate level of evidence. These risk factors should be taken in consideration when designing future delirium prevention strategies trials or when controlling for confounding in future etiological studies.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-1060-0) contains supplementary material, which is available to authorized users.

Respiratory rate measurements after cardiac surgery - incidence of abnormal breathing patterns in an observational case series

The respiR8® monitor is a novel device measuring respiratory rates (RR) accurately by quantifying the humidity of exhaled air. So far this monitor has been assessed in volunteers and in patients after abdominal surgery (1). The aim of this observational audit was to assess the frequency of abnormal breathing patterns after cardiac surgery with the respiR8® monitor. A series of patients undergoing cardiac surgery age 60 years and above were connected to the non-invasive respiR8® monitor for up to 5 hours after extubation. We recorded postoperative apnoea (10s of no breathing activity or a RR ≤6 breaths/min), tachypnea (≥18 breaths/min), bradypnoea (≤10 breaths/min), max/min RR and oxygen saturation (SatO2) every 10min during the first hour and every 30min thereafter. 9 patients undergoing bypass and/or valve surgery were studied. All patients were extubated within 6hrs postoperatively, and monitored with the respiR8® monitor within two hours for a median of 2.5hrs (range 2-4.5hrs). 7 patients developed at least one episode and 6 patients at least 5 episodes of postoperative apnoea. All patients had at least 2 episodes of postoperative tachypnea with a median max RR of 31 (range 27-36 breaths/min). One patient showed one episode of SatO2 below 90%. Current clinical practice for measurements of postoperative RR includes ECG recorded chest excursions, which can be misleading as it may indicate a RR without gas movement. Pulse oximetry may only be a late indicator of hypoventilation. However, irregular breathing patterns postoperatively are essential clinical signs for optimizing postoperative clinical care.

Is postoperative delirium a relevant outcome?

potentially confounding neurological dysfunctions. In their study with 100 postoperative patients without a known risk factor of POD, the incidence of POD diagnosed using CAM was 28 %. Their result suggested that the incidence of POD was common in patients after major surgery even without known risk factors. Major surgery might evoke a strong stress response. Recent studies provided the hypothesis that it may introduce postoperative delirium or cognitive dysfunction [9, 10]. As the authors have pointed out, prior studies have commonly been conducted in postoperative patients with known risk factors; their study is relevant and novel. Another finding was a significant association of the use of thiopental with the risk of POD compared with propofol. Thiopental, a barbiturate class of drug, has effects on the gamma-aminobutyric acid (GABA) receptor [11] and propofol is also considered to act through potentiation of GABA receptor activity. Although their finding on thiopental may be skewed by the bias of patient characteristics and conditions which may cause anesthesiologists to choose thiopental rather than propofol, the potential action of thiopental on non-GABA-ergic ligand-gated ion channels, including the neuronal nicotinic acetylcholine receptor channels, may contribute to its association [12]. Although there are potential hypotheses for the etiology and pathophysiology of POD including cholinergic inhabitation, serotonin deficiency, dopamine activation [13], GABA activity [14], and melatonin activity [15], they are not fully understood [16]. This is one of the reasons why there are still just a few strategies for preventing POD [17]; the use of dexmedetomidine in post-cardiac surgery patients [18], multicomponent interventions, and antipsychotics. In this regard, further study should be warranted to develop a detailed understanding and preventive strategy for these postoperative complications. Delirium is characterized by the acute onset of mental status or a fluctuating course and inattention and disorganized thinking or an altered level of consciousness [1], which is common in critically ill patients [2]. Recently, the diagnosis of delirium is recommended by using the Confusion Assessment Method for the intensive care unit (CAM-ICU) [3]. Postoperative delirium (POD) was defined as so because it occurs postoperatively. Although operation, anesthetics, and analgesics can contribute to POD, it is not just associated with emergence from anesthesia, but often occurs between postoperative days 1 and 3. Although POD is commonly recovered from within a short period of time [4], patients with POD are more likely to die or develop dementia and require institutionalization [5]. A number of risk factors are reported for POD, including older age, preoperative cognitive or functional impairment, decreased postoperative hemoglobin, markedly abnormal sodium potassium and glucose, the presence of alcohol abuse, noncardiac thoracic surgery, aortic aneurysm surgery, history of delirium, preoperative use of narcotics, low postoperative oxygen saturation, history of cerebrovascular disease, and untreated pain [6, 7]. In a recent prospective observational study conducted by Saporito and Sturini [8], they excluded patients with any known preexisting predisposing factor for POD; types of surgery, preoperative dementia, sensory deficits, requirement of psychotropic drugs, and alcoholism etc., and other

Optimal Graft Size of Modified Blalock-Taussig Shunt for Biventricular Circulation in Neonates and Small Infants.

The modified Blalock-Taussig shunt (mBTS) is one of the most important palliative procedures in congenital heart surgery. However, in neonates and small infants, operative mortality and morbidity due to excessive pulmonary blood flow or shunt failure remains high. In this study, a small shunt graft (3.0-mm diameter) was estimated to determine the optimal shunt graft size of BTS as an initial palliation for ultimate biventricular circulation. Eighteen patients weighing an average 3.5 kg who underwent mBTS from July 2004 to January 2013 at our institute were reviewed. We divided the study cohort into two groups: group S (n = 10) included patients with 3.0-mm diameter shunt grafts, and group L (n = 8) included patients with 3.5-mm diameter shunt grafts. There were no hospital deaths or shunt occlusion in either group. One group L patient (12.5%) had cardiogenic shock due to excessive pulmonary blood flow. There were no differences in postoperative arterial oxygen saturation (SaO2) between the groups. There were no differences in body weight at intracardiac repair (ICR) between the groups. During the interstage to ICR, body weight gain was significantly greater in group S than in group L (P = 0.008). The small shunt graft (3.0-mm diameter) in BTS was safe, provided adequate pulmonary blood flow, and led to significant weight gain between mBTS and ICR for ultimate biventricular circulation in neonates and small infants with low body weight.

The Modified Fontan Procedure With Use of Extracardiac Conduit in Adults: Analysis of 32 Consecutive Patients

Uncommonly, adults with functionally univentricular hearts are becoming candidates for a Fontan procedure. The purpose of this study was to evaluate the course of patients undergoing the modified Fontan procedure with an extracardiac conduit in recent years. Between January 2003 and December 2013, 32 adult patients (17 female and 15 male) underwent total cavopulmonary connection (TCPC) with extracardiac conduit. The median age at procedure was 24.5 years (interquartile range [IQR] 20 to 33 years). The diagnoses included double-inlet left ventricle (DILV) in 10patients (31.2%), tricuspid atresia in 8 patients (25%), double-outlet right ventricle in 4 patients (12.5%), heterotaxia in 4 patients (12.5%), and mitral atresia in 2 patients (6.2%). Seventy-eight percent of patients had undergone at least one prior palliative procedure; the most common procedures were Blalock-Taussig shunt (16patients), superior cavopulmonary shunt (12 patients), and pulmonary artery banding (6 patients). All patients underwent cardiac catheterization preoperatively. Aortic cross-clamping was necessary in 15 patients for intracardiac procedures. Fenestration was required in 9 patients (28%). Four concomitant intraoperative cryoablation procedures were performed. There was no hospital mortality. One patient (3.1%) died 6 months after undergoing TCPC. Morbidities included prolonged pleural effusion lasting more than 7 days in 20 patients (62.5%), atrial arrhythmias in 4patients (12.5%), and permanent pacemakers in 3 patients (9.3%). The median follow-up time was 33 months (interquartile range [IQR], 10.5 to 50 months). Actuarial survival was 91.83% (95% confidence limits, 71.07 to 97.89) at 1 year and 5 years. Ninety-two percent of patients were in New York Heart Association class I or II atfollow-up. The median postoperative oxygen saturation was 95% (IQR, 93% to 95.5%). Cardiac arrhythmia occurred in 4 patients. Systolic ventricular function improved during follow-up for all patients except 1 patient, who underwent cardiac transplantation 7 months after the TCPC. The modified Fontan procedure with use of an extracardiac conduit can be performed in adults with encouraging early and midterm results. The majority of late survivors had improved quality of life. The incidence of late death, reoperation, arrhythmias, and thromboembolic events was low during follow-up.

Clinical Usefulness of Watch-PAT for Assessing the Surgical Results of Obstructive Sleep Apnea Syndrome

This study aimed to assess the accuracy and clinical efficacy of a wrist-worn device that is based on peripheral arterial tonometry (watch-PAT) to evaluate the surgical results of obstructive sleep apnea (OSA) syndrome subjects. Thirty-five subjects who were diagnosed with OSA and underwent sleep surgeries such as septoplasty, tonsillectomy, or uvuloplasty to correct their airway collapse, participated in this study; the watch-PAT-derived respiratory disturbance index (RDI), apnea and hypopnea index (AHI), lowest oxygen saturation, and valid sleep time were measured after the sleep surgery. The present study showed that RDI (32.8 ± 10.7 vs. 14.8 ± 7.5), AHI (30.3 ± 8.6 vs. 13.4 ± 8.2 events/h), lowest oxygen saturation (78.2% ± 8.4% vs. 90.5% ± 7.1%), and valid sleep time (329.1 ± 47.2 min and a postoperative value of 389.1 ± 50.1 min) recovered to within a normal range after surgery in 28 subjects. In addition, good agreement was found between watch-PAT-derived factors and visual analogue scales for changes in subjective symptoms, such as snoring, apnea, and daytime somnolence. Seven of the 35 subjects showed no improvement for their subjective symptoms and complained of snoring and apnea after surgery. We found that the RDI and AHI of those 7 subjects were not reduced, and the changes between pre- and postoperative values which were measured with watch-PAT were minimal. Their postoperative lowest oxygen saturation and valid sleep time were not elevated per the watch-PAT. The results support a strong correlation between the findings from watch-PAT and improved symptoms after surgical correction of an airway collapse. Our study provides evidence that the factors measured by the watch-PAT might be reliable indicators of symptomatic changes in OSA subjects after sleep surgery and also shows that the watch-PAT is a highly sensitive portable device for estimating treatment results in OSA.

Impact of afterload reduction strategies on regional tissue oxygenation after the Norwood procedure for hypoplastic left heart syndrome

Low cerebral tissue oxygenation saturations have been observed by near-infrared spectroscopy (NIRS) after the Norwood procedure. Altered cerebral vascular resistance and pharmacological afterload reduction redirecting blood flow away from the cerebral circulation are possible mechanisms. Two different afterload reduction strategies were evaluated in patients with hypoplastic left heart syndrome or variants after the Norwood procedure. In patients of Group 1 (n=34), afterload reduction was controlled with sodium nitroprusside or with the α-blocker phentolamine. In addition, a phosphodiesterase-III inhibitor was administered. Patients of Group 2 (n=34) received a phosphodiesterase-III inhibitor only. Cerebral and somatic tissue oxygenation saturations and routine intensive care monitoring data were recorded for 24 h before and 48 h after the Norwood procedure. Mean values of the last 4 preoperative (baseline) and of the first and last 4 postoperative hours (early and late course) were calculated. Baseline, early and late cerebral saturations were 58±7, 52±9 and 60±6% for Group 1 and 58±7, 52±12 and 61±7% for Group 2 and somatic saturations were 59±8, 76±10 and 67±9% and 58±9, 78±8 and 69±10%, respectively. Regional saturations were not different between groups. The postoperative cerebral tissue oxygen saturation was below 40% for 50 (0-1040) min in Group 1 and for 45 (0-720) min in Group 2 (P=1.00). Preoperative cerebral NIRS values (OR 0.85 [0.76-0.96], P=0.007), age at operation (OR 1.39 [1.02-1.88], P=0.034) and early postoperative diastolic blood pressure (OR 0.88 [0.78-0.99], P=0.038) were associated with cerebral tissue oxygen saturations below 40% for more than 60 min. Patients with a prolonged period of low cerebral tissue oxygen saturation had longer duration of mechanical ventilation (69 (37-192) vs 60 (33-238) h, P=0.039) and afterload reduction therapy was terminated later (95 (47-696) vs 74 (39-650) h, P=0.006). Early mortality was 9.4% (3 of 32) compared with 2.8% (1 of 36) in the remainder (P=0.336). The postoperative decline of cerebral tissue oxygen saturation was observed with both afterload reduction strategies. The difference between cerebral and somatic NIRS values may indicate a mismatch between cerebral and splanchnic oxygenation. Other strategies to improve cerebral tissue oxygenation are warranted.

Total Cavopulmonary Direct Anastomosis in the Beating Heart without Prosthetic Material: Preliminary Experience with Modified Extracardiac Fontan Procedure

To describe modified extracardiac Fontan procedure characterized with total cavopulmonary direct anastomosis in the beating heart without using prosthetic material in seven patients and summarize the clinical experiences and follow-up results. From April 2007 to April 2011, seven patients with complex cardiac anomalies underwent this operation. The main pulmonary artery (MPA) was transected at the base of the pulmonary valve and the pulmonary annulus was oversewn. Then the inferior vena cava (ICV) was transected at the junction with the atrium. The MPA was brought to the side of the ICV and anastomosed in an end-to-end fashion. The superior vena cava (SVC) was transected at its entrance into the right atrium and was anastomosed to the right pulmonary artery. Five patients received transcatheter device closure of the fenestration with either a small atrial septal defect or ventricular septal defect occluder. All patients were in sinus rhythm and extubated on the first postoperative day. Immediate postoperative arterial oxygen saturation was 95% (93% to 96%). During the follow-up period from 17 to 65 months (median 48 months), there were no deaths and reoperations. Arterial oxygen saturation ranged from 88% to 92% on room air. The fenestration was closed in five patients postoperatively and the arterial oxygen saturation rose to 95%. Total cavopulmonary direct anastomosis in the beating heart without the use of prosthetic material provides growth potential, and avoids the need for anticoagulation. Longer follow-up will be necessary to evaluate this modification.

P47 Post-Operative Oxygen Saturation, Prescribing & Administration in Patients Undergoing Elective Orthopaedic Surgery

IntroductionThere is increasing interest in maximising perioperative care of surgical patients, including response to oxygen desaturation which may occur in association with anaesthesia, analgesic/sedative drugs, and/or indicate pathology. There is...

Is Indexed Preoperative Superior Vena Cava Blood Flow a Risk Factor in Patients Undergoing Bidirectional Cavopulmonary Shunt?

This study evaluated the effect of a new measurement-superior vena cava (SVC) flow-and anatomic factors on postoperative arterial oxygen saturation and clinical outcome in patients who underwent bidirectional cavopulmonary shunt (BCPS). We reviewed 19 patients who underwent a BCPS between January 2009 and May 2011 who also had SVC blood flow measurements. Median age was 6 months (range, 2 to 29 months). Body weight was 7.0 ± 1.7 kg. Bilateral SVCs were present in 4. SVC flow was measured at the time of BCPS by a Transonic flow probe (Transonic Systems Inc, Ithaca, NY). SVC flow, preoperative hemodynamics, pulmonary artery size, and clinical outcome were analyzed to determine risk for morbidity and death. Mean absolute and indexed pre-BCPS SVC flow was 0.65 ± 0.23 L/min and 1.63 ± 0.55 L/min/m(2) or 91.1 ± 30.8 mL/kg/min, respectively. In all but 1 patient, the SVC flow was increased after BCPS from 1.63 ± 0.55 to 1.99 ± 0.57 L/min/m(2) (p = 0.005). There was a significant positive correlation between pre-BCPS and post-BCPS SVC flow (r = 0.627, p = 0.029). Pulmonary artery size correlated with post-BCPS SVC flow (r = 0.560, p = 0.016). Two patients with preoperative SVC flow of below 1.0 L/min/m(2) died or required BCPS takedown. SVC size did not correlate with BCPS flow (r = 0.231, p = 0.356). Univariate analysis indicated pre-BCPS pulmonary artery pressure was a risk factor for low arterial oxygen saturation (≤ 75%) immediately after BCPS (p = 0.042) and at discharge (p = 0.030). A new indicator-low SVC flow, may be a marker for BCPS failure or death, suggesting that the SVC flow vs size is more important in predicting successful BCPS.

EComment. Two-stage repair of Ebstein's anormaly in a neonate

Ebstein's anomaly is a congenital heart disease, which rarely requires surgical intervention in the neonatal period. Therefore, the case involving surgical treatment for neonatal Ebstein's anomaly with circular shunting by Yohsuke Yanasa et al. is very interesting [1]. The clinical symptoms vary in severity depending on the anatomical malformation. Severe tricuspid regurgitation and right ventricular hypoplasia may produce a critical state in the neonate. Concomitant pulmonary regurgitation is rare, with the reversal of blood flow to the right ventricle, resulting in a 'circular shunt' and necessitating urgent surgical treatment for severe neonatal Ebstein's anomaly. Between 2006 and 2010, 107 patients (including one neonate and one infant) underwent surgery for Ebstein's anomaly at Bakoulev Scientific Center for Cardiovascular Surgery at the Russian Academy of Medical Sciences. In our practice, due to the decrease in pulmonary vascular resistance, minimal antegrade blood flow via pulmonary valve was restored but it was not sufficient to ensure adequate oxygen saturation. We performed a modified Blalock-Taussig shunt with a 4-mm graft. Postoperative oxygen saturation was 80% and the baby was discharged. Six months later, a successful one and a half surgical repair was performed. Surgery in the neonatal period has previously focused on palliation and conversion to single-ventricle physiology. Successful two-ventricle repair with good clinical results can safely be performed in the neonatal period but requires an individual approach in each case.

No Perioperative Pulmonary Complications after Restricted Oxygen Exposition in Bleomycin-Treated Patients: A Short Report

Hyperoxic exposure during general anaesthesia after receiving bleomycin treatment is purported to potentiate bleomycin-induced pulmonary toxicity. The aim of this study was to retrospectively assess perioperative pulmonary complications after general anaesthesia for retroperitoneal lymphadenectomy in patients who underwent bleomycin treatment &lt;6 months earlier. A consecutive series of 47 patients who underwent surgery after bleomycin treatment were reviewed. Anaesthesia was induced with an inspired fraction of oxygen (FiO2) of 100% for 3 minutes and pertained with a FiO2 just under 30% throughout the procedure. We assessed all potential risk factors for bleomycin-induced pulmonary toxicity. Clinical signs for pulmonary damage were documented preoperatively (dyspnea, tachypnea, nonproductive cough, and postoperative oxygen saturation problems). No pathognomic clinical signs for pulmonary damage were detected up to 7 days postoperatively. Administration of 100% oxygen for 3 minutes during induction of anaesthesia and maintaining a FiO2 &lt; 30% during surgery was safe.

Changes of Right Ventricular Function and Longitudinal Deformation in Children with Hypoplastic Left Heart Syndrome before and after the Norwood Operation

The purpose of this study was to investigate changes in right ventricular (RV) function and deformation parameters before and at steady state after the Norwood operation in neonates with hypoplastic left heart syndrome. A further aim was to delineate factors that affected these changes. On echocardiograms before and 21 days (range, 10-35 days) after the Norwood operation, the two-dimensional speckle-tracking parameters global and regional peak systolic longitudinal strain and strain rate were retrospectively compared in 33 patients with hypoplastic left heart syndrome. In addition, RV functional assessment included RV fractional area change and tricuspid annular plane systolic excursion. The associations between postoperative echocardiographic findings and preoperative or postoperative complications, prenatal diagnosis, postoperative heart rate, oxygen saturation, and medication use as well as cardiopulmonary bypass and aortic cross-clamp times were tested. Global strain (-18.3 ± 3.6% vs -16.8 ± 3.8%, P= .02) and global strain rate (-1.6 ± 0.3 vs -1.2 ± 0.3 sec(-1), P < .0001) decreased significantly. Regional strain decreased significantly in the apical and mid lateral segments, while regional strain rate decreased significantly in all but the basal septal segments. Tricuspid annular plane systolic excursion of the lateral annulus decreased significantly, while RV fractional area change remained the same. No significant associations were found between postoperative RV function and potential impact factors. Two-dimensional global and regional longitudinal strain and strain rate as well as tricuspid annular plane systolic excursion were reduced in patients with hypoplastic left heart syndrome after the Norwood operation. None of the examined preoperative and postoperative patient or surgical factors was found to explain this decrease.

Combined Central Venous Oxygen Saturation and Lactate as Markers of Occult Hypoperfusion and Outcome Following Cardiac Surgery

To assess the association between postoperative central venous oxygen saturation (ScvO(2)) and arterial lactate with outcome after cardiac surgery. Prospective observational study. University-affiliated tertiary care hospital. Patients after coronary artery bypass and/or valve surgery. None. Postoperative ScvO(2) and arterial lactate were obtained on arrival to the intensive care unit (ICU). ScvO(2) and lactate were drawn again at 8 and 24 hours, respectively, after ICU admission. Moderate global tissue hypoxia (GTH) was defined as ScvO(2) <70% and lactate ≥2 to <4 mmol/L, and severe GTH was defined as ScvO(2) <70% and lactate ≥4 mmol/L. Occult hypoperfusion was defined as moderate-to-severe GTH with mean arterial pressure ≥65 mmHg, central venous pressure ≥8 mmHg, and urine output ≥0.5 mL/kg/h. ScvO(2) on ICU admission negatively correlated with postoperative 24-hour lactate (p = 0.009), which was a strong predictor of time on mechanical ventilation, total complications, and ICU and hospital lengths of stay (p < 0.001 for all comparisons). On admission to the ICU, 19 patients (32%) exhibited occult hypoperfusion. Patients with severe GTH (n = 8) had longer ICU lengths of stay (p = 0.04) and a trend toward longer length of mechanical ventilation (p = 0.17) and number of complications per patient (p = 0.09) compared with those without GTH (n = 10). The incidence of GTH is high after cardiac surgery. Postoperative ScvO(2) and lactate may be valuable measurements to identify patients with occult hypoperfusion and subsequently guide hemodynamic optimization to positively affect postoperative outcomes in patients after cardiac surgery.

Individual Risk Profiles for Postoperative Delirium after Joint Replacement Surgery

Delirium occurs in nearly half of older patients after joint replacement surgery. However, risk profiles for developing delirium have not been established. We sought to identify risk profiles for delirium in patients following joint replacement surgery. Based on data from a randomized, double-blind, placebo-controlled trial of olanzapine (10 mg) as delirium prophylaxis in 400 patients (67-81 years old) undergoing hip or knee replacement surgery, we performed a signal detection analysis to develop risk profiles for postsurgical delirium (using baseline patient characteristics, iatrogenic factors, and physiologic response parameters). Olanzapine reduced the incidence of delirium by 63% relative to placebo. Among patients receiving placebo, those with an ASA class = 3 and age ≥ 74 years had a 64% risk of delirium. Those with ASA class < 3 still had a 67% risk of delirium if postoperative oxygen saturation was < 95%. Patients who received olanzapine had an 83% risk of developing delirium if they received ≥ 42.5 mg equivalents of intra-operative morphine, were ≥ 74 years old, and had a mean arterial pressure (MAP) < 90 mm Hg at the presurgical screening visit. Patients with the lowest risk (6%) of developing delirium received olanzapine had a hematocrit ≥ 28%, and a presurgical MAP ≥ 90. Although use of prophylactic olanzapine reduced the incidence of delirium, subsets of patients remained likely to develop delirium. The risk of developing delirium may be reduced through prophylactic dispensation of olanzapine, maintaining optimal perfusion and oxygenation, and limiting intra-operative opioids.

Outcomes after Bidirectional Glenn Operation in Single Ventricular Anatomy: A Single Centre Experience

Outcomes after Bidirectional Glenn Operation in Single Ventricular Anatomy: A Single Centre Experience Maqsood M. Elahi 1,∗, Hong C. Chew1, Hari Ravindranathan2, Alan Farnsworth1, Graham R. Nunn1, David Winlaw1, Peter W. Grant 1 1Department of Cardiothoracic Surgery, Sydney Children’s Hospital, Barker Street, Randwick, NSW, Australia 2 Department of Neonatal & Children’s Intensive Care, Sydney Children’s Hospital, Barker Street, Randwick, NSW, Australia Objective: The bidirectional Glenn (BDG) procedure is a well-established procedure. Numerous studies have highlighted its potential benefits in the single-ventricle palliation pathway. We report our experience for predictive variables and outcomes associated with BDG procedures. Methods: Demographics, age at the time of the BDG procedure, associated procedures, length of hospital stay, duration ofmechanical ventilation, length of ICU stay, and primary diagnoses for 29 consecutive patients undergoing the BDG procedure was collected. All data were analysed with Kaplan–Meier survival analysis and the Cox proportional hazard regression test to assess the probability of survival after the BDG procedure. A stepwise regression analysis was performed for identification of independent factors for postoperative oxygen saturation at hospital discharge. and demonstrate that performing BDG procedure at sixmonths of age is feasible and safe. doi:10.1016/j.hlc.2010.11.057 Surgery vs Percutaneous Valvuloplasty for Neonatal and Infant Critical Aortic Stenosis Fountas Nikolas ∗, Cole Andrew, Roberts Philip, Chard Richard ∗ Optimal management for critical aortic stenosis in neonatal and infantpopulations ispoorlyunderstood.This study sought to evaluate outcomes of percutaneous transcatheter balloon valvuloplasty versus surgical therapy. Thirty-nine neonates and 37 infants (mean age 10 days and 4.3 months respectively) underwent treatment for critical aortic stenosis at the Children’s Hospital Westmead between 1998 and 2010. Valvuloplasty was done in 37 (95%) neonates and 37 (100%) infants. Aortic valvotomy, Konno, or Ross-Konno procedures were performed in 12 (31%) neonates and seven (19%) infants. Ten patients had surgery for concomitant aortic coarctation repair (nine), mitral valvotomy/repair (two), or ASD closure (one). Four neonate mortalities occurred (10%); all balloon valvuloplasty related.Re-interventions, either catheteror surgery, occurred in 15 (38%) neonates andnine (24%) infants. Four patients (three neonate, one infant) required both catheter Results: All patients in our study except two required initial palliation with either BT shunt or PA banding in early postnatal care. The mean period from initial surgery to BDG surgerywas approximately 11months. At the time of the BDG procedure, the youngest patient was fivemonths old, and the oldest patient was 4.5 years old. There was an equal distribution of patients with right-sided or leftsided single ventricle anatomy. The postoperative oxygen saturations at discharge (all on room air) were positively associated with previous antegrade flow defined as any flow through the native pulmonary artery and pulmonary valve (P< 0.005) and negatively associated with preoperative end-diastolic ventricular pressure (P< 0.005). Age at the time of the BDG procedure was not associated with worse postoperative oxygen saturations at discharge. There was only one late death (3.4%). Time to Fontan procedure was 23± 4.5 months. The significant independent variables for morbidity in Fontan completion after the BDG procedure were preoperative mean pulmonary artery pressure, bypass time and postoperative oxygen saturations. Conclusion: Our results demonstrated that low mortality in single ventricle anatomy. We found that the post-BDG oxygen saturations at hospital discharge were associated with previous native antegrade flow. We hypothesise that antegrade native pulmonary flow include promotion of normal pulmonary artery growth andmaintenance of pulmonary artery endothelial function for a better outcome towards Fontan completion. Our results support the international trend towards BDG procedure in younger age and surgical re-interventions. Children requiring intervention for congenital critical aortic stenosis as neonates fared worse than infants in mortality and re-intervention rates, and surgery was safe and effective when catheter intervention was unsuccessful. doi:10.1016/j.hlc.2010.11.058 Effect of Physical Activity on Continuous-Flow Left Ventricular Assist Device Function in Outpatients Sharon Hu1,2,3,∗, Anne Keogh1,2, Peter Macdonald1,2, Eugene Kotlyar 1, Desiree Robson1, Michelle Harkess 1, Paul Jansz1,3, Phillip Spratt 1,3, Chris Hayward1,2 1Heart Failure and Transplant Unit, St Vincent’s Hospital, Sydney, Australia 2 Faculty of Medicine, The University of New South Wales, Sydney, Australia 3 Department of Cardiothoracic Surgery, St Vincent’s Hospital, Sydney, Australia Introduction: Left ventricular assist devices (LVADs) augment the heart’s pumping action in patientswithmedically refractory heart failure. Pump flow in continuousflow LVADs have been shown to increase with graded exercise testing [1,2]. However, data on pump behaviour during activities of daily living where cardiac output requirements vary are lacking. Purpose: To observe whether LVAD flow changes with everyday physical activity without active alterations in pump settings.

Impact of Fontan conversion with arrhythmia surgery and pacemaker therapy☆

In the long-term period after Fontan operation, atrial arrhythmia was one of the important factors to decide the postoperative quality of life. We reviewed the impact of Fontan conversion with arrhythmia surgery and pacemaker therapy. Thirty-eight patients underwent Fontan conversion using extracardiac conduit from 1992, and 22 patients with atrial arrhythmia underwent maze procedure simultaneously using cryoablation or radiofrequency ablation and epicardial DDD pacemaker implantation and 16 patients had regular 'sinus' rhythm before Fontan conversion. Mean follow-up period was 52 months. Pre- and postoperative clinical course were analyzed. Average weight, age at Fontan conversion, and years after first Fontan operation were 49.0 kg, 25.8 years old, 14.7 years, respectively. Nineteen percent of patients were in New York Heart Association class I (NYHA I), and 74% of patients were in NYHA II, and 7% were in NYHA III, respectively. Except three early deaths, actual survival rate at 1 year and 5 years were 80% and 64%, respectively. In survivors, 80% of the patients obtained regular heart rhythm including artificial pacemaker rhythm, although only 43% of the patients had regular 'sinus' rhythm before the Fontan conversion. Postoperative average cardiothoracic ratio and oxygen saturation (SpO(2)) were 50% and 94%, and 74% of patients were in NYHA I and 26% were in NYHA II, respectively, after Fontan conversion. Mid-term results of Fontan conversion with arrhythmia surgery and pacemaker therapy were acceptable. Restoration of regular rhythm might improve the postoperative NYHA status and the activity of the daily life.

Risk Assessment of Obstructive Sleep Apnea in a Population of Patients Undergoing Ambulatory Surgery

The aims of this study were to: (a) assess the prevalence of diagnosed OSA and symptoms of undiagnosed OSA in a cohort of ambulatory surgical patients, and (b) characterize the frequency of postoperative complications in outpatients with a diagnosis of or a propensity to OSA. Patients presenting for ambulatory surgery completed a self-administered questionnaire. Using a previously validated prediction model, the probability for OSA was determined. Patients with > or = 70% propensities were considered to be at high risk of having the disorder. Relevant perioperative data and complications were tracked and recorded, and differences in median estimated propensities for OSA were considered by these data. Three-thousand five hundred fifty-three patients 'completed the preoperative survey. A total of 2139 patients had perioperative data and estimated propensity scores. Ninety-four of the 2139 (4.4%) patients gave a self-reported prior diagnosis of OSA. One hundred three (4.8%) patients were found to be at high risk of OSA based on the survey and prediction model. Seventy-five percent of the patients with > 70% propensity for OSA had not yet been diagnosed. There was no association between OSA propensity scores and unplanned hospital admission, however there was an association of increased propensity with difficult intubation, intraoperative use of pressors, and postoperative oxygen saturation in the PACU. The results of this study suggest that undiagnosed OSA may be relatively common in an ambulatory surgical population. There was no relationship between unplanned hospital admission and diagnosis of or increased risk of OSA. However, there was an association of increased perioperative events requiring additional anesthetic management in patients with a diagnosis of, or with a higher propensity to OSA.