Conservative Management of Large Post-Intubation Tracheal Laceration

ABSTRACT

Tracheal rupture is a very rare but life-threatening complication of endotracheal intubation. It is more common in women and patients older than 50 years old. Overinflation of endotracheal tube cuff and tracheal wall weakening are the most important pathogenetic mechanisms. Laceration sites are located in the posterior membranous wall in most cases. Subcutaneous and mediastinal emphysema and respiratory distress are the most common manifestations. A 55-year-old female presented with postoperative subcutaneous and mediastinal emphysema without dyspnea because of a tear in the posterior tracheal wall. The diagnosis was based on clinical manifestation, chest computer tomography scans (CT), and endoscopic findings. A conservative approach by broad-spectrum antibiotic therapy was decided because of patients' vital signs stability and the absence of esophageal injury. The follow-up showed that there was no lesion in the posterior tracheal wall. Our case showed that in clinically stable patients without mediastinitis and with spontaneous breathing, conservative management of tracheal tears is a safe procedure.

Fate of the moderately diseased aorta: a single-center experience

Introduction

The fate of the aorta after tube graft replacement remains unclear.

Aim

We investigated the evolution of aortic dilatation after non-aortic cardiac operations and the dimensions of the root and arch after ascending aorta replacement.

Material and methods

From 252 patients with aortic dilatation operated on between January 2010 and June 2019, 160 were followed with CT angiography. Two groups were formed according to the initial operation. Group I (n = 36) included patients with a dilated aorta, unreplaced during different indication cardiac surgery. Group II (n = 124) included patients receiving tube graft aorta replacement with or without aortic valve replacement. Mean preoperative and follow-up diameters of the different aortic segments were compared in both groups using the two-sided paired t-test for repeated measurements.

Results

Eighteen patients died during follow-up, with one death occurring during reoperation for a false aneurysm of the distal anastomosis on the aortic arch. There was no other re-operation for aortic aneurysm, rupture or dissection. In group I the aortic arch diameter increased slightly, while the rest of the aortic segments remained stable. In group II the aortic root diameter decreased slightly while the aortic arch remained stable.

Conclusions

Ascending aorta replacement with a tube graft remodeled the aortic root and did not allow progressive dilatation of the aortic arch. In patients with moderate ascending aorta dilatation, the unreplaced ascending aorta and aortic root remained relatively stable but the aortic arch increased slightly during follow-up.

A comparison of postoperative blood lactate concentrations and kinetics in cardiac surgical patients being and not being administered metformin

Aim. Early discontinuation of metformin before cardiac surgery is advised by several national societies but no hard evidence exist supporting this practice. This precaution is mostly extrapolated by data on different clinical settings. The aim of this study is to investigate the impact of preoperative metformin use on lactate concentrations and lactate clearance during the first postoperative day after cardiac surgery.Methods. Among 367 consecutive patients who underwent elective on-pump cardiac surgery from January 2019 to October 2019, 109 were diabetics, 74 of which were treated with metformin. Data on lactate concentrations and clearance during the first postoperative day were prospectively collected on arrival, H6, H12 and H24 in the ICU and compared. A subgroup analysis focusing only on diabetic patients was also performed. Repeated measures multivariate analysis of variance (MANOVA) was used to investigate the data based on group, time and their interaction effects.Results. Lactate concentrations were the same for both groups upon arrival in the ICU. Interestingly, metformin users had lower lactate concentrations than non-users on the following measurements (p = 0.003 at 6 h and p = 0.01 at 24 h). No significant interaction was found between the two groups (p = 0.76). No difference was found between the two groups in terms of lactate clearance (p = 0.53). In the subgroup analysis no difference was found between metformin users and non-users neither on lactate concentrations (p = 0.61) nor on lactate clearance (p = 0.86).Conclusions. In a post cardiac surgery ICU setting, using metformin up until the night before surgery was not associated with increased postoperative lactate concentrations or impaired lactate clearance.

Smoking behavior after coronary artery bypass surgery: Quit, relapse, continuing

Objective:

Tobacco smoking represents a major risk factor for coronary artery disease. Our study aimed to investigate whether Coronary Artery Bypass Graft (CABG) surgery could act as a motivating factor to enforce smoking cessation. Specifically, we observed the success rate in individuals who quitted smoking, along with the number and reasons of relapse(s) at least one year after the operation.

Methods:

The pre-operative characteristics, pre-operative tobacco exposure, socioeconomic factors and perioperative complications in patients who underwent isolated Coronary Artery Bypass Graft surgery in our Department from June 2012 to September 2016 were reviewed. Our survey was conducted via phone interview and using a standardized questionnaire. Only patients who were current smokers at the time of surgery were interviewed.

Results:

Our study group consisted of a total of 120 patients, 91 (75.8%) reported initially quitting tobacco smoking. Because of relapse(s), one year after the procedure the number of patients who were still non-smokers dropped to 69 (57.5%). Smoking cessation attempts were not supported by professional assistance.

Conclusions:

Our findings demonstrate that there is a desire from CABG patients to quit smoking, as indicated by the high percentage of initial attempts in early postoperative period. However, a year after the procedure, only 57.5% of CABG patients were able to achieve or maintain smoking cessation. Patients who were retired or who were unemployed at the time of the surgery, found it easier to stop smoking than patients who were active employees. Patients who lived alone at the time of surgery also found it harder to stop smoking. Finally, patients with COPD also found quitting smoking harder in the post-operative period.

Integrating continuous monitoring and evaluation of risk-adjusted outcomes in a cardiac surgical program

BACKGROUND

The variable life-adjusted display (VLAD) method shows the difference between predicted and observed outcomes over time. Our study aims to implement routine in-house monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery.

METHODS

The Society of Thoracic Surgeons (STS) risk score was calculated for 249 isolated and combined coronary and aortic or mitral valve cases performed during a 6-month period. The nine predicted STS variables were operative mortality, permanent stroke, renal failure (RF), prolonged ventilation, deep sternal wound (DSW) infection, reoperation for any reason, short and long length of stay (LOS), and major morbidity or operative mortality. EuroSCORE II was also calculated for the study population. VLAD plots were generated for each variable indicating whether performance is better or worse than expected on the basis of predicted risk of failure.

RESULTS

The mortality plot was fluctuating close to baseline risk. The prolonged ventilation, RF, reoperation, morbidity/mortality, and LOS plots were consistently positive, indicating favorable results. The stroke chart showed an upward trend for most of the period until two incidents toward last month led to a steep descent. The DSW infections plot though, indicated a worse-than-expected performance. The VLAD charts were shared in multidisciplinary meetings and clinicians were able to confront the performance with the population-specific expectancies and respond to adverse trends with further actions.

CONCLUSION

Graphical tool monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery is feasible and allows detection of underperformance and implementation of changes in clinical practice.

Noninvasive Ventilation to Treat Respiratory Failure After Cardiac Surgery: Predictors of Application and Outcome

BACKGROUND

Respiratory complications remain a major cause of morbidity in cardiac surgery patients. This study aimed to determine the prognostic parameters associated with the application of noninvasive ventilation (NIV) for the treatment of acute respiratory failure, along with the possible predictors associated with NIV failure, among the subjects who underwent cardiac surgery.

METHODS

This was a retrospective cohort study. Data on all adult patients who underwent cardiac surgery in a single center between May 2012 and December 2016 were analyzed. Multivariate regression analysis with bootstrapping was used to identify which baseline and intraoperative parameters were associated with the application of NIV to treat acute postoperative respiratory failure. A univariate analysis was also applied to identify potential variables associated with NIV failure. P < .05 was considered significant.

RESULTS

A total of 1,657 subjects (mean ± SD age 65.2 ± 10.7 y; 21.7% females) constituted the study population, 145 (8.8%) of whom were treated with NIV due to acute postoperative respiratory failure. Body mass index adjusted odds ratio 1.02, bias-corrected 95% CI 1.01-1.04), EuroSCORE (European System for Cardiac Operative Risk Evaluation) II (adjusted odds ratio 1.11, bias-corrected 95% CI 1.02-1.32), COPD (adjusted odds ratio 4.004, bias-corrected 95% CI 2.53-8.93), and preoperative estimated glomerular filtration rate (adjusted odds ratio 0.99, bias-corrected 95% CI 0.98-0.99) independently predicted NIV application. NIV treatment failed in 16 of the 145 subjects (11%) and age, EuroSCORE II, COPD, heart failure, renal replacement therapy, and postoperative stroke were all univariately associated with the outcome.

CONCLUSIONS

NIV successfully treated acute respiratory failure in the vast majority of cardiac surgery subjects and COPD, EuroSCORE II, body mass index, and preoperative renal function were independently associated with its application.

Endovascular approach in chronic aortoiliac disease in patient undergoing coronary artery bypass surgery

Internal thoracic artery (ITA) is an excellent conduit for coronary artery bypass surgery (CABG). We present a patient with known preoperative aortoiliac disease with anterior collateral pathway who had an indication for elective coronary bypass. The use of ITA in these patients may cause lower limb ischemia. Detecting Winslow's anastomotic pathway before CABG is of utmost importance.

Abdominal compartment syndrome after surgical repair of Type A aortic dissection

Abdominal compartment syndrome is associated with severe dysfunction of intra-abdominal and intrathoracic organs. Medical therapy, with the goal of reducing intra-abdominal pressure, leads to improvement in organ perfusion.

Serum Creatinine and Chronic Kidney Disease-Epidemiology Estimated Glomerular Filtration Rate: Independent Predictors of Renal Replacement Therapy following Cardiac Surgery

BACKGROUND

Most studies evaluating predictors of renal replacement therapy (RRT) following cardiac surgery use arbitrary defined limits of preoperative serum creatinine. The aim of this study was to evaluate the effect of preoperative renal function using either estimated-glomerular filtration rate (eGFR) derived using Chronic Kidney Disease-Epidemiology (CKD-EPI) or serum creatinine alone as a predictor for RRT after cardiac surgery.

METHODS

In this prospective cohort study, baseline, intraoperative, and postoperative data of all patients who underwent an elective, urgent, or emergency cardiac surgery between 2012 and 2016 in a single center were analyzed in order to identify multivariate parameters determining the need for RRT after surgery. For preoperative renal function, we used serum creatinine levels and eGFR-derived CKD-EPI equation. We also divided our cohort into eGFR groups following the thresholds of the currently proposed CKD classification.

RESULTS

From the 1,614 patients (mean age: 65.4 ± 10.6 years; male: 77.6%) that constituted the study population, 42 (2.6%) underwent RRT postoperatively. EUROSCORE II, cardiopulmonary bypass time, cross clamp time, red blood cell (RBC) units transfused, type and urgency of surgery, combined/non combined operation, peripheral vascular disease, heart failure, chronic obstructive pulmonary disease, dyslipidemia, and preoperative renal function were all univariately associated with RRT use. Multivariate regression with bootstrap utilization indicated that CKD-EPI eGFR (OR 0.979; 95% CI 0.956-0.998), heart failure with the New York Heart Association class ≥2 (OR 4.695; 95% CI 1.756-14.061) and RBC units transfused (OR 1.287; 95% CI 1.081-1.850) were independently associated with RRT need. When serum creatinine (OR 2.920, 95% CI1.056-8.074) was used in the model, the associations with RRT were also significant.

CONCLUSION

Preoperative renal function, defined by serum creatinine or eGFR by CKD-EPI, NYHA class II-IV, and the number of blood units transfused were all independent predictors of RRT postoperatively.

Surgical treatment of atrial septum lipomatous hypertrophy associated with syncopal attacks

Lipomatous hypertrophy of atrial septum (LHAS) is a rare benign cardiac condition characterized by fatty tissue infiltration located in the atrial septum. We presented a rare case of LHAS resulting in recurrent syncopal attacks.

Comparison of a new simplified acid-base tool to the original Stewart-Figge approach: a study on cardiac surgical patients

PURPOSE

To suggest a simplified method for strong ion gap ([SIG]) calculation.

PATIENTS AND METHODS

To simplify [SIG] calculation, we used the following assumptions: (1) the major determinants of apparent strong ion difference ([SID_a]) are [Na⁺], [K⁺] and [Cl^-] (2) [Ca²⁺] and [Mg²⁺] do not contribute significantly to [SID_a] variation and can be replaced by their reference concentrations (3) physiologically relevant pH variation is at the order of 10^-2 and therefore we can assume a standard value of 7.4. In the new model, [SID_a] is replaced by its adjusted form, i.e. [SID_a,adj] = [Na⁺] + [K⁺] - [Cl^-] + 6.5 and [SIG] is replaced by "bicarbonate gap", i.e. [BIC_gap] = [SID_a,adj] - (0.25·[Albumin]) - (2·[Phosphate]) - [HCO₃^-]. The model was tested in 224 postoperative cardiac surgical patients.

RESULTS

Strong correlations were observed between [SID_a,adj] and [SID_a] (r = 0.93, p < 0.0001) and between [BIC_gap] and [SIG] (r = 0.95, p < 0.0001). The mean bias (limits of agreement) of [SID_a,adj] - [SID_a] and of [BIC_gap]-[SIG] was - 0.6 meq/l (- 2.7 to 1.5) and 0.2 meq/l (- 2 to 2.4), respectively. The intraclass correlation coefficients between [SID_a,adj] and [SID_a] and between [BIC_gap] and [SIG] were 0.90 and 0.95, respectively. The sensitivities and specificities for the prediction of a [lactate^-] > 4 meq/l were 73.4 and 82.3% for a [BIC_gap] > 12.2 meq/l and 74.5 and 83.1% for a [SIG] > 12 meq/l, respectively.

CONCLUSIONS

The [BIC_gap] model bears a very good agreement with the [SIG] model while being simpler and easier to apply at the bedside. [BIC_gap] could be used as an alternative tool for the diagnosis of unmeasured ion acidosis.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

The Role of Blood Transfusion in the Development of Atrial Fibrillation after Coronary Artery Bypass Grafting

Objectives Atrial fibrillation (AF) is the most common complication after coronary artery bypass grafting (CABG). It is associated with prolonged hospital stay and increased cost. The aim of this study is to investigate the relationship between transfusion of blood derivatives and occurrence of postoperative paroxysmal AF. Materials and Methods From June 2012 to February 2014, 446 patients undergoing CABG with cardiopulmonary bypass (CPB) were prospectively evaluated for occurrence of postoperative AF. Patients and procedural variables were recorded and were associated with the development of new-onset AF with logistic regression analysis. Results AF developed in 111 patients (24.9%). Preoperative factors associated with the development of new-onset AF included age (p < 0.05), higher EuroSCORE II (p < 0.05), carotid disease (p = 0.01), peripheral vascular disease (p = 0.02), chronic obstructive pulmonary disease (p = 0.03), renal failure (p = 0.05), and cardiac failure (p = 0.01). Intraoperative and postoperative parameters included duration of CPB (p < 0.05), number of grafts (p = 0.009), intubation time (p = 0.001), occurrence of postoperative stroke (p = 0.01), transient ischemic attack (p = 0.02), need for prolonged ventilation (p = 0.002), development of respiratory tract infection (p = 0.02), need for noninvasive ventilation (p = 0.001), reintubation (p = 0.02), development of postoperative acute kidney injury (p = 0.002), and postoperative neurocognitive dysfunction (p = 0.002). The number of red blood cell (RBC) units transfused during surgery (p = 0.7) and the total number of RBC units transfused (p = 0.2) as well as units of fresh frozen plasma (p = 0. 7) and platelets units transfused in total (p = 0.3) were not found to increase the risk of postoperative AF. Conclusion Intraoperative and postoperative blood products transfusion in patients operated for CABG is not associated with increased risk of developing postoperative AF.

Pericardial fat is strongly associated with atrial fibrillation after coronary artery bypass graft surgery†

OBJECTIVES

Recent evidence suggests that pericardial fat may represent an important risk factor for cardiovascular disease because of its unique properties and its proximity to cardiac structures. It has been reported that pericardial fat volume (PFV) is associated with atrial fibrillation (AF). The purpose of this study was to investigate the association between PFV and new-onset AF following coronary artery bypass graft surgery (CABG).

METHODS

PFV was measured using computed tomography in 83 patients with coronary artery disease scheduled to undergo elective isolated on-pump CABG. Patient characteristics, medical history and perioperative variables were prospectively collected. Any documented episode of new-onset postoperative AF until discharge was defined as the study end point.

RESULTS

Twenty-eight patients (33.7%) developed postoperatively AF during hospital stay. There was no significant difference in demographics and comorbidities among patients that maintained sinus rhythm (SR) and their AF counterparts. In univariate analysis, patients with postoperative AF had significantly more pericardial fat compared with SR patients (195 ± 80 ml vs 126 ± 47 ml, P = 0.0001). Larger left atrial diameter was also associated with postoperative AF (42.4 ± 6.9 mm vs 39.3 ± 4.8 mm, P = 0.017). Additionally, the prebypass use of calcium channel-blocking agents was independently associated with a lower incidence of postoperative AF, confirmed also by multivariate analysis (P = 0.035). In multivariate logistic regression analysis, PFV was the strongest independent variable associated with the development of postoperative AF (odds ratio: 1.018, 95% confidence interval: 1.009-1.027, P = 0.0001). The best discriminant value assessed by receiver operating characteristic analysis was 129.5 ml (sensitivity 86% and specificity 56%).

CONCLUSIONS

PFV is strongly associated with AF following CABG, independently of many traditional risk factors. Our findings suggest that PFV may represent a novel risk factor for postoperative AF. However, the role of pericardial fat in AF mechanism needs to be further delineated.

Aortic root aneurysm in an adult patient with aortic coarctation: a single-stage approach

Coarctation of the aorta is a common congenital defect that may be undiagnosed until adulthood. Moreover, coarctation is associated with congenital and acquired cardiac pathology that may require surgical intervention. The management of an adult patient with aortic coarctation and an associated cardiac defect poses a great technical challenge since there are no standard guidelines for the therapy of such a complex pathology. Several extra-anatomic bypass grafting techniques have been described, including methods in which distal anastomosis is performed on the descending thoracic aorta, allowing simultaneous intracardiac repair. We report here a 37-year old man who was diagnosed with an aortic root aneurysm and aortic coarctation. The patient was treated electively with a single-stage approach through a median sternotomy that consisted of valve-sparing replacement of the aortic root and ascending-to-descending extra-anatomic aortic bypass, using a 18-mm Dacron graft. Firstly, the aortic root was replaced with the Yacoub remodelling procedure, and then the distal anastomosis was performed to the descending aorta, behind the heart, with the posterior pericardial approach. The extra-anatomic bypass graft was brought laterally from the right atrium and implanted in the ascending graft. Postoperative recovery was uneventful and a control computed tomographic angiogram 1 month after complete repair showed good results.

The role of ascorbic acid in the prevention of atrial fibrillation after elective on-pump myocardial revascularization surgery: a single-center experience--a pilot study

Atrial fibrillation (AF) is a common arrhythmia that occurs postoperatively in cardiac surgery. There is evidence for the role of oxidative stress in the etiology of AF. In our study, we examined whether antioxidant ascorbic acid (vitamin C), could help in the reduction of the incidence of postoperative AF. Patients who were scheduled to undergo elective isolated on-pump coronary artery bypass grafting (CABG) were included in our study. One hundred and seventy patients were randomly divided in two groups: Group A (n=85) received vitamin C preoperatively and postoperatively whereas Group B (n=85) did not receive any (control group). The incidence of AF was 44.7% in the vitamin C group and 61.2% in the control group (P=0.041). The hospitalization time, the intensive care unit stay and the time interval for the conversion of AF into sinus rhythm was significantly shorter in the vitamin C group. Patients that developed AF also had longer hospital length of stay (9.5±2.8 days vs. 6.7±1.9, P=0.034). Supplementation of vitamin C reduces the incidence of postCABG AF, and decreases the time needed for rhythm restoration and length of hospital stay.

Endovascular treatment of symptomatic and ruptured abdominal aortic aneurysms

AIM

To report our early experience with endovascular treatment of symptomatic and ruptured abdominal aortic aneurysms (AAA) using the Talent bifurcated stent graft.

PATIENTS-METHODS

From August 2003 to May 2007 nine patients with symptomatic AAA (sAAA) (two after previous endovascular repair and endoleak), and eleven patients with ruptured AAA (rAAA) (one with ruptured iliac aneurysm and one with spontaneous aortic rupture) were treated endovascularly. Seven bifurcated stent grafts, (six Talent), and two iliac extensions were implanted into the patients with sAAA, and nine bifurcated stent grafts (eight Talent) and two aorto-uniliacs were implanted into the patients with rAAA.

RESULTS

The deployment of the endovascular device in the intended location was successful in all patients. There was no conversion to open surgery. One patient with sAAA died after stroke and sepsis resulting in 11.1% 30-day mortality in this group. One required re-intervention for a type I endoleak before his discharge. Eight patients were discharged and during a follow-up period of 4-42 months (median 18 months) they have remained well. Two patients with rAAA died in the 30-day postoperative period. Thirty-day mortality was 18.1%. An unintended occlusion of one renal artery was performed. There were 9 survivors. During a follow-up period of 17-45 months (median 26 months) one more died of myocardial infarction.

CONCLUSION

Initial experience with endovascular treatment of patients with symptomatic or ruptured AAA, using the Talent bifurcated stent graft is promising. Bifurcated endografts can be implanted into patients with rAAA. A larger number of patients and longer follow-up is necessary to arrive at more reliable conclusions.