Journal of cardiothoracic and vascular anesthesia
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J. Cardiothorac. Vasc. Anesth. · Aug 2019
Observational StudyCharacteristics Associated With Mortality in 372 Patients Receiving Low-Dose Recombinant Factor VIIa (rFVIIa) for Cardiac Surgical Bleeding.
Activated recombinant factor VII (rFVIIa) has been used to treat cardiac surgical bleeding in an off-label manner. This observational report analyzes the outcomes with use of a low dose and early administration of rFVIIa for cardiac surgical bleeding. ⋯ Mortality after life-threatening cardiac surgical bleeding treated with rFVIIa was more common in aortic procedures and emergent and urgent surgeries. Lower doses of rFVIIa than previously reported may achieve bleeding cessation because overall blood component transfusions were low in this cohort.
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Hemodynamic monitoring is an essential part of the perioperative management of the cardiovascular patient. It helps to detect hemodynamic alterations, diagnose their underlying causes, and optimize oxygen delivery to the tissues. Furthermore, hemodynamic monitoring is necessary to evaluate the adequacy of therapeutic interventions such as volume expansion or vasoactive medications. ⋯ Less-invasive monitoring techniques use, for example, pulse contour analysis to originate flow-derived variables such as stroke volume and CO from the arterial pressure signal, or they may measure the velocity-time integral in the descending aorta to estimate the stroke volume, using, for example, the esophageal Doppler. Completely noninvasive methods such as the volume clamp method use finger cuffs to reconstruct the arterial pressure waveform, from which stroke volume and CO are calculated. All of these less-invasive CO monitoring devices have percentage errors around 40% compared with reference methods (thermodilution), meaning that the values are not interchangeable.
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Transcranial Doppler is a bedside procedure that measures linear cerebral blood flow velocity (CBFV) and the pulsatility index through the intracranial circulation. Transcranial color-coded duplex Doppler (TCCD) provides both CBFV and B-mode functions. In this review they are both referred to as brain ultrasound TCCD. ⋯ In these applications, TCCD can be used for the detection of cerebral vessel occlusion, estimation of cerebrovascular reactivity, right-to-left cardiac shunts, noninvasive estimation of cerebral perfusion and intracranial pressure, optic nerve sheath diameter, midline shift, hydrocephalus, and the presence of foreign objects. Finally, TCCD has a high accuracy in confirming total cerebral circulatory arrest and has been used as an ancillary test to support clinical diagnosis of brain death. Other indications for TCCD include assessment of collateral blood flow and embolization during carotid endarterectomy, assessment of patterns and extent of collateral circulation in severe stenosis or occlusion, assessment of patent foramen ovale/paradoxical embolism, assessment of arteriovenous malformations and studying their supply arteries and flow patterns, assessment of noncardiac right-to-left shunts, assessment of severe stenosis in the arteries of the circle of Willis, and assessment of vertebral artery dissection.
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J. Cardiothorac. Vasc. Anesth. · Aug 2019
ReviewA Practical Approach to Cerebro-Somatic Near-Infrared Spectroscopy and Whole-Body Ultrasound.
Near-infrared spectroscopy (NIRS) is an emerging noninvasive monitoring modality based on chromophore absorption of infrared light. Because NIRS provides instantaneous information on cerebral and somatic tissue oxygenation, it becomes mandatory to identify rapidly the etiology of impaired regional oxygenation and thus perfusion. ⋯ This narrative review describes the authors' experience since 2002 in the use of combined NIRS and WHOBUS. A practical approach in the use of both modalities and their respective limitations is described.
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The care of patients undergoing cardiac surgery is becoming more complex, in part owing to the increasing burden of comorbid disease, frailty, and psychosocial issues. Many risk factors for postoperative morbidity and mortality are potentially modifiable if identified and treated in a timely fashion before surgery. ⋯ There is substantial evidence that in multiple domains, including aerobic conditioning, respiratory muscle training, lifestyle modification, diabetic control, sleep, and psychoeducation, selected interventions before cardiac surgery may improve outcomes. However, the optimal preoperative program remains unclear and there is an unmet need for a comprehensive evaluation of the range of interventions specifically targeted at modifiable perioperative risk factors that may reduce adverse outcomes after cardiac surgery.