Soporte mecánico con membrana de oxigenación extracorpórea veno-arterial (ECMO-VA): evolución a corto y a largo plazo tras la retirada de la asistencia / Mechanical support with venoarterial extracorporeal membrane oxygenation (ECMO-VA): Short-term and long-term prognosis after a successful weaning

Objetivo: La membrana de oxigenación extracorpórea (ECMO) es un tipo de asistencia circulatoria que asocia elevada mortalidad. Sin embargo, superar la fase inicial de soporte mecánico no implica supervivencia ni a corto ni a largo plazo. Objetivo: describir las características y evolución de los pacientes con shock cardiogénico refractario (SCR) asistidos con ECMO veno-arterial (ECMO-VA) en un hospital con programa de trasplante cardíaco. Diseño: Estudio de cohortes y retrospectivo de centro único. Ámbito: UCI cardiológica de un hospital terciario. Pacientes: Un total de 46 pacientes asistidos consecutivamente con una ECMO-VA durante 6 años. Intervenciones: Análisis de la mortalidad hospitalaria tras la retirada del soporte mecánico, de la supervivencia global (SG) y de los factores asociados. Resultados: Quince pacientes (33%) fallecieron con la ECMO-VA y 31 (67%) sobrevivieron a su retirada tras un soporte de 8 días (RIC: 5-15); 14 pacientes fueron trasplantados. La mortalidad hospitalaria en estos pacientes fue del 32% (10/31) y se relacionó con: edad (p=0,001), SAPS-II (p=0,009), sangrado de cánulas (p=0,01), indicación de SCR post-IAM (p=0,001). Con una mediana de seguimiento de 27 meses (RIC: 11-49), seguían vivos el 91% de los pacientes que fueron dados de alta del hospital. La SG tras la retirada de la ECMO-VA se relacionó con el tipo de indicación (p=0,002), teniendo peor pronóstico los pacientes con SCR postinfarto. Conclusiones: En nuestra experiencia, la ECMO-VA es un tipo de asistencia mecánica que puede utilizarse en el manejo del SCR. Asocia una mortalidad precoz elevada, pero tras superar la fase hospitalaria la supervivencia de los pacientes es buena (AU)

Objective: Extracorporeal membrane oxygenation (ECMO) affords mechanical circulatory assistance associated to high mortality. However, weaning from such mechanical support may not imply improved short- or long-term survival. This study describes the characteristics and evolution of patients with refractory cardiogenic shock (RCS) subjected to venoarterial ECMO (VA-ECMO) in a hospital with a heart transplant program. Design: A single-center, retrospective cohort study was carried out. Setting: The cardiovascular ICU of a tertiary hospital. Patients: Forty-six patients consecutively subjected to VA-ECMO over 6 years. Interventions: Hospital mortality after weaning from ECMO and overall survival (OS) were analyzed. Results: Fifteen patients (33%) died with VA-ECMO and 31 (67%) were weaned after 8 days of support (IQR: 5-15). Fourteen patients under went transplantation. Hospital mortality in these patients was 32% (10/31), and was associated to age (P=.001), SAPS II score (P=.009), cannulation bleeding (P=.01) and post-acute myocardial infarction RCS (P=.001). After a median follow-up of 27 months (IQR: 11-49), 91% of the patients discharged from hospital were still alive. Overall survival after weaning from assistance was associated to the type of cardiac disease (P=.002). Patients with RCS after acute myocardial infarction had a poorer prognosis. Conclusions: In our experience, VA-ECMO can be used as mechanical assistance in the management of RCS. The technique is associated to high early mortality, though the long-term survival rate after hospital discharge is good (AU)

Mechanical support with venoarterial extracorporeal membrane oxygenation (ECMO-VA): Short-term and long-term prognosis after a successful weaning. / Soporte mecánico con membrana de oxigenación extracorpórea veno-arterial (ECMO-VA): evolución a corto y a largo plazo tras la retirada de la asistencia.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) affords mechanical circulatory assistance associated to high mortality. However, weaning from such mechanical support may not imply improved short- or long-term survival. This study describes the characteristics and evolution of patients with refractory cardiogenic shock (RCS) subjected to venoarterial ECMO (VA-ECMO) in a hospital with a heart transplant program. DESIGN: A single-center, retrospective cohort study was carried out. SETTING: The cardiovascular ICU of a tertiary hospital. PATIENTS: Forty-six patients consecutively subjected to VA-ECMO over 6 years. INTERVENTIONS: Hospital mortality after weaning from ECMO and overall survival (OS) were analyzed. RESULTS: Fifteen patients (33%) died with VA-ECMO and 31 (67%) were weaned after 8 days of support (IQR: 5-15). Fourteen patients under went transplantation. Hospital mortality in these patients was 32% (10/31), and was associated to age (P=.001), SAPS II score (P=.009), cannulation bleeding (P=.01) and post-acute myocardial infarction RCS (P=.001). After a median follow-up of 27 months (IQR: 11-49), 91% of the patients discharged from hospital were still alive. Overall survival after weaning from assistance was associated to the type of cardiac disease (P=.002). Patients with RCS after acute myocardial infarction had a poorer prognosis. CONCLUSIONS: In our experience, VA-ECMO can be used as mechanical assistance in the management of RCS. The technique is associated to high early mortality, though the long-term survival rate after hospital discharge is good.

Compresión extrínseca de la arteria coronaria derecha en el postoperatorio de un hematoma aórtico intramural tipo A. Otro mecanismo de isquemia miocárdica / Right coronary artery compression in the postoperatory of an aortic intramural haematoma tipe A. Another mechanism of myocardial ischemia

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ICU outcomes in adult cardiac surgery patients in relation to ultrafiltration type.

Ultrafiltration (UF) is used to ameliorate the deleterious effects of cardiopulmonary bypass (CPB) in cardiac surgery patients. There are two different methods; conventional ultrafiltration (CUF), performed during CPB, and modified ultrafiltration (MUF), performed after CPB is finished. It has not been established which is better, and controversy remains regarding the optimal UF strategy. The objective of this study was to evaluate if MUF alone, or combined with CUF, could achieve greater fluid removal and contribute to better postoperative clinical outcomes. Also, the potential technique complications were studied. This was a prospective study which enrolled 125 consecutive adult patients receiving elective cardiac surgery with CPB. We analysed three treatment groups: MUF, CUF and both. Ultrafiltration was performed using a non-pulsatile CPB with a non-occlusive roller pump, Sarns 9000, and a polysulfone ultrafilter, Minntech. We studied pre- and intraoperative data and immediate postoperative clinical outcomes: total amount of drainage, transfusion needs, respiratory outcome, cardiac, renal and neurologic complications. Statistical analysis was performed using SPSS 11.0. All three groups were homogeneous and did not have differences in terms of demographic factors, previous history, risk scores, intervention and operative data. Volume of filtrate removal in the group which applied both techniques was larger than in the CUF or MUF groups alone (2569+/-823 vs 1679+/-651 vs 1398+/-353 ml, respectively, p=0.0001); however, despite this difference, there was no difference in the immediate postoperative fluid balances between the groups (596+/-1244 vs 880+/-1054 vs 986+/-1190 ml, p=0.30). Respiratory parameters and postoperative morbidity data analysed (total amount of drainage, transfusion needs, haemoglobin, acute lung injury, time with inotropes, ventricular failure, cardiogenic shock, neurologic complications and renal failure) were similar in all three groups, without statistical differences. Extubation time (10+/-7 vs 8.9+/-3 vs 9.4+/-7.9 hours, p=0.72) and ICU stay (56.6+/-72 vs 66.5+/-109 vs 44.2+/-25 hours, p=0.43) also were similar between the groups. We did not find any technique complication associated with any patient. In the present study, with adult patients receiving elective cardiac surgery, the combined ultrafiltration group had a larger fluid removal. However, neither type of ultrafiltration nor amount of filtered volume was accompanied by different postoperative ICU clinical outcomes. Ultrafiltration was considered a safe and reliable technique, with no related complications.

[Neurological complications in cardiac surgery post-operative period]. / Complicaciones neurológicas en el postoperatorio de cirugía cardíaca.

The incidence of neurological complications after cardiac surgery continues to be elevated, although this is variable in the different studies published, fundamentally because of the different populations studied and the different definitions of neurological dysfunction. The etiology of these alterations is attributed to a multifactorial origin, aortic artherosclerosis, cerebral hypoperfusion and inflammatory phenomenon secondary to the technique. This review arises from the recognition of the personal, economic, and socio-health care repercussion entailed by these complications, with high rates of mortality and morbidity recorded, and it tries to give an objective view of the current literature on the subject. Having knowledge of the risk markers and understanding the pathogenesis is important to try to plan strategies that may minimize the appearance and development of these complications and contribute to the decrease of their serious consequences. The data and the experience obtained by our group are shown at the end of the review.

Complicaciones neurológicas en el postoperatorio de cirugía cardíaca / Neurological complications in cardiac surgery post-operative period

La incidencia de complicaciones neurológicas tras cirugía cardíaca continúa siendo elevada, aunque ésta es variable en los diferentes estudios publicados, debido fundamentalmente a las diferentes poblaciones estudiadas y a las distintas definiciones de disfunción neurológica. La etiología de dichas alteraciones se atribuye a un origen multifactorial, destacando la aterosclerosis aórtica, la hipoperfusión cerebral y el fenómeno inflamatorio secundario a la propia técnica. Esta revisión surge del reconocimiento de la repercusión personal, económica y sociosanitaria que estas complicaciones representan, con altas tasas de morbilidad y de mortalidad registradas, y trata de dar una visión objetiva de la literatura actual sobre el tema. Es importante el conocimiento de los marcadores de riesgo y la comprensión de la patogénesis para intentar con ello plantear estrategias que puedan minimizar la aparición y desarrollo de estas complicaciones para así contribuir a la disminución de sus graves consecuencias. Los datos de la experiencia obtenidos por nuestro grupo se muestran al final de la revisión

The incidence of neurological complications after cardiac surgery continues to be elevated, although this is variable in the different studies published, fundamentally because of the different populations studied and the different definitions of neurological dysfunction. The etiology of these alterations is attributed to a multifactorial origin, aortic artherosclerosis, cerebral hypoperfusion and inflammatory phenomenon secondary to the technique. This review arises from the recognition of the personal, economic, and socio-health care repercussion entailed by these complications, with high rates of mortality and morbidity recorded, and it tries to give an objective view of the current literature on the subject. Having knowledge of the risk markers and understanding the pathogenesis is important to try to plan strategies that may minimize the appearance and development of these complications and contribute to the decrease of their serious consequences. The data and the experience obtained by our group are shown at the end of the review

Extubación precoz en pacientes quirúrgicos cardíacos adultos / Early extubation for adult cardiac surgical patients

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Analgesia con remifentanilo en el postoperatorio de cirugía cardíaca / Analgesia with remifentanil after cardiac surgery

Introducción. El remifentanilo presenta unas características farmacocinéticas que le permiten variar rápidamente sus acciones farmacológicas en respuesta a los cambios de la infusión. Comparamos la eficacia y seguridad de remifentanilo frente a fentanilo, en el postoperatorio inmediato de cirugía cardíaca (CC). Método. Estudio prospectivo, observacional, en pacientes consecutivos. Se estudian 2 grupos de tratamiento: remifentanilo a 0,1-0,2 µg/kg/min y fentanilo 30 µg/h, durante 5 h. Se analizan el nivel de confort, la solicitud de analgesia por parte del paciente (SA) y tiempo hasta solicitarla (TA).Se cuantifican el dolor según escala numérica del 1-10 al despertar (E1), a los 30 min (E2), 2 (E3) y 4 h postextubación (E4), los fracasos terapéuticos, los efectos adversos atribuibles a los opiáceos y la evolución general. Resultados. Se estudió a 74 pacientes (37 del grupo remifentanilo y 37 del grupo fentanilo). El 71,2 por ciento se encontró confortable (más en el grupo fentanilo: 86 frente a 55 por ciento). El número de bolos y dosis totales de opiáceos y otros analgésicos fue similar en ambos grupos, excepto tramadol (fue mayor en el grupo de remifentanilo). El fentanilo mostró controlar mejor el dolor en la escala numérica y con mayor diferencia cuanto mayor era el tiempo desde el ingreso en la unidad: E1, 3,23 frente a 3,03 (p < NS); E2, 4,5 frente a 5 (p < 0,005); E3, 4,2 frente a 2,5 (p < 0,001); E4, 4,2 frente a 2,1 (p < 0,01), en los grupos remifentanilo frente a fentanilo, respectivamente. Dos pacientes del grupo remifentanilo presentaron efecto "naloxona-like"; en la evolución general, no presentaron diferencias significativas. No se produjeron fracasos terapéuticos. El tiempo hasta la extubación fue más corto en el grupo remifentanilo (7,6 frente a 8,9 h), pero sin diferencia significativa. El tiempo de estancia en la Unidad de Cuidados Intensivos fue similar. Conclusiones. La analgesia proporcionada con una infusión de "transición" de remifentanilo durante el postoperatorio inmediato de CC es factible, pero en nuestra serie, el fentanilo mostró un mejor control analgésico postoperatorio, probablemente en relación con su distinto perfil farmacocinético. Ambos fármacos mostraron un buen perfil de seguridad, sin presentar efectos adversos graves. La fugacidad de los efectos del remifentanilo obliga a realizar una mayor vigilancia, al conocimiento de la farmacodinamia y al entrenamiento en su uso (AU)

[Changes in tissue oxygen extraction in patients with acute respiratory insufficiency]. / Alteraciones en la extracción hística de oxígeno en pacientes con insuficiencia respiratoria aguda.

We analyzed the tissue oxygen extraction in 25 patients with acute respiratory failure. Fourteen met the clinical criteria for the adult respiratory distress syndrome (ARDS). The 11 remaining patients had acute respiratory failure with causes different from ARDS. In all cases the changes in the oxygen extraction ratio (O2ER) and in the oxygen consumption (VO2) were evaluated after changing oxygen availability (O2A) with positive end-expiratory pressure (PEEP) and dobutamine infusion. The patients with ARDS showed a change in VO2 parallel to O2A changes, with a significant correlation (r = 0.85); however, no changes were found in O2ER (r = 18). In the patients without ARDS, the changes in O2A did not modify the VO2 (r = 0.02) but there was a significant inverse relationship between DO2 and O2ER (r = -0.70). These findings suggest an abnormal regulation of tissue oxygen extraction and an abnormal dependence of VO2 on O2A in cases with ARDS. Dobutamine therapy, in addition to inotropic effects, could improve a situation of hidden hypoxia, as it is a vasodilator that might act on microvasculature.