History of cardiopulmonary bypass (CPB)

Revolutionizing Cardiac Anesthesia: A Comprehensive Review of Contemporary Approaches Outside the Operating Room

This review article provides a comprehensive examination of the evolution of cardiac anesthesia, emphasizing contemporary approaches beyond the traditional operating room (OR) setting. Tracing the historical roots of cardiac anesthesia from its inception in the mid-20th century, the narrative explores the significant paradigm shift driven by technological advancements and changing procedural approaches. The review highlights the emergence of non-OR environments, such as hybrid operating rooms, catheterization laboratories, and electrophysiology labs, as integral spaces for cardiac interventions. Key findings underscore the importance of patient selection, preoperative assessment, and specialized anesthetic management in optimizing outcomes. Implications for the future of cardiac anesthesia include the potential for enhanced patient-centered care, reduced complications, and improved resource utilization through the integration of advanced technologies. The call to action involves encouraging ongoing research and fostering collaboration among healthcare professionals to refine protocols further, address challenges, and propel the field toward continued innovation in contemporary cardiac interventions.

Origins and Evolution of Extracorporeal Circulation: JACC Historical Breakthroughs in Perspective

Midway through the 20th century, direct open-heart operations were not yet a reality, awaiting safe methods to support the cardiopulmonary circulation during cardiac surgery. The scientific advancements collectively leading to safe cardiopulmonary bypass are considered some of the most impactful advances of modern medicine. Stimulated by the work of physiologists and engineers in the late 19th century, primitive pump and oxygenator designs were the forerunners of major work by DeBakey and others in roller pump design and by Gibbon in oxygenator development. Following Gibbon's historic successful closure of an atrial septal defect in 1953 with his heart-lung machine, it was left to Lillehei and Kirklin to first successfully repair large series of cardiac malformations. The history leading to these historic events and the subsequent evolution of cardiopulmonary bypass machines for short- and longer-term support is filled with engineering and surgical brilliance, daring innovations, and serendipity.

Pulmonary complications following cardiac surgery

Coronary heart disease is a common diseases of atherosclerosis. Despite the development of noninvasive therapies and the advancement of pharmacological methods and extensive drug regimens, coronary artery bypass grafting surgery is still the ultimate treatment option in many patients. Among the various complications following open heart surgery, one of the common difficulties is pulmonary complications associated with subsequent morbidity and mortality, which should be studied according to preoperative, perioperative, and postoperative factors. Preoperative factors include genetics, age, family history of pulmonary disease, smoking, coexisting disease, etc. Perioperative factors include surgical procedures like sternotomy incision, cardioplegia, and internal mammary artery harvesting; anaesthesia procedure effects like pulmonary collapse, maintenance drugs and morphine administration; and cardiopulmonary bypass pump by systemic inflammatory response syndromes. And finally, postoperative factors, especially mediastinitis and the role of nursing in the intensive care unit. Pulmonary complications after cardiac surgery include atelectasis, pleural effusions, pneumonia, pulmonary oedema, cardiogenic pulmonary oedema, acute respiratory distress syndrome, pulmonary embolism, phrenic nerve injury, pneumothorax, sternal wound infection, and mediastinitis, with different outbreaks in patients reported. Although the preoperative, perioperative, and postoperative factors play an important role in the occurrence of these complications, the preoperative factors, as factors that can be adjusted, should be considered more than the others and explained to the patient, and the preoperative patient’s assessment should be noted. Also, postoperative care with the goal of reducing infections and pulmonary complications should be addressed by the nursing team.

Remote Ischemic Preconditioning and Clinical Outcomes in On-Pump Coronary Artery Bypass Grafting: A Meta-Analysis of 14 Randomized Controlled Trials

The purpose of this article is to perform the first pooled analysis on remote ischemic preconditioning (RIPC) used for the improvement of clinical outcomes of patients only undergoing on-pump coronary artery bypass grafting (CABG) in randomized controlled trials (RCTs). A systematic search was performed using PubMed, the Cochrane Library, and the Web of Science to identify studies that described the effect of RIPC on postoperative mortality in patients only undergoing on-pump CABG. The outcomes included postoperative mortality, postoperative morbidity (including incidence of myocardial infarction, atrial fibrillation, stroke, acute kidney injury, and renal replacement therapy), mechanical ventilation (MV), intensive care unit length of stay (ICU LOS), and hospital length of stay (HLOS). A total of 14 RCTs (2830 participants) were included. Our meta-analysis found that RIPC failed to reduce the postoperative mortality in patients only undergoing on-pump CABG compared with control individuals (odds ratio, 0.81; 95% confidence interval, [0.40, 1.64]; P = 0.55; I²  = 25%). Moreover, there were no differences in postoperative morbidity, ICU LOS, and HLOS between the two groups. However, MV in the RIPC group was shorter than that in control individuals (standard mean difference, -0.41; 95% confidence interval, [-0.80, -0.01]; P = 0.04; I²  = 73%). The present meta-analysis found that RIPC failed to improve most of clinical outcomes in patients only undergoing on-pump CABG; however, MV was reduced. Adequately powered trials are warranted to provide more evidence in the future.

Impact of Periapical Abscess on Infectious Complications in Patients Undergoing Extracorporeal Circulation Auxiliary to Open-Heart Surgical Procedures

OBJECTIVE

Extracorporeal circulation auxiliary to open-heart surgeries (ECAOHS) may exert nonphysiological stresses on periapical abscessed tissues leading to hematogenous spread of microbes. The aim of this report was to estimate risk of postoperative infectious complications in patients with periapical abscesses and undergoing ECAOHS.

METHODS

A retrospective analysis of Nationwide Inpatient Sample (years 2009 and 2010) was conducted. All patients (aged 19 to 65 years) who underwent ECAOHS were selected. International Classification of Diseases-9-Clinical Modification codes were used to identify the presence of periapical abscess and infectious complications. Multivariable logistic regression models were used to examine the associations between the presence of periapical abscess and occurrence of infectious complications.

RESULTS

A total of 265,235 patients underwent an ECAOH procedure. Of these, 431 patients had a periapical abscess. Septicemia developed in 16% of those with periapical abscess (compared with 4.2% in those without periapical abscess). Those with periapical abscess had higher rates of any of the infectious complications when compared with those without periapical abscess (30.2% vs 11.6%, respectively). After adjustment for multiple confounders, those with periapical abscess were associated with higher odds for developing septicemia (odds ratio = 2.51, 95% confidence interval = 1.06-5.91, P = .04) and any of the infectious complications (odds ratio = 2.23, 95% confidence interval = 1.08-4.59, P = .03) when compared with those who did not have periapical abscess.

CONCLUSIONS

Those with periapical abscess are associated with higher odds for infectious complications when compared with those without periapical abscess.

Pediatric transport medicine and the dawn of the pediatric anesthesiology and critical care medicine subspecialty: an interview with pioneer Dr. Alvin Hackel

Dr. Alvin 'Al' Hackel (1932-) Professor Emeritus of Anesthesiology, Perioperative and Pain Medicine, and Pediatrics at the Stanford University School of Medicine, has been an influential pioneer in shaping the scope and practice of pediatric anesthesia. His leadership helped to formally define the subspecialty of pediatric anesthesiology ('who is a pediatric anesthesiologist?') and the importance of specialization and regionalization of expertise in both patient transport and perioperative care. His enduring impact on pediatric anesthesia and critical care practice was recognized in 2006 by the American Academy of Pediatrics when it bestowed upon him the profession's highest lifetime achievement award, the Robert M. Smith Award. Of his many contributions, Dr. Hackel identifies his early involvement in the development of pediatric transport medicine as well as the subspecialty of pediatric anesthesiology as his defining contribution. Based on a series of interviews held with Dr. Hackel between 2009 and 2014, this article reviews the early development of transportation medicine and the remarkable career of a pioneering pediatric anesthesiologist.

The potential of the novel leukocyte removal filter in cardiopulmonary bypass

Cardiopulmonary bypass (CPB) is indispensable for cardiac surgery but leads to systemic inflammatory responses and leukocyte activation, possibly due to blood contact with the surface of the CPB unit, surgical, ischemic reperfusion injury, etc. Systemic inflammatory responses during CPB result in increased morbidity and mortality. Activation of leukocytes is an important part of this process and directly contributes to coagulopathy and hemorrhage. This inflammatory response may contribute to the development of postoperative complications, including myocardial dysfunction, respiratory failure, renal and neurologic dysfunction, altered liver function and ultimately, multiple organ failure. Various pharmacologic and mechanical strategies have been developed to minimize the systemic inflammatory response during CPB. For example, leukocyte removal filters were developed in the 1990s for incorporation into the CPB circuit. However, studies of this approach have yielded conflicting findings. The purpose of this was to review the studies of a novel leukocyte removal filter in patients undergoing CPB.