Mortality associated with standard prescription transfusions in cardiac surgery.

BACKGROUND: Before applying new blood management strategies, the extent of blood product transfusions and its correlation with perioperative mortality should be identified. METHODS: This study retrospectively analyzed the extent of perioperative transfusions of red blood cells (RBC), fresh frozen plasma (FFP), and platelets (PLT) in 565 consecutive cardiac surgery patients, who received transfusions based on standard prescriptions. Patients were stratified in four groups according to perioperative transfusion units (no transfusion, <5, 5-10, >10 units). Mortality was analyzed in relation to the type and extent of each blood product transfused and their combinations. Subsequently, the ability of transfusion volume to predict mortality was tested. RESULTS: Most patients received blood product transfusions perioperatively.  The observed mortality (11.7 %) correlated significantly with the volume of transfusion. Patients transfused with >5 RBC or FFP units or >10 PLT units had increased mortality compared with those receiving fewer transfusions (23.9 % vs 4.5 %, 27.4 % vs 6 %, 24.5 % vs 8.5 %, p <0.05, respectively). Analysis revealed that cutoffs of >5 units of RBC or >15 units of RBC, FFP, and PLT additively (sensitivity: 74.2 % and 72.7 %, specificity: 68.7 % and 69.5 %, respectively) had an acceptable discrimination ability for perioperative mortality (Area under the ROC curve: 0.756, p <0.001, and 0.735, p <0.001, respectively). CONCLUSIONS: This study confirmed a dose-dependent, transfusion-associated, increased mortality in cardiac surgery patients who received standard prescription transfusions. The results support the need for applying validated, patient-specific blood conservation strategies that correspond to the patient's actual perioperative transfusion needs. HIPPOKRATIA 2018, 22(2): 68-74.

Cardiac troponin I versus creatine kinase-MB in the detection of postoperative cardiac events after coronary artery bypass grafting surgery.

AIM: Several studies suggest that postoperarive concentrations of cardiac troponin-I (cTnI) may increase in patients undergoing aorto-coronary bypass grafting (CABG). The degree and pattern of release appears to be associated with perioperative myocardial damage. METHODS: This was a prospective observational study with serial sampling conducted at the Departments of Cardiothoracic Surgery and Anesthesiology, University Hospital of Ioannina, Ioannina, Greece. The levels of cTnI and creatine kinase-MB (CK-MB) preoperatively, upon admission to the intensive care unit and at 12, 24, 36 and 48 hours after surgery, as well as daily from postoperative days 3-7 were determined in 41 consecutive patients (33 males and 8 females, aged 64.8+/-6.1 years) who underwent CABG with cardiopulmonary bypass. The Authors compared the patterns and variation of cTnI and creatine kinase (CK)-MB after CABG in patients with or without postoperative cardiac events (PCEs). RESULTS: Eleven patients experienced a PCE (postoperative ventricular and supraventricular arrhythmia, need for intra-aortic balloon pump (IABP) for >12 hours, or postoperative myocardial infarction, [MI]). In patients without PCE the elevation of cTnI peaked at 24 hours after surgery, while in patients with PCE maximal values of cTnI occurred after 36 hours. CTnI levels correlated with CK-MB after the procedure. Receiver-operating characteristic (ROC) curve analysis indicated that cTnI is superior to CK-MB with regard to PCE diagnosis following CABG (area under the ROC curve, 0.73, 95% CI (0.53-0.93) versus 0.54, 95% CI, (0.25-0.83). CONCLUSION: CTnI seems to be more valuable compared to CK-MB in the detection of PCEs in patients undergoing coronary surgery.

Knotting of an epidural catheter: a rare complication.

Knotting of an epidural catheter leading to entrapment is a rare complication of epidural catheterization. A lumbar epidural catheter inserted in a 28-year-old woman for caesarean section anesthesia and postoperative analgesia proved difficult to remove. After multiple attempts and placing the patient in the same position as when the catheter was initially inserted, the entrapped catheter was dislodged intact, revealing a double knot near its distal tip. Leaving catheters of less than 4 cm in length in the epidural space may help to avoid this complication. It is important the patient be informed of the techniques involved in the extraction of the resistant catheter because patient's cooperation is important for the nonsurgical removal of an entrapped epidural catheter.

The treatment of Reflex Sympathetic Dystrophy in a 9 year-old boy with long standing symptoms.

Reflex sympathetic dystrophy is an uncommonly reported entity in children and it continues to be underdiagnosed. Compared with adult, childhood reflex sympathetic dystrophy is of unknown etiology and has a better prognosis. The most common therapy in children is progressive mobilization supported by antiphlogistic, analgesic drugs, psychological and physical therapy. We report an interesting case of reflex sympathetic dystrophy of the left knee joint of a nine years old child with symptoms insisting more than four years and recalcitrant to the above treatments. The use of intravenous regional anaesthesia with lidocaine 0.5% and methylprednisolone was successful. No other reports seem to exist on the use of lidocaine 0.5% and methylprednisolone for the therapy of reflex sympathetic dystrophy in children. The treatment is simple, safe and well tolerated by children. Psychological factors should not be underestimated. Early diagnosis and aggressive therapy are important factors for the full recovery of the patients.

[The effect of volume status of the right-left shunt in a patient with a patent foramen ovale]. / Einfluss des Volumenstatus auf den Rechts-links-Shunt bei einem Patienten mit funktionell offenem Foramen ovale.

This is a description of the anaesthetic management of a patient with a flow patent foramen ovale undergoing intramedullary nailing of the femur. In order to detect the flow patent foramen ovale, we used transoesophageal echocardiography. During the ventilation maneuver with positive airway pressure of 20 cmH2O, a right-to-left interatrial shunt was observed. After the administration of 500 ml hydroxy-starch solution (6%) intravenously, detection of the right-to-left shunt flow was no longer possible. This case report shows that the volume status in a patient with a patent foramen ovale could influence the right to left interatrial shunt during general anaesthesia.

Cardiac tamponade in a child with ascariasis.

Ascaris infection, when severe, may manifest with constitutional symptoms. The parasites penetrate the intestinal walls, reach the venules and lymphatics and, through the portal circulation, may affect the heart. To the best of our knowledge, involvement of the pericardium has yet to be reported. We describe here a case of severe pericardial effusion and cardiac tamponade in a child with ascariasis.

Contrast echocardiography and transcranial Doppler sonography for detection of a patent foramen ovale.

We report the case of a patient, in whom a patent foramen ovale was detected. For the detection of a patent foramen ovale simulation of Valsalva's manoeuvre with a positive airway pressure of 20 cm H2O was applied. Change of ventilation manoeuvre by ventilation with positive airway pressure of 35/30/15 cm H2O at a tidal volume of 1200 ml make a distinct increase in passage of contrast medium from the right to the left atrium. These findings were detected by contrast transesophageal echocardiography and indirectly by transcranial Doppler sonography and were reproducible. This may stress the importance of preoperative screening of patent foramen ovale in patients to be operated on in the sitting position. Contrast echocardiography and the ventilatory manoeuvre with high airway pressure and PEEP might increase the detection rate of patent foramen ovale with a right to left shunt during general anaesthesia.

Continuous propofol administration for suxamethonium-induced postoperative myalgia.

The effect of continuous propofol administration on creatine kinase and suxamethonium-induced postoperative myalgia was evaluated in 50 patients randomised into two groups of 25 patients each. Induction of anaesthesia was identical in all patients. Anaesthesia was maintained with 66% nitrous oxide in oxygen supplemented by either isoflurane 1% or continuous propofol. Creatine kinase was measured before and after operation. Myalgia was evaluated postoperatively by a blinded observer. The median level of myalgia was reduced significantly in the continuous propofol group (p = 0.011). The median creatine kinase value increased significantly in the isoflurane group (from 90 to 160 IU, p = 0.001).

Clinical criteria and treatment of segmental versus upper extremity reflex sympathetic dystrophy.

The effectiveness of a multimodal treatment protocol in the long-term management of upper extremity reflex sympathetic dystrophy (RSD), as well as of isolated finger involvement, was analyzed. In the present series, 62 patients diagnosed with RSD were treated and followed for a mean of 22.2 +/- 1.5 months. The findings in the present study indicate that: 1) RSD occurs predominantly in females (female:male, 3:1); 2) regional dystrophy is twice as common as segmental dystrophy; 3) segmental dystrophy is most often associated with minor traumatic dystrophy, whereas regional dystrophy is more evenly distributed among the various clinical types; 4) patients with regional dystrophy score their pain significantly higher; and 5) segmental and regional dystrophy respond with equal satisfaction to the multimodal treatment regimen. In conclusion, the weight of the available evidence strongly suggests that RSD is a complex multifaceted disease entity which responds well when managed with a multimodal treatment program aimed at the various interacting components of the disorder. Furthermore, the finding that segmental dystrophy did not behave differently from the treatment protocol compared to extensive upper extremity RSD, suggests that the anatomic location of the syndrome may not significantly alter the course of the disease during treatment.

Ki-1 lymphoma with cardiac involvement at initial presentation.

Anaplastic large cell lymphoma is a rare malignancy in childhood. We describe the case of a 6-year-old boy with Ki-1 lymphoma of the thymus who presented with an endocardiac mass. The first histologic analysis suggested a high-grade undifferentiated sarcoma, but reevaluation and immunohistochemistry confirmed the CD30+ lymphoid derivation of the process. The patient was given chemotherapy and 24 months later he remains in complete remission. It is noted that echocardiography was repeated many times to detect heart lesion.

Closure of atrial septal defects with the Amplatzer occlusion device: preliminary results.

OBJECTIVES: This study reports our clinical experience with transcatheter closure of secundum atrial septal defects (ASDs) in children, using the Amplatzer, a new occlusion device. BACKGROUND: None of the devices previously used for transcatheter closure of interatrial communications has gained wide acceptance. METHODS: We examined the efficacy and safety of the Amplatzer, a new self-centering septal occluder that consists of two round disks made of Nitinol wire mesh and linked together by a short connecting waist. Sixteen patients with secundum ASD met established two- and three-dimensional echocardiographic and cardiac catheterization criteria for transcatheter closure. The Amplatzer's size was chosen to be equal to or 1 mm less than the stretched diameter. The device was advanced transvenously into a 7F long guiding sheath and deployed under fluoroscopic and ultrasound guidance. Once its position was optimal, it was released. RESULTS: The mean ASD diameter by transesophageal echocardiography was 14.1+/-2.3 mm and was significantly smaller (p < 0.001) than the stretched diameter of the ASD (16.8+/-2.4 mm). The mean device diameter was 16.6+/-2.3 mm. No complications were observed. After deployment of the prosthesis, there was no residual shunt in 13 (81.3%) of 16 patients. In three patients there was trivial residual shunt immediately after the procedure that had disappeared in two of them at the 3-month follow-up. CONCLUSIONS: The Amplatzer is an efficient prosthesis that can be safely applied in children with secundum ASD. However, a study including a large number of patients and a longer follow-up period are required before this technique can be widely used.

Transient solitary diastolic murmurs in the newborn.

Three newborn infants were observed to have murmurs restricted to diastole. None was considered ill, and none has exhibited symptoms or findings of cardiopulmonary disease throughout follow-up. Localization of the diastolic timing and absence of a significant systolic component of the murmur were confirmed by phonocardiography. The transient nature of the finding was established by serial phonocardiography. Essentially normal cardiac anatomy was determined by routine chest radiograms, electrocardiograms, and echocardiography in both M and two-dimensional modes. Suggestive evidence for left-to-right shunting was present in each case. Invasive studies were not performed. An anatomic cause for the diastolic murmur was not discovered, suggesting it could be related to the ductus arteriosus or mild pulmonary insufficiency.