Propofol infusion syndrome in adult cardiac surgery.

We report a case of rapid and progressive severe metabolic acidosis in the postoperative period after coronary artery bypass grafting. After exclusion of potential causes for this phenomenon, it was attributed to perioperative intravenous propofol infusion causing propofol infusion syndrome. We discontinued this intravenous agent resulting in a prompt and considerable improvement in the lactic acidosis and clinical condition in the subsequent 6 hours resulting in an uneventful recovery and hospital discharge.

C-reactive protein levels and atrial fibrillation after cardiac surgery in women.

BACKGROUND: The aim of this study was to evaluate whether risk for postoperative atrial fibrillation in women is related to preexisting inflammation as detected by plasma C-reactive protein (CRP) concentrations. We further sought to assess the importance of atrial fibrillation for outcome after cardiac surgery in women. METHODS: The CRP was measured before coronary artery bypass grafting and (or) valvular surgery using cardiopulmonary bypass in 141 women. Univariate and multivariate analyses were used to evaluate for differences in CRP levels between women with and without atrial fibrillation, and to assess for the importance of the arrhythmia and postoperative outcomes. RESULTS: Atrial fibrillation developed in 46 (33%) women. Neither CRP concentrations (median +/- standard error, 13.3 +/- 2.5 mg/L vs 11.7 +/- 1.4 mg/L, p = 0.847), nor the frequency of elevated levels (defined as > upper 95% confidence interval or >19.2 mg/L) (19% vs 21%, p = 0.807) differed between women with or without atrial fibrillation. Patient age and previous stroke, but not CRP levels, were independently associated with atrial fibrillation. Women with atrial fibrillation were more likely to have low cardiac output syndrome (p = 0.018), stroke (p = 0.031), longer duration of hospitalization in the intensive care unit (p = 0.012) and on the postoperative (p = 0.0008) ward, and they were more likely to require an extended care facility after surgery (p = 0.046). CONCLUSIONS: In contrast to findings from studies that have included mostly men, preoperative CRP concentrations are not associated with risk for atrial fibrillation after cardiac surgery for women. Postoperative atrial fibrillation in women is associated with increased risk for stroke, longer hospitalization, and extended care facility admission.

Cardiopulmonary bypass management and neurologic outcomes: an evidence-based appraisal of current practices.

Neurologic complications after cardiac surgery are of growing importance for an aging surgical population. In this review, we provide a critical appraisal of the impact of current cardiopulmonary bypass (CPB) management strategies on neurologic complications. Other than the use of 20-40 microm arterial line filters and membrane oxygenators, newer modifications of the basic CPB apparatus or the use of specialized equipment or procedures (including hypothermia and "tight" glucose control) have unproven benefit on neurologic outcomes. Epiaortic ultrasound can be considered for ascending aorta manipulations to avoid atheroma, although available clinical trials assessing this maneuver are limited. Current approaches for managing flow, arterial blood pressure, and pH during CPB are supported by data from clinical investigations, but these studies included few elderly or high-risk patients and predated many other contemporary practices. Although there are promising data on the benefits of some drugs blocking excitatory amino acid signaling pathways and inflammation, there are currently no drugs that can be recommended for neuroprotection during CPB. Together, the reviewed data highlight the deficiencies of the current knowledge base that physicians are dependent on to guide patient care during CPB. Multicenter clinical trials assessing measures to reduce the frequency of neurologic complications are needed to develop evidence-based strategies to avoid increasing patient morbidity and mortality.

Atrial fibrillation after cardiac surgery: an evidence-based approach to prevention.

A number of advances in surgical and anesthetic techniques have reduced the risk for patients undergoing cardiac surgery. However, postoperative atrial fibrillation remains common, with an incidence ranging between 25% and 40%. It is associated with an increased incidence of congestive heart failure, renal insufficiency, and stroke that prolongs hospitalization and increases rates of readmission after discharge. Consequently, there has been great interest in strategies to prevent this arrhythmia. When both safety and efficacy are considered, the available evidence to date suggests that only beta-blockers can be recommended for the prevention of atrial fibrillation after cardiac surgery. Other treatments might be considered on an individual basis after careful consideration of the patient's potential for side effects.

Atrial fibrillation after cardiac surgery: pathophysiology and treatment.

Atrial fibrillation (AF) occurs in 25% to 60% of patients after cardiac surgery. It is most consistently associated with advanced age and valvular heart operations. Despite improving knowledge of the pathophysiology of chronic AF, postoperative AF remains an obstinate clinical problem. It is associated with an increased risk of stroke, longer hospital stay, and higher hospital expenditure. Consequently, there has been great interest in strategies to prevent and treat this arrhythmia. Treatment for postoperative AF may require immediate electrical cardioversion for hemodynamically unstable patients. Heart rate control is useful in most patients, with anticoagulation considered after 48 hours. Antiarrhythmic therapy is often effective in restoring sinus rhythm but its use needs to be balanced against the patient's risk of proarrhythmic side effects such as torsade de pointes.

Vasopressin during spinal anesthesia in a patient with primary pulmonary hypertension treated with intravenous epoprostenol.

Primary pulmonary hypertension (PPH) is a progressive disease with frequent morbidity and mortality, including the risk of cardiac decompensation and death, during general anesthesia. Administration of IV epoprostenol (Flolan) improves symptoms and survival of patients with PPH and thus is an increasingly used long-term treatment for this condition. This therapy is associated with impaired platelet aggregation, which may complicate the perioperative management of patients with PPH. We present a case report of a patient with severe PPH receiving a continuous epoprostenol infusion undergoing skin grafting for a leg ulcer under spinal anesthesia. An IV infusion of vasopressin was given to prevent systemic hypotension resulting from sympathetic blockade while avoiding increases in pulmonary vascular resistance that may have resulted from catecholamine usage.