Florian Falter

High-dose tranexamic Acid is associated with nonischemic clinical seizures in cardiac surgical patients.

BACKGROUND: In 2 separate centers, we observed a notable increase in the incidence of postoperative convulsive seizures from 1.3% to 3.8% in patients having undergone major cardiac surgical procedures. These events were temporally coincident with the initial use of high-dose tranexamic acid (TXA) therapy after withdrawal of aprotinin from general clinical usage. The purpose of this review was to perform a retrospective analysis to examine whether there was a relation between TXA usage and seizures after cardiac surgery. METHODS: An in-depth chart review was undertaken in all 24 patients who developed perioperative seizures. Electroencephalographic activity was recorded in 11 of these patients, and all patients had a formal neurological evaluation and brain imaging studies. RESULTS: Twenty-one of the 24 patients did not have evidence of new cerebral ischemic injury, but seizures were likely due to ischemic brain injury in 3 patients. All patients with seizures did not have permanent neurological abnormalities. All 24 patients with seizures received high doses of TXA intraoperatively ranging from 61 to 259 mg/kg, had a mean age of 69.9 years, and 21 of 24 had undergone open chamber rather than coronary bypass procedures. All but one patient were managed using cardiopulmonary bypass. No evidence of brain ischemic, metabolic, or hyperthermia-induced causes for their seizures was apparent. CONCLUSION: Our results suggest that use of high-dose TXA in older patients in conjunction with cardiopulmonary bypass and open-chamber cardiac surgery is associated with clinical seizures in susceptible patients.

Xenon anaesthesia may preserve cardiovascular function in patients with heart failure

Background:  The hypothesis that xenon anaesthesia provided haemodynamic stability was tested in patients with heart failure in a prospective, randomized, single‐blind design.

Consensus statement: minimal criteria for reporting the systemic inflammatory response to cardiopulmonary bypass.

The lack of established cause and effect between putative mediators of inflammation and adverse clinical outcomes has been responsible for many failed anti-inflammatory interventions in cardiopulmonary bypass (CPB). Candidate interventions that impress in preclinical trials by suppressing a given inflammation marker might fail at the clinical trial stage because the marker of interest is not linked causally to an adverse outcome. Alternatively, there exist examples in which pharmaceutical agents or other interventions improve clinical outcomes but for which we are uncertain of any antiinflammatory mechanism. The Outcomes consensus panel made 3 recommendations in 2009 for the conduct of clinical trials focused on the systemic inflammatory response. This panel was tasked with updating, as well as simplifying, a previous consensus statement. The present recommendations for investigators are the following: (1) Measure at least 1 inflammation marker, defined in broad terms; (2) measure at least 1clinical end point, drawn from a list of practical yet clinically meaningful end points suggested by the consensus panel; and(3) report a core set of CPB and perfusion criteria that maybe linked to outcomes. Our collective belief is that adhering to these simple consensus recommendations will help define the influence of CPB practice on the systemic inflammatory response, advance our understanding of causal inflammatory mechanisms, and standardize the reporting of research findings in the peer-reviewed literature.

Life-threatening impending paradoxical embolus caught "red-handed": successful management by multidisciplinary team approach.

erosive damage and recurrence of BVA by use of muscle flap interposition. Because BVF with severe hemorrhage after lung resection is rare, there are no guidelines concerning the adequate surgical treatment in such an emergency situation. In the present case, completion pneumonectomy was considered inappropriate given the cardiopulmonary reanimation and history of coronary artery disease. Therefore, we performed a segmental resection of the main stem bronchus followed by end-to-end airway suture. The PA was reconstructed by the interposition of a reversed SFV segment. The 2 reconstructed structures were separated by the interposition of an intrathoracically transposed serratus anterior muscle flap. Postoperative angio-computed tomography imaging at 3 and 18 months showed a patent PA reconstruction and appropriate perfusion of the residual lobe.

Long-term follow-up after laser-induced endotracheal fire

The objective of this presentation is to outline long-term complications and their management in contrast to acute measures after endotracheal laser-induced fire. This case focuses on a 56-year-old patient in whom an endotracheal fire occurred during CO2 laser surgery. Despite local swelling and evidence of acute lung injury, the patient was extubated the following day under single-shot cortisone and inhalation of dispersed adrenaline under assisted spontaneous breathing. Wound healing was assessed by regular flexible bronchoscopy and spirometry. Fourteen weeks after uneventful recovery, the patient presented with acute inspiratory stridor, related to a tracheal stenosis 2.5 cm distal to the glottic level. After tracheal end-to-end anastomosis, further follow-up was uneventful. Early extubation under ITU conditions avoided the need for tracheostomy and its sequelae. However, tracheal stenosis did not become apparent before week 14. While in acute management of laser-induced endotracheal fire a conservative approach was established successfully, the risk of further long-term complications implies the need for a prolonged follow-up regime even in cases of less extensive burns.

Evaluation of hypoxemic patients with transesophageal echocardiography.

Objective:To summarize the use of transesophageal echocardiography when investigating hypoxemic patients in the intensive care unit, to assess its risks and benefits, and to evaluate which diseases of the cardiopulmonary system, mediastinum, and thorax it will help to guide therapeutic decisions. Design:A review of current literature and practice guidelines was performed. Results:Hypoxemia, due to a number of different reasons, is common in critically ill patients. Many diagnoses and therapeutic decisions have to rely on good-quality imaging. However, transthoracic echocardiography often produces poor-quality pictures; other imaging modalities involve transferring unstable patients to the imaging suite. Transesophageal echocardiography can safely be performed at the bedside and generates excellent image quality. Conclusion:Transesophageal echocardiography is a safe procedure that can be performed at the bedside and that produces high-quality images of the heart, its related structures, and its function. It helps detect extracardiac pathology leading to hypoxemia and may be used to guide fluid resuscitation and optimize tissue oxygenation.

Physiological controversies and methods used to determine fluid responsiveness: a qualitative systematic review.

Accurate assessment of intravascular fluid status and measurement of fluid responsiveness have become increasingly important in peri‐operative medicine and critical care. The objectives of this systematic review and narrative synthesis were to discuss current controversies surrounding fluid responsiveness and describe the merits and limitations of the major cardiac output monitors in clinical use today in terms of usefulness in measuring fluid responsiveness. We searched the MEDLINE and EMBASE databases (2002–2015); inclusion criteria included comparison with an established reference standard such as pulmonary artery catheter, transthoracic echocardiography and transoesophageal echocardiography. Examples of clinical measures include static (such as central venous pressure) and dynamic (such as stroke volume variation and pulse pressure variation) parameters. The static parameters measured were described as having little value; however, the dynamic parameters were shown to be good physiological determinants of fluid responsiveness. Due to heterogeneity of the methods and patient characteristics, we did not perform a meta‐analysis. In most studies, precision and limits of agreement (bias ±1.96SD) between determinants of fluid responsiveness measured by different devices were not evaluated, and the definition of fluid responsiveness varied across studies. Future research should focus on the physiological principles that underlie the measurement of fluid responsiveness and the effect of different volume expansion strategies on outcomes.

Ex vivo perfusion of the swine heart as a method for pre-transplant assessment.

We describe a cost-effective, reproducible circuit in a porcine, ex vivo, continuous warm-blood, bi-ventricular, working heart model that has future possibilities for pre-transplant assessment of marginal hearts donated from brain stem dead donors and hearts donated after circulatory determination of death (DCDD). In five consecutive experiments over five days, pressure volume loops were performed. During working mode, the left ventricular end systolic pressure volume relationship (LV ESPVR) was 23.1±11.1 mmHg/ml and the LV preload recruitable stroke work (PRSW) was 67.8±7.2. (Standard PVAN analysis software) (Millar Instruments, Houston, TX, USA) All five hearts were perfused for 219±64 minutes and regained normal cardiac function on the perfusion system.They displayed a significant upward and leftward shift of the end systolic pressure volume relationship, a significant increase in preload recruitable stroke work and minimal stiffness. These hearts could potentially be considered for transplantation. The circuit was effective during reperfusion and working modes whilst proving to be successful in maintaining cardiac function in excess of four hours. Using an autologous prime of approximately 20% haematocrit (Hct), electrolytes and blood gases were easy to control within this period using standard perfusion techniques.

Effect of PEEP and inhaled nitric oxide on pulmonary gas exchange during gaseous and partial liquid ventilation with small volumes of perfluorocarbon

Background: Partial liquid ventilation, positive end‐expiratory pressure (PEEP) and inhaled nitric oxide (NO) can improve ventilation/perfusion mismatch in acute lung injury (ALI). The aim of the present study was to compare gas exchange and hemodynamics in experimental ALI during gaseous and partial liquid ventilation at two different levels of PEEP, with and without the inhalation of nitric oxide.

Impact of xenon anaesthesia in isolated cardiopulmonary bypass on very early leucocyte and platelet activation and clearance: a randomized, controlled study

BACKGROUND Cardiopulmonary bypass (CPB) is associated with leucocyte and platelet activation and also organ dysfunction. Xenon has been found to have organ-protective effects. We therefore investigated the effect of isolated CPB on leucocyte and platelet activation and the efficacy of xenon in inhibiting these changes. METHODS Isolated CPB was conducted according to strict standardized clinical criteria using blood from healthy volunteers. They were randomized to an air-oxygen mixture (control group) vs xenon-oxygen mixture (xenon group). Blood samples were drawn at 5, 15, 30, 60, and 90 min from commencement of circuits and analysed for haemoglobin concentrations, white cell, neutrophil, monocyte, lymphocyte, and platelet counts. Leucocyte and platelet activation and also complex formation were determined by measuring levels of CD14++ monocytes, CD16+ monocytes, platelet-monocyte complexes, and platelet-neutrophil complexes (PNC). Differences between and within the groups were analysed with Students t-test. RESULTS Biomarker levels were not different between the groups. The data were pooled to identify the effects of isolated bypass. The neutrophils, monocytes, platelets, CD14++ monocytes, and CD16+ monocytes decreased within 5 min of the bypass experiments, whereas the percentage of platelet-CD++ monocyte complexes and PNC increased. CONCLUSIONS Isolated CPB elicited rapid, substantial leucocyte and platelet activation, and xenon had no impact on inhibiting these changes.