Infections following major heart surgery in European intensive care units: there is room for improvement (ESGNI 007 Study).

Patients undergoing major heart surgery (MHS) may be at increased risk for nosocomial infections. To assess the incidence and type of infections in MHS patients in European intensive care units (ICUs) and their quality of care, a questionnaire was sent to a selection of MHS ICUs in Europe. Seventeen hospitals from seven European countries participated. Overall, 53% of the ICUs received patients only for MHS and the other 47% were mixed. During the study period, 11 915 patients underwent MHS and 1181 (9.9%) developed one or more nosocomial infections. Ventilator-associated pneumonia (VAP) was the most common infection [median 3.8%; interquartile range (IQR) 1.8-4.9], followed by surgical wound infection (median 1.6%; IQR 0.8-2.3), catheter-related bloodstream infection (median 1.3%; IQR 0.8-2.1), mediastinitis (median 1.1%; IQR 0.4-1.6), urinary tract infection (median 0.6; IQR 0.4-1.4) and nosocomial endocarditis (median 0.2%; IQR 0.0-0.9). Median mortality was 4.7% (IQR 2.7-8.4) and median infection-related mortality was 1% (IQR 0.5-2.7). Regarding VAP, 18% of the ICUs did not routinely pursue a diagnosis. Microbiological information was quantitative in 35% of cases and exclusively qualitative in 65% of cases. An infectious disease specialist was regularly involved in VAP management in only 35% of the ICUs, and the therapeutic approach to VAP involved de-escalation in 59% of the ICUs. MHS ICUs in Europe still have a high rate of postoperative infections. Well-recognized routine practices for the diagnosis and treatment of VAP are not implemented regularly in many European institutions.

[Aortic coarctation and postcoarctation mycotic aneurysm in a woman 20 weeks pregnant: anesthetic management]. / Coartación aórtica y aneurisma micótico postcoartación en gestante de 20 semanas: manejo anestésico.

A 28-year-old woman, 20 weeks pregnant, was diagnosed with aortic coarctation and postcoarctation mycotic aneurysm. After anesthetic induction, blood pressure was monitored in the radial artery of the right arm and the femoral artery of the right leg for two purposes: to verify hemodynamic stability as required in this type of operation and to determine the pressure gradient between the upper and lower limbs, which was approximately 40 mm Hg. To prevent spinal cord ischemia, an intradural catheter was inserted into the fourth and fifth lumbar space for spinal fluid drainage. A double lumen tube was used for intubation so that the left lung could be blocked, and a centrifugal pump was used instead of extracorporeal circulation. The aneurysm was resected through a left thoracotomy and an aortic prosthesis was placed. Satisfactory outcome was indicated by resolution of the pressure gradient, and fetal viability was verified by ultrasound. The mother suffered no neurological complications and the pregnancy continued to term uneventfully. We review the anesthetic procedure to follow in such cases.

Coartación aórtica y aneurisma micótico postcoartación en gestante de 20 semanas: manejo anestésico / Aortic coarctation and postcoarctation mycotic aneurysm in a woman 20 weeks pregnant: anesthetic management

Presentamos el caso de una paciente de 28 años de edad, gestante de 20 semanas, diagnosticada de coartación aórtica y aneurisma micótico post-coartación. Una vez realizada la inducción anestésica, se monito-rizó la arteria radial en el miembro superior derecho así como la arteria femoral en el miembro inferior derecho con el doble objetivo de tener la monitorización hemodinámica requerida siempre en este tipo de intervenciones y observar el gradiente de presión existente entre miembros superiores e inferiores, que era de unos 40 mmHg. Para intentar evitar la isquemia medular, se colocó un catéter intradural en el espacio L4-L5, para drenaje de líquido cefalorraquídeo. Se realizó intubación con tubo de doble luz, para bloqueo de pulmón izquierdo. Se usó bomba centrífuga en lugar de circulación extracorpórea. La resección aneurismática fue por toracotomía izquierda, colocándose una prótesis aórtica. El resultado final fue satisfactorio, pues desapareció el gradiente de presión y se demostró la viabilidad fetal por la ecografía. La paciente no presentó ninguna secuela neurológica y el embarazo finalizó sin problemas. Revisamos la conducta anestésica a seguir en estos casos

A 28-year-old woman, 20 weeks pregnant, was diagnosed with aortic coarctation and postcoarctation mycotic aneurysm. After anesthetic induction, blood pressure was monitored in the radial artery of the right arm and the fem-oral artery of the right leg for two purposes: to verify hemodynamic stability as required in this type of operation and to determine the pressure gradient between the upper and lower limbs, which was approximately 40 mm Hg. To prevent spinal cord ischemia, an intradural catheter was inserted into the fourth and fifth lumbar space for spinal fluid drainage. A double lumen tube was used for intubation so that the left lung could be blocked, and a centrifugal pump was used instead of extracorporeal circulation. The aneurysm was resected through a left thoracotomy and an aortic prosthesis was placed. Satisfactory outcome was indicated by resolution of the pressure gradient, and fetal viability was verified by ultrasound. The mother suffered no neurological complications and the pregnancy continued to term uneventfully. We review the anesthetic procedure to follow in such cases

Tratamiento del dolor postoperatorio en cirugía cardíaca / Pain management after cardiac surgery

El dolor postoperatorio constituye una de las principales preocupaciones en los pacientes recién operados y, en los últimos años, se toma en consideración de forma muy especial. La liberación de catecolaminas en respuesta del estímulo nociceptivo se asocia a una mayor incidencia de complicaciones hemodinámicas, respiratorias, endocrinas, metabólicas e inmunitarias que empeoran el pronóstico. A pesar de esto, el dolor postoperatorio en cirugía cardíaca del adulto ha sido poco investigado, probablemente por ser menos intenso que el dolor postoracotomía. La importancia de una correcta analgesia perioperatoria obliga a un profundo conocimiento de las características del dolor, de las armas terapéuticas de las que se dispone y de la técnica utilizada. Si bien la analgesia intravenosa pautada es la forma más extendida de control del dolor postoperatorio, el desarrollo de técnicas de analgesia controlada por el paciente (PCA) y las ventajas que ofrece la analgesia epidural obliga a plantear cuál es el tratamiento ideal. Por tanto, las ventajas que ofrece un estricto control del dolor postoperatorio tras la cirugía cardíaca obliga a tenerlo cada vez más en cuenta y perseguirlo como uno de los objetivos primordiales del período postoperatorio (AU)

[Treatment of postoperative pain in heart surgery]. / Tratamiento del dolor postoperatorio en cirugía cardíaca.

Postoperative pain ranks among the major problems surgical patients face and it has been taken particularly seriously in recent years. Catecholamine release in response to nociceptive stimulus is associated with higher rates of hemodynamic, respiratory, endocrine, metabolic and immune system complications that worsen the prognosis. Pain after cardiac surgery in the adult has been investigated little, however, probably because it is less intense than pain after thoracotomy. The importance of providing good perioperative analgesia requires us to have an in-depth understanding of the characteristics of such pain, the therapeutic armamentarium available and the technique to be used. Although intravenous analgesia is the most widely applied approach to postoperative pain management, the development of devices for patient controlled analgesia and the advantages of epidural analgesia require us to analyze what the ideal technique might be. The advantages of strict pain control after cardiac surgery oblige us to place greater emphasis on such management among our main postoperative objectives.

Ecocardiografía transesofágica intraoperatoria / Transesophageal echocardiography during surgery

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[Intraoperative transesophageal echocardiography]. / Ecocardiografía transesofágica intraoperatoria.

Transesophageal echocardiography is being used increasingly by anesthesiologists for monitoring and diagnosis. Real-time imaging provides valuable information about anatomy, preloading and cardiac contractility. Its use is mandatory in valve repair surgery and it has been shown to detect cardiac ischemia before any other monitoring tool. Programs to teach transesophageal echocardiography to anesthesiologists should be implemented; the availability of backup support staff from the echocardiography unit is of great value.

The influence of transoesophageal echocardiography on intra-operative decision making. A European multicentre study. European Perioperative TOE Research Group.

The role of transoesophageal echocardiography (TOE) in anaesthesia remains controversial because it is a rapidly evolving technique with few proven benefits and considerable cost. Recently, the Society of Cardiovascular Anaesthesiologists has published practice guidelines for the use of peri-operative TOE. To determine the current role of transoesophageal echocardiography and the relative impact of category-based transoesophageal echocardiographic indications the present study investigated its use in seven Western European countries. The study sample was taken from a prospective cohort of 224 patients with acute or chronic haemodynamic disturbances or at risk of myocardial ischaemia. All patients were monitored with two-lead electrocardiography and radial and pulmonary artery catheters, as well as biplane or multiplane transoesophageal echocardiography. A total of 2232 clinical interventions were made in these patients. The most frequently observed intervention was the administration of a fluid bolus (45% of all interventions). Overall, transoesophageal echocardiography was the most important guiding factor in 560 (25%) interventions. It was the most important monitor in guiding the following therapeutic interventions: anti-ischaemic therapy--207 of 372 interventions (56%); fluid administration--275 of 996 (28%) interventions; vasopressor or inotrope administration--56 of 316 (16%) interventions; vasodilator therapy--six of 142 (4%) interventions and depth of anaesthesia--four of 211 (2%) interventions. We found that transoesophageal echocardiography is frequently influential in guiding clinical decision making and is used most frequently for category II indications but category I indications were associated with more frequent change in management.

[Reoperations of myocardial revascularization]. / Reoperaciones de revascularización miocárdica.

UNLABELLED: Coronary by-pass grafting is a well established procedure for ameliorating ischemic coronary disease. From time to time it is necessary to re-operate these patients. The objective of our paper is to present our experience in this field. Retrospective analysis of 128 patients operated on between February 1978 and November 1996, has been analyzed. The mean age was 57.4 +/- 0.7 years. 77.2 +/- 5 months elapsed between operations. Stable angina (20.4%) or unstable angina (76.3%), myocardial infarction (48%) and congestive heart failure (17%) were the predominant clinical manifestations. RESULTS: Hospital mortality was 10.9% (14 patients) and in the follow-up there were 16 deaths (14%). Perioperative myocardial infarction was the main cause of in-hospital mortality. In the follow-up there were 4 deaths due to myocardial infarction and another 4 patients died from neoplasms. Perioperative myocardial infarction was present in 9.3% (12 patients) IN CONCLUSION: a) Re-do coronary by-pass grafting is still a good procedure for solving myocardial ischemia in spite of a higher mortality and morbidity than in the original operation. b) There is no progression in the number of patients according to our experience, probably due to better techniques and the frequent actions by an intervention cardiologist. c) The long-term results are good enough, but with a higher mortality.

[Changes in therapeutic attitude based on transesophageal echocardiography in cardiac surgery]. / Cambio de la actitud terapéutica debido a la ecocardiografía transesofágica en cirugía cardíaca.

Transesophageal echocardiography is a monitoring system that is changing the practice of cardiovascular anesthesia and surgery by providing real time images of cardiovascular anatomy and pathophysiology. Our hospital's anesthesiology and postoperative intensive care departments, in particular the cardiac anesthesia team, initiated a joint project in June 1993 with the echocardiography laboratory team to incorporate this surgical monitoring system. Here we report the wealth of information we obtained and describe the possibility of modifying a therapeutic approach based on the images visualized, even when conventional monitoring gives contradictory information. Two illustrative case reports are included.

[Late ischemia and carpal tunnel syndrome secondary to catheterization of the radial artery]. / Isquemia tardía y síndrome del túnel del carpo secundarios a cateterización de la arteria radial.

Invasive measurement of blood pressure has many advantages. Although arterial canalization is a low-risk technique of great benefit to the patient, complications must be looked for. We report the case of a man who underwent triple coronary bypass with arterial canalization requiring several punctures to achieve. Two weeks after the procedure the patient showed signs of hand ischemia and acute carpal tunnel syndrome, which evolved favorably after treatment with heparin sodium and prostaglandin E1. We emphasize the importance of an earlier wrist fracture as the predisposing factor for both conditions and the need to examine collateral circulation in the hand and look for carpal tunnel syndrome before canalization.

Massive calcification of the left atrium: surgical implications.

BACKGROUND: Massive calcification of the atrial walls ("porcelain atrium") is a rare condition that usually has been reported as an incidental radiologic findings. METHODS: Between January 1988 and June 1993, 971 patients underwent valvular operation at our institution; 21 patients showed extensive calcification of the left atrium. In 8 patients the calcification was massive, involving almost all the atrial surface. The diagnoses were established by radiology and were confirmed at operation. The mean age of these patients (4 men, 4 women) was 55 +/- 9.6 years. All had rheumatic valve disease, were on atrial fibrillation, and had undergone at least one operation previously. Pulmonary artery pressure was severely increased, even up to systemic levels, in all patients except 1. Total endoatriectomy of the left atrium and mitral valve replacement were performed. No patient was lost during the follow-up. RESULTS: Hospital mortality rate was 12.5% (1 patient) and 2 patients died in the late postoperative period. None of these deaths are attributable to the surgical procedure. CONCLUSIONS: In toto endoatriectomy of a massively calcified atrium is an easy to perform technique that helps to replace the mitral valve and close the atrial wall.

[Analysis of a study of the contacts of pulmonary tuberculosis patients in a Health Area during 1991 and 1992]. / Análisis del estudio de contactos de enfermos de tuberculosis pulmonar durante 1991 y 1992 en un área de salud.

OBJECTIVE: To find whether the systematic investigation of the contacts of Pulmonary Tuberculosis patients is carried out. DESIGN: Crossover and descriptive. SETTING: Asturias Health Area VIII. PATIENTS AND OTHER PARTICIPANTS: We examined whether contacts of the cases of Pulmonary Tuberculosis diagnosed in our area during 1991 and 1992 were correctly studied, in line with the criteria of the American Thoracic Society (ATS). MEASUREMENTS AND MAIN RESULTS: During the two years there were 139 cases of Tuberculosis of all types, which supposes an incidence rate of 74 per 100,000 inhabitants per year. We excluded 29 of the 110 Pulmonary Tuberculosis patients (decease, change of residence, incomplete personal data). We found 227 contacts of the remaining 81 (2.8 per patient). The initial study was complete for 133 contacts (58.5%), incomplete for 40 (17.6%) and was not carried out for the remaining 54 (23.7%). Only 61 (26.9%) of the total number of contacts were correctly studied and followed up. Only 58 contacts benefitted from Chemoprophylaxis. Out of the 79 cases where the repetition of the Mantoux test was indicated because the first was negative, it was in fact only repeated in 17 (21.5%). There were no significant differences between Primary and Secondary Care as to the study and proper follow-up of the contacts. CONCLUSIONS: A high incidence of Tuberculosis in our area. A deficient study and follow-up of contacts at all the levels of care.

[The midterm (6 years) clinical results of the Carpenter-Edwards supra-annular bioprosthesis]. / Resultados clínicos a medio plazo (6 años) de la bioprótesis de Carpentier-Edwards supraanular.

We present here the clinical results with a second-generation porcine bioprosthesis, the Carpentier-Edwards supra-annular valve (CESA). Two-hundred and twenty-two CESA bioprostheses were implanted in 189 patients during a four-year period (from 1984 to 1987), either as an isolated procedure or associated to mitral or tricuspid repair. The mid-term clinical results have been evaluated after a mean follow-up of 3.4 years, being 96% complete. There were 16 in-hospital deaths (8.4%) and 6 late, potentially valve-related, cardiac deaths (1.1% patients/year). Overall, 86.7 +/- 2% of the patients were free from cardiac death at 6 years (95.1 +/- 2% of the patients surviving the operative period). Linearized rates of valve related complications were the following: 1.4% patients/year for thromboembolism (including valve thrombosis), 0.5% patients/year for treatment-related hemorrhage and 0.7% patients/year for endocarditis. We did not found any case of either intrinsic or extrinsic valve failure, unrelated to infection of thrombosis. Two patients were reoperated, one because of valve thrombosis and the other due to prosthetic valve endocarditis (reoperation rate of 0.3% patients/year). When lethal and nonlethal valve-related complications (including in-hospital deaths) were considered all together, 75.8 +/- 8.4% of the patients remained alive and free of morbid events at 6 years. When patients were grouped according to the valve replaced (aortic, mitral and multiple), best results were found with patients submitted to isolated aortic valve replacement. We conclude that the CESA bioprosthesis has an excellent mid-term clinical performance. However, longer follow-up is necessary to know if improvement in valve design and manufacturing results in increased valve durability.