Corey Scurlock

Chromium Infusion Reverses Extreme Insulin Resistance in a Cardiothoracic ICU Patient

Insulin resistance is common and often multifactorial in acutely critically ill patients. At our institution, glycemic control is achieved in these patients using an intravenous insulin protocol. The authors present a case in which a patient developed severe insulin resistance following surgical repair of a thoracic aorta aneurysm. Postoperatively, the patient required 2110 units of insulin over 40 hours while receiving pressors and glucocorticoids. After the administration of intravenous chromium at 3 microg/h, the blood sugar normalized and insulin therapy was discontinued. This case represents a unique approach using intravenous chromium to achieve glycemic control in a patient with extreme insulin resistance and acute critical illness. Prospective clinical trials using intravenous chromium may provide the means to optimize intensive insulin therapy for critically ill patients.

Isolated Tricuspid Valve Surgery: Predictors of Adverse Outcome and Survival

BACKGROUNDnIsolated tricuspid valve surgery is a rare operation, for which outcomes are not well defined. We describe a single-centre experience with isolated tricuspid surgery, and an analysis of risk factors for adverse outcome and predictors of survival.nnnMETHODSnRetrospective analysis of 56 consecutive adult patients undergoing isolated tricuspid valve surgery between November 1998 and November 2010 was performed.nnnRESULTSnEight patients died in hospital (early mortality 14.2%). In comparison with tricuspid repair patients, tricuspid replacement patients required more intraoperative red cell blood transfusion (RBC>1 unit: p=0.033), platelet transfusion (p=0.051), and more postoperative ventilator support (p=0.023). Predictors of early (in hospital) mortality include advanced age (p=0.019) higher euroSCORE (p<0.001), transfusion of intraoperative red blood cells (p=0.005), and cryoprecipitate (p=0.014). Twenty-five patients (44.6%) reached the end-point of death. There was no statistical difference in early and late survival rates between repair and replacement groups.nnnCONCLUSIONSnPatients with isolated tricuspid valve surgery continue to be a high-risk group in cardiac surgery with unacceptable operative mortality and limited survival. There were no statistical differences in early and late outcomes between the isolated tricuspid valve repair versus replacement surgery. Timely referral to surgery before the onset of class 3 heart failure, malnutrition, renal dysfunction and age>60 years is recommended.

Adjuvant therapy with methylene blue in the treatment of right ventricular failure after pulmonary embolectomy.

Severe pulmonary embolism often leads to right ventricular failure after surgical embolectomy secondary to ischaemia reperfusion injury and acute lung injury (ALI). Acute right ventricular dysfunction is traditionally treated with inotropes and vasopressors to maintain cardiac output and coronary perfusion as well as selective pulmonary vasodilators to provide right ventricular afterload reduction. We report the first case of utilisation of methylene (MB) in a patient with acute right ventricular failure and vasoplegic shock after surgical pulmonary embolectomy.

Adjuvant Therapy With Methylene Blue in the Treatment of Postoperative Vasoplegic Syndrome Caused by Carcinoid Crisis After Tricuspid Valve Replacement

N INCREASING BODY of literature continues to show the benefits of methylene blue in cases of refractory hypotension caused by the systemic inflammatory response syndrome (SIRS), septic shock, or vasoplegic syndrome. 1,2 Methylene blue, by its indirect inhibition of bradykinin, may alleviate the hypotension associated with carcinoid crisis. The authors report the successful use of methylene blue to treat refractory hypotension in a patient with carcinoid syndrome who underwent a tricuspid valve replacement. CASE PRESENTATION A 74-year-old man was referred for tricuspid valve surgery after being diagnosed with tricuspid insufficiency as a result of carcinoid syndrome. His past medical history was significant for small intestinal carcinoid tumor resection 5 years prior and radiation for liver metastases secondary to carcinoid. His medications included octreotide (200 g subcutaneously, 3 times a day), tamsulosin, folic acid, furosemide, mometasone, and psyllium. His body mass index was 23 kg/m2. A transthoracic echocardiogram performed before surgery revealed severe tricuspid regurgitation, normal biventricular function, the absence of pulmonary hypertension, and thickening of the tricuspid valve leaflets. Before surgery, the patient had been experiencing New York Heart Association class IV symptoms. In addition, he also had complained of flushing and diarrhea over the past 4 months that were being controlled with octreotide. The patient was admitted to the hospital 2 days before surgery and was placed on 300 g of octreotide subcutaneously 3 times a day. On the day of the surgery, he was given his regular 300-g subcutaneous dose of octreotide followed by a 500-g dose subcutaneously 3 hours later. This was all done in an effort to reduce his risk of perioperative carcinoid crisis. The patient was taken to the operating room where general anesthesia was induced, and he was intubated without difficulty. On induction of anesthesia, an octreotride infusion was begun at 100 g/h. He also was given 11 g of the antifibrinolytic -aminocaproic acid during the case. On insertion of his pulmonary artery catheter, he had a baseline central venous pressure (CVP) of 20 mmHg and pulmonary artery pressures (PAP) of approximately 35/18 mmHg. An intraoperative tranesophageal echocardiogram (TEE) was performed that agreed with his preoperative echocardiographic findings. A median sternotomy was performed, and the patient was anticoagulated with 31,000 U of heparin and placed on cardiopulmonary bypass. A tricuspid valve replacement was performed through a right atriotomy. After bypass, the CVP was noted to be 22 mmHg, with PAPs of approximately 35/15 mmHg and systemic blood pressures of approximately 90/60 mmHg. The patient then was started on 100 ng/kg/min of epinephrine (7.7 g/min) and 150 ng/kg/min of norepinephrine (11.5 g/min), and his octreotide infusion was continued at 100 g/h. This resulted in a successful wean from cardiopulmonary bypass. To reverse his anticoagulation, 200 mg of protamine were given over 30 minutes. In the immediate post-bypass period, his CVP lowered to 18 mmHg, and his systemic mean blood pressure was maintained at 65 mmHg with this

Dexmedetomidine controls twitch-convulsive syndrome in the course of uremic encephalopathy

An 85 year old man with a history of chronic renal insufficiency was admitted to the cardiothoracic intensive care unit after aortic valve replacement. His postoperative course was marked by acute oliguric renal failure for high blood urea nitrogen (BUN) and acute hyperactive delirium. At this time he also developed tremors with muscle twitching; he received no other form of sedatives. A neurology consult made the diagnosis of twitch-convulsive syndrome associated with uremic encephalopathy. While the patient was receiving the dexmedetomidine infusion, the signs of the twitch-convulsive syndrome, particularly the twitching and tremors, disappeared. Within 30 minutes of the end of the dexmedetomidine infusion, symptoms of the twitch-convulsive syndrome returned, manifesting as acute tremulousness. After several dialysis treatments, his BUN decreased and the dexmedetomidine was weaned, without return of the symptoms of twitch-convulsive syndrome.

Glycemic Control and Nutritional Strategies in the Cardiothoracic Surgical Intensive Care Unit—2010: State of the Art

Patients in the cardiothoracic surgical intensive care unit are generally critically ill and undergoing a systemic inflammatory response to cardiopulmonary bypass, ischemia/reperfusion, and hypothermia. This presents several metabolic challenges: hyperglycemia in need of intensive insulin therapy, catabolism, and uncertain gastrointestinal tract function in need of nutritional strategies. Currently, there are controversies surrounding the standard use of intensive insulin therapy and appropriate glycemic targets as well as the use of early enteral nutrition ± parenteral nutrition. In this review, an approach for intensive metabolic support in the cardiothoracic surgical intensive care unit is presented incorporating the most recent clinical evidence. This approach advocates an IIT blood glucose target of 80-110 mg/dL if, it can be implemented safely, with early nutrition support (using parenteral nutrition as needed) to prevent a critical energy debt.

Pheochromocytoma Presenting as Severe Biventricular Failure Requiring Insertion of a Biventricular Assist Device

ATASTROPHIC CARDIOMYOPATHY resulting from pathologic catecholamine release has been well described in several disease states. Pheochromocytoma, a rare neuroendocrine tumor, can present with acute and profound myocardial depression requiring inotropic support and, in some instances, left ventricular assist device insertion. An unusual case of occult pheochromocytoma presenting as diabetic ketoacidosis (DKA) and biventricular failure, which was then managed with insertion of a biventricular assist device (BiVAD) and, subsequently, surgical resection of the primary tumor is presented. CASE REPORT The patient was a 38-year-old man with a past medical history significant for type-1 diabetes and mild mental retardation with developmental delay. He presented to an outside hospital with nausea, vomiting, fever, and signs of DKA. The laboratory workup revealed an initial blood glucose level of 1,100 mg/dL, arterial pH of 6.9, and an anion gap metabolic acidosis. After admission, he was intubated for acute respiratory failure. Upon transfer to The Mount Sinai Hospital, an echocardiogram revealed severely depressed left ventricular function (ejection fraction 5%-10%) with global hypokinesis and mild tricuspid and mitral regurgitation. An attempt was made to place a tandem heart percutaneous ventricular assist device without success. Despite intense inotropic and vasopressor support, the patient’s condition continued to deteriorate with the development of acute renal failure and mild hepatic failure. The cardiothoracic surgery service was consulted and a Thoratec CentriMag (Thoratec Corp, Pleasanton, CA) was implanted. Over a short span of 4 days, inotropes were weaned, and the BiVAD was explanted. A transthoracic echocardiogram revealed normalization of right and left ventricular function. Despite this, the patient was unable to be weaned from the ventilator secondary to an ongoing systemic inflammatory response syndrome and the development of pneumonia. Because of prolonged endotracheal intubation, a tracheostomy was performed. On postoperative day 5, the patient developed unexplained elevated serum lactate levels with acidosis. Variations in blood pressure also were noted. A computed tomography (CT) scan of the abdomen was performed to exclude possible ischemic bowel. There was an incidental finding of a 6.5-cm left suprarenal mass (Fig 1). Pheochromocytoma was considered in the differential diagnosis of a possible adrenal mass in the setting of labile blood pressure. The patient was treated with large doses of norepinephrine and other vasopressor agents precluding the immediate use of serum catecholamine levels for diagnostic purposes. After successful weaning of all vasopressors, urinary metanephrines levels were found to be markedly elevated at greater than 10,600 nmol/24 hours (normal, 1-145 nmol/24 hours), and plasma metanephrines were noted to be greater than 7,100 pmol/L (normal, 0-62 pmol/L). While awaiting the results of the urinary and plasma metanephrines, a meta-iodobenzylguanidine scan was requested and found to be strongly positive and supportive of the diagnosis of pheochromocytoma. In addition, while this evaluation was being completed, an -receptor blockade with phentolamine was instituted. After 14 days and adequate establishment of the -receptor blockade, an infusion of esmolol was begun. The patient was then taken to the operating room for surgical resection of the presumed pheochromocytoma. Anesthetic management included 1% isoflurane in 80% oxygen/air, fentanyl, and cisatracurium infusion. A pulmonary arterial catheter and transesophageal echocardiography were used to assist with fluid management. The infusions of phentolamine and esmolol were discontinued before ligation of the adrenal vessels (Fig 2). Immediately after ligation, fluid resuscitation and vasopressor therapy were needed to restore blood pressure and perfusion. With continued resuscitation, the patient left the operating room on minimal vasopressors. Her postoperative course was complicated by critical illness polyneuropathy that eventually resolved. The patient was subsequently discharged from the hospital in good condition.

Extracorporeal Peritoneovenous Shunt for the Management of Postaneurysmectomy Chylous Ascites in a Marfan Patient

Chylous ascites is an uncommon complication after aortic and other retroperitoneal surgeries. The management is very specific to the etiology and clinical status of the patient. The mortality from chylous ascites is not negligible, and aggressive measures are often needed. A voluminous chylous ascites developed in a 38-year-old woman after an open abdominal aortic aneurysm repair that was refractive to initial therapeutic interventions. We used an extracorporeal peritoneovenous shunt to control the abdominal ascites and improve the patients immunologic and nutritional status.

Letter by Raikhelkar and Scurlock Regarding Article, “Determinants of Surgical Outcome in Patients With Isolated Tricuspid Regurgitation”

To the Editor:nnWe applaud Kim et al1 for addressing the importance of determining the preoperative risk factors of clinical outcomes in patients after isolated tricuspid valve surgery. The authors concluded that the preoperative hemoglobin level and right-ventricular end-diastolic area were independent determinants of clinical outcomes.nnThis …

Successful conservative management of a tracheal tear in a septic octogenarian.

An 87-year-old woman with a tracheal tear was admitted from an outside institution for surgical management. She had suffered a myocardial infarction complicated by cardiogenic shock 2 weeks before admission and had been intubated. In the days that followed, she had been extubated and reintubated twice. One week before admission, she had become febrile, and subcutaneous air was noted by chest radiography. A tracheostomy had been performed 3 days before the admission and the continued, requisite use of positive-pressure ventilation had resulted in massive subcutaneous emphysema of the trunk, arms, and face. Given her advanced age, positive blood cultures (Staphylococcus sp), and recent cardiac events, conservative management of her tracheal tear was advocated. She was taken to the operating room where fiberoptic bronchoscopy confirmed the presence of a 3-cm full-thickness longitudinal tear of the membranous portion of the trachea, ending approximately 0.5 cm from the carina. Separate 5.5F single-lumen cuffed endotracheal tubes (ETTs) were placed into the right and left mainstem bronchi via the tracheal stoma under bronchoscopic guidance (Fig 1). The cuffs were inflated, and positive-pressure ventilation of the lungs without further air leak from the tear was achieved by using the Y-piece adaptor from a standard double-lumen ETT (Fig 2). Daily chest x-rays were performed as well as daily bronchoscopy to assure that the right single-lumen ETT did not occlude the takeoff of the right upper lobe. The massive subcutaneous emphysema resolved within 4 days. Antibiotic therapy with vancomycin, cefepime, and metronidazole resulted in a resolution of her sepsis, and significant nutritional deficiencies were addressed with enteral feedings. The 5.5F ETTs were uneventfully replaced on postoperative day 7 (6.5F on the left and 7.0 on the right) to facilitate suctioning of pulmonary secretions. Intermittent bronchoscopic surveillance was performed, and the ETTs were replaced by a standard tracheostomy (#8 Shiley) on postoperative day 12. The tear was bronchoscopically noted to be healed by postoperative day 28. Despite experiencing catheter sepsis, intermittent delirium, Clostridium difficile enteritis, intermittent congestive heart failure, and the development of a significant sacral decubitus ulcer,