Total robotic-enhanced pericardiectomy for effusive pericarditis.

With the DaVinci Robot only recently in clinical use, limitations of video-assisted thoracoscopy could disappear due to Endo-Wrist features, tremor cancellation and three-dimensional view. This report describes the total endoscopic pericardiectomy successfully achieved with robotic assistance in a 50-year-old man suffering from effusive pericarditis.

Indications and impact of postoperative transesophageal echocardiography in cardiac surgical patients.

OBJECTIVE: Transesophageal echocardiography (TEE) has gained widespread acceptance among intensivists as a tool to facilitate decision-making in the management of critically ill patients. This observational study analyzes the indications and impact of TEE and the outcome in patients following cardiac surgery. DESIGN: Standardized reports containing indication, main diagnosis, and impact on patient management were completed during TEE. SETTING: Intensive care unit in a university hospital. PATIENTS: Postoperative cardiac surgery patients requiring TEE. INTERVENTION: TEE in sedated and mechanically ventilated patients. MEASUREMENTS AND RESULTS: Reports were obtained in 301 adult patients between June 1996 and June 2000. Indications were postoperative control of left ventricular function in 102 (34%) cases; unexplained, sudden hemodynamic deterioration in 89 (29%); suspicion of pericardial tamponade in 41 (14%); cardiac ischemia in 26 (9%); and "other" in 43 (14%). In 136 patients (45%), a new diagnosis was established or an important pathology was excluded. Pericardial tamponade was diagnosed in 34 cases (11%) and excluded in 36 cases (12%). Other diagnoses included severe left ventricular failure, large pleural effusion, and others. Therapeutic impact was found in 220 cases (73%): change of pharmacologic treatment and/or fluid therapy in 118 cases (40%), resternotomy in 43 (14%), no reoperation necessary in 39 (13%), and various in 20 (7%). No impact was found in 81 cases (27%). In a subgroup of patients in whom preoperative risk scores were evaluated, the indication for a postoperative TEE was significantly associated with a prolonged stay in the intensive care unit: 7 (5.6, 8.4) days vs. 1 (0.8, 1.2) day (median, [95% confidence interval]) (p <.0001), more neurologic complications (18/137 = 13.1% vs. 21/680 = 3.0%) (p <.0001), and increased mortality (34/153 = 22.2% vs. 18/709 = 2.5%) (p <.0001). Corrected for preoperative risk scores, these differences were still significant. CONCLUSION: Although TEE provided important findings and therapeutic impact in postoperative cardiac surgical patients, patients with comparable preoperative risk who had postoperative TEE examinations had a significantly worse outcome than those without the need for postoperative TEE.

Emergency repair of incidentally diagnosed ascending aortic aneurysm immediately after caesarean section.

A 36-yr-old pregnant woman with a history of hypertension presented at term for elective Caesarean section because of breech position. At preoperative examination, a diastolic murmur was found and transoesophageal echocardiography (TOE) revealed a large, 8.1-cm diameter ascending aortic aneurysm with severe aortic regurgitation and moderate pericardial effusion. Surgical repair was not considered to be urgently required. The patient was delivered electively by Caesarean section under epidural anaesthesia using invasive arterial pressure monitoring. TOE performed 6 h post-partum showed progressing pericardial effusion, for which emergency replacement of the aortic valve and ascending aorta were indicated. The epidural catheter was removed 4 h before starting the cardiopulmonary bypass procedure. Arterial pressure was controlled by a titrated infusion of esmolol and clonidine. To improve uterine tone, the patient received an i.v. infusion of oxytocin throughout surgery. After implantation of an aortic composite graft and weaning from cardiopulmonary bypass, the patient was transferred to the intensive care unit. Awake and receptive to neurological evaluation, her trachea was extubated 4 h after surgery. Mother and baby made an uneventful recovery.

Prone postioning and low-volume pressure-limited ventilation improve survival in patients with severe ARDS.

STUDY OBJECTIVES: Investigating the effect of low-volume pressure-limited ventilation and repeated prone positioning on the short-term course and outcome in patients with severe ARDS. SETTING: Level 1 trauma center of a university hospital. PATIENTS: Twenty-five patients suffering from ARDS with a lung injury score (LIS) > or = 2.5 admitted consecutively to our ICU from January 1992 to December 1994. METHODS: Mechanical ventilation with peak inspiratory pressure limitation to 35 mbar, irrespective of hypercapnia and prone positioning to achieve adequate oxygenation. SCORING AND MEASUREMENTS: Patient assessment with LIS, APACHE (acute physiology and chronic health evaluation) II score, injury severity score, and multiple organ failure score. Blood gas analyses and estimation of static compliance were repeated at least every 4 h during the treatment period. PaO2/FIO2 (fraction of inspired oxygen) ratio, alveolo-arterial oxygen difference, and intrapulmonary shunt were calculated according to standard equations. The best values taken from each 4-h period during the investigation were used to evaluate the best possible performance of the lung within this interval and to investigate the entire course. RESULTS: Mean predicted mortality based on the APACHE II score was 35.4+/-15.2%. Three of the 25 patients (12%) died. However, none was related to respiratory failure. No pneumothorax occurred. Sixteen patients, lacking any contraindication for prone positioning, responded positively to this change in position, each to a different individual degree. CONCLUSION: We assume that our low mortality in patients with severe ARDS might be due mainly to low-volume pressure-limited ventilation and prone positioning. This simple strategy seems to allow successful treatment for patients with severe ARDS.

Different pattern of local and systemic release of proinflammatory and anti-inflammatory mediators in severely injured patients with chest trauma.

BACKGROUND: Excessive release of proinflammatory cytokines has been involved in pathogenesis of acute respiratory distress syndrome. DESIGN: Since injured patients with chest trauma reveal a high risk for posttraumatic acute respiratory distress syndrome, local and systemic release of proinflammatory cytokines and their naturally occurring inhibitors were determined in the early posttraumatic period. MATERIALS AND METHODS: Proinflammatory and anti-inflammatory mediators were measured in plasma and bronchoalveolar lavage fluid (BALF) from 16 patients with multiple injuries including severe chest injury (Injury Severity Score of 34.4 +/- 2.3 points) and compared with healthy volunteers (n = 17). RESULTS: Tumor necrosis factor-alpha was detectable neither in plasma nor in BALF. Interleukin-1beta and interleukin-8 were significantly increased in BALF from injured patients, while plasma levels were similar in both groups. Soluble tumor necrosis factor receptors p55 and p75 and interleukin-1ra were markedly elevated in plasma (p < or = 0.01) and BALF (p < or = 0.001) from injured patients compared with controls. CONCLUSION: Highly increased concentrations of proinflammatory cytokines in BALF, but not in circulation, indicate a strong local inflammatory response early after multiple injuries combined with chest injury rather than severe systemic inflammation. In contrast, anti-inflammatory mechanisms seem to be activated locally and systemically.