Diagnostic accuracy of a calibrated abdominal compression to predict fluid responsiveness in children.

BACKGROUND: Fluid administration to increase stroke volume index (SVi) is a cornerstone of haemodynamic resuscitation. We assessed the accuracy of SVi variation during a calibrated abdominal compression manoeuvre (ΔSVi-CAC) to predict fluid responsiveness in children. METHODS: Patients younger than 8 yr with acute circulatory failure, regardless of their ventilation status, were selected. SVi, calculated as the average of five velocity-time integrals multiplied by the left ventricular outflow tract surface area, was recorded at four different steps: baseline, after an abdominal compression with a calibrated pressure of 25 mm Hg, after return to baseline, and then after a volume expansion (VE) of 10 ml kg-1 lactated Ringer solution over 10 min. Patients were classified as responders if SVi variation after volume expansion (ΔSVi-VE) increased by at least 15%. RESULTS: The 39 children included had a median [inter-quartile range (IQR)] age of 9 [5-31] months. Twenty patients were fluid responders and 19 were non-responders. ΔSVi-CAC correlated with ΔSVi-VE (r=0.829; P<0.001). The area under the receiver operating characteristic curve (ROCAUC) was 0.94 [95% confidence interval (CI), 0.85-0.99]. The best threshold for ΔSVi-CAC was 11% with a specificity of 95% [95% CI, 84-100] and a sensitivity of 75% [95% CI, 55-95]. ROCAUC of respiratory variation of IVC diameter (ΔIVC) was 0.53 [95% CI, 0.32-0.72]. CONCLUSION: ΔSVi-CAC during abdominal compression was a reliable method to predict fluid responsiveness in children with acute circulatory failure regardless of their ventilation status. CLINICAL TRIALS REGISTRATION: CPP Lyon sud est II: n° ANSM 2015-A00388-41 Clinicaltrial.gov: NCT02505646.

[Clinical usefulness of new-generation pulse oximetry in the paediatric cardiac surgery setting]. / Utilisation clinique d'un oxymètre de pouls de nouvelle génération dans le cadre de la chirurgie cardiaque pédiatrique.

OBJECTIVES: Arterial oxygen saturation (SaO(2)) monitoring using pulse oximeter (SpO(2)) is mandatory in the intensive care unit. The aim was to assess bias and precision of new (SpO(2)ng) and old (SpO(2)og) pulse oximeter technologies in the postoperative period following pediatric cardiac surgery in cyanotic children. STUDY DESIGN: Prospective, monocentric. PATIENTS AND METHODS: Ten patients (7 days to 53 months old) were studied in the postoperative period following palliative cardiac surgery. SaO(2), SpO(2)og, and SpO(2)ng were obtained every 4 hours. SaO(2) of arterial blood sample was obtained from an intra-arterial catheter located in the radial artery, on the same side as the oximeters. Bias and precision were assessed using Bland-Altman analysis. RESULTS: We obtained 136 SaO(2) determinations. Mean SaO(2) was 76+/-15%. SpO(2)og was significantly different from SaO(2), while SpO(2)ng was not different from SaO(2). In 21 (15%) cases, SpO(2)og was not available whereas SpO(2)ng was available in 136 (100%) cases. In the remaining 115 cases, SpO(2)ng's precision was significantly better than SpO(2)og's precision. DISCUSSION: SpO(2)ng is more accurate and more reliable than SpO(2)og for SaO(2) monitoring in the postoperative period following pediatric cardiac surgery in cyanotic children.

[Anaesthesia and intensive care for cardiac surgery in France: results of the three days national survey realised in 2001 by the club of Anaesthesia, Intensive Care and Technics in Cardiac Surgery (ARTECC)]. / L'anesthésie en chirurgie cardiaque adulte en France en 2001: résultats de l'enquête nationale de trois jours du club Anesthésie-Réanimation-Techniques en Chirurgie Cardiaque (ARTECC).

OBJECTIVES: Ageing of the surgical population and the evolution in anaesthetic techniques have led the Club d'anesthésie-réanimation et techniques en chirurgie cardiaque (ARTECC) to conduct a survey among French cardiac surgery centers. The aim was to profile patient population undergoing cardiac surgery and perioperative techniques employed. STUDY: National prospective study including all adult patients undergoing cardiac surgery on January 23rd, 24th and 25th, 2001. Data were collected during the first 48 postoperative hours. MATERIAL AND METHODS: Seven referent centers drafted a record form. Sixty-one centers sent back 425 patient forms, 399 were analyzed. The following were statistically studied: type of surgery, patient characteristics, preoperative treatment, monitoring, anaesthesia, cardio-pulmonary bypass (CPB) characteristics, duration of mechanical ventilation, length of stay in intensive care unit, postoperative complications. RESULTS: Patient mean age was 64.3 +/- 13.3 years. Patients over 80-year-old represented 2.5% of the population. Beating heart coronary aortic bypass grafts (13% surgery) and preoperative transoesophagal echography were not frequent. Propofol and sufentanil were the main anaesthetic agents used. There was a marked trend for fast-track procedures. CONCLUSIONS: The ARTECC study pointed out some reserve in practices and that the impact of new techniques seems limited. Regular use of studies of that kind will provide an effective tool to compare national practices.

Bilateral internal thoracic artery harvesting under robotic video-assistance.

BACKGROUND: Following upon the recent development of minimally invasive coronary robotic surgery, we set out to evaluate the feasibility of bilateral internal mammary artery (IMA) harvesting using the voice-controlled AESOP 2000 video assisted robot. METHODS: The robot is placed on the right side of the patient. The left IMA is first totally video-harvested, with the arm of the robot crossing over the patient to reach the left chest. The voice-controlled movement of the arm allows the surgeon to obtain the best video image of the artery. After completion of the dissection, the arm is positioned on the right part of the chest. The right IMA is then harvested using the same technique. RESULTS: Two patients underwent harvest of a bilateral IMA using this technique. The time of dissection was 52 min and 86 min, respectively. CONCLUSION: This technique allows a more precise, faster, tremor-free dissection, as compared to a conventional thoracoscopic harvesting.

Glucose versus lactated Ringer's solution during pediatric cardiac surgery.

OBJECTIVE: Whether intraoperative fluid infusion should contain glucose during pediatric cardiac surgery remains controversial. This study was performed to compare the effects of glucose and glucose-free solutions on blood glucose and blood insulin levels during total repair of congenital heart diseases. DESIGN: Prospective randomized and blinded study. SETTING: Cardiovascular university center. PARTICIPANTS: Forty nondiabetic children, weight ranging from 4 to 10 kg, scheduled for cardiac surgical procedures requiring cardiopulmonary bypass (CPB) without total circulatory arrest. INTERVENTIONS: Group R (n = 20) was administered lactated Ringer's solution intraoperatively, and group G (n = 20) received 5% glucose. Fluids were infused at a rate of 3 mL/kg/h in the two groups from the induction of anesthesia to the end of the surgical procedure. Blood glucose and insulin were sampled before infusion (Tzero), before CPB (T1), 10 minutes after initiation of CPB (T2), 10 minutes after initiation of rewarming (T2), and at the end of the procedures (T4). Postoperatively, blood glucose was measured at the first, 12th, and 24th hours. MEASUREMENTS AND RESULTS: During the prabypass period, three children in group R had severe hypoglycemia (blood glucose < 40 mg/dL). After initiation of CPB, blood glucose increased in both groups, with a small difference at the end of the procedure. No infants in the two groups had blood glucose higher than 239 mg/dL. CONCLUSIONS: Glucose withdrawal during pediatric cardiac surgery induces threatening hypoglycemia during the prabypass period, and moderate intraoperative glucose administration (2.5 mg/kg/min) is not responsible for major hyperglycemia.

Myocardial protection during coronary artery bypass graft surgery: a randomized, double-blind, placebo-controlled study with trimetazidine.

We conducted a randomized, double-blind, placebo-controlled study to assess the cardioprotective effects of trimetazidine (TMZ), an antiischemic drug, on left ventricular function using transesophageal echocardiography (TEE) after coronary artery bypass grafting (CABG). Forty patients undergoing elective CABG received either TMZ or a placebo (PCB). The primary measures of efficacy were serial measurements of fractional area change (FAC), percent of systolic wall thickening (SWT), and malonedialdehyde (MDA) production. The two groups were similar for the following variables: number of vessels revascularized (2.5 +/- 0.2 in the TMZ group and 2.8 +/- 0.1 in the PCB group), duration of aortic clamping (46 +/- 4 min in the TMZ group and 48 +/- 3 min in the PCB group), and bypass time (63 +/- 4 min in the TMZ group and 70 +/- 4 min in the PCB group). FAC increased by 12% in both groups 20 min after aortic unclamping (P < 0.05) and remained above the initial value at the sixth postoperative hour. SWT was 23.8% +/- 1.6%, 25.4% +/- 1.9%, then 21.6% +/- 1.5% in the TMZ group and 22.8% +/- 1.6%, 23.8% +/- 1.4%, then 22.3% +/- 1.6 % in the PCB group, after induction of anesthesia and 1 and 6 h after aortic unclamping (not significant). MDA increased by 24% in the PCB group and 25% in the TMZ group 20 min after aortic unclamping (P < 0.01). Lactate levels were lower in the TMZ group (P < 0.05) and patients from the TMZ group received less intravenous calcium before aortic clamping (P < 0.02) and less calcium channel entry blocking drugs in the early phase after aortic unclamping (P < 0.01) compared to the PCB group. We conclude that in patients with good preoperative ejection fraction undergoing CABG, TMZ as administered did not demonstrate clinically significant cardioprotective effects on left ventricular performance and lipid peroxidation compared to PCB.

[CK-MB isoenzyme in the diagnosis of myocardial infarction after myocardial revascularization surgery]. / Isoenzyme CK-MB dans le diagnostic d'infarctus myocardique après chirurgie de revascularisation myocardique.

The usefulness of measuring serum MB creatine kinase activity (CK-MB) for the diagnosis of per- and postoperative myocardial infarction (MI) was assessed in 104 patients undergoing coronary artery bypass grafts. In each patient, 15 samples were taken during the week which followed the surgical procedure. New Q waves were considered to be a criteria of MI. 19 patients developed new Q waves (MI group), whereas 57 had no significant ECG changes (control group); 13 showed only ST changes, whilst 15 had unassessable recordings. In the MI group, CK-MB was greater than in the control group, both at the first peak (8 to 10 h after induction of anaesthesia) and at the greater peak (13 to 21 h after induction) (p less than 0.05). Significant differences were also seen between both groups between 8 and 32 h after induction, but there was also a large overlap. An area under the curve (AUC) greater than 50,000 IU.l-1.min-1 had a positive predictive value of 0.64, and an AUC less than 50,000 IU.l-1.min-1 a negative predictive value of 0.89 if all the groups of patients were taken into account. An AUC greater than 65,000 IU.l-1.min-1 was always seen in MI patients, but only 25% of MI patients had a value greater than this threshold. There were no significant differences between the patient groups in the first peak time, nor in the CK-MB/total CK ratio. CK-MB appeared therefore as a less reliable criterium of per- and postoperative MI during coronary artery bypass operations than previously reported, especially when intermediate values are found.