Perioperative cardiac arrests in children at a university teaching hospital of a developing country over 15 years

Objective/Aim:  To study the incidence, causes, and outcome of perioperative cardiac arrests in children at a university teaching hospital with an aim of improving quality of care.
Background:  Analysis of anesthesia-related complications is routinely performed by most anesthesia departments to make prevention strategies.
Methods:  All perioperative cardiac arrests in children up to 18 years from induction of anesthesia to postanesthesia care unit discharge or ICU admission during noncardiac surgery from January 1992 to December 2006 were analyzed. Outcome variable was noted as survival to discharge. Anesthesia-related cardiac arrests were identified and their causes analyzed.
Results:  Ten cardiac arrests occurred among 20216 patients. Overall incidence was 4.95 per 10000 (95% CI: 1.88–8.01). Six (6.53/10000) were females. Seven (19.44/10000) patients belonged to the classification III–IV of ASA physical status, eight (18.28/10000) were below 1 year, and two (1.26/10000) above 1 year. Three patients (6.53/10000) were undergoing emergency surgery. Anesthesia was primarily responsible in four cases. The causes of anesthesia-related arrests were medication-related (two), airway-related (one), and under-replacement of fluids (one). Seven patients died during the arrest and three were discharged home. The event was considered avoidable in seven (70%) cases.
Conclusion:  Perioperative cardiac arrests were higher in patients with poor physical status, in those under 1 year of age, and in female patients. Anesthesia-related cardiac arrests were mainly due to medication- or airway-related causes. The majority of arrests were avoidable indicating the importance of prevention strategies.     

Central venous catheterization and fatal cardiac tamponade

Cardiac tamponade is a poorly recognized complication of centralvenous catheterization associated with a high mortality. Wepresent a case of fatal cardiac tamponade after intra- pericardialinfusion of total parenteral nutrition in a patient who hadtwo central venous catheters. We suggest that catheter tip positionshould always be confirmed before use of a catheter. Tamponadeshould be suspected in a patient who deteriorates when a centralvenous catheter is used and resuscitation via the catheter shouldbe avoided. Br J Anaesth 2001; 87: 298–302     

Perioperative myocardial infarction--aetiology and prevention

Perioperative myocardial infarction (PMI) is one of the mostimportant predictors of short- and long-term morbidity and mortalityassociated with non-cardiac surgery. Prevention of a PMI isthus a prerequisite for an improvement in overall postoperativeoutcome. The aetiology of PMI is multifactorial. The perioperativeperiod induces large, unpredictable and unphysiological alterationsin coronary plaque morphology, function and progression, andmay trigger a mismatch of myocardial oxygen supply and demand.With many diverse factors involved, it is unlikely that onesingle intervention will successfully improve cardiac outcomefollowing non-cardiac surgery. A multifactorial, step-wise approachis indicated. Based on increasing knowledge of the nature ofatherosclerotic coronary artery disease, and in view of thepoor positive predictive value of non-invasive cardiac stresstests, and the considerable risk of coronary angiography andcoronary revascularization in high-risk patients, the paradigmis shifting from an emphasis on extensive non-invasive preoperativerisk stratification to a combination of selective non-invasivetesting and aggressive pharmacological perioperative therapy.Perioperative plaque stabilization by pharmacological meansmay be as important in the prevention of PMI as an increasein myocardial oxygen supply or a reduction in myocardial oxygendemand.     

Perioperative hyperoxia and post‐operative cardiac complications in adults undergoing non‐cardiac surgery: Systematic review protocol

Background

Oxygen therapy is used liberally for all patients undergoing anaesthesia. Recent studies have raised concerns that it may not be without complications when arterial oxygen concentrations reach supranormal concentrations (hyperoxia). Studies of oxygen therapy have raised concerns that the risk of myocardial injury and infarction is elevated in patients with hyperoxia due to vasoconstriction and formation of reactive oxygen species. Due to lack of symptoms or silent ischaemia, post‐operative myocardial injury may be missed clinically. In some studies, perioperative hyperoxia has been linked to increased long‐term mortality, but cardiac complications are sparsely evaluated. The aim of this review is to summarize current evidence to assess the risk and benefits of perioperative hyperoxia on post‐operative cardiac complications.

Methods

This systematic review will include meta‐analyses and Trial Sequential Analyses. We will include randomized clinical trials with patients undergoing non‐cardiac surgery if the allocation separates patients into a target of either higher (above 0.60) or lower (below 0.40) inspired oxygen fraction. To minimize the risk of systematic error, we will assess the risk of bias of the included trials using the Cochrane Risk of Bias Tool. The overall quality of evidence for each outcome will be assessed with the Grading of Recommendation, Assessment, Development and Evaluation (GRADE).

Discussion

This systematic review will provide data on a severe, albeit rare, potential risk of oxygen therapy. We will do a trial sequential analysis to assess the robustness of results as well as help estimate the required patient size for future clinical trials.

     

心脏手术后早期昏迷的病因探讨

目的探讨心脏手术后早期昏迷的病因和预防措施。方法回顾性分析武汉亚洲心脏病医院2002年1月1日至2004年5月31日4358例心血管手术后早期昏迷的22例患者,研究原发疾病、外科术式、体外循环参数、水电解质平衡和血液生化等因素与昏迷发生发展的关系。结果不同手术方式术后脑损害发生率显著不同(P<0.001);术后Glasgow评分与术中平均动脉压正相关,与手术时间负相关(P<0.01);体外循环中最低血红蛋白与深昏迷时间和脑损害的总病程负相关(P<0.05);手术时间、术后Glasgow评分、血肌酐、白细胞和中性粒细胞计数对患者的预后有显著性影响(P<0.05)。结论体外循环中的动脉压下降、血液稀释和失血性贫血、涉及主动脉的手术方式和手术时间延长是心脏术后发生昏迷的高危因素。因此,提高手术技巧、缩短手术时间、减少失血、减少主动脉损伤、维持有效的脑灌注压是减少术后昏迷、改善预后的关键。     

Postoperative care of adult cardiac surgery patients

Over 35,000 cardiac operations are performed in the UK each year, with the majority requiring cardiopulmonary bypass (CPB). CPB replaces the heart and lung function temporarily by providing non-pulsatile oxygenated blood flow in order to facilitate arrested heart surgery. The use of an extracorporeal circuit and cardioplegia causes the release of pro-inflammatory cytokines inducing a systemic inflammatory response, coagulation cascade activation, haemodilution and transient myocardial depression among other effects. These manifest as a series of typical pathophysiological derangements, which require the adoption of a standard management strategy. The aim of this article is to provide an overview of the key issues including cardiac, respiratory, neurological, renal and haemostatic complications, which may arise while managing the postoperative cardiac surgical patient.     

Peri-operative cardiac morbidity in kidney transplant recipients: incidence and risk factors

BACKGROUND: Renal transplant recipients are known to be at increased risk for developing cardiac disease. In both general and peripheral vascular surgery, pre-operative risk stratification (and intervention when indicated) has decreased the incidence of peri-operative cardiac complications. In this study, we set out to identify subsets of patients at high risk for peri-operative cardiac complications after a renal transplant. METHODS: We retrospectively reviewed the records of 2694 adult renal transplants performed at the University of Minnesota between January 1, 1985 and December 31, 1998. We determined the incidence of peri-operative (within 30 d post-transplant) cardiac complications, including myocardial infarction (MI). Risk factors for the development of these complications were determined by multivariate analysis. RESULTS: We found 163 peri-operative cardiac complications, for an overall incidence of 6.1%. Specific cardiac complications included MI (n=43, 1.6%), arrhythmia (n=74, 2.7%), angina (n=31, 1.2%), cardiac arrest (n=13, 0.5%), and congestive heart failure (n= 2, 0.1%). By multivariate analysis, significant risk factors for any cardiac complication were age> or =50 yr (relative risk (RR)=3.0, p=0.0001) and pre-transplant cardiac disease (RR=3.3, p=0.0001). Not significant were diabetes mellitus (DM), cadaver donor source, pre-transplant dialysis, a history of smoking, and hypertension. Significant risk factors for peri-operative MI were age> or =50 yr, pre-existing cardiac disease, and DM. Diabetic patients with pre-existing cardiac disease were at especially high risk for peri-operative cardiac events. CONCLUSIONS: Patients>50 yr and those with pre-existing cardiac disease, especially if diabetic, are at significantly increased risk for developing peri-operative cardiac complications after a renal transplant. Such patients require aggressive pre-operative investigations, which may include coronary angiography, to decrease the risk of post-transplant complications.     

A meta‐analysis and meta‐regression of outcomes including biliary complications in donation after cardiac death liver transplantation

Donation after cardiac death (DCD) liver transplantation is increasingly common but concerns exist over the development of biliary complications and ischemic cholangiopathy (IC). This study aimed to compare outcomes between DCD and donation after brain death (DBD) liver grafts. Studies reporting on post‐transplantation outcomes after Maastricht category III DCD liver transplantation were screened for inclusion. Odds ratios (OR) with 95% confidence intervals were produced using random‐effects models for the incidence of biliary complications, IC, graft and recipient survival. Meta‐regression was undertaken to identify between‐study predictors of effect size for biliary complications and IC. PROSPERO Record: CRD42012002113. Twenty‐five studies with 62 184 liver transplant recipients (DCD = 2478 and DBD = 59 706) were included. In comparison with DBD, there was a significant increase in biliary complications [OR = 2.4 (1.9, 3.1); P < 0.00001] and IC [OR = 10.5 (5.7, 19.5); P < 0.00001] following DCD liver transplantation. In comparison with DBD, at 1 year [OR = 0.7 (0.5, 0.8); P = 0.0002] and 3 years [OR = 0.6 (0.5, 0.8); P = 0.001], there was a significant decrease in graft survival following DCD liver transplantation. At 1 year, there was also a nonsignificant decrease [OR = 0.8 (0.6, 1.0); P = 0.08] and by 3 years a significant decrease [OR = 0.7 (0.5, 1.0); P = 0.04] found in recipient survival following DCD liver transplantation. Eleven factors were entered into meta‐regression models, but none explained the variability in effect size between studies. DCD liver transplantation is associated with an increase in biliary complications, IC, graft loss and mortality. Significant unexplained differences in effect size exist between centers.     

Looking after the cardiac surgery patient: pitfalls and strategies

With over 32,000 cardiac operations being performed in the UK annually with a mortality of 2.71%, effective postoperative management is crucial for successful outcomes. Management of these patients is complex due to numerous factors: the operation being performed on the heart, pathophysiology of the disease and the use of cardiopulmonary bypass. While standard operating proceedings (SOPS) are in place for many scenarios, familiarity of postoperative recovery pathway and invasive monitoring help identify deteriorating patients. However, awareness of complications such as bleeding, arrhythmias, low cardiac output state and cardiac tamponade is paramount to prevent these complications becoming fatal. In this article we provide an overview of postoperative management strategies for cardiac surgical patients and how to help avoid these pit falls.     

Prevention of cardiac complications following non-cardiac surgery

It is the challenging task of the anaesthesiologist as primary peri-operative care provider to identify patients with unstable or high-risk conditions and ensure adequate care prior to, during and following surgery. Approximately 5% of the population undergoing non-cardiac surgery suffer from some form of peri-operative cardiac morbidity. The yearly costs associated with peri-operative cardiac complications can be as high as 2% of the total national health care budget. Active measures to prevent myocardial ischaemia will save more lives than monitoring and waiting until cardiac complications occur. There are no randomized controlled trials showing that prophylactic coronary revascularization reduces the cardiac risk of non-cardiac surgery. The anaesthesiologist has many means to influence the cardiac outcome of non-cardiac surgery. Peri-operative optimization of cardiac medication reduces the incidence of cardiac complications. Pre-operative optimization of high-risk surgical patients in the intensive care unit and prophylactic treatment with β-blockers will reduce the cardiac morbidity and mortality significantly. The use of local or regional anaesthesia techniques may influence the cardiac outcome following non-cardiac surgery. Maintaining the haemoglobin level between 9 and 10 g/ dl (haematocrit 0.28–0.33) and the temperature above 36°C in the peri-operative period will reduce cardiac morbidity and mortality. Future therapies probably consist of drugs that influence the inflammatory process in the atherosclerotic vascular wall, the opioid receptors, the clotting system and the potassium-dependent ATP channel. Ischaemic preconditioning as an intervention to improve cardiac outcome of non-cardiac surgery is a subject for future research.     

517例瓣膜置换术后发生肺不张的危险因素分析

目的分析瓣膜置换术后肺不张的危险因素,为临床选择治疗方法和评估预后提供依据。方法将我院1998年1月至2005年10月完成的517例瓣膜置换术患者按有无肺不张分成两组,进行单因素分析和多因素Logistic回归分析。结果全组有肺不张31例,单因素显著性分析发现年龄、吸烟史、左心房直径、术前肺动脉高压、体外循环时间、主动脉阻断时间、胸膜完整、使用膜肺以及应用药物和长期应用呼吸机有相关性;多因素Logistic回归分析结果显示高龄、体外循环时间、联合瓣膜病等是独立的相关危险因素。结论瓣摸置换术后肺不张与多种因素有关,临床应引起高度重视。