Off-pump coronary artery bypass grafting (OP-CABG) surgery without the use of cardiopulmonary bypass (CPB) has come into practice for surgical treatment of Coronary artery disease (CAD) to reduce the post-operative systemic inflammatory response and post-operative morbidity. However, manipulation of the beating heart during OP-CABG surgery brings significant fluctuations in the patients haemodynamics leading to occult hypo-perfusion and 'Global tissue hypoxia' (GTH) -a decrease in oxygen utilization associated with anaerobic metabolism.
Outcome After Procedures for Retained Blood Syndrome in Coronary SurgeryPaul Molloy
OBJECTIVES:
Incomplete drainage of blood from around the heart and lungs can lead to retained blood syndrome (RBS) after cardiac sur-
gery. The aim of this study was to assess the incidence of and the outcome after procedures for RBS in patients undergoing isolated coronary artery bypass grafting (CABG)-
Effects of red blood cell transfusions on exercise tolerance and rehabilitati...anemo_site
This study examined 217 patients who received red blood cell transfusions after cardiac surgery. It found that:
1. The patients' exercise tolerance, as measured by a 6-minute walk test, was not dependent on the number of red blood cell units transfused or their hemoglobin level upon entering rehabilitation.
2. Factors like older age and higher blood urea nitrogen levels were associated with worse exercise tolerance.
3. The length of patients' rehabilitation stay was independently associated with the number of red blood cell units transfused, with each additional unit increasing the stay by 0.6 days on average. Left ventricular function and blood urea nitrogen levels also predicted longer rehabilitation times.
Myocardial viability testing all STICHed up, or about to be REVIVEDNicolas Ugarte
Patients with ischaemic left ventricular dysfunction frequently undergo myocardial viability testing. The historical model presumes that
those who have extensive areas of dysfunctional-yet-viable myocardium derive particular benefit from revascularization, whilst those without extensive viability do not. These suppositions rely on the theory of hibernation and are based on data of low quality: taking a dogmatic
approach may therefore lead to patients being refused appropriate, prognostically important treatment. Recent data from a sub-study of
the randomized STICH trial challenges these historical concepts, as the volume of viable myocardium failed to predict the effectiveness of
coronary artery bypass grafting. Should the Heart Team now abandon viability testing, or are new paradigms needed in the way we interpret viability? This state-of-the-art review critically examines the evidence base for viability testing, focusing in particular on the presumed
interactions between viability, functional recovery, revascularization and prognosis which underly the traditional model. We consider
whether viability should relate solely to dysfunctional myocardium or be considered more broadly and explore wider uses of viability testingoutside of revascularization decision-making. Finally, we look forward to ongoing and future randomized trials, which will shape evidence-based clinical practice in the futur
Postoperative chylothorax after cardiothoracicgisa_legal
This study examines the incidence, risk factors, and outcomes of postoperative chylothorax in children undergoing cardiothoracic surgery. The researchers found that the incidence of chylothorax was 3.8% and was significantly higher after heart transplantation, Fontan procedures, and tetralogy of Fallot repairs. Patients with chylothorax had significantly longer hospital stays compared to those without chylothorax. Nutritional management including low fat diets and octreotide were used to treat chylothorax, but surgical interventions provided limited benefit when reserved for severe or prolonged cases. Early diagnosis may reduce the duration of chylothorax.
1. The document discusses several studies that have evaluated the use of thromboelastography (TEG) or thromboelastometry (ROTEM) to guide blood product transfusion in patients undergoing cardiac surgery or with massive bleeding.
2. The studies found that TEG/ROTEM-guided transfusion protocols may reduce the use of blood products such as fresh frozen plasma, platelets, and total units transfused compared to usual care. However, the evidence is still weak to moderate and did not show significant effects on mortality or other clinical outcomes.
3. Confounding factors between studies include differences in the time points for TEG/ROTEM monitoring, transfusion triggers, and
Management of anticoagulation in lvad recipientsdrucsamal
This document discusses management of anticoagulation for patients receiving left ventricular assist devices (LVADs). It notes that thrombosis is a major problem for LVADs. Under-anticoagulation is thought to be a key cause of pump thrombosis. The relationship between activated partial thromboplastin time (aPTT) and anti-Xa levels is poor in LVAD patients on warfarin compared to heart failure patients, indicating aPTT may not accurately reflect anticoagulation levels in LVAD patients. Future directions include further evaluating the role of anti-platelet agents and factors like blood type and hyperco
Outcome After Procedures for Retained Blood Syndrome in Coronary SurgeryPaul Molloy
OBJECTIVES:
Incomplete drainage of blood from around the heart and lungs can lead to retained blood syndrome (RBS) after cardiac sur-
gery. The aim of this study was to assess the incidence of and the outcome after procedures for RBS in patients undergoing isolated coronary artery bypass grafting (CABG)-
Effects of red blood cell transfusions on exercise tolerance and rehabilitati...anemo_site
This study examined 217 patients who received red blood cell transfusions after cardiac surgery. It found that:
1. The patients' exercise tolerance, as measured by a 6-minute walk test, was not dependent on the number of red blood cell units transfused or their hemoglobin level upon entering rehabilitation.
2. Factors like older age and higher blood urea nitrogen levels were associated with worse exercise tolerance.
3. The length of patients' rehabilitation stay was independently associated with the number of red blood cell units transfused, with each additional unit increasing the stay by 0.6 days on average. Left ventricular function and blood urea nitrogen levels also predicted longer rehabilitation times.
Myocardial viability testing all STICHed up, or about to be REVIVEDNicolas Ugarte
Patients with ischaemic left ventricular dysfunction frequently undergo myocardial viability testing. The historical model presumes that
those who have extensive areas of dysfunctional-yet-viable myocardium derive particular benefit from revascularization, whilst those without extensive viability do not. These suppositions rely on the theory of hibernation and are based on data of low quality: taking a dogmatic
approach may therefore lead to patients being refused appropriate, prognostically important treatment. Recent data from a sub-study of
the randomized STICH trial challenges these historical concepts, as the volume of viable myocardium failed to predict the effectiveness of
coronary artery bypass grafting. Should the Heart Team now abandon viability testing, or are new paradigms needed in the way we interpret viability? This state-of-the-art review critically examines the evidence base for viability testing, focusing in particular on the presumed
interactions between viability, functional recovery, revascularization and prognosis which underly the traditional model. We consider
whether viability should relate solely to dysfunctional myocardium or be considered more broadly and explore wider uses of viability testingoutside of revascularization decision-making. Finally, we look forward to ongoing and future randomized trials, which will shape evidence-based clinical practice in the futur
Postoperative chylothorax after cardiothoracicgisa_legal
This study examines the incidence, risk factors, and outcomes of postoperative chylothorax in children undergoing cardiothoracic surgery. The researchers found that the incidence of chylothorax was 3.8% and was significantly higher after heart transplantation, Fontan procedures, and tetralogy of Fallot repairs. Patients with chylothorax had significantly longer hospital stays compared to those without chylothorax. Nutritional management including low fat diets and octreotide were used to treat chylothorax, but surgical interventions provided limited benefit when reserved for severe or prolonged cases. Early diagnosis may reduce the duration of chylothorax.
1. The document discusses several studies that have evaluated the use of thromboelastography (TEG) or thromboelastometry (ROTEM) to guide blood product transfusion in patients undergoing cardiac surgery or with massive bleeding.
2. The studies found that TEG/ROTEM-guided transfusion protocols may reduce the use of blood products such as fresh frozen plasma, platelets, and total units transfused compared to usual care. However, the evidence is still weak to moderate and did not show significant effects on mortality or other clinical outcomes.
3. Confounding factors between studies include differences in the time points for TEG/ROTEM monitoring, transfusion triggers, and
Management of anticoagulation in lvad recipientsdrucsamal
This document discusses management of anticoagulation for patients receiving left ventricular assist devices (LVADs). It notes that thrombosis is a major problem for LVADs. Under-anticoagulation is thought to be a key cause of pump thrombosis. The relationship between activated partial thromboplastin time (aPTT) and anti-Xa levels is poor in LVAD patients on warfarin compared to heart failure patients, indicating aPTT may not accurately reflect anticoagulation levels in LVAD patients. Future directions include further evaluating the role of anti-platelet agents and factors like blood type and hyperco
Antibiotic dose modification is crucial on patients with CRRT with sepsis and MOF. This talk highlights the importance of achieving plasma therapeutic drug concentration in ICU patients to enhance their chances of survival while on CRRT
This document discusses the remodeling of the brachial artery (AB) in arterial hypertension (HTA). It covers the following key points:
1. AB remodeling in HTA can be adaptive/compensatory (increasing diameter and wall thickness to maintain luminal area) or maladaptive. Imaging techniques like ultrasound can evaluate AB morphology and function.
2. Spectral Doppler analysis of AB blood flow shows broadening of the spectral envelope in HTA, reflecting increased arterial stiffness. Flow-mediated dilation (%FMD) evaluates endothelial function. Lower %FMD correlates with cardiovascular risk factors and subclinical atherosclerosis.
3. AB remodeling correlates with target organ damage in HTA. Different HTA phenotypes (e
This document summarizes two studies on percutaneous left ventricular assist devices (LVADs) and coronary artery fistulas.
The first study investigated the ability of a percutaneous LVAD to deliver blood to the systemic circulation during cardiac arrest in pigs. The LVAD maintained blood flow and preferentially perfused vital organs like the brain. Intensified fluid loading further improved LVAD performance.
The second study evaluated the microvascular effects of ultrasound contrast (Definity) in hamsters with conditions like ischemia-reperfusion, diabetes, and sepsis. Inflammatory responses were higher in diabetes with ischemia and sepsis groups, independent of contrast use. Contrast did not alter hemodynamics or reology.
A predictive model to reduce allogenic transfusions in primary total hip arth...anemo_site
This document presents a predictive model to reduce allogenic blood transfusions in primary total hip arthroplasty patients. The authors developed a model to predict bleeding and subsequent anemia based on age, gender, and pre-operative hemoglobin levels using data from 580 patients. Statistical analysis showed that post-operative hemoglobin levels were significantly associated with gender, age, and pre-operative hemoglobin concentration. The predictive model estimates expected post-operative hemoglobin differences compared to a threshold of 10 g/dL based on patient characteristics to help guide transfusion decisions. The goal is to ensure adequate hemoglobin levels to reduce risks and speed rehabilitation while minimizing unnecessary transfusions.
Peritoneal dialysis (PD) is associated with better preservation of residual kidney function compared to hemodialysis (HD). PD also has advantages such as lower infection risks and improved quality of life through increased employment rates and lifestyle flexibility compared to HD. However, PD remains underutilized in many countries despite its benefits. Factors contributing to underutilization include modality preferences of nephrologists, lack of patient education, and system-related barriers. Integrated care approaches emphasizing early referral and shared modality decision-making between patients and nephrologists are optimal for end-stage renal disease treatment.
This document summarizes a research article about developing a strategy for performing heart surgery on patients who refuse blood transfusions for religious reasons. The strategy involves four parts: administering high doses of erythropoietin preoperatively to increase red blood cell counts; optimizing platelet and coagulation levels; reinfusing lost blood intraoperatively and postoperatively; and restricting fluid administration to minimize dilution. This multimodal strategy has allowed over 200 heart surgeries to be performed at one hospital on patients refusing transfusions, with no transfusions required and mortality lower than expected.
Papua New Guinea has about seven active mining and exploration activities for minerals like gold, copper, and other minor minerals. Each is managed by different company and
together employs about ten thousand workers. A fifth of this would be foreign workers. Most of the Mine workers that are screened at the Employees Health and Wellness clinics tend to
have similar compounding health risks
Manual thrombus aspiration during primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) was not associated with reduced long-term mortality according to a study of 10,929 patients. While thrombus aspiration was linked to higher procedural success rates and lower in-hospital complications, long-term survival was similar between patients who received thrombus aspiration and those who underwent PPCI only. After adjusting for differences in patient characteristics and procedures using propensity score matching, thrombus aspiration during PPCI was still not found to reduce mortality risk.
Dr. Sharfuddin Chowdhury: Tranexamic Acid administration in traumaShakila Rifat
Time since injury is the major factor in preventing Tranexamic Acid (TXA) use in the trauma setting: An observational cohort study from a major trauma centre in a middle income country.
This study evaluated a novel transcatheter interatrial shunt device for treating heart failure with preserved ejection fraction (HFPEF). 64 patients underwent successful implantation of the device. At 6 months follow up, 71% of patients had a reduction in pulmonary capillary wedge pressure at rest or during exercise compared to baseline. The procedure was well tolerated with no safety issues. The results suggest the device may help reduce left atrial pressure and improve functional status for patients with HFPEF, though the study had limitations as an open-label single-arm trial with short follow up.
Tranexamic acid in hip hemiarthroplasty Conrad Lee
This study examined whether administering tranexamic acid (TXA) before hip hemiarthroplasty surgery reduces postoperative blood transfusions. The study reviewed 271 patient records, with 84 patients receiving TXA and 187 not receiving it. Patients receiving TXA saw a lower drop in postoperative hemoglobin levels and lower transfusion rates. Specifically, the TXA group saw a 26% transfusion rate compared to 42% in the non-TXA group. The study concluded that TXA reduces postoperative blood loss and transfusions in hip hemiarthroplasty patients, and is a safe and cost-effective intervention.
This study examined the relationship between volume overhydration and endothelial dysfunction in 81 stable patients on continuous ambulatory peritoneal dialysis. Volume status was assessed by normalized extracellular water and endothelial function was estimated by flow-mediated dilation of the brachial artery. There was an independent correlation between the index of volume status (normalized extracellular water) and endothelial function (flow-mediated dilation), with higher normalized extracellular water related to worse endothelial function. Multiple regression analysis identified calcium-phosphate product, normalized extracellular water, and dialysis vintage as independent determinants of endothelial function. The results suggest that volume overhydration may lead to increased cardiovascular risk in dialysis patients through its effects on endothelial dysfunction.
Intraoperative oesophageal Doppler monitoring (ODM) guided fluid management was compared to standard central venous pressure (CVP) guided fluids in a randomized controlled trial of 128 colorectal surgery patients. ODM guided fluid optimization resulted in significantly shorter hospital length of stay, earlier return of gut function, fewer postoperative complications, and cost savings compared to CVP-guided fluids. ODM provided a more reliable assessment of intravascular volume status and cardiac preload than CVP alone.
1) The study compared outcomes of STEMI patients undergoing primary PCI with thrombectomy (Group T) versus without thrombectomy (Group S).
2) MRI results at 3 months showed significantly smaller infarct size and less transmurality in Group T compared to Group S.
3) Procedural results favored Group T with higher rates of TIMI 3 flow and complete ST resolution. One-year outcomes also favored Group T with lower rates of MACE.
Thrombus aspiration during percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is said to reduce PCI-induced distal occlusion.
In an attempt to enhance its effectiveness, thrombus aspiration is often coupled with glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors, although conflicting results with this strategy have been reported.
GP IIb/IIIa antagonists inhibit the final common pathway that leads to platelet aggregation and leukocyte plugging, which are the main components of fresh thrombi.
This document provides an updated summary of guidelines for blood conservation in cardiac surgery from The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists. Major revisions include new recommendations regarding dual anti-platelet therapy management before surgery, drugs that augment red blood cell volume or limit blood loss, blood derivatives, blood salvage management, minimally invasive procedures, extracorporeal membrane oxygenation, hemostatic agents, and insights into team-based interventions. The guidelines were updated based on a literature review using standardized search terms to ensure the recommendations reflect the most current evidence available.
The document summarizes various strategies for managing thrombus burden during primary angioplasty for myocardial infarction. It discusses thrombus grading scales, the composition and types of thrombus, and the role of medications like GP IIb/IIIa inhibitors (abciximab, tirofiban, eptifibatide), heparin, and bivalirudin. It also compares intracoronary versus intravenous administration of these drugs and evaluates trials comparing different treatment strategies. Mechanical thrombectomy devices and a combined pharmacologic and mechanical approach are also reviewed.
This study compared the effects of levosimendan, dobutamine, and vasodilator therapy on ongoing myocardial injury in patients with acute decompensated heart failure. The study found that while all treatments were associated with decreases in cardiac troponin I levels and improvements in hemodynamic and functional indicators, levosimendan treatment showed the most pronounced improvements, especially in left ventricular ejection fraction and systolic pulmonary artery pressure. However, none of the treatments significantly reduced cardiac troponin I levels compared to each other. The study demonstrated beneficial effects of short-term use of levosimendan, dobutamine, and nitroglycerin on ongoing myocardial injury in acute decompensated heart failure.
1) The study examined predictors of ischemia and outcomes in 169 Egyptian patients with diabetes referred for nuclear perfusion imaging over 2 years of follow up.
2) Significant relationships were found between higher summed stress scores and outcomes of sudden cardiac death, myocardial infarction, and heart failure. Higher summed rest scores also significantly predicted several adverse outcomes.
3) Degree of typical chest pain, transient left ventricular dilation, lung uptake on imaging, and extent of ischemia (summed difference score) were independent predictors of myocardial infarction. Transient left ventricular dilation was the strongest predictor of sudden cardiac death.
Coronary angioplasty has revolutionized the management of coronary artery disease. It has not ceased to develop to become the reference method of myocardial revascularization. The aim of our study is to evaluate the ultrasound parameters of left ventricular function after coronary angioplasty. This is a prospective analytical study including patients with stable coronary artery disease with a known coronary artery anatomy programmed for coronary angioplasty. Transthoracic echocardiography was performed four hours before and seven days after myocardial revascularization.
Antibiotic dose modification is crucial on patients with CRRT with sepsis and MOF. This talk highlights the importance of achieving plasma therapeutic drug concentration in ICU patients to enhance their chances of survival while on CRRT
This document discusses the remodeling of the brachial artery (AB) in arterial hypertension (HTA). It covers the following key points:
1. AB remodeling in HTA can be adaptive/compensatory (increasing diameter and wall thickness to maintain luminal area) or maladaptive. Imaging techniques like ultrasound can evaluate AB morphology and function.
2. Spectral Doppler analysis of AB blood flow shows broadening of the spectral envelope in HTA, reflecting increased arterial stiffness. Flow-mediated dilation (%FMD) evaluates endothelial function. Lower %FMD correlates with cardiovascular risk factors and subclinical atherosclerosis.
3. AB remodeling correlates with target organ damage in HTA. Different HTA phenotypes (e
This document summarizes two studies on percutaneous left ventricular assist devices (LVADs) and coronary artery fistulas.
The first study investigated the ability of a percutaneous LVAD to deliver blood to the systemic circulation during cardiac arrest in pigs. The LVAD maintained blood flow and preferentially perfused vital organs like the brain. Intensified fluid loading further improved LVAD performance.
The second study evaluated the microvascular effects of ultrasound contrast (Definity) in hamsters with conditions like ischemia-reperfusion, diabetes, and sepsis. Inflammatory responses were higher in diabetes with ischemia and sepsis groups, independent of contrast use. Contrast did not alter hemodynamics or reology.
A predictive model to reduce allogenic transfusions in primary total hip arth...anemo_site
This document presents a predictive model to reduce allogenic blood transfusions in primary total hip arthroplasty patients. The authors developed a model to predict bleeding and subsequent anemia based on age, gender, and pre-operative hemoglobin levels using data from 580 patients. Statistical analysis showed that post-operative hemoglobin levels were significantly associated with gender, age, and pre-operative hemoglobin concentration. The predictive model estimates expected post-operative hemoglobin differences compared to a threshold of 10 g/dL based on patient characteristics to help guide transfusion decisions. The goal is to ensure adequate hemoglobin levels to reduce risks and speed rehabilitation while minimizing unnecessary transfusions.
Peritoneal dialysis (PD) is associated with better preservation of residual kidney function compared to hemodialysis (HD). PD also has advantages such as lower infection risks and improved quality of life through increased employment rates and lifestyle flexibility compared to HD. However, PD remains underutilized in many countries despite its benefits. Factors contributing to underutilization include modality preferences of nephrologists, lack of patient education, and system-related barriers. Integrated care approaches emphasizing early referral and shared modality decision-making between patients and nephrologists are optimal for end-stage renal disease treatment.
This document summarizes a research article about developing a strategy for performing heart surgery on patients who refuse blood transfusions for religious reasons. The strategy involves four parts: administering high doses of erythropoietin preoperatively to increase red blood cell counts; optimizing platelet and coagulation levels; reinfusing lost blood intraoperatively and postoperatively; and restricting fluid administration to minimize dilution. This multimodal strategy has allowed over 200 heart surgeries to be performed at one hospital on patients refusing transfusions, with no transfusions required and mortality lower than expected.
Papua New Guinea has about seven active mining and exploration activities for minerals like gold, copper, and other minor minerals. Each is managed by different company and
together employs about ten thousand workers. A fifth of this would be foreign workers. Most of the Mine workers that are screened at the Employees Health and Wellness clinics tend to
have similar compounding health risks
Manual thrombus aspiration during primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) was not associated with reduced long-term mortality according to a study of 10,929 patients. While thrombus aspiration was linked to higher procedural success rates and lower in-hospital complications, long-term survival was similar between patients who received thrombus aspiration and those who underwent PPCI only. After adjusting for differences in patient characteristics and procedures using propensity score matching, thrombus aspiration during PPCI was still not found to reduce mortality risk.
Dr. Sharfuddin Chowdhury: Tranexamic Acid administration in traumaShakila Rifat
Time since injury is the major factor in preventing Tranexamic Acid (TXA) use in the trauma setting: An observational cohort study from a major trauma centre in a middle income country.
This study evaluated a novel transcatheter interatrial shunt device for treating heart failure with preserved ejection fraction (HFPEF). 64 patients underwent successful implantation of the device. At 6 months follow up, 71% of patients had a reduction in pulmonary capillary wedge pressure at rest or during exercise compared to baseline. The procedure was well tolerated with no safety issues. The results suggest the device may help reduce left atrial pressure and improve functional status for patients with HFPEF, though the study had limitations as an open-label single-arm trial with short follow up.
Tranexamic acid in hip hemiarthroplasty Conrad Lee
This study examined whether administering tranexamic acid (TXA) before hip hemiarthroplasty surgery reduces postoperative blood transfusions. The study reviewed 271 patient records, with 84 patients receiving TXA and 187 not receiving it. Patients receiving TXA saw a lower drop in postoperative hemoglobin levels and lower transfusion rates. Specifically, the TXA group saw a 26% transfusion rate compared to 42% in the non-TXA group. The study concluded that TXA reduces postoperative blood loss and transfusions in hip hemiarthroplasty patients, and is a safe and cost-effective intervention.
This study examined the relationship between volume overhydration and endothelial dysfunction in 81 stable patients on continuous ambulatory peritoneal dialysis. Volume status was assessed by normalized extracellular water and endothelial function was estimated by flow-mediated dilation of the brachial artery. There was an independent correlation between the index of volume status (normalized extracellular water) and endothelial function (flow-mediated dilation), with higher normalized extracellular water related to worse endothelial function. Multiple regression analysis identified calcium-phosphate product, normalized extracellular water, and dialysis vintage as independent determinants of endothelial function. The results suggest that volume overhydration may lead to increased cardiovascular risk in dialysis patients through its effects on endothelial dysfunction.
Intraoperative oesophageal Doppler monitoring (ODM) guided fluid management was compared to standard central venous pressure (CVP) guided fluids in a randomized controlled trial of 128 colorectal surgery patients. ODM guided fluid optimization resulted in significantly shorter hospital length of stay, earlier return of gut function, fewer postoperative complications, and cost savings compared to CVP-guided fluids. ODM provided a more reliable assessment of intravascular volume status and cardiac preload than CVP alone.
1) The study compared outcomes of STEMI patients undergoing primary PCI with thrombectomy (Group T) versus without thrombectomy (Group S).
2) MRI results at 3 months showed significantly smaller infarct size and less transmurality in Group T compared to Group S.
3) Procedural results favored Group T with higher rates of TIMI 3 flow and complete ST resolution. One-year outcomes also favored Group T with lower rates of MACE.
Thrombus aspiration during percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is said to reduce PCI-induced distal occlusion.
In an attempt to enhance its effectiveness, thrombus aspiration is often coupled with glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors, although conflicting results with this strategy have been reported.
GP IIb/IIIa antagonists inhibit the final common pathway that leads to platelet aggregation and leukocyte plugging, which are the main components of fresh thrombi.
This document provides an updated summary of guidelines for blood conservation in cardiac surgery from The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists. Major revisions include new recommendations regarding dual anti-platelet therapy management before surgery, drugs that augment red blood cell volume or limit blood loss, blood derivatives, blood salvage management, minimally invasive procedures, extracorporeal membrane oxygenation, hemostatic agents, and insights into team-based interventions. The guidelines were updated based on a literature review using standardized search terms to ensure the recommendations reflect the most current evidence available.
The document summarizes various strategies for managing thrombus burden during primary angioplasty for myocardial infarction. It discusses thrombus grading scales, the composition and types of thrombus, and the role of medications like GP IIb/IIIa inhibitors (abciximab, tirofiban, eptifibatide), heparin, and bivalirudin. It also compares intracoronary versus intravenous administration of these drugs and evaluates trials comparing different treatment strategies. Mechanical thrombectomy devices and a combined pharmacologic and mechanical approach are also reviewed.
This study compared the effects of levosimendan, dobutamine, and vasodilator therapy on ongoing myocardial injury in patients with acute decompensated heart failure. The study found that while all treatments were associated with decreases in cardiac troponin I levels and improvements in hemodynamic and functional indicators, levosimendan treatment showed the most pronounced improvements, especially in left ventricular ejection fraction and systolic pulmonary artery pressure. However, none of the treatments significantly reduced cardiac troponin I levels compared to each other. The study demonstrated beneficial effects of short-term use of levosimendan, dobutamine, and nitroglycerin on ongoing myocardial injury in acute decompensated heart failure.
1) The study examined predictors of ischemia and outcomes in 169 Egyptian patients with diabetes referred for nuclear perfusion imaging over 2 years of follow up.
2) Significant relationships were found between higher summed stress scores and outcomes of sudden cardiac death, myocardial infarction, and heart failure. Higher summed rest scores also significantly predicted several adverse outcomes.
3) Degree of typical chest pain, transient left ventricular dilation, lung uptake on imaging, and extent of ischemia (summed difference score) were independent predictors of myocardial infarction. Transient left ventricular dilation was the strongest predictor of sudden cardiac death.
Coronary angioplasty has revolutionized the management of coronary artery disease. It has not ceased to develop to become the reference method of myocardial revascularization. The aim of our study is to evaluate the ultrasound parameters of left ventricular function after coronary angioplasty. This is a prospective analytical study including patients with stable coronary artery disease with a known coronary artery anatomy programmed for coronary angioplasty. Transthoracic echocardiography was performed four hours before and seven days after myocardial revascularization.
This study examined the association between preoperative serum potassium levels and perioperative outcomes in 2402 patients undergoing elective cardiac surgery. The study found that serum potassium levels below 3.5 mmol/L were associated with increased risks of perioperative arrhythmias, intraoperative arrhythmias, and postoperative atrial fibrillation/flutter. Lower potassium levels were also linked to greater needs for cardiopulmonary resuscitation, though this association was not statistically significant after adjusting for confounding factors. The results suggest that screening for and correcting hypokalemia prior to cardiac surgery could help mitigate adverse perioperative events.
técnicas de reparación de una hernia, ... bien al paciente para elegir la técnica ... La reparación clásica de la hernia umbilical es la hernioplastia de Mayo, que
This study aimed to determine if preoperative hematological parameters and risk factors could predict in-hospital mortality for patients undergoing surgery to repair Type A aortic dissection. The study reviewed data from 78 patients who underwent deep hypothermic circulatory arrest surgery. Only preoperative creatinine levels were higher in patients who died. Total circulatory arrest time and cross-clamp time during surgery were found to be factors affecting mortality, with times over 44.5 minutes and 71 minutes respectively predicting higher risk of death. The study concluded that hematological biomarkers alone may be insufficient for estimating mortality risk, and intraoperative factors like longer circulatory arrest and clamp times impact outcomes for Type A aortic dissection surgery.
Efek varicocelectomy tentang aliran arteri antara laaproskopik dengan mikroandilania
This study investigated the effects of laparoscopic varicocelectomy (LV) and microsurgical subinguinal varicocelectomy (MV) on testicular blood flow and semen quality. Color Doppler Flow Imaging was used to measure blood flow parameters in the testicular arteries before and after surgery. Both LV and MV significantly improved testicular blood flow and semen parameters. However, MV resulted in greater improvements in testicular blood flow earlier after surgery compared to LV. The study concludes that varicocelectomy improves testicular function by enhancing blood supply and microperfusion to the testes.
This study analyzed angiographic data from 3,428 patients who underwent percutaneous coronary intervention (PCI) for non-ST-segment elevation acute coronary syndrome in the ACUITY trial to determine the incidence and impact of intraprocedural thrombotic events (IPTE). IPTE occurred in 121 patients (3.5%) and was associated with significantly higher rates of major adverse cardiac events, including death, myocardial infarction, and stent thrombosis at in-hospital, 30-day, and 1-year follow-up compared to patients without IPTE. IPTE was an independent predictor of adverse outcomes at 30 days and 1 year after adjusting for other factors. The results suggest that although infrequent, IPTE during PCI for acute
Effect Of Remote Ischemic Preconditioning On AKI Among.pptxNayyarSaleem2
This document summarizes a randomized controlled trial that evaluated the effect of remote ischemic preconditioning (RIPC) on acute kidney injury (AKI) in patients undergoing cardiac surgery. The study found that among 240 high-risk patients, those who received RIPC had a lower rate of AKI within 72 hours compared to controls. Biomarkers also indicated less kidney damage in the RIPC group. While the study was not powered for secondary outcomes like mortality, RIPC was associated with reduced need for renal replacement therapy. The results provide preliminary evidence that RIPC may help mitigate AKI risk in cardiac surgery patients but larger trials are still needed.
This study prospectively examined cardiac arrhythmias in 90 patients undergoing cardiac surgery at a hospital in Romania between January and June 2017. The study found that postoperative atrial fibrillation was more common in older patients (above 60 years old) with enlarged left atriums. Patients who developed arrhythmias tended to have lower ejection fractions, higher creatinine levels, and more postoperative hemodynamic and renal complications compared to patients without arrhythmias. Risk factors for developing arrhythmias after cardiac surgery included older age, enlarged left atrium, lower arterial oxygen saturation, lower potassium levels, and need for higher doses of inotropic drugs.
The effects of_rosuvastatin_on_plaque_regression_i19844
This study evaluated the effects of rosuvastatin versus atorvastatin on plaque regression in patients with mild to moderate coronary stenosis and vulnerable plaque. 30 patients received either rosuvastatin 20 mg or atorvastatin 40 mg daily for 12 months. Intravascular ultrasound was performed at baseline and follow-up to measure atheroma volume, lipid pool size, and other metrics. Both statins significantly reduced LDL cholesterol by over 40% from baseline to follow-up. Both treatments also significantly reduced total atheroma volume while increasing lumen volume, with no significant differences between the groups. Follow-up LDL levels correlated with reductions in atheroma, lipid pools, and increases in lumen size.
Suporte inotrópico e DP em RN após cx cardíacagisa_legal
This study examined the impact of cardiovascular support on peritoneal dialysis (PD) adequacy in 20 neonates requiring renal replacement therapy after cardiac surgery involving cardiopulmonary bypass. PD was administered for an average of 2.5 days. PD creatinine clearance averaged 3.4 ml/min/1.73 m2 and ultrafiltration rate was 9.75 ml/h, with clearance correlated to dialysate flow up to 100 ml/h but not to inotropic score. In-hospital mortality was 20%, higher than the neonatal ICU overall rate of 4.8%. PD allowed adequate solute clearance and ultrafiltration irrespective of hemodynamic status or vasopressor support.
Cerebral oximetry as a real time monitoring tool to assess qualityEmeka Onuorah
This study evaluated the use of near-infrared spectroscopy to monitor regional cerebral oxygen saturation (rSO2) during in-hospital cardiac resuscitation and post-cardiac arrest care. Higher rSO2 levels at the start of resuscitation and during resuscitation were associated with achieving return of spontaneous circulation, but rSO2 was not predictive of survival to discharge or good neurological outcomes. While rSO2 may reflect the quality of cardiopulmonary resuscitation, larger studies are still needed to determine if rSO2 monitoring can be used to improve clinical outcomes after cardiac arrest.
This document discusses various aspects of renal replacement therapy for acute kidney injury. It begins by outlining the stage-based management of AKI, with increasing intervention and monitoring recommended as the stage progresses from risk to injury to failure. The document then addresses indications for starting renal replacement therapy, appropriate modalities including intermittent hemodialysis, slow continuous ultrafiltration, and continuous renal replacement therapy. Key factors like vascular access, solutions, membranes, anticoagulation, and dose are discussed. The overall conclusions are that while data from high-quality randomized controlled trials are still lacking, earlier initiation of renal replacement therapy may aid recovery, and continuous modalities are generally preferred over intermittent hemodialysis for unstable patients. Individualization of
cardiorenal syndrome and its characteristics and complications and causes.pptxArunDeva8
This study analyzed the risk factors and outcomes of acute cardiorenal syndrome (CRS-1) in 460 patients admitted with acute coronary syndrome or acute decompensated heart failure at a tertiary care center in South India. 34% of patients developed CRS-1, defined as acute kidney injury resulting from acute worsening of cardiac function. Risk factors for CRS-1 included diabetes, chronic kidney disease, lower ejection fraction, and higher levels of cardiac biomarkers. Patients with CRS-1 required more intensive care interventions and had higher in-hospital mortality of 20.2% compared to 7.8% in patients without CRS-1. Early detection and multidisciplinary management can help provide better outcomes for patients with
The document summarizes a study comparing outcomes of patients who underwent aortic arch surgery using antegrade cerebral perfusion (ACP) versus without ACP. The study found significantly lower rates of postoperative stroke (2% vs 13%) and better 3-year survival (93% vs 78%) in the ACP group. Multivariate analysis confirmed ACP was associated with reduced stroke risk and improved long-term survival. The results suggest ACP provides neuroprotective and survival advantages over surgery without ACP for aortic arch pathology requiring prolonged repair periods.
This document describes a study examining cytokine expression and inflammation in the myocardium of patients with heart failure undergoing mechanical unloading via left ventricular assist devices (LVADs). The study found that:
1) Cytokine mRNA levels were significantly decreased in the myocardium of "Responders" (patients whose heart function improved after LVAD unloading) compared to "Non-Responders", suggesting decreased inflammatory burden correlates with improved heart structure and function.
2) The transcription factor Stat3, which controls cytokine expression, was significantly downregulated in Responders' myocardium, indicating it may coordinate the differential inflammatory response.
3) Stat3 could be a potential therapeutic target to enhance heart recovery following LVAD unloading in
This study developed and validated a preoperative acute kidney injury (PO-AKI) risk prediction index called SPARK for noncardiac surgeries. Using data from two Korean hospitals, the study identified preoperative risk factors to stratify patients into four risk classes (A to D). Class A patients had the lowest PO-AKI risk while class D the highest. The simple index uses only preoperative variables and can help clinicians decide which patients need PO-AKI monitoring after surgery. While not perfect, the SPARK index provides a practical tool to predict and prevent PO-AKI.
This study evaluated the feasibility of transthoracic echocardiography (TTE) for assessing cardiac function in 76 patients with septic shock. TTE was able to determine left ventricular systolic function in 90% of patients, right ventricular function in 99%, and left ventricular diastolic function in 73%. Diastolic dysfunction was present in 50% of patients. Factors like obesity, mechanical ventilation, age, and illness severity did not impact the ability of TTE to evaluate cardiac function. TTE is therefore a reliable tool for comprehensive cardiac assessment, including diastolic function, in critically ill septic shock patients.
Similar to Does Serum Lactate and Central Venous Saturation Predict Perioperative Outcomes in Patients Undergoing Off-Pump CABG_Crimson Publishers (20)
This case report describes a 37-year-old man who presented with sudden onset severe left-sided neck pain and ST elevations on his ECG. He was incorrectly diagnosed with an anterior wall myocardial infarction and thrombolyzed. Further examination revealed differential blood pressures between his upper and lower extremities, suggesting an underlying aortic coarctation. Imaging confirmed severe coarctation of the aorta. The atypical presentation of neck pain and ECG changes were likely due to vasospasm and compression related to the coarctation. This case highlights the importance of a full clinical assessment prior to thrombolytic therapy to avoid unnecessary procedures.
This document discusses a study of 72 patients with bradycardia. Autonomic nervous system testing revealed autonomic dysfunction in most patients, with increased vagal tone being the most common finding present in 83.3% of patients. Several autonomic syndromes were also identified, with postural orthostatic tachycardia syndrome being present in 34.7% of patients. Treatment targeting the identified autonomic abnormalities improved symptoms in most patients. The study demonstrates that autonomic nervous system testing can help explain causes of bradycardia when clinical exams are otherwise normal.
The study objective was to evaluate the cardioprotective activity of Biofield Energized test item (DMEM) in rat cardiomyocytes (H9c2) cells. The test item (DMEM medium) was divided into three parts, first part received one-time Consciousness Energy Healing Treatment by a renowned Biofield Energy Healer, Dahryn Trivedi and was labeled as the one-time Biofield Energy Treated (BT-I) DMEM, while second part received the two-times Biofield Energy Treatment and is denoted as BT-II DMEM.
Essential hypertension, the most common type, is an important cause of morbidity and mortality in the elderly, a rapidly growing section of the population. It is a sad reality that until the 1950s treating benign hypertension was not thought to be necessary. The tragic death of Franklin Delano Roosevelt on April 12, 1945 at the age of 63 years, with a blood pressure of 350/195mmHg, and without treatment shocked the healthcare community.
This document presents an optimization of algorithms for real-time ECG beat classification. It compares algorithms using voltage values in the time domain versus those using Daubechies wavelet analysis. It extracts features around reference peaks within the QRS complex and uses clustering methods to classify beats in real-time as normal, premature ventricular contraction, or unclassified. Evaluating algorithms on 32 MIT-BIH records, the method using Daubechies wavelets and correlation measure achieved 93.25% sensitivity and 91.43% positive predictivity for premature ventricular contraction detection, making it suitable for real-time systems due to low computational cost.
Coronary artery diseases (CAD) known as atherosclerotic heart disease, atherosclerotic cardiovascular disease, coronary heart disease (CHD), or ischemic heart disease (IHD). CAD is the largest contributor of cardiovascular diseases (CVDs) and mortality rate is due in prevalence to atherosclerosis, a chronic inflammatory condition of the arterial wall. Unfortunately, myocardial infarction (MI) is still a first common manifestation of CHD and, in about 50% of patients; angina pectoris is the first symptom of the pathology.
This document proposes a new hypothesis that some heart diseases may be caused by endogenous toxicological factors within the body over time. It suggests that metabolic and catabolic imbalances can create conditions like congestive heart failure, and that allowing sufficient time to restore balance through rest can resolve pathologies. Coronary artery spasm is discussed as an example that may be triggered by activated platelets releasing vasoconstrictor substances. The hypothesis is that better understanding endogenous local toxicity and its kinetics over time could provide new insights into the etiology, diagnosis and treatment of certain heart conditions.
Intraoperative aortic dissection during cardiac surgery is infrequent, complicating surgical intervention in 0.04 - 1% of cases. Dissections can occur anywhere, most often as a result of direct mechanical damage at the location of the side clamp, site of cannulation of the aorta, or at the site of proximal anastomosis and may manifest as hematoma, bleeding at the cannulation site or bleeding from the proximal anastomoses or aortic suture lines. Delayed diagnosis and treatment can lead to extremely (23-41%) high mortality rate.
Hemorheological indexes, living habits, medical history and genetics factor are primary risk factors in Coronary Heart Disease (CHD). In the present study the relation of all factors to the severity of CHD was examined. The data of 282 patients (mean age: 60±9 years) diagnosed with CHD and 229 healthy controls (mean age: 59±7 years) from Wenzhou Medical University were analyzed.
This document reviews a 2001 mathematical model by Feng, Sitek and Gullberg for determining the surface area and volume of the left ventricle (LV) based on its geometry as a truncated prolate spheroid. It finds that using the same model to calculate both volume and area results in a perfect linear correlation between the two due to their dependence on the model. Alternative models using Cartesian coordinates are explored that use echocardiographic measurements of the LV to calculate volume and area independently, finding still a very strong linear correlation between the two. The document concludes it is unrealistic to expect a perfect correlation when the same model is used to calculate both parameters.
Transcatheter Aortic Valve Replacement (TAVR) had become a novel and secure procedure to treat aortic stenosis that had become more accepted over the years; the approach and different types of device improve the life expectancy, diminish the complications and costs in public health. Along with the improvement in technology the minimalist approach had gain popularity to ameliorate the overall patient health.
Despite the advances in diagnostic methods and techniques for surgical treatment in the last two decades, aortic diseases remain a major cause of mortality and cardiovascular morbidity, challenging physicians and molecular biologists. It is believed that about 600 million years ago, during the Cambrian period, variant forms of life appeared, among them were the oxygen-producing cyano bacteria.
The central venous access is one of the most common procedures in interventional nephrology [1-3]. One of the known complications of this procedure is the right branch lesion of the His bundle that leads to temporary or permanent blockage.
Infective endocarditis is a life-threatening disease caused by bacterial infection of the endothelium and cardiac valves, either native or prosthetic. In the present work the role of the new microbiological techniques (techniques of detection and amplification of the subunit 16 ribosomal sRNA by means of the chain reaction of the polymerase in blood or tissue, fluorescent in situ hybridization, and matrix-assisted laser is reviewed desorption/ ionization time-of-flight mass spectrometry (MALDI-TOF MS) in the diagnosis of infective endocarditis.
Epidemiological and clinical evidence confirm that hearts are sensitive to ionizing radiation (IR). They are even more radiosensitive than formerly believed. Mechanistic studies show that the radiosensitivity is not due to the heart muscles but mainly to the cardiovascular system (CV).
This document summarizes research on CRP3/MLP (cysteine-rich protein 3/muscle LIM protein) and its role in vein graft failure and arterialization. It discusses how CRP3/MLP expression is normally present in arteries but absent in veins, but becomes upregulated in veins during adaptation to arterial hemodynamics. Studies in a CRP3/MLP knockout rat model showed it acts as a key modifier of vein remodeling by sensitizing stretched smooth muscle cells to apoptosis. The research suggests CRP3/MLP may be a new target to prevent neointimal growth and vein graft failure, and could help predict outcomes of vascular therapies.
In cardiology practice, we often come across patients presenting with anginal pain who undergo coronary angiogram which reveals either normal or non-obstructive epicardial coronaries. Importance is given to epicardial coronaries and the coronary microvasculature which could be the cause of angina is often overlooked. These patients are then labeled to have non-cardiac chest pain and musculoskeletal or psychogenic etiology is suggested. However, with growing interest in coronary microvasculature which are the tiny blood vessels at the tissue level in myocardium, diagnostic modalities and treatment options for coronary microvascular disease are being explored.
Cardiomyopathies are heart muscle diseases originated from a series of aggressions, such as genetic defects, cardiac myocyte injury or infiltration of myocardial tissue. Dilated cardiomyopathy (DCM) is characterized by an impairment of the left ventricular or biventricular contraction, caused by familial, genetic, viral, autoimmune, alcoholic, toxic, or of unknown cause.
A hypothesis is presented which suggests that the cardiac L-type calcium channel opens in a stochastic fashion as the calcium channel protein complex moves around in the lipid of the outer leaflet of the sarcolemma. Opening occurs when there is release of calcium ions that are bound in the polarised state to anionic phospholipid of the inner leaflet, the release being a consequence of proton penetration into the sarcolemma upon depolarisation.
Catheter ablation of premature ventricular complexes (PVCs) is an effective treatment when disabling symptoms or ectopy-induced cardiomyopathy are present in patients refractory to pharmacological therapy. When PVCs originate close to His bundle, radiofrequency ablation is burdened by unacceptable risk of conduction pathways damage or atrio-ventricular block. Here we report a case of a patient with highly symptomatic ventricular ectopy originating close to His bundle undergoing successfull cathetercryoablation.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
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Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Kat...rightmanforbloodline
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
2. How to cite this article: Namratha, Dinesh K, Nalini K. Does Serum Lactate and Central Venous Saturation Predict Perioperative Outcomes in Patients
Undergoing Off-Pump CABG. Open J Cardiol Heart Dis. 1(2). OJCHD.000506. 2018. DOI: 10.31031/OJCHD.2018.01.000506
Open Journal of Cardiology & Heart Diseases
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Open J Cardiol Heart Dis
Volume 1 - Issue - 2
selected for the study and a written informed consent was obtained.
A thorough pre-anesthetic evaluation was performed and the
following data were collected age, sex, height, weight, Euro score
II, pre-op requirement of Intra-aortic Balloon pump (IABP), serum
creatinine, hemoglobin, Co-morbidities, pre-operative ejection
fraction.
All the patients underwent OP-CABG under general anaesthesia
with endotracheal intubation and controlled ventilation. With strict
asepsis, Central line (7F, 16cms triple lumen, Arrow) in the right
internal jugular vein was secured under local anaesthesia before
induction. All venous blood samples for measuring serum lactate
and central venous saturation was collected from the distal port of
triple lumen. Anaesthesia was administered as per our institutional
protocol. Induction was done with oxygen, Sevoflurane-2%,
Fentanyl 10ug/kg, Midazolam 0.05mg/kg, Propofol 2mg/kg and
Pancuronium 0.1mg/kg for endotracheal intubation. Standard
monitoring included 12-lead electrocardiogram with ST analysis,
invasive arterial pressure, pulse oximetry, end-tidal carbon
dioxide, central venous pressure, nasopharyngeal temperature
and urine output. Trans-oesophageal echocardiography (TEE)
was used to monitor the left ventricular function, regional wall
motion abnormality and to calculate the cardiac output and
systemic vascular resistance. The position of the tip of the triple
lumen central venous catheter was confirmed to be at the superior
venacava (SVC) and right atrium (RA) junction by TEE. Isoflurane
1%, Air: O2 (FiO2=0.6) was used for maintenance along with
Dexmedetomidine (0.3ug/kg/hr) and Morphine (20ug/kg/hr)
infusion. Neuromuscular blockade was achieved with Vecuronium.
Coronary artery bypass grafting was performed off pump by
stabilizing the heart with Octopus and Atmos suction apparatus
while grafting. Left internal mammary artery was used for grafting
leftanteriordescendingarteryandotherarteriesweregraftedusing
saphenous vein grafts. All patients were admitted post-operatively
to ICU, electively ventilated and received standard post-operative
care. Blood samples from the right internal Jugular central venous
catheter were collected using vacutainer tubes for measuring
central venous saturation and lactate. First sample was obtained
after induction (T1), the second sample was obtained at ICU
admission (T2) and the third was obtained 12hours after induction
(T3). The samples were sent for venous blood gas analysis, ScVO2
and lactate values were obtained (Blood gas analyzer ABL 800).
Patients were considered to have major morbidity if they develop
renal failure (serum creatinine more than twice the pre-operative
value) and requirement of dialysis, a high inotropic requirement
in first 48hrs (Vasoactive Inotropic score >15), the requirement
of Intra-aortic balloon pump (IABP), low cardiac output (MAP
<65mmHg and urine output <0.5ml/kg/hr), infection, sepsis and
other complications (stroke, respiratory distress syndrome) were
recorded. Based on the outcome, the patients included in the study
were divided into Group M having major morbidity and Group N
having no morbidity. Mortality at 30 days following surgery was
evaluated by a telephonic call to the patient relative.
ScVO2 and Lactate values measured at induction (T1), at ICU
admission (T2) and12 hours after induction (T3) were defined
as Low ScVO2 (≤65%) or normal ScVO2 (>65%), high Lactate
(≥3mmol/L) or normal Lactate (<3mmol/L) and abnormal
combined index (lactate ≥3mmol/L and ScVO2 ≤65%) or normal
combined index (Lactate <3mmol/L and ScVO2>65%).
Data was analyzed by IBM SPSS software version 22.0. A p
value <0.05 was considered significant. Continuous variables were
expressed as Mean±Standard Deviation. Categorical variables were
expressed as Number (n) or Percentage (%). The Independent
t-test was used to compare continuous variables and Chi-square
test was used to compare categorical variables between two groups.
Univariate/multivariate Logistic regression analysis was used to
test the association of high lactate, low ScVO2 and an abnormal
combined index with major morbidity. Sensitivity, Specificity,
Positive Predictive value, Negative Predictive value, and Diagnostic
accuracy of high Lactate, low ScVO2 and abnormal combined
index as predictors of major morbidity were calculated using 2X2
contingency table.
Inclusion criteria
1. Age - 40-80 years, male and female patients
2. Patients undergoing off pump CABG with triple vessel
disease with ejection fraction >30%.
Exclusion criteria
1. Emergency surgery
2. Coexisting valvular heart disease
3. Preoperative COPD/cardiogenic shock/renal failure
4. Ejection fraction <30%
5. Patients with Left Main Coronary Artery (LMCA) lesion
6. Unwilling to give consent
7. Central venous catheter tip couldn’t be visualized with
TEE.
8. Patients lost to follow-up.
Results
Sixty patients with coronary artery disease who underwent
elective off-pump CABG from 2014 to 2015 satisfying the eligibility
criteria were included in this prospective observational study.
Based on the post-operative morbidity they were divided into two
groups. As shown in Table 1 the demographic parameters in both
the group-M and group-N were comparable except the Euroscore
which was higher in group-M. Out of the sixty patients, 19 patients
(31.66%) belonged to the group M who developed major post-
operative morbidity. Three (5%) patients had renal failure and
required dialysis, sixteen (26.66%) patients required high inotropic
support in first 48hours, four (6.66%) patients required intra-aortic
balloon pump and two (3.33%) of them developed an infection
and sepsis. Patients who developed sepsis and subsequent multi-
organ dysfunction accounted for the mortality of two (3.33%)
3. Open Journal of Cardiology & Heart Diseases
How to cite this article: Namratha, Dinesh K, Nalini K. Does Serum Lactate and Central Venous Saturation Predict Perioperative Outcomes in Patients
Undergoing Off-Pump CABG. Open J Cardiol Heart Dis. 1(2). OJCHD.000506. 2018. DOI: 10.31031/OJCHD.2018.01.000506
3/5
Open J Cardiol Heart Dis
Volume 1 - Issue - 2
patients during the post-operative ICU care. The perioperative risk
assessment parameter used in our study, Euroscore II [5] was found
to be a good predictor of post-operative outcome in our study (p
=0.003).
Table 1: Demographic parameters of the patients with morbidity (Group M) and without morbidity (Group N).
GROUP N (41) GROUP M (19)
P value
Mean Median S D Mean Median SD
AGE 60.85 63.00 8.36 63.68 62.00 9.23 0.2
HEIGHT (cm) 160.37 162.00 9.37 159.53 161.00 9.05 0.8
WEIGHT (kg) 65.17 65.00 9.10 62.21 60.00 9.13 0.3
BMI (kg/m2
) 25.37 25.40 4.21 24.36 24.57 3.38 0.4
BSA (m2
) 1.68 1.69 0.13 1.64 1.61 0.16 0.4
Hb (g/dL) 12.97 13.10 1.79 12.69 12.80 2.10 0.6
EF (%) 53.00 60.00 10.21 47.68 45.00 9.97 0.07
EUROSCOREII 1.33 1.18 0.55 2.25 2.11 1.15 0.003
SC (mg/dL) 0.93 0.90 0.19 1.11 1.00 .38 0.02
Independent t test, BMI: Body Mass Index; BSA: Body Surface Area; Hb: Hemoglobin; EF: Ejection Fraction; SC: Serum Creatinine.
Table 2: Association between lactate, ScVO2 and combined index with morbidity at induction (T1), at ICU admission (T2) and 12hours
after induction (T3) (LOGISTIC REGRESSION ANALYSIS).
SEM P Value OR (95%CI)
At induction
(T1)
Lactate 0.798 0.034 5.405(1.132-25.807)
ScVO2
0.611 0.679 1.287(0.389-4.260)
Combined index 0.918 0.072 5.200 (0.861-31.421)
At ICU admission
(T2)
ScVO2 0.663 0.274 2.065 (0.563-7.577)
Lactate 0.685 0.001 10.797 (2.822-41.312)
Combined index 1.112 0.001 44.444 (5.029-392.815)
12hours after Induction
(T3)
ScVO2
0.673 0.022 4.696 (1.256-17.560)
Lactate 0.807 0.037 5.389 (1.109-26.198)
Combined index 1.119 0.005 23.333 (2.605-208.979)
SEM: Standard Error of Mean; OR: Odds Ratio; CI: Confidence Interval.
P <0.05 -significant
Table 3: Validity of ScVO2, lactate and combined index measured at various time intervals -at induction (T1), at ICU admission (T2)
and 12 hours after induction (T3).
ScVO2
≤65% Sensitivity Specificity PPV NPV Diagnostic Accuracy
T1 47.3% 65.85% 39.13% 72.97% 60%
T2 63.16% 63.41% 44.44% 78.79% 63.33%
T3 78.95% 60.98% 48.39% 86.21% 66.67%
Lactate ≥3mmol/L Sensitivity Specificity PPV NPV Diagnostic Accuracy
T1 31.58% 92.68% 66.67% 74.51% 73.33%
T2 63.16% 87.8% 70.59% 83.72% 80%
T3 36.84% 92.68% 70% 76% 75%
Combined Index Sensitivity Specificity PPV NPV Diagnostic Accuracy
T1 21.05% 95.12% 66.67% 72.22% 71.67%
T2 52.63% 97.56% 90.91% 81.63% 83.33%
T3 36.84% 97.56% 87.5% 76.92% 78.33%
NPV: Negative Predictive Value; PPV: Positive Predictive Value.
At induction (T1), Lactate was independently associated with
major morbidity (p = 0.034). High Lactate at the induction was
found to predict morbidity independently with an odds ratio of
5.405 (95%CI, 1.132-25.807). (Table 2) at ICU admission (T2),
Lactate and the combined index were found to be associated with
major morbidity (p =0.001) with an odds ratio of 10.797 and 44.444
respectively. (Table 2) at 12hrs after induction (T3), lactate and
ScVO2 both independently and as a combined index were associated
4. How to cite this article: Namratha, Dinesh K, Nalini K. Does Serum Lactate and Central Venous Saturation Predict Perioperative Outcomes in Patients
Undergoing Off-Pump CABG. Open J Cardiol Heart Dis. 1(2). OJCHD.000506. 2018. DOI: 10.31031/OJCHD.2018.01.000506
Open Journal of Cardiology & Heart Diseases
4/5
Open J Cardiol Heart Dis
Volume 1 - Issue - 2
with major morbidity. Lactate (p=0.037) and ScVO2 (p=0.022) were
independently associated with major morbidity with an odds ratio
of 4.696 and 5.389 respectively. The combined index (p=0.005)
positively correlated with major morbidity with an odds ratio of
23.333. (Table 2) low ScVO2, high lactate and abnormal combined
index as predictors of morbidity were studied at all the three time
intervals for sensitivity, specificity, positive predictive value (PPV),
negative predictive value (NPV) and diagnostic accuracy using the
2X2 contingency table. (Table 3) High Lactate measured at all three
time intervals (T1, T2, T3) had an NPV between 74.51% at T1 to
83.72% at T2. ScVO2 as predictor of morbidity was found to have a
higher NPV of 86.21% at T3. However, PPV for Lactate was found to
range from 66.67% at T1 and 70.59% at T2. ScVO2 at T3 had a PPV
of 48.49%. A combined index (ScVO2<65% and Lactate >3mmol/
dL) had a PPV of 90.91% with an NPV of 81.63% when measured at
ICU admission (T2).
Discussion
Cardiac and high risk surgeries are known to be associated
with global tissue hypoxia (GTH) due to low cardiac output,
anaemia, bleeding, CPB and large volume shift perioperatively. OP-
CABG in particular is associated with haemodynamic instability
and GTH intraoperatively and in post-operative ICU care if not
managed properly [6]. In our study, nineteen out of sixty patients
(31.6%) developed post-operative major morbidity. Ten among
these patients (52.63%) had a low MAP or decreased urine output
recorded in first 48 hours. Failure of conventional indicators like
urine output and MAP to indicate GTH has led to usage of bio-
markers like ScVO2 and Lactate [7]. High blood lactate levels and
low ScVO2 have independently proved to be bio-markers of GTH
and potential early predictors of morbidity and mortality. However,
there are studies showing blood lactate level and ScVO2 are also
influenced by many factors and cannot be independently used as
early predictors of morbidity and mortality in cardiac surgery. So
we studied Lactate and ScVO2 as the combined index predict major
morbidity and mortality. We found that low ScVO2 (< 65%) at 12
hours after induction (T3) was associated with major morbidity
[odds ratio =4.696 (95% CI, 1.256-17.560)] with 78.95% sensitivity
and 60.98% specificity (Table 2). This was in agreement with the
observation by Pearse et al. [8] in which low ScVO2 (<64.4%) was
found to be associated with morbidity with a sensitivity of 67%
and specificity of 56%. A drop in ScVO2 commonly occurs without
change in cardiac index, which is due to various factors like pain,
emergence, body temperature and shivering, but not hypoperfusion
[8]. The low ScVO2 observed at induction (T1) and at ICU admission
(T2) in our study, which was not associated with post-operative
morbidity may be attributed to the increased oxygen extraction due
to these factors rather than decreased perfusion.
According to Ranucci et al. [9] and Maillet et al. [10] Lactate
>3mmol/L was found to be associated with mortality and morbidity
in patients undergoing cardiac surgery on CPB [9,10]. Similarly, in
our study, the lactate value of >3mmol/L at all three time intervals
were found to predict major morbidity. (Table 2) with an odds ratio
of 5.405 (95% CI, 1.132-25.807) at T1, 10.797 (95% CI, 2.822-
41.312) at T2 and 5.389 (95% CI, 1.109-26.198) at T3.
Graph 1: Scatter plot of patient distribution according to cutoff values 65% (ScVO2) and 3mmol/L (lactate) measured at ICU
admission (T2).
Lactate production is not always suggestive of tissue hypoxia.
Type B hyperlactemia is dependent on various other causes like
the inability of tissues to consume oxygen, and not related to tissue
hypoxia. However, Lactate coupled with low ScVO2 is suggestive of
tissue hypoperfusion (type A hyperlactemia) [11].When ScVO2 and
lactate in combination is used, the clinician may be able to decide if
an elevated lactate is due to hypoperfusion or not. In our study an
abnormal combined index at T2 (ICU admission) and T3 (12hours
5. Open Journal of Cardiology & Heart Diseases
How to cite this article: Namratha, Dinesh K, Nalini K. Does Serum Lactate and Central Venous Saturation Predict Perioperative Outcomes in Patients
Undergoing Off-Pump CABG. Open J Cardiol Heart Dis. 1(2). OJCHD.000506. 2018. DOI: 10.31031/OJCHD.2018.01.000506
5/5
Open J Cardiol Heart Dis
Volume 1 - Issue - 2
later) was found to predict post-operative major morbidity (Table
2) with an odds ratio of 44.444 (95% CI, 5.029-392.815) and
23.333 (95% CI, 2.605-208.979) respectively. The combined index
measured at ICU admission had a specificity of 97.56% and a
PPV of 90.91%, which was higher than that of Lactate and ScVO2
considered individually in predicting outcome (Table 3). Similar
results were obtained in the study by Ranucci et al. [9] in which
combined index of Lactate and ScVO2 was found to have a higher
specificity (99%) and a lower positive predictive value (89%) as
compared to our study in predicting mortality and morbidity [9].
The study group was graphically represented as a scatter plot
showing the patient distribution according to the cut offs of 65%
for ScVO2 and 3mmol/L for Lactate in Graph 1. Low ScVO2 (≤65%)
with normal Lactate (<3mmol/L) represented by the patients in
lower left quadrant may be interpreted as a condition of increased
oxygen-extraction rate, sufficient for covering the consumption
(VO2). On prolonged inadequate delivery, a progressive increase in
bloodlactatewasfound,asamarkerofanaerobicenergyproduction.
UpperleftquadrantinGraph1havingLactate≥3mmol/LwithScVO2
≤65% (abnormal combined index) therefore, can be interpreted as
hyperlactemia (Type A) which is only due to tissue hypoxia. Out of
eleven patients placed in this quadrant, ten (90.90%) patients had
major morbidity. This also explains the higher PPV (90.91%) and
accuracy (83.33%) of the combined index (both lactate and ScVO2)
in comparison to individual indices (ScVO2 or lactate alone) in our
study.
Limitation
The sample size was small and a single center study. Therefore,
the reliability of the results and thus the applicability in practice
will need to be validated further by a larger trial. The PA catheter
was not used to measure the cardiac output and systemic vascular
resistance in post-operative ICU care. Therefore, low cardiac output
in ICU was diagnosed based on clinical acumen, mean arterial
pressure (MAP) and urine output and managed with inotropes.
So Inotrope requirement and LCOS as one of the factors in major
morbidity may not be accurate. A low incidence of 30 day mortality
(two among sixty patients) in our study was not adequate to analyze
its association with lactate or ScVO2.
Conclusion
Our study supports routine measurement of both ScVO2 and
Lactate (combined index) in detecting global tissue hypoxia in
patients undergoing elective off-pump CABG. At ICU admission,
the combined index was found to have highest specificity and
PPV in our study. Detection of low ScVO2 (≤65%) along with high
Lactate (≥3mmol/L) should be considered a warning signal for
inadequate tissue perfusion. Early detection and interventions to
improve tissue oxygenation prevent the degree of hypoperfusion,
development of post-operative major morbidity and organ failure
resulting in improved outcome. High lactate and low central
venous saturation as a combined index are a better predictor of
major morbidity and mortality in patients undergoing off pump
cardiac surgery. A goal directed therapy using these bio-markers
may decrease the postoperative morbidity and duration of ICU and
hospital stay.
Author Contributions
Dr Namratha G C: Data collection and manuscript preparation.
Dr Dinesh Kumar: Conceptualization of idea, Data analysis and
manuscript preparation.
Dr Nalini Kotekar: Conceptualization of idea, Data analysis and
manuscript preparation.
Acknowledgement
We acknowledge Dr Sumanth for his inputs on statistics.
We also like to acknowledge the cooperation of patients and
anaesthesiologist.
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