Off-pump CABG reduces complement activation but does not significantly affect peripheral endothelial function: a prospective randomized study

OBJECTIVE--Cardiac surgery initiates a systemic inflammatory response, which may affect endothelial function. The aim of this study was to investigate if off-pump CABG (OPCAB) reduces the postoperative inflammatory response and affects endothelial function less than conventional on-pump CABG. DESIGN--Fifty-two patients submitted for elective CABG were included in a prospective, randomized study. Twenty-six patients were operated with, and 26 without cardiopulmonary bypass (CPB). Plasma levels of complement (C3a), cytokines (IL-8, TNF-alpha), endothelin-1 and neopterin were measured before and during surgery and 2 and 24 h after surgery. Endothelial function was assessed by forearm plethysmography and acetylcholine infusion in 30 patients 2-4 h after surgery. RESULTS--C3a and neopterin concentrations were significantly higher during and early after surgery in the CPB group while TNF-alpha and IL-8 tended to be higher in the CPB group but the difference did not reach statistical significance. Endothelial function did not differ significantly between the two groups. CONCLUSION--OPCAB reduces complement activation compared with on-pump CABG but does not significantly affect TNF-alpha and IL-8 release or endothelial function.     

Positive end-expiratory pressure affects regional redistribution of ventilation differently in prone and supine sheep

OBJECTIVE: To examine interactions between positive end-expiratory pressure (PEEP) and posture on regional distribution of ventilation and to compare measurements of regional ventilation with two aerosols: a wet fluorescent microsphere aerosol (FMS, median mass aerodynamic diameter 1.1 microm) and a dry Tc-labeled carbon particle aerosol (Technegas, TG, median mass aerodynamic diameter approximately 0.1 microm). DESIGN: Experimental study. SETTING: Academic laboratory. SUBJECTS:: Anesthetized and mechanically ventilated sheep (n = 16). INTERVENTIONS: Four conditions were studied: prone or supine posture with or without 10 cm H2O PEEP. MEASUREMENTS AND MAIN RESULTS: Comparisons of FMS and TG were made in five animals. The median correlation coefficient of the two ventilation tracers was .95 (range, .91-.96). The mean ventilation per unit weight of dry lung for horizontal planes was almost identical whether measured with TG or FMS. The distribution of ventilation was assessed by analyzing deposition of aerosol in about 1,000 lung regions per animal. Distribution of ventilation down the vertical axis was linear in prone (the slope indicated a dorsal-to-ventral three-fold difference in ventilation) but unimodal in supine animals with the mode in the center of the lung. Redistribution of ventilation with 10 PEEP differed between posture, shifting the mode in supine toward dependent lung regions while eliminating the dorsal-to-ventral gradient in prone. The regional heterogeneity in ventilation was greater in supine sheep at both levels of PEEP, and this was due mostly to greater isogravitational heterogeneity in supine than in prone position. CONCLUSIONS: The wet fluorescent microsphere aerosol was as reliable as Technegas for high-resolution measurements of regional ventilation. The markedly different effects of 10 PEEP in supine and prone sheep may have important implications for gas exchange both in noninjured and injured lungs.     

An instrument for measuring health-related quality of life in patients with Deep Venous Thrombosis (DVT): development and validation of Deep Venous Thrombosis Quality of Life (DVTQOL) questionnaire

Background

Few studies have evaluated patient-reported outcomes in connection with a primary event of deep venous thrombosis, partly due to a lack of disease-specific measures. The aim here was to develop a disease-specific health-related quality of life (HRQL) measure, the deep venous thrombosis quality of life questionnaire (DVTQOL), for patients with recent exposition and treatment of proximal deep venous thrombosis.

Methods

A total of 121 consecutive outpatients (50 % males; mean age 61.2 ± 14 years) treated with warfarin (Waran^®) for symptomatic proximal deep venous thrombosis were included in the study. Patients completed the SF-36, EQ-5D and the pilot version of the DVTQOL.

Results

Items having: high ceiling and floor effect, items with lower factor loadings than 0.50 and items loading in several factors were removed from the pilot version of DVTQOL. In addition, overlapping and redundant items identified by the Rasch analysis were excluded. The final DVTQOL questionnaire consists of 29 items composing six dimensions depicting problems with: emotional distress; symptoms (e.g. pain, swollen ankles, cramp, bruising); limitation in physical activity; hassle with coagulation monitoring; sleep disturbance; and dietary problems. The internal consistency reliability was high (alpha value ranged from 0.79 to 0.93). The relevant domains of the SF-36 and EQ-5D significantly correlated with DVTQOL, thereby confirming its construct validity.

Conclusions

The DVTQOL is a short and user-friendly instrument with good reliability and validity. Its test-retest reliability and responsiveness to change in clinical trials, however, must be explored.

     

Excision of a recurrent mediastinal cyst through mid sternotomy with high thoracic epidural anesthesia as the sole anesthetic—A case report

Conclusion Our case report highlights the possibility of tackling mediastinal, pericardial and pleural problems with regional anesthesia alone even if the surgery requires opening of the pleura.     

Increased FiO2 improves intrathecal oxygenation during thoracic aortic cross-clamping in pigs

OBJECTIVES: To investigate the effect of 100% oxygen ventilation on cerebrospinal fluid (CSF) oxygenation in 11 pigs during thoracic aortic cross-clamping. DESIGN: An aorto-aortic shunt was used for control of central hemodynamics and study of hypoperfusion by exsanguination. CSF PO2, PCO2 and pH were continuously monitored before and during clamping. The changes in hemodynamic parameters and intrathecal gas tensions in response to variations in proximal mean aortic pressure and fraction of inspired oxygen (FiO2) were recorded. RESULTS: Baseline CSF PO2 decreased from 4.8 +/- 1.9 to 2.6 +/- 2.2 kPa following aortic occlusion. Increasing FiO2 to 1.0 resulted in a significant increase in CSF PO2 to 4.1 +/- 3.0 with a return to 2.7 +/- 2.1 kPa after reducing FiO2 to 0.4 again. The same variations in FiO2 did not induce any significant changes in CSF PO2 during hypotension. CONCLUSION: Increased FiO2 during experimental thoracic aortic cross-clamping with stable proximal arterial pressure helps to maintain CSF PO2, whereas severe hypotension could not be compensated for by hyperoxemia.