End-of-life decisions in surgical intensive care medicine - the relevance of blood transfusions.

BACKGROUND: End-of-life decisions (EOLDs) are common in the intensive care unit (ICU). EOLDs underlie a dynamic process and limitation of ICU-therapies is often done sequentially. Questionnaire-based and observational studies on medical ICUs and in palliative care reveal blood transfusions as the first therapy physicians withhold as an EOLD. METHODS: To test whether this practice also applies to surgical ICU-patients, in an observational study, all deceased patients (n = 303) admitted to an academic surgical ICU in a three-year period were analyzed for the process of limiting ICU-therapies. RESULTS: Restriction of further surgery (85.4%) and limiting doses of vasopressors (75.8%) were the most frequent forms of limitations in surgical ICU therapies. Surgical patients, who had blood transfusions withheld (44.6%), had more ICU-therapies withheld or withdrawn simultaneously than patients who had transfusions maintained (5 ± 2 vs. 2 ± 1, p < 0.001). Secondary EOLDs and subsequent limitations occurred less frequently in patients who had transfusions withheld with their first EOLD (17.1% vs. 35.6%, p < 0.05). CONCLUSION: Limitation orders for blood transfusions are not a prioritized decision in EOLDs of surgical ICU patients. Withholding blood transfusions correlates with discontinuation of further significant life-support therapies. This suggests that EOLDs to withhold blood transfusions are part of the most advanced limitations of therapy on the surgical ICU.

Early levosimendan administration is associated with decreased mortality after cardiac surgery.

PURPOSE: The aim of this study was to assess the effects on postoperative outcome of levosimendan with respect to timing of its administration in cardiac surgery patients. MATERIALS AND METHODS: Levosimendan administration was triggered by a severely reduced left ventricular systolic function (left ventricular ejection fraction, <35%) and/or signs of a low cardiac output syndrome. A total of 159 patients were retrospectively assigned depending on an early (perioperatively up to the first hour after intensive care unit [ICU] admission) vs late (later than the first hour after ICU admission) start of treatment. RESULTS: Patients receiving levosimendan after the first hour of ICU admission (n = 89) had a significantly increased inhospital (P = .004) and 1-year (P = .027) mortality. Duration of mechanical ventilation (P = .002), incidence of renal dysfunction (P = .002), and need of renal replacement therapy (P = .032) were significantly increased in the late start group. A late start of levosimendan treatment was associated with an odds ratio of 2.258 (95% confidence interval, 1.139-4.550; P = .021) for inhospital mortality and an adjusted hazard ratio of 1.827 (95% confidence interval, 1.155-2.890; P = .010) for 1-year survival. CONCLUSIONS: Findings of this retrospective analysis favor an "early," that is, intraoperatively up to the first hour after ICU admission, start of perioperative levosimendan treatment to maximize its ability to reduce mortality and morbidity.

Early administration of levosimendan is associated with improved kidney function after cardiac surgery - a retrospective analysis.

BACKGROUND: Several animal studies suggest beneficial effects on kidney function upon administration of levosimendan. As recent data from clinical studies are heterogeneous, we sought to investigate whether levosimendan is associated with improved postoperative kidney function in cardiac surgery patients with respect to timing of its administration. METHODS: Retrospective, single centre, observational analysis at a university hospital in Berlin, Germany. All adult patients without preoperative renal dysfunction that underwent coronary artery bypass grafting and/or valve reconstruction/replacement between 01/01/2007 and 31/12/2011 were considered for analyses. RESULTS: Out of 1.095 included patients, 46 patients were treated with levosimendan due to a severely reduced left ventricular systolic function preoperatively (LVEF < 35%) and/or clinical signs of a low cardiac output syndrome. Sixty-one percent received the drug whilst in the OR, 39% after postoperative intensive care unit admission. When levosimendan was given immediately after anaesthesia induction, creatinine plasma levels (p = 0.009 for nonparametric analysis of longitudinal data in a two-factorial design) and incidence of postoperative renal dysfunction (67.9% vs. 94.4%; p = 0.033) were significantly reduced in contrast to a later start of treatment. In addition, duration of renal replacement therapy was significantly shorter (79 [35;332] vs. 272 [132;703] minutes; p = 0.046) in that group. CONCLUSIONS: Postoperative kidney dysfunction is a common condition in patients under going cardiac surgery. Patients with severely reduced left ventricular function and/or clinical signs of a low cardiac output syndrome who preoperatively presented with a normal kidney function may benefit from an early start of levosimendan administration, i.e. immediately after anaesthesia. TRIAL REGISTRATION: Clinicaltrials.gov-ID: NCT01918618 .

Mid-term clinical results using a tissue-engineered pulmonary valve to reconstruct the right ventricular outflow tract during the Ross procedure.

BACKGROUND: The Ross procedure is mainly limited by the durability of the valve prostheses used to reconstruct the right ventricular outflow tract. This study was performed to collect prospective safety and effectiveness data of the Ross procedure using a tissue-engineered heart valve to reconstruct the right ventricular outflow tract. METHODS: Between May 2000 and February 2003, 23 patients received tissue-engineered heart valves. Two to four weeks before the Ross operation, a piece of forearm or saphenous vein was harvested to isolate, characterize, and expand endothelial cells. A pulmonary allograft (n = 11) or xenograft (n = 12) was decellularized, coated with fibronectin, and seeded with autologous vascular endothelial cells, using a specially developed bioreactor. Follow-up was performed by clinical evaluation, transthoracic echocardiography, magnetic resonance imaging, and multislice computed tomography. RESULTS: The patient mean age was 44.0 +/- 13.7 years. Cell seeding density was 1.1 x 10(5) +/- 0.5 x 10(5) cells/cm2, with a viability of 90.2% +/- 8.9%. All patients survived the operation. One patient died during follow-up, and 1 patient required reoperation. All surviving patients are currently in New York Heart Association functional class I. Transthoracic echocardiographic evaluation of the tissue-engineered heart valve showed a mean flow velocity of 0.9 +/- 0.4 m/s at 5 years. Multislice computed tomography showed no calcification up to 5 years postoperatively. CONCLUSIONS: Tissue-engineered heart valves showed excellent hemodynamic performance during mid-term follow-up. Decellularization of heart valves and seeding with autologous vascular endothelial cells may prevent tissue degeneration and improve valve durability.

Clonidine attenuated early proinflammatory response in T-cell subsets after cardiac surgery.

T-cells play a central role in the immune response to injury. Cardiac surgery is associated with significant risk of systemic inflammatory response syndrome and subsequent unbalanced induction of proinflammatory cytokines. As clonidine has immunomodulating properties via reducing sympathetic activity, this study involved the analysis of T-cell function in the early postoperative period in patients undergoing coronary artery bypass graft surgery. Forty patients undergoing cardiac surgery were randomly allocated to one of the following groups: clonidine group (n = 20) [clonidine 1 microg kg(-1) h(-1)] and placebo group (n = 20). Study medication was started after induction of anesthesia and maintained until 6 h after surgery. Blood samples to determine Th1 and Th2 cells and cytotoxic lymphocytes (Tc1 and Tc2 cells) were drawn preoperatively, on admission to the intensive care unit, 6 and 12 h postoperatively as well as on the morning of days 1 and 2 after surgery. In the clonidine group significantly lower levels of Th1/Th2 ratios as well as Tc1/Tc2 ratios were found 6 h postoperatively compared to the placebo group (P < 0.05). Clonidine changed the ratio of T-lymphocyte subpopulations in peripheral blood in favor of a proinflammatory response, which might be favorable for maintaining immune balance after surgery.

Increased interleukin-10 and cortisol in long-term alcoholics after cardiopulmonary bypass: a hint to the increased postoperative infection rate?

BACKGROUND: Previous studies have shown that 20% of all patients admitted to the hospital abuse alcohol and have increased morbidity after surgery. Long-term alcoholic patients are shown to suffer from immune alterations, which might be critical for adequate postoperative performance. Cardiac surgery with cardiopulmonary bypass (CPB) also leads to pronounced immune alteration, which might be linked with patients' ability to combat infections. Therefore, the aim of our study was to investigate the perioperative levels of TNF-alpha, interleukin-6, interleukin-10, and cortisol in long-term alcoholic and nonalcoholic patients undergoing cardiac surgery to elucidate a possible association with postoperative infections. METHODS: Forty-four patients undergoing elective cardiac surgery were included in this prospective study. Long-term alcoholic patients (n=10) were defined as having a daily ethanol consumption of at least 60 g and fulfilling the Diagnostic and Statistical Manual of Mental Disorders for alcohol abuse. The nonalcoholic patients (n=34) were defined as drinking less than 20 g ethanol per day. Blood samples were obtained to analyze the immune status upon admission to hospital, the morning before surgery and on admission to the ICU, the morning of days one and three after surgery. RESULTS: Basic characteristics of patients did not differ between groups. Long-term alcoholics had a fourfold increase in postsurgery infection rate and prolonged need for ICU treatment and mechanical ventilation. Postoperative levels of interleukin-10 and cortisol were significantly increased in long-term alcoholic patients compared with nonalcoholic patients. These observations were in line with postoperative interleukin-10 being predictive for postoperative infectious complications. CONCLUSIONS: The increased infection rate in long-term alcoholics strengthens the urgent need for interventional approaches providing modulation of the perioperative immune and HPA response in these high-risk patients to counteract their postoperative immune suppression.

Temporary left ventricular assist and levosimendan for coronary artery spasm.

Coronary vasospasm is a life threatening complication in the early postoperative period after coronary artery bypass grafting. We report a 45-year-old patient with normal preoperative ventricular function who could not be stabilized using established treatments such as: systemic application of glyceryl trinitrate, diltiazem and milrinone, intraaortic balloon pumping and intracoronary injection of glyceryl trinitrate. Severe stunning of the myocardium required support with a centrifugal left ventricular assist device. Subsequent application of levosimendan, a calcium sensitizer, may have contributed to prevent recurrence of repeated episodes of coronary spasm, enabling early explantation of the assist device and a full recovery.