Intravenous ivabradine versus placebo in patients with low cardiac output syndrome treated by dobutamine after elective coronary artery bypass surgery: a phase 2 exploratory randomized controlled trial.

BACKGROUND: Low cardiac output syndrome (LCOS) is a severe condition which can occur after cardiac surgery, especially among patients with pre-existing left ventricular dysfunction. Dobutamine, its first-line treatment, is associated with sinus tachycardia. This study aims to assess the ability of intravenous ivabradine to decrease sinus tachycardia associated with dobutamine infused for LCOS after coronary artery bypass graft (CABG) surgery. METHODS: In a phase 2, multi-center, single-blind, randomized controlled trial, patients with left ventricular ejection fraction below 40% presenting sinus tachycardia of at least 100 beats per minute (bpm) following dobutamine infusion for LCOS after CABG surgery received either intravenous ivabradine or placebo (three ivabradine for one placebo). Treatment lasted until dobutamine weaning or up to 48 h. The primary endpoint was the proportion of patients achieving a heart rate (HR) in the 80- to 90-bpm range. Secondary endpoints were invasive and non-invasive hemodynamic parameters and arrhythmia events. RESULTS: Nineteen patients were included. More patients reached the primary endpoint in the ivabradine than in the placebo group (13 (93%) versus 2 (40%); P = 0.04). Median times to reach target HR were 1.0 h in the ivabradine group and 5.7 h in the placebo group. Ivabradine decreased HR (112 to 86 bpm, P <0.001) while increasing cardiac index (P = 0.02), stroke volume (P <0.001), and systolic blood pressure (P = 0.03). In the placebo group, these parameters remained unchanged from baseline. In the ivabradine group, five patients (36%) developed atrial fibrillation (AF) and one (7%) was discontinued for sustained AF; two (14%) were discontinued for bradycardia. CONCLUSION: Intravenous ivabradine achieved effective and rapid correction of sinus tachycardia in patients who received dobutamine for LCOS after CABG surgery. Simultaneously, stroke volume and systolic blood pressure increased, suggesting a beneficial effect of this treatment on tissue perfusion. TRIAL REGISTRATION: European Clinical Trials Database: EudraCT 2009-018175-14 . Registered February 2, 2010.

Evaluation of blind nasotracheal suctioning and non-bronchoscopic mini-bronchoalveolar lavage in critically ill patients with infectious pneumonia: a preliminary study.

BACKGROUND: We evaluated the diagnostic performance and safety of combined blind nasotracheal suctioning and non-bronchoscopic mini-bronchoalveolar lavage (mini-BAL) to obtain respiratory secretion specimens from spontaneously breathing, non-intubated patients with infectious pneumonia in intensive care. METHODS: Patients suspected of having infectious pneumonia were included prospectively. Three samples were obtained: expectorated sputum, nasotracheal suctioning, and mini-BAL via a double telescopic catheter (Combicath). Under local anesthesia, nasotracheal suctioning was done according to standard recommendations. Then mini-BAL was performed; the bronchial catheter serves as a guide for the mini-BAL catheter, and tracheal position is verified via colorimetric capnography. RESULTS: We included 36 subjects (29 men, median age 69 y, median Simplified Acute Physiology Score II 32), of which 32 (89%) underwent nasotracheal suctioning and mini-BAL, and from 13 (36%) we collected expectorated sputum. Based on colorimetric capnography confirmation of the tracheal position, 75% (24/32) of the successful combined procedures were achieved on the first attempt. The median duration of the combined procedure was 7 min. Bacterial pneumonia was diagnosed in 24/36 (67%) subjects, among whom 21 (88%) had undergone successful nasotracheal suctioning and mini-BAL, respectively, for 8/21 (38% [95% CI 0.17-0.58%] and 14/21 (67% [95% CI 0.46-0.86%]). Mini-BAL diagnosed a significantly higher percentage of bacterial pneumonias than did nasotracheal suctioning. Expectorated sputum yielded no diagnoses. CONCLUSIONS: Blind nasotracheal suctioning confirmed via colorimetric capnography allows microbiological diagnosis, and can be enhanced by non-bronchoscopic mini-BAL. Colorimetric capnography helps confirm bronchial tube position. Non-bronchoscopic mini-BAL is a novel and feasible way to collect bronchial secretions without fibroscopy. (ClinicalTrials.gov NCT00763620.).

An unusual cause of acute abdominal pain after cardiac surgery: acute epiploic appendagitis.

Abdominal complications following cardiac surgery remain unusual, but are associated with high mortality. The most common abdominal surgical complications are mesenteric ischaemia, diverticulitis, pancreatitis, gastrointestinal bleeding and cholecystitis. We describe a case of a 73-year old woman with acute abdominal pain mimicking cholecystitis on day 10 after aortic valve replacement. An abdominal examination showed tenderness of the right upper quadrant with Murphy's sign. Complete blood count, blood chemistries and urinalysis were normal as were the abdominal and chest X-rays and abdominal ultrasonography. The abdominal computed-tomography (CT) scan enabled us to rule out cholecystitis, as it demonstrated the typical appearance of epiploic appendagitis on the right colon, 1 cm below the gallbladder. Epiploic appendagitis results from twisting, kinking or venous thrombosis of an epiploic appendage. Depending on its localization, it mimics many diagnoses requiring surgery: colitis, diverticulitis, appendicitis and cholecystitis. An abdominal CT scan is the diagnostic imaging tool of choice. All physicians involved in post-cardiac surgery care should be aware of this self-limiting disease that usually resolves with non-steroidal anti-inflammatory drugs and watchful waiting, and to avoid unnecessary surgery because the spontaneous evolution of epiploic appendagitis is usually benign.

Preoperative carriage and postoperative same-species sternal wound infection after cardiac surgery.

Sternal wound infection (SWI) after cardiac surgery remains an important problem. Prediction of pathogens involved in such infection could guide antibiotics. From April 1, 2006 to December 31, 2008, retrospectively, we evaluated the diagnostic value of preoperative methicillin-sensible Staphylococcus aureus (MSSA), methicillin-resistant S. aureus (MRSA) or multi-drug resistant Gram-negative bacillus (MDRGNB) carriage to predict same-pathogens involved in postoperative SWI. All patients referred for elective cardiac surgery were screened using multisite (nares, axillae, rectal) sampling at admission to detect MSSA, MRSA, and MDRGNB. Of the 1895 patients addressed, 425 patients (22.4%) were colonized at admission. Preoperative carriers more frequently developed SWI than non-carriers, respectively, 11% vs. 5.5% (P<0.05). Because of the small sample, MDRGNB carriers could not be analyzed. For prediction of MSSA SWI with preoperative MSSA carriage, the area under the receiver operating characteristic (ROC) curve was 0.720 (95% confidence interval (CI), 0.364-0.796) and 0.710 (95% CI, 0.623-0.787) for prediction of MRSA SWI with preoperative MRSA carriage. Preoperative MSSA carriage is frequent but preoperative MRSA or MDRGNB carriage remains infrequent. The ability of preoperative carriage to predict a same-pathogen-postoperative SWI was low and should not be used to guide empirical antibiotherapy.

Prone positioning and acute respiratory distress syndrome after cardiac surgery: a feasibility study.

OBJECTIVE: To determine the feasibility, safety, and efficacy on PaO(2)/F(I)O(2) ratio of prone positioning (PP) for acute respiratory distress syndrome (ARDS) after cardiac surgery. DESIGN: Retrospective review of information entered prospectively in the authors' database. SETTING: A private community nonteaching hospital. PARTICIPANTS: Sixteen patients who developed ARDS after cardiac surgery from January 2004 through June 2005. INTERVENTIONS: PP to improve oxygenation. MEASUREMENTS AND MAIN RESULTS: After a median duration of 18 (range, 14-27) hours in PP, PaO(2)/F(I)O(2) improved in 14 (87.5%) patients. For the entire population, median PaO(2)/F(I)O(2) rose from 87 (range, 56-161) before PP to 194 (range, 94-460; p < 0.05) after it. After supine repositioning (SR), PaO(2)/F(I)O(2) declined to 146 (range, 72-320; not significant). PaO(2)/F(I)O(2) at the end of PP and 1 day after SR were comparable, respectively, 194 (range, 94-460) and 184 (range, 105-342). No severe complication was associated with PP, but 5 patients developed pressure sores and 2 others had superficial sternal wound infections. Intensive care unit mortality of 37.5% reflected the number of organ failure(s); there were no deaths with 2 failures, and 60% with > or = 3 organ failures died (p = 0.03). Mortality rates were comparable regardless of whether patients were PaO(2)/F(I)O(2) responders or their PaCO(2) decreased by > or = 1 mmHg. CONCLUSION: PP to treat ARDS after cardiac surgery is feasible, safe, and can efficiently improve oxygenation. Measures to prevent pressure sores are mandatory.

Reliability of HemoCue in patients with gastrointestinal bleeding.

OBJECTIVE: HemoCue is routinely used to manage bleeding patients, but few studies have evaluated its accuracy in this population. We compared HemoCue with laboratory determination of blood hemoglobin in patients with gastrointestinal bleeding. DESIGN AND SETTING: A prospective observational study in a 14-bed medicosurgical ICU and an emergency department in an urban general hospital. PATIENTS: 94 patients admitted to the emergency department or to the ICU for gastrointestinal bleeding. INTERVENTIONS: Blood was drawn at admission to measure laboratory hemoglobin and capillary hemoglobin was measured simultaneously by HemoCue. The unit of hospitalization and the presence or absence of impaired vital signs (tachycardia and/or hypotension and/or shock) were recorded. MEASUREMENTS AND RESULTS: The mean difference between HemoCue and hemoglobin (bias) was -0.06 g/dl and standard deviation (precision) 0.87 g/dl. (95% CI -1.8 to 1.68). Discrepancies between HemoCue and hemoglobin were greater than 1 g/dl in 21% of cases. Bias was comparable between patients admitted to the ICU and those in the emergency department. The accuracy of HemoCue was not affected by the presence of impaired vital signs or by a hemoglobin level below 9 g/dl or 7 g/dl. CONCLUSIONS: Although we demonstrated a low bias between HemoCue and blood hemoglobin determination, large HemoCue vs. hemoglobin differences may still occur, and therefore therapeutic decisions based upon capillary HemoCue alone should be very cautious.

Pulmonary edema induced by calcium-channel blockade for tocolysis.

Nicardipine is used in the treatment of premature labor. There are no previous reports in the anesthesia literature of serious side effects associated with this drug. We report a case of pulmonary edema induced by nicardipine therapy for tocolysis in a pregnant 27-yr-old patient admitted to our hospital for preterm labor with intact membranes at 27 wk of gestation.

Evaluation of a new invasive continuous cardiac output monitoring system: the truCCOMS system.

OBJECTIVE: To compare measurements of cardiac output using a new pulmonary artery catheter with those obtained using two "gold standard" methods: the periaortic transit time ultrasonic flow probe and the conventional pulmonary artery thermodilution. DESIGN: Prospective clinical trial. SETTING: Cardiac surgery operating room and surgical ICU in a university hospital. MATERIAL AND METHODS: In the operating room, a new pulmonary artery catheter (truCCOMS system) was inserted in eight patients. A periaortic flow probe was inserted in four of them. Measurements of cardiac output obtained with the truCCOMS catheter and with the flow probe were compared at different phases of the surgical procedure. In the intensive care unit, the cardiac output displayed by the truCCOMS monitor was compared with the value obtained after bolus injection performed subsequently. RESULTS: In the operating room (70 measurements), the coefficient of correlation between cardiac output measured by the flow probe and the truCCOMS system was r2 = 0.79, the bias was +0.11 l/min with a precision of 0.47 l/min, and limits of agreement -0.83 to +1.05 l/min. In the intensive care unit (108 measurements), the coefficient of correlation between cardiac output measured by thermodilution and the truCCOMS system was r2 = 0.56, the bias was -0.07 l/min, the precision was 0.66 l/min, and the limits of agreement were -1.39 to +1.25 l/min. CONCLUSION: The truCCOMS system is a reliable method of continuous cardiac output measurement in cardiac surgery patients.