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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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Sevoflurane vs propofol in high risk cardiac surgery: design of the randomized trial “Sevo-Aifa”

Abstract

Objective. Recent evidence indicates that volatile anesthetics improve post-ischemic recovery. In a meta-analysis of 22 randomized studies, the use of volatile anesthetics was associated with significant reduction in myocardial infarction and mortality. All the studies in this meta-analysis included low risk patients undergoing isolated procedures (mostly isolated coronary artery bypass grafting). We want to confirm the cardioprotective effects of volatile anesthetics, in cardiac surgery, as indicated by a reduced intensive care unit stay and/or death in a high risk population of patients, undergoing combined valvular and coronary procedures.
Methods. Four centres will randomize 200 patients to receive either total intravenous anesthesia with propofol or anesthesia with sevoflurane. All patients will receive a standard average dose of opiates. Perioperative management will be otherwise identical and standardized. Transfer out of the intensive care unit will follow standard criteria.
Results. Reduced cardiac damage will probably translate into better tissue perfusion and faster recovery, as documented by a reduced intensive care unit stay. The study is powered to detect a reduction in the composite end point of prolonged intensive care unit stay (>2days) and/or death from 60% to 40%.
Conclusions. This will be the first multicentre randomized controlled trial comparing the effects of volatile anesthetics and total intravenous anesthesia in high risk patients undergoing cardiac procedures. Our trial should help clarify whether or not volatile agents should be recommended in high risk patients undergoing cardiac surgery.

Key words: anesthetic gases, cardiac surgical procedures, myocardium protection, sevoflurane, cardiac anesthesia, intensive care, volatile agents

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Preoperative management of hypoplastic left heart syndrome

Abstract

Pediatricians are frequently involved in the care of cyanotic newborns in the labor and delivery room, as well as in the well baby nursery. Causes of hypoxia and cyanosis in the term newborn can be found within all physiological systems. Congenital heart structural diseases account for the largest diagnostic category. There have been significant advances during the past years in the diagnosis and treatment of neonates with critical congenital heart disease, especially in the field of pre- and post-operative intensive care.

The term hypoplastic left heart syndrome (HLHS) describes a spectrum of cardiac structural abnormalities characterized by marked hypoplasia of the left ventricle and ascending aorta. Prenatal diagnosis, initial resuscitation and optimal preoperative management are key elements that allow the best opportunity for low mortality and normal neurodevelopment in affected newborns.  Preoperatively, the goal is to achieve adequate systemic oxygen delivery. Patency of the ductus arteriosus (DA) is critical for survival until surgery. Blood flow to the pulmonary and systemic circulations should be nearly balanced (goal Qp/Qs ratio of 1).  The immediate therapy for all infants with HLHS is an intravenous infusion of prostaglandin E1 (PGE1) in order to manipulate the DA and maintain ductal patency. Oxygen saturations of 75% to 85% by pulse oximetry suggest an adequate balance between systemic and pulmonary blood flow.  Judicious use of inotropic support is initiated if evidence of low cardiac output is detected. Diuretics may be necessary to help alleviate the increased volume load on the right ventricle. The goal of respiratory management is to increase pulmonary vascular resistance and decrease systemic vascular resistance.  Infants with HLHS who are born with a severely restricted or no inter-atrial communication, a rare occurrence, have profound hypoxemia.  The severe restriction of blood flow across the atrial septum results in a life-threatening situation and these patients, which present with severe cyanosis and hemodynamic instability, require urgent postnatal cardiac catheterization to relieve the septal obstruction and improve oxygenation. Special attention should be paid to the prevention of brain injury and poor neurodevelopmental outcome.

Care for infants with HLHS is complex, and often multiple specialists are involved. Despite an increase in the number of newborns with complex congenital heart disease and a growing percentage of patients with single-ventricle physiology, it is possible to care for this particular group of patients and achieve acceptable mortality risks, even in centres with no pediatric cardiac surgery facilities, if good preoperative management protocols are followed.

Key words: congenital heart disease, newborn, intensive care, hemodynamics, PGE1, ductus arteriosus

 

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First measured intrathoracic blood volume in icu patients indicates the appropriateness of circulatory volume management

Abstract

Hemodynamic monitoring in Intensive Care Unit (ICU) settings is usually introduced when a patient becomes hemodynamically unstable. We analyzed how empirically guided volume management relates to first measured intrathoracic blood volume (ITBV), at the moment of the beginning of Puls Contour Cardiac Output (PiCCO) hemodynamic monitoring.
Data and measurements from 37 ICU patients, divided into four groups according to diagnosis of primary condition, were retrospectively studied. The first group consisted of polytrauma patients, second group of patients with pancreatitis and/or peritonitis, third group were postoperative patients, and fourth group were patients with various medical diagnosis: sepsis, acute respiratory distress syndrome (ARDS), acute lung failure (ALF), and acute heart failure (AHF). PiCCO monitor was introduced when the signs of hemodynamic instability were observed. First measured ITBV was recorded and analyzed according to deviation from reference values.
First measured ITBV was in reference range in 14 (37.8%) patients. Volume overloading was observed in 16 (43.2%) and hypovolemia in 7 (18.9%) patients.
The observed inappropriate blood volume in patients of all studied groups suggests that there is the need for defining indications and earlier application of hemodynamic monitoring, as well as reassessment of usual empirically guided infusion therapy in ICU setting.

Key words: hemodynamic process, intensive care, hypovolemia, monitoring

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