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Zhao B, Zhu P, Zhang H, Gao Y, Zha L, Jin L, Zhang L. Nanofiber Hydrogel Drug Delivery System for Prevention of Postsurgical Intestinal Adhesion. ACS Biomater Sci Eng 2024; 10:3164-3172. [PMID: 38671385 DOI: 10.1021/acsbiomaterials.3c01936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Intestinal adhesion is one of the complications that occurs more frequently after abdominal surgery. Postsurgical intestinal adhesion (PIA) can lead to a series of health problems, including abdominal pain, intestinal obstruction, and female infertility. Currently, hydrogels and nanofibrous films as barriers are often used for preventing PIA formation; however, these kinds of materials have their intrinsic disadvantages. Herein, we developed a dual-structure drug delivery patch consisting of poly lactic-co-glycolic acid (PLGA) nanofibers and a chitosan hydrogel (NHP). PLGA nanofibers loaded with deferoxamine mesylate (DFO) were incorporated into the hydrogel; meanwhile, the hydrogel was loaded with anti-inflammatory drug dexamethasone (DXMS). The rapid degradation of the hydrogel facilitated the release of DXMS at the acute inflammatory stage of the early injury and provided effective anti-inflammatory effects for wound sites. Moreover, PLGA composite nanofibers could provide sustained and stable release of DFO for promoting the peritoneal repair by the angiogenesis effects of DFO. The in vivo results indicated that NHP can effectively prevent PIA formation by restraining inflammation and vascularization, promoting peritoneal repair. Therefore, we believe that our NHP has a great potential application in inhibition of PIA.
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Affiliation(s)
- Bei Zhao
- Zhoukou Central Hospital, Zhoukou 466001, China
| | - Panyong Zhu
- Zhoukou Central Hospital, Zhoukou 466001, China
| | | | - Yaoran Gao
- Zhoukou Central Hospital, Zhoukou 466001, China
| | - Ling Zha
- Zhoukou Central Hospital, Zhoukou 466001, China
| | - Lin Jin
- International Joint Research Laboratory for Biomedical Nanomaterials of Henan, Zhoukou Normal University, Zhoukou 466001, P. R. China
| | - Lei Zhang
- Zhoukou Central Hospital, Zhoukou 466001, China
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2
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Hossne NA. The Role of Hemodynamic, Metabolic, and Biomarkers in Predicting Mortality after Coronary Artery Bypass Grafting: Are we there yet? Arq Bras Cardiol 2024; 121:e20240117. [PMID: 38695404 PMCID: PMC11081087 DOI: 10.36660/abc.20240117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 05/12/2024] Open
Affiliation(s)
- Nelson Americo Hossne
- Universidade Federal de São PauloEscola Paulista de MedicinaDisciplina de Cirurgia CardiovascularSão PauloSPBrasilDisciplina de Cirurgia Cardiovascular, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP – Brasil
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Yang J, Xie X, Li J, Li Y, Li B, Wang C, Jiang P. Which strategy is better for lung transplantation: Cardiopulmonary bypass or extracorporeal membrane oxygenation? Perfusion 2024:2676591241242018. [PMID: 38557237 DOI: 10.1177/02676591241242018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background: In lung transplantation surgery, extracorporeal life support (ECLS) is essential for safety. Various support methods, including cardiopulmonary bypass (CPB) and off-pump techniques, are used, with extracorporeal membrane oxygenation (ECMO) gaining prominence. However, consensus on the best support strategy is lacking.Purpose: This article reviews risks, benefits, and outcomes of different support strategies in lung transplantation. By consolidating knowledge, it aims to clarify selecting the most appropriate ECLS modality.Research Design: A comprehensive literature review examined CPB, off-pump techniques, and ECMO outcomes in lung transplantation, including surgical results and complications.Study Sample: Studies, including clinical trials and observational research, focused on ECLS in lung transplantation, both retrospective and prospective, providing a broad evidence base.Data Collection and/or Analysis: Selected studies were analyzed for surgical outcomes, complications, and survival rates associated with CPB, off-pump techniques, and ECMO to assess safety and effectiveness.Results: Off-pump techniques are preferred, with ECMO increasingly vital as a bridge to transplant, overshadowing CPB. However, ECMO entails hidden risks and higher costs. While safer than CPB, optimizing ECMO postoperative use and monitoring is crucial for success.Conclusions: Off-pump techniques are standard, but ECMO's role is expanding. Despite advantages, careful ECMO management is crucial due to hidden risks and costs. Future research should focus on refining ECMO use and monitoring to improve outcomes, emphasizing individualized approaches for LT recipients.
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Affiliation(s)
- Jianbao Yang
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Xinling Xie
- Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Jian Li
- Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Bin Li
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Cheng Wang
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Peng Jiang
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
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Laskey D, Housman B, Dawodu G, Scheinin S. Intraoperative Extracorporeal Support during Lung Transplantation: Not Just for the High-Risk Patient. J Clin Med 2023; 13:192. [PMID: 38202198 PMCID: PMC10779858 DOI: 10.3390/jcm13010192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
The use of intraoperative mechanical support during lung transplantation has traditionally been a controversial topic. Trends for intraoperative mechanical support strategies swing like a pendulum. Historically, cardiopulmonary bypass (CPB) was the modality of choice during transplantation. It provides full hemodynamic support including oxygenation and decarboxylation. Surgical exposure is improved by permitting the drainage of the heart and provides more permissive retraction. CPBs contain drainage reservoirs with hand-held pump suction catheters promoting blood conservation through collection and re-circulation. But CPB has its disadvantages. It is known to cause systemic inflammation and coagulopathy. CPB requires high doses of heparinization, which increases bleeding risks. As transplantation progressed, off-pump transplantation began to trend as a preferable option. ECMO, however, has many of the benefits of CPB with less of the risk. Outcomes were improved with ECMO compared to CPB. CPB has a higher blood transfusion requirement, a higher need for post-operative ECMO support, a higher re-intubation rate, high rates of kidney injury and need for hemodialysis, longer ICU stays, higher incidences of PGD grade 3, as well as overall in-hospital mortality when compared with ECMO use. The focus now shifts to using intraoperative mechanical support to protect the graft, helping to reduce ischemia-reperfusion injury and allowing for lung protective ventilator settings. Studies show that the routine use of ECMO during transplantation decreases the rate of primary graft dysfunction and many adverse outcomes including ventilator time, need for tracheostomy, renal failure, post-operative ECMO requirements, and others. As intraoperative planned ECMO is considered a safe and effective approach, with improved survival and better overall outcomes compared to both unplanned ECMO implementation and off-pump transplantation, its routine use should be taken into consideration as standard protocol.
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Affiliation(s)
- Daniel Laskey
- Thoracic Surgery Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, One Gustave L. Levy Place, Box 1023, New York, NY 10029, USA; (B.H.); (G.D.); (S.S.)
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5
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Sethasathien S, Jariyasakoolroj T, Silvilairat S, Srisurapanont M. Aortic Peak Flow Velocity As a Predictor of Fluid Responsiveness in Mechanically Ventilated Children: A Systematic Review and Meta-Analysis. Pediatr Crit Care Med 2023; 24:e352-e361. [PMID: 36856439 DOI: 10.1097/pcc.0000000000003219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
OBJECTIVES This meta-analysis aimed to determine the accuracy of the respiratory variations in aortic peak flow velocity (delta Vpeak) in predicting fluid responsiveness and the moderators of that accuracy. DATA SOURCES We performed searches for studies that used delta Vpeak as a predictor of fluid responsiveness in mechanically ventilated children in PubMed, Embase, Scopus, and CINAHL from inception to June 20, 2022. STUDY SELECTION AND DATA EXTRACTION Fifteen studies ( n = 452) were included in this meta-analysis. The diagnostic test data of the included studies were synthesized as pooled sensitivity, specificity, and diagnostic odds ratio (DOR) and the area under the curve (AUC) of the summary receiver operating characteristic of delta Vpeak. DATA SYNTHESIS The delta Vpeak cutoff values applied in these studies had a median of 12.3% (interquartile range, 11.50-13.25%). The pooled sensitivity and specificity of delta Vpeak were 0.80 (95% CI, 0.71-0.87) and 0.82 (95% CI, 0.75-0.87), respectively. The DOR of delta Vpeak was 23.41 (95% CI, 11.61-47.20). The AUC of delta Vpeak was 0.87. Subgroup analyses revealed that the accuracy of delta Vpeak was not moderated by ventilator settings, measures of delta Vpeak, gold standard index, the cutoff gold standard value of responders, type and volume of fluid, duration of fluid challenge, use of vasoactive drugs, general anesthesia, and cardiopulmonary bypass. CONCLUSIONS By using the cutoff of approximately 12.3%, the delta Vpeak appears to have good accuracy in predicting fluid responsiveness in mechanically ventilated children. The moderators of delta Vpeak predictability are not found.
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Affiliation(s)
- Saviga Sethasathien
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine Chiang Mai University, Chiang Mai, Thailand
| | - Theerapon Jariyasakoolroj
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Suchaya Silvilairat
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine Chiang Mai University, Chiang Mai, Thailand
| | - Manit Srisurapanont
- Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Iglesias-Álvarez D, Fu X, Martínez-Cereijo JM, Agra-Bermejo RM, Veiras-Del Río S, Selas-Cobos S, Rial-Munin MV, Eiras-Mariño M, Martínez-Salgado A, Taboada-Muñiz M, Reija-López L, Souaf S, García-Carro J, Fernández-González ÁL, Adrio-Nazar B, González-Juanatey JR, Eiras S, Rodríguez-Mañero M. Clinical Profiling and Biomarkers for Post-Operative Atrial Fibrillation Prediction in Patients Undergoing Cardiac Surgery. J Clin Med 2023; 12:jcm12103565. [PMID: 37240672 DOI: 10.3390/jcm12103565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/17/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
Post-operative atrial fibrillation (POAF) is the most common arrhythmia in the post-operative period after cardiac surgery. We aim to investigate the main clinical, local, and/or peripheral biochemical and molecular predictors for POAF in patients undergoing coronary and/or valve surgery. Between August 2020 and September 2022, consecutive patients undergoing cardiac surgery without previous history of AF were studied. Clinical variables, plasma, and biological tissues (epicardial and subcutaneous fat) were obtained before surgery. Pre-operative markers associated with inflammation, adiposity, atrial stretch, and fibrosis were analyzed on peripheral and local samples with multiplex assay and real-time PCR. Univariate and multivariate logistic regression analyses were performed in order to identify the main predictors for POAF. Patients were followed-up until hospital discharge. Out of 123 consecutive patients without prior AF, 43 (34.9%) developed POAF during hospitalization. The main predictors were cardiopulmonary bypass time (odds ratio (OR) 1.008 (95% confidence interval (CI), 1.002-1.013), p = 0.005), and plasma pre-operative orosomucoid levels (OR 1.008 (1.206-5.761). After studying differences regarding sex, orosomucoid was the best predictor for POAF in women (OR 2.639 (95% CI, 1.455-4.788), p = 0.027) but not in men. The results support the pre-operative inflammation pathway as a factor involved in the risk of POAF, mainly in women.
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Affiliation(s)
- Diego Iglesias-Álvarez
- Department of Cardiology, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
| | - Xiaoran Fu
- Traslational Cardiology, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
- CIBERCV-Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, 28029 Madrid, Spain
| | - José Manuel Martínez-Cereijo
- Department of Cardiac Surgery, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
| | - Rosa María Agra-Bermejo
- Department of Cardiology, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
- Traslational Cardiology, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Sonia Veiras-Del Río
- Department of Anaesthesia and Critical Care, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
| | - Salomé Selas-Cobos
- Department of Anaesthesia and Critical Care, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
| | - María Victoria Rial-Munin
- Department of Anaesthesia and Critical Care, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
| | - María Eiras-Mariño
- Department of Anaesthesia and Critical Care, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
| | - Adrián Martínez-Salgado
- Department of Anaesthesia and Critical Care, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
| | - Manuel Taboada-Muñiz
- Department of Anaesthesia and Critical Care, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
| | - Laura Reija-López
- Department of Cardiac Surgery, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
| | - Souhayla Souaf
- Department of Cardiac Surgery, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
| | - Javier García-Carro
- Department of Cardiac Surgery, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
| | | | - Belén Adrio-Nazar
- Department of Cardiac Surgery, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
| | - José Ramón González-Juanatey
- Department of Cardiology, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
- Traslational Cardiology, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
- CIBERCV-Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, 28029 Madrid, Spain
| | - Sonia Eiras
- Department of Cardiology, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
- Traslational Cardiology, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
- CIBERCV-Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, 28029 Madrid, Spain
| | - Moisés Rodríguez-Mañero
- Department of Cardiology, Complexo Hospitalario Universitario de Santiago, 15706 Santiago de Compostela, Spain
- Traslational Cardiology, Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
- CIBERCV-Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, 28029 Madrid, Spain
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Garcia LR, Garzesi AM, Felicio ML, Zornoff LAM. PTEN in the Context of Myocardial Revascularization: The Iceberg Tip? Arq Bras Cardiol 2023; 120:e20230170. [PMID: 37042859 PMCID: PMC10263417 DOI: 10.36660/abc.20230170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Affiliation(s)
- Leonardo Rufino Garcia
- UNESPHospital das Clínicas de Botucatu e Faculdade de Medicina de BotucatuServiço de Cirurgia Cardiovascular e Transplante CardíacoSão PauloSPBrasilServiço de Cirurgia Cardiovascular e Transplante Cardíaco – Hospital das Clínicas de Botucatu e Faculdade de Medicina de Botucatu – UNESP, São Paulo, SP – Brasil
| | - André Monti Garzesi
- UNESPHospital das Clínicas de Botucatu e Faculdade de Medicina de BotucatuServiço de Cirurgia Cardiovascular e Transplante CardíacoSão PauloSPBrasilServiço de Cirurgia Cardiovascular e Transplante Cardíaco – Hospital das Clínicas de Botucatu e Faculdade de Medicina de Botucatu – UNESP, São Paulo, SP – Brasil
| | - Marcello Laneza Felicio
- UNESPHospital das Clínicas de Botucatu e Faculdade de Medicina de BotucatuServiço de Cirurgia Cardiovascular e Transplante CardíacoSão PauloSPBrasilServiço de Cirurgia Cardiovascular e Transplante Cardíaco – Hospital das Clínicas de Botucatu e Faculdade de Medicina de Botucatu – UNESP, São Paulo, SP – Brasil
| | - Leonardo Antônio Mamede Zornoff
- UNESPFaculdade de Medicina de BotucatuDepartamento de Clínica MédicaSão PauloSPBrasilDepartamento de Clínica Médica - Faculdade de Medicina de Botucatu - UNESP, São Paulo, SP – Brasil
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8
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κ-Opioid Receptor Agonist U50448H Protects Against Acute Lung Injury in Rats with Cardiopulmonary Bypass via the CAP-NLRP3 Signaling Pathway. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:2868135. [PMID: 36034965 PMCID: PMC9410796 DOI: 10.1155/2022/2868135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/30/2022] [Accepted: 08/01/2022] [Indexed: 11/17/2022]
Abstract
Objective. Acute lung injury (ALI) is one of the common and severe complications of cardiopulmonary bypass (CPB), which is the primary cause of death in intensive care units. Nevertheless, there is a lack of effective treatment for ALI secondary to CPB. κ-Opioid receptor (KOR) agonists have been demonstrated to improve lung function after pulmonary hypertension. However, its protective role has been barely reported in CPB-induced acute respiratory distress syndrome (ARDS). Therefore, this research focused on the protective effect of a KOR agonist U50448H on ARDS and investigated its potential relationship with the NOD-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome. Method. Forty-five rats were randomly allocated into Sham, CPB, and U50448 groups (n = 15 rats/group). After a CPB model was successfully established in rats, CPB rats were treated with the KOR agonist U50448H. The values of extravascular lung water (EVLW), alveolar-arterial oxygen tension difference (AaDO2), and respiratory index (RI) were examined, and the lung wet/dry (W/D) weight ratio was also calculated. Western blot (WB) was utilized to measure the expression of MMP-9, GSDMD-C, GSDMD-N, NLRP3, ASC, pro-Caspase-1, pro-IL-1β, and α7-nAChR. The immunofluorescence assay was performed for examining the expression of ROS, F480, iNOS, CD206, and α7-nAChR. Cell apoptosis was detected by the TUNEL assay. ELISA was used to test the level of LPS in serum and the level of MDA, GSH, SOD, TNF-α, IL-4, IL-6, IL-18, and IL-1β in lung tissues. Results. It was observed that the administration of U50448H significantly reduced EVLW values and LPS levels in the lung of rats. Meanwhile, U50448H increased AaDO2 values while decreasing RI values. Moreover, the administration of U50448H alleviated the pathological damage caused by ALI secondary to CPB. U50448H repressed ROS release and oxidative stress responses, as well as lowered LPS levels in plasma and MMP-9 expression in the lung of CPB rats. Furthermore, U50448H facilitated the shift of macrophage phenotype to M2. In addition, U50448H decreased the activity of the CAP-NLRP3 inflammasome and suppressed pyroptosis in pulmonary cells. Conclusion. The KOR agonist U50448H improved lung function and relieved lung injury in CPB rats, accompanied by diminished ROS and MMP-9 levels in lung tissues, promoted macrophage polarization from M1 to M2, and reduced NLRP3 inflammasome activities. These results indicated U50448H as a promising drug for the treatment of ALI secondary to CPB.
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Sanfilippo F, Palumbo GJ, Bignami E, Pavesi M, Ranucci M, Scolletta S, Pelosi P, Astuto M. Acute Respiratory Distress Syndrome in the Perioperative Period of Cardiac Surgery: Predictors, Diagnosis, Prognosis, Management Options, and Future Directions. J Cardiothorac Vasc Anesth 2022; 36:1169-1179. [PMID: 34030957 PMCID: PMC8141368 DOI: 10.1053/j.jvca.2021.04.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/08/2021] [Accepted: 04/16/2021] [Indexed: 12/13/2022]
Abstract
Acute respiratory distress syndrome (ARDS) after cardiac surgery is reported with a widely variable incidence (from 0.4%-8.1%). Cardiac surgery patients usually are affected by several comorbidities, and the development of ARDS significantly affects their prognosis. Herein, evidence regarding the current knowledge in the field of ARDS in cardiac surgery is summarized and is followed by a discussion on therapeutic strategies, with consideration of the peculiar aspects of ARDS after cardiac surgery. Prevention of lung injury during and after cardiac surgery remains pivotal. Blood product transfusions should be limited to minimize the risk, among others, of lung injury. Open lung ventilation strategy (ventilation during cardiopulmonary bypass, recruitment maneuvers, and the use of moderate positive end-expiratory pressure) has not shown clear benefits on clinical outcomes. Clinicians in the intraoperative and postoperative ventilatory settings carefully should consider the effect of mechanical ventilation on cardiac function (in particular the right ventricle). Driving pressure should be kept as low as possible, with low tidal volumes (on predicted body weight) and optimal positive end-expiratory pressure. Regarding the therapeutic options, management of ARDS after cardiac surgery challenges the common approach. For instance, prone positioning may not be easily applicable after cardiac surgery. In patients who develop ARDS after cardiac surgery, extracorporeal techniques may be a valid choice in experienced hands. The use of neuromuscular blockade and inhaled nitric oxide can be considered on a case-by-case basis, whereas the use of aggressive lung recruitment and oscillatory ventilation should be discouraged.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-San Marco", Catania, Italy.
| | | | - Elena Bignami
- Unit of Anesthesiology, Division of Critical Care and Pain Medicine, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Marco Pavesi
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Sabino Scolletta
- Department of Urgency and Emergency, of Organ Transplantation, Anesthesia and Intensive Care, Siena University Hospital, Siena, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Marinella Astuto
- Department of Anaesthesia and Intensive Care, A.O.U. “Policlinico-San Marco”, Catania, Italy,Department of General Surgery and Medical-Surgical Specialties, Section of Anesthesia and Intensive Care, University of Catania, Catania, Italy
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10
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Urbanowicz T, Michalak M, Al-Imam A, Olasińska-Wiśniewska A, Rodzki M, Witkowska A, Haneya A, Buczkowski P, Perek B, Jemielity M. The Significance of Systemic Immune-Inflammatory Index for Mortality Prediction in Diabetic Patients Treated with Off-Pump Coronary Artery Bypass Surgery. Diagnostics (Basel) 2022; 12:diagnostics12030634. [PMID: 35328187 PMCID: PMC8947274 DOI: 10.3390/diagnostics12030634] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/14/2022] [Accepted: 02/25/2022] [Indexed: 02/08/2023] Open
Abstract
Diabetes mellitus (DM) represents a complex carbohydrate metabolism disorder characterized by inflammatory over-reactivity. The study aimed to investigate the potential influence of postoperative inflammatory activation on mortality risk after off-pump coronary artery bypass grafting in diabetic patients. There were 510 patients treated with off-pump coronary artery bypass grafting due to stable complex coronary artery disease, including 175 patients with type-2 DM (T2DM.) The mean follow-up time was 3.7 +/− 1.5 years with a 9% all-cause mortality rate in the diabetic group. In multivariable analysis, preoperative comorbidities (stroke, peripheral artery disease, postoperative systemic inflammatory index >952, and postoperative left ventricle ejection fraction (LVEF) < 45%) were revealed as prognostic factors. The receiver operator characteristics curve analysis for postoperative calculations of systemic immune-inflammatory index (SII) appeared significant (AUC = 0.698, p = 0.008), yielding sensitivity of 68.75% and specificity of 71.07%. Systemic immune-inflammatory index (SII) can be regarded as a predictive marker for long-term prognosis in diabetic patients after off-pump coronary artery bypass grafting. The role of perioperative inflammatory activation may play a crucial role in mortality prediction.
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Affiliation(s)
- Tomasz Urbanowicz
- Cardiac Surgery and Transplantalogy Department, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.O.-W.); (M.R.); (A.W.); (P.B.); (B.P.); (M.J.)
- Correspondence: ; Tel.: +48-61-854-9210
| | - Michał Michalak
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, 61-806 Poznan, Poland; (M.M.); (A.A.-I.)
| | - Ahmed Al-Imam
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, 61-806 Poznan, Poland; (M.M.); (A.A.-I.)
- Department of Anatomy and Cellular Biology, College of Medicine, University of Baghdad, Baghdad 10047, Iraq
| | - Anna Olasińska-Wiśniewska
- Cardiac Surgery and Transplantalogy Department, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.O.-W.); (M.R.); (A.W.); (P.B.); (B.P.); (M.J.)
| | - Michał Rodzki
- Cardiac Surgery and Transplantalogy Department, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.O.-W.); (M.R.); (A.W.); (P.B.); (B.P.); (M.J.)
| | - Anna Witkowska
- Cardiac Surgery and Transplantalogy Department, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.O.-W.); (M.R.); (A.W.); (P.B.); (B.P.); (M.J.)
| | - Assad Haneya
- Herz and Gefaschirurgie, Universitatklinikum Schleswig-Holstein, 24105 Kiel, Germany;
| | - Piotr Buczkowski
- Cardiac Surgery and Transplantalogy Department, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.O.-W.); (M.R.); (A.W.); (P.B.); (B.P.); (M.J.)
| | - Bartłomiej Perek
- Cardiac Surgery and Transplantalogy Department, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.O.-W.); (M.R.); (A.W.); (P.B.); (B.P.); (M.J.)
| | - Marek Jemielity
- Cardiac Surgery and Transplantalogy Department, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.O.-W.); (M.R.); (A.W.); (P.B.); (B.P.); (M.J.)
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11
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D’Onofrio A, Mastro F, Nadali M, Fiocco A, Pittarello D, Aruta P, Evangelista G, Lorenzoni G, Gregori D, Gerosa G. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6540696. [PMID: 35234902 PMCID: PMC9252130 DOI: 10.1093/icvts/ivac053] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 01/31/2022] [Accepted: 02/19/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- A D’Onofrio
- Division of Cardiac Surgery, University of Padova, Padova, Italy
- Corresponding author. Division of Cardiac Surgery, University of Padova, Via Giustiniani 2, Padova 35178, Italy. Tel: +39-0498212410; e-mail: (A. D’Onofrio)
| | - F Mastro
- Division of Cardiac Surgery, University of Padova, Padova, Italy
| | - M Nadali
- Division of Cardiac Surgery, University of Padova, Padova, Italy
| | - A Fiocco
- Division of Cardiac Surgery, University of Padova, Padova, Italy
| | - D Pittarello
- Division of Anesthesiology, University of Padova, Padova, Italy
| | - P Aruta
- Division of Cardiology, Echo Lab, University of Padova, Padova, Italy
| | - G Evangelista
- Division of Cardiac Surgery, University of Padova, Padova, Italy
| | - G Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, University of Padova, Padova, Italy
| | - D Gregori
- Unit of Biostatistics, Epidemiology and Public Health, University of Padova, Padova, Italy
| | - G Gerosa
- Division of Cardiac Surgery, University of Padova, Padova, Italy
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12
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Li Y, Cheang I, Zhang Z, Zuo X, Cao Q, Li J. Prognostic Association Between Perioperative Red Blood Cell Transfusion and Postoperative Cardiac Surgery Outcomes. Front Cardiovasc Med 2021; 8:730492. [PMID: 34631829 PMCID: PMC8497961 DOI: 10.3389/fcvm.2021.730492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/24/2021] [Indexed: 12/28/2022] Open
Abstract
Objective: To investigate the correlation between red blood cell transfusion and clinical outcome in patients after cardiac surgery. Methods: Demographic, clinical characteristics, treatment with/without transfusion, and outcomes of patients after cardiac surgery from the Medical Information Mart for Intensive Care—III database were collected. Patients were divided into two groups according to perioperative transfusion. A multivariable logistic regression analysis was utilized to adjust for the effect of red blood cell transfusion on outcomes for baseline and covariates and to determine its association with outcomes. Results: In total, 6,752 patients who underwent cardiac surgery were enrolled for the analysis. Among them, 2,760 (40.9%) patients received a perioperative transfusion. Compared with patients without red blood cell transfusion, transfused patients demonstrated worse outcomes in inhospital mortality, 1-year mortality, and all-cause mortality. Adjusting odds ratios (ORs) for the significant characteristic, patients with perioperative transfusion remained significantly associated with an increased risk of inhospital mortality [OR = 2.8, 95% confidence interval (CI) 1.5–5.1, P = 0.001], 1-year mortality (OR = 2.0, 95% CI 1.4–2.7, P < 0.001), and long-term mortality (OR = 2.2, 95% CI 1.8–2.8, P < 0.001). Conclusion: Perioperative red blood cell transfusion is associated with a worse prognosis of cardiac surgery patients. Optimal perioperative management and restricted transfusion strategy might be considered in selected patients.
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Affiliation(s)
- Yanxiu Li
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Iokfai Cheang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhongwen Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Xiangrong Zuo
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Quan Cao
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jinghang Li
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Abdelbaser I, Mageed NA, Elfayoumy SI, Elgamal MAF, Elmorsy MM, Taman HI. The direct comparison of inhaled versus intravenous levosimendan in children with pulmonary hypertension undergoing on-cardiopulmonary bypass cardiac surgery: A randomized, controlled, non-inferiority study. J Clin Anesth 2021; 71:110231. [PMID: 33735670 DOI: 10.1016/j.jclinane.2021.110231] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE Pulmonary arterial hypertension is commonly seen in children with left to right intracardiac shunts and affects the outcomes of cardiac surgery. Our study aimed to compare the efficacy of inhaled levosimendan (LS) versus intravenous LS in reducing elevated pulmonary artery pressure (PAP) in children scheduled for cardiac surgery. DESIGN Non-inferiority, prospective, randomized, blinded, controlled study. SETTING Operative room and intensive care unit (ICU), institutional children's hospital of Mansoura Faculty of Medicine, Egypt. PATIENTS 50 patients of either sex, aged 1 to 5 years undergoing surgical repair of intracardiac left to right shunt complicated by pulmonary hypertension were recruited for the study. INTERVENTIONS In the intravenous LS group, patients received intravenous infusion of LS a rate of 0.1 μg/kg/min and in the inhaled LS group, LS (36 μg/kg/6 h) was delivered by nebulization. MEASUREMENTS The primary endpoint was systolic PAP, while the secondary endpoints were the heart rate, mean arterial blood pressure, dose of norepinephrine, time to extubation and ICU length of stay. MAIN RESULTS Both intravenous and inhaled routes of LS similarly reduced the high systolic PAP over all time points of measurement and intravenous LS was associated with higher heart rate, lower arterial pressure and the need for a higher dose of norepinephrine than the inhaled LS. CONCLUSION Inhalation of LS is non-inferior to intravenous LS in reducing high PAP in children who underwent on-pump cardiac surgery and it is associated with less tachycardia and hypotension with reduced need for vasoactive drugs.
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Affiliation(s)
- Ibrahim Abdelbaser
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| | - Nabil A Mageed
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Sherif I Elfayoumy
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Portsaid University, Portsaid, Egypt
| | - Mohamed-Adel F Elgamal
- Department of Cardiac Surgery, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed M Elmorsy
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Hani I Taman
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Hirose H, Jaekel A. Commentary: Autologous blood transfusion effects. J Thorac Cardiovasc Surg 2021; 164:1582-1583. [PMID: 33640136 DOI: 10.1016/j.jtcvs.2021.01.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 10/31/2022]
Affiliation(s)
- Hitoshi Hirose
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pa.
| | - Ashley Jaekel
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pa
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Condello I, Santarpino G, Rimmaudo F. Perioperative Strategies and Influenza Vaccinations, Toward a More Physiological Cardiac Surgery. Ann Thorac Surg 2021; 112:1030-1031. [PMID: 33497665 DOI: 10.1016/j.athoracsur.2020.10.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/17/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Ignazio Condello
- GVM Care & Research, Perfusion Service, Anthea Hospital, Via Camillo Rosalba 35/37, 70124 Bari, Italy.
| | - Giuseppe Santarpino
- Anthea Hospital, GVM Care & Research, Bari, Italy; Department of Cardiac Surgery, Paracelsus Medical University, Nuremberg, Germany; Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Flavio Rimmaudo
- Cardio-Thoracic Department, University of Bari Aldo Moro, Bari, Italy
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Göçer S, Karaçalilar M, Yazici S, Aydin C. Use of native Y-saphenous vein graft in multi-vessel coronary bypass surgery. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2020. [DOI: 10.25083/2559.5555/5.2/96.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective. Demonstration of the advantages of using the natural Y shaped form of saphenous vein graft, which is the most preferred coronary bypass graft after internal thoracic artery (ITA). Methods. 32 patients with coronary artery disease who underwent coronary bypass grafting (CABG) with 3 or more distal anastomoses between January 2014 and January 2018 were included in the study. The natural Y saphenous vein grafts were used in these operations beside of LİMA-LAD anastomosis. Patients have been evaluated in terms of early and short-term survival, early cardiac events, the need for reoperation, and the need for percutaneous transluminal coronary angioplasty (PTCA). All patients were followed up directly by outpatient examination or telephone consultation. Results. New cardiac events, reoperation and death were not seen in the early postoperative period. Coronary angiography performed in 3 patients due to angina in the second and third years revealed that all anastomoses of y-saphenous grafts were open. No mortality was observed in the patients who were followed remotely. The duration of operation and the duration of cardiopulmonary bypass resulted in a reduction in the number of proximal anastomoses and the time by about 10 to 15 minutes. The incision in the saphenous leg was about 10 cm shorter for each anastomosis. Conclusion. The natural shaped Y saphenous vein can be used safely in multi vessel coronary artery disease (CAD) patients for reducing the surgical trauma.
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Weingarten N, Schraufnagel D, Plitt G, Zaki A, Ayyat KS, Elgharably H. Comparison of mechanical cardiopulmonary support strategies during lung transplantation. Expert Rev Med Devices 2020; 17:1075-1093. [PMID: 33090042 DOI: 10.1080/17434440.2020.1841630] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Lung transplantation outcomes are influenced by the intraoperative mechanical cardiopulmonary support strategy used. This surgery was historically done either on cardiopulmonary bypass (CPB) or off pump. Recently, there has been increased interest in intraoperative support with veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO). However, there is a lack of consensus on the relative risks, benefits and indications for each intraoperative support strategy. AREAS COVERED This review includes information from cohort studies, case-control studies, and case series that compare morbidity and/or mortality of two or more intraoperative cardiopulmonary support strategies during lung transplantation. EXPERT OPINION The optimal strategy for intraoperative cardiopulmonary support during lung transplantation remains an area of debate. Current data suggest that off pump is associated with better outcomes and could be considered whenever feasible. ECMO is generally associated with preferable outcomes to CPB, but the data supporting this association is not robust. Interestingly, whether CPB is unplanned or prolonged might influence outcomes more than the use of CPB itself. These observations can help guide surgical teams in their approach for intraoperative mechanical support strategy during lung transplantation and should serve as the basis for further investigations.
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Affiliation(s)
- Noah Weingarten
- Department of General Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Dean Schraufnagel
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Gilman Plitt
- Department of General Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Anthony Zaki
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Kamal S Ayyat
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
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Fujii Y. Evaluation of Inflammation Caused by Cardiopulmonary Bypass in a Small Animal Model. BIOLOGY 2020; 9:biology9040081. [PMID: 32326072 PMCID: PMC7236599 DOI: 10.3390/biology9040081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 01/20/2023]
Abstract
Extracorporeal circulation (ECC) methods are being increasingly used for mechanical support of respiratory and cardio-circulatory failure. Especially, cardiopulmonary bypass (CPB) during cardiovascular surgery, sustenance of the patient’s life by providing an appropriate blood flow and oxygen supply to principal organs. On the other hand, systemic inflammatory responses in patients undergoing cardiovascular surgery supported by CPB contribute significantly to CPB-associated mortality and morbidity. Our previous research showed that CPB causes a systemic inflammatory response and organ damage in a small animal CPB model. We have been studying the effects of hyperoxia and blood plasma substitute on CPB. In this review, we present a study focusing on the systemic inflammatory response during CPB, along with our findings.
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Affiliation(s)
- Yutaka Fujii
- Department of Clinical Engineering and Medical Technology, Niigata University of Health and Welfare, Niigata 950-3198, Japan
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Elbaser IIA, El Aleem El Derie AA. Does Inhaled Milrinone Facilitate Weaning From Cardiopulmonary Bypass in Children with Congenital Heart Diseases Complicated with Pulmonary Arterial Hypertension? Turk J Anaesthesiol Reanim 2020; 48:127-133. [PMID: 32259144 PMCID: PMC7101185 DOI: 10.5152/tjar.2019.91145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 05/06/2019] [Indexed: 11/22/2022] Open
Abstract
Objective The aim of the present study was to evaluate the efficacy of inhaled milrinone in controlling pulmonary arterial hypertension (PAH) in paediatric cardiac surgery and its effect on weaning from cardiopulmonary bypass (CPB). Methods A total of 40 patients with congenital heart diseases complicated by PAH submitted to cardiac surgery requiring CPB were included in the present study and were randomly classified into the control group (n=20) who received intravenous milrinone 0.5 μg kg−1 min−1 and the inhaled group (n=20) who received inhaled milrinone 50 μg kg−1 before initiation and just before weaning off CPB. Mean pulmonary artery pressure (mPAP), mean systemic arterial pressure (MAP), heart rate (HR), MAP/mPAP ratio, vasoactive drug requirements and time needed to wean the patients from CPB were collected. Results mPAP and HR were significantly lower, and MAP and MAP/mPAP ratio were significantly higher in the inhaled group than in the control group. Vasoactive drug requirements were significantly lesser, and the time needed to wean the patients was significantly shorter in the inhaled group than in the control group. Conclusion Milrinone inhalation facilitated the weaning from CPB as it significantly reduced mPAP and maintained MAP with subsequently less needs for vasoactive drugs.
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Affiliation(s)
- Ibrahim Ibrahim Abd Elbaser
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Nenna A, Chello C, Lusini M, Nappi F, Mastroianni C, Chello M. Impact of psoriasis in patients undergoing cardiac surgery. Int J Dermatol 2019; 59:e45-e46. [PMID: 31556102 DOI: 10.1111/ijd.14661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Antonio Nenna
- Cadiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | | | - Mario Lusini
- Cadiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Francesco Nappi
- Cardiac surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Ciro Mastroianni
- Cadiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Massimo Chello
- Cadiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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