Evaluation of Reperfusion Pulmonary Edema by Extravascular Lung Water Measurements After Pulmonary Endarterectomy.

OBJECTIVES: Reperfusion pulmonary edema is a specific complication of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Extravascular lung water measurement may be valuable for diagnosing reperfusion pulmonary edema. The primary objective of this study was to describe and assess the clinical significance of extravascular lung water variations after pulmonary endarterectomy. DESIGN: Prospective observational study. SETTING: Nineteen-bed cardiothoracic ICU. PATIENTS: Consecutive patients who were hemodynamically stable after pulmonary endarterectomy were divided into two groups based on whether their preoperative pulmonary vascular resistance indicated severe or nonsevere chronic thromboembolic pulmonary hypertension (> 900 or ≤ 900 dynes·s/cm, respectively). INTERVENTIONS: Hemodynamic variables obtained by right heart catheterization and transpulmonary thermodilution measurements were recorded 1 hour, 1 day, and 2 days after pulmonary endarterectomy. Extravascular lung water was indexed to predicted body weight (EVLWPBW). MEASUREMENTS AND MAIN RESULTS: We studied 31 patients. Overall, 26 patients (84%) experienced reperfusion pulmonary edema during the first 72 hours after pulmonary endarterectomy. EVLWPBW significantly increased between the first hour after pulmonary endarterectomy and day 2 (10.2 ± 2.6 vs 11.4 ± 3.6; p = 0.03). EVLWPBW measured at the first hour after pulmonary endarterectomy is closely associated with reperfusion pulmonary edema occurrence in the next 48 hours (area under the receiver-operating characteristics curve = 0.88 ± 0.07). EVLWPBW correlated with duration of mechanical ventilation (ρ = 0.59; p < 0.0001) and ICU stay (ρ = 0.52; p < 0.0001). Patients with severe chronic thromboembolic pulmonary hypertension (n = 15) had higher EVLWPBW values at day 2 compared with those without (n = 16) (13.2 ± 3.6 vs 9.7 ± 2.7 mL/kg; p = 0.004). Cardiac output was measured simultaneously by pulmonary artery catheter and aortic transpulmonary thermodilution on 92 occasions; agreement was good, with a bias of 0.50 ± 0.95 L/min (95% CI, -1.36-2.36). CONCLUSIONS: Accurate extravascular lung water measurements were obtained after pulmonary endarterectomy. Extravascular lung water may prove valuable for diagnosing reperfusion pulmonary edema after pulmonary endarterectomy and had prognostic value. Extravascular lung water values were significantly higher in patients with severe compared with nonsevere chronic thromboembolic pulmonary hypertension.

Incidence of nosocomial pneumonia and risk of recurrence after antimicrobial therapy in critically ill lung and heart-lung transplant patients.

Little is known about the resolution of symptoms of nosocomial pneumonia (NosoP) after lung and heart-lung transplantation. The aim of this study was to describe the clinical response to antimicrobial therapy in (ICU) patients with NosoP after lung or heart-lung transplantation. Between January 2008 and August 2010, 79 lung or heart-lung transplantations patients were prospectively studied. NosoPwas confirmed by quantitative cultures of bronchoalveolar lavage or endotracheal aspirates. Clinical variables, sequential organ failure assessment (SOFA) score, and radiologic score were recorded from start of therapy until day 9. Thirty-five patients (44%) experienced 64 episodes of NosoP in ICU. Fourteen patients (40%) had NosoP recurrence. Most frequently isolated organisms were Enterobacteriaceae (30%), Pseudomonas aeruginosa (25%), and Staphylococcus aureus (20%). Sequential organ failure assessment (SOFA) score improved significantly at day 6 and C-reactive protein level at day 9. SOFA and radiologic scores differed significantly between patients with and without NosoP recurrence at day 3 and 9. The ICU mortality rate did not differ between patients with and without NosoP recurrence, and free of NosoP (14.3%, 9.5%, 11.4%, respectively) (p = 0.91). Severities of illness and lung injury were the two major risk factors for NosoP recurrence. Occurrence of NosoP has no impact on ICU mortality.

Outcomes of patients with antiphospholipid syndrome after pulmonary endarterectomy.

OBJECTIVES: Antiphospholipid syndrome (APS) is a risk factor for chronic thromboembolic pulmonary hypertension, for which the treatment of choice is pulmonary endarterectomy. The increased risk of postoperative thrombotic complications in patients with APS may complicate the perioperative management. The primary objective of this study was to investigate the impact of APS on mortality and morbidity rates after pulmonary endarterectomy. The secondary objective was to describe platelet count changes after pulmonary endarterectomy in patients with APS. METHODS: Data were collected prospectively for consecutive patients with APS who underwent pulmonary endarterectomy over a 5-year period [2007-2011] and for consecutive patients without APS who underwent pulmonary endarterectomy at the same centre during 2008-2011 [controls]. Major complications and daily platelet counts were collected. Haemodynamic parameters obtained by right heart catheterisation were recorded preoperatively and on the day after surgery. RESULTS: We identified 17 patients with APS [3.6% of all pulmonary endarterectomies] and 190 controls. Early haemodynamic results after pulmonary endarterectomy were similar in the two groups, with a greater than 35% decrease in pulmonary vascular resistance. Significantly higher proportions of patients with APS than of controls experienced stroke [11.8 vs 1.0%, P= 0.03] and delirium [47 vs 20%; P = 0.02]. Compared with the controls, the patients with APS had significantly lower platelet counts and had a higher occurrence rate of platelet counts of ≤ 50 g/l (71 vs 4%; P < 0.0001). Intensive care unit (ICU) mortality was not significantly different between the two groups [0/17 vs 7/190 (3.7%), P = 0.49]. CONCLUSIONS: Neurological complications and severe thrombocytopenia were more common after pulmonary endarterectomy in patients with than without APS. Haemodynamic results and ICU mortality rate were similar in the two groups.

Use of prothrombin complex concentrate for excessive bleeding after cardiac surgery.

OBJECTIVES: Prothrombin complex concentrates (PCCs) are sometimes used as 'off label' for excessive bleeding after cardiopulmonary bypass (CPB). The main objective of this study was to retrospectively evaluate the clinical and biological efficacy of PCC in this setting. METHODS: We reviewed the charts of all patients who had undergone cardiac surgery under CPB in our institution for 2 years. Patients treated for active bleeding with haemostatic therapy were identified. Chest tube blood loss was quantified postoperatively in the first 24 h. Coagulation parameters were recorded at intensive care unit admission and in the patient's first 24 h. Thromboembolic complications were also ascertained. RESULTS: Seventy-seven patients out of the 677 studied (11.4%) were included: PCC was solely administered in 24 patients (group I), fresh frozen plasma in 26 (group II) and both in 27 (group III). The mean dose of PCC was 10.0 UI/kg ± 3.5 for group I vs 14.1 UI/kg ± 11.2 for group III (P = 0.09). Initial blood loss in the first hour was different between the three groups (P = 0.05): 224 ± 131 ml for group I, 369 ± 296 ml for group II and 434 ± 398 ml for group III. Only group I vs group III presented a significant difference (P = 0.02). Variations of blood loss over time were no different according to the treatment groups (P = 0.12). Reductions in blood loss expressed in percentage showed no difference between the three groups after 2 h: 54.5% (68.6-30.8) for group I; 45.0% (81.6-22.2) for group II; 57.6 (76.0-2.1) for group III; (P = 0.89). Re-exploration for bleeding involved 1 patient in group I (4%), 2 in group II (8%) and 10 in group III (37%) (P = 0.002). Except for fibrinogen, variations of prothrombin time, activated partial thromboplastin time and platelets with time were not different according to the treatment groups. Cerebral infarction occurred in one patient in group II. CONCLUSIONS: Administration of low-dose of PCC significantly decreased postoperative bleeding after CPB.

Anesthetic management of pregnant women with sickle cell disease--effect on postnatal sickling complications.

PURPOSE: Currently, there is no consensus regarding the choice of anesthetic technique for parturients with sickle cell disease (SCD). The aim of the study was to determine the impact of the anesthetic technique on the occurrence of postnatal sickling complications. METHODS: We reviewed the charts of all pregnant women with SCD who had given birth in our institution between January 2002 and January 2007. Data related to pregnancy and anesthetic management and complications related, or unrelated, to SCD were recorded. Full blood count and lactate dehydrogenase values were recorded on the day of delivery. Risk factors for postnatal sickling complications were evaluated using a logistic regression analysis to estimate odds ratios (OR) and their 95% confidence intervals (95% CI). RESULTS: Fourteen of the 55 women (24%) experienced at least one postnatal sickling complication. Women who developed postnatal sickling complications were found to have a higher leukocyte count (17.0+/-6.1x10(9).L(-1) vs 12.8+/-4.4x10(9).L(-1), P=0.008) and a lower hemoglobin level (7.8+/-1.1 vs 8.9+/-1.0 g.dL(-1), P=0.002). General anesthesia (OR=16.0; 95% CI, 1.6 to 165.6) and a leukocyte count>or=15x10(9).L(-1) (OR=8.4; 95% CI, 1.6 to 44.5) were identified as risk factors. Neuraxial anesthesia and use of ephedrine were not identified as risk factors. There were no deaths. CONCLUSION: Our study suggests that general anesthesia could be associated with postnatal sickling complications, even when the severity of illness was taken into account.