Comparison of analgesic efficacy between erector spine plane block and intravenous patient-controlled analgesia with morphin after open heart surgery

Pain after cardiac surgery is always an obsession of patients and a top concern of anesthesiologists. Experimental subjects challenged by acute pain and patients in chronic pain experience impairments in attention control, working memory, mental flexibility, problem solving, and information processing speed. The two most commonly used analgesia methods are patient-controlled analgesia (PCA) and erector spinea plane block (ESP). Our study aimed to compare the analgesic effect of ESP with PCA in patients after cardiac surgery using extracorporeal circulation and evaluate the disavantages of these two pain relief techniques. Subject and methods: This study was a randomized controlled intervention study of adult patients who underwent open-heart surgery patients with extracorporeal circulation from May 2020 to September 2021 in the Department of Anesthesiology and Intensive Care Unit - Hanoi Heart Hospital. Results: Two hundred and four (204) consecutive patients were collected, included 108 patients in the ESP group and 96 patients in the PCA group. The mean intraoperative fentanyl amount in the ESP group (0.57±0.50 mg) was lower than in the PCA group (1.00±0.00 mg) (p<0.05). The average VAS score when the patient was lying still and taking deep breaths at the time of assessment in both groups was below 3 (corresponding to low pain level) (p>0.05). The mean morphin consumption 24 hours after surgery was significantly lower in the ESP group (0,23±0,12 mg) than in the PCA group (17,92±3,32 mg) (p<0.05). The mean time after surgery in the ESP group (3.80±1.02 hours) and the PCA group (5.21±1.10 hours) had a clear difference between p<0.05. The mean time of extubation in the ESP group (8.06±1.60 hours) was statistically significantly lower than in the PCA group (8.83±1.43 hours) (p<0.05). The rate of nausea in the ESP group (20.98%) was lower than in the PCA group (58.33%) (p<0.05). Conclusion: Both methods had good analgesic effect with an average VAS score ≤ 3. The ESP group had a lower mean postoperative morphine consumption, a higher patient satisfaction level, and a lower rate of nausea, vomiting, and slow breathing statistically significant less than the PCA group.

Clinical and Surgical Characteristics of Patients Undergoing Valve Replacement

Cardiovascular diseases have been the leading the causes of hospital admissions, being one of the main public health problems in Brazil, and one of the forms of treatment is cardiac surgery, being more prevalent in older people who have several other comorbidities associated. This study aimed to describe the clinical and surgical profile of patients undergoing valve replacement. Thus, an ambispective study was carried out with patients admitted to the Intensive Care Unit of Instituto Nobre de Cardiologia. An analysis was carried out in the patients' medical records in search of data related to their clinical and surgical profile. During the research period, 55 patients underwent valve replacement, 10 of which were excluded. Thus, 45 patients were evaluated, with 28 (62%) male participants with a mean age of 43 ± 6 years, hypertension and sedentary lifestyle were the most common comorbidities (49% and 56% respectively) and 60% with the Body Mass Index within the normal range. Regarding the surgical characteristics, the extracorporeal circulation time was 211 ± 22 minutes and the Mechanical Ventilation time was 6 ± 2 hours. Based on the findings, it can be characterized that patients undergoing cardiac valve replacement surgery are over 40 years old, male, sedentary, hypertensive. Keywords: Thoracic Surgery. Artificial Breathing. Extracorporeal Circulation. Resumo As doenças cardiovasculares têm liderado as causas de internação hospitalar, sendo um dos principais problemas de saúde publica no Brasil, sendo que umas das formas de tratamento é a cirurgia cardíaca, sendo mais prevalente em pessoas com idade mais avançada, e que possuem várias outras comorbidades associadas. O presente estudo teve como objetivo descrever o perfil clínico e cirúrgico de pacientes submetidos à troca valvar. Para isso foi realizado um estudo ambispectivo com os pacientes internados na Unidade de Terapia Intensiva do Instituto Nobre de Cardiologia. Foi feita uma análise no prontuário dos pacientes na busca de dados relacionados ao seu perfil clinico e cirúrgico. Durante o período da pesquisa foram submetidos a troca valvar 55 pacientes sendo que 10 foram excluídos. Desse modo foram avaliados 45 pacientes, com 28 (62%) participantes do sexo masculino com idade média de 43 ± 6 anos, hipertensão e sedentarismo as comorbidades mais encontradas (49% e 56% respectivamente) e 60% com o Índice de Massa Corpórea dentro da normalidade. Em relação às características cirúrgicas o tempo da circulação extracorpórea 211 ± 22 minutos e o tempo de Ventilação Mecânica 6 ± 2 horas. Com base nos achados pode-se caracterizar que os pacientes submetidos à cirurgia cardíaca de troca de válvulas têm mais de 40 anos, do gênero masculino, sedentários, hipertensos. Palavras-chaves: Cirurgia Torácica. Respiração Artificial. Circulação Extracorpórea.

Minimally invasive extracorporeal circulation in end-stage coronary artery disease patients undergoing myocardial revascularization

Background Patients with coronary artery disease and concomitant heart failure (left ventricular ejection fraction < 35%) requiring myocardial revascularization are at risk of poor long-term prognosis and higher mortality. The benefits of minimally invasive extracorporeal circulation (MiECC), particularly in end-stage coronary artery disease patients undergoing myocardial revascularization, have not been completely described. Materials and methods In this single-centre control study, 60 end-stage coronary artery disease patients undergoing isolated coronary artery bypass grafting (CABG) were included. Patients were divided into two groups of 30 patients each undergoing CABG using MiECC or conventional extracorporeal circulation (cECC). Results In the MiECC group, oxygen delivery index (DO2i) was 305 mL/min/m2 in relation to indexed oxygen extraction ratio (O2ERi) 21.5%, whereas in the cECC group DO2i was 288 mL/min/m2 in relation to O2ERi 25.6% (p = 0.037). Lactate levels > 3 mmol/L were reported in 7 MiECC patients vs 20 cECC patients (p = 0.038), with blood glucose peak. Mean nadir hemoglobin values during cardiopulmonary bypass (CPB) were 9.7 g/dL in the MiECC group vs 7.8 g/dL in the cECC group (p = 0.044). Cardiac index during CPB was 2.4 L/min/m2 in both groups. Red blood cell units administered were 8 vs 21 units in the MiECC vs cECC group (p = 0.022). A glycemic peak was recorded in 7 patients of the MiECC group and in 20 patients of the cECC group (p = 0.037). Conclusion In end-stage coronary artery disease, the MiECC technique was associated with a higher DO2i compared to cECC. MiECC patients showed a significant reduction in red blood cell unit administration and peak intraoperative lactate levels, which correlated with better postoperative outcome.

Regression of tumor thrombus in the suprahepatic vena cava of hepatocellular carcinoma and conversion hepatectomy induced by lenvatinib

Recent developments in systemic chemotherapy for advanced hepatocellular carcinoma have been outstanding. However, reports on conversion surgery after lenvatinib therapy are scarce. We present the first case of advanced hepatocellular carcinoma with tumor thrombus in the suprahepatic vena cava close to the right atrium, which shrank after 12 weeks’ administration of lenvatinib, thereby leading to successful conversion surgery without using total vascular exclusion or extracorporeal circulation. The treatment strategy for hepatocellular carcinoma with macroscopic hepatic vein tumor thrombus is controversial, however, from a Japanese nationwide survey, surgical resection has been accepted as one of the treatment options for advanced hepatocellular carcinoma with hepatic vein tumor thrombus in Japan. However, the survival rate after resection of hepatocellular carcinoma having inferior vena cava tumor thrombus with extracorporeal circulation was reported to be worse than without extracorporeal circulation, and some preoperative down-sizing therapy for inferior vena cava tumor thrombus was advocated. Preoperative lenvatinib therapy might be a promising option among the multidisciplinary treatments for hepatocellular carcinoma with macroscopic tumor thrombus in the hepatic veins.

Additional Thrombocytopenia after Cardiac Surgery with Extracorporeal Circulation: A Case Report

Thrombocytopenia occurs almost systematically in cardiac surgery under extracorporeal circulation (ECC). Its usual causes are multiple and recognized, but sometimes uncommon mechanisms are added, posing the problem of etiological diagnosis and the dilemma of optimal adequate management. The etiological diagnosis of thrombocytopenia after extracorporeal circulation requires a careful analysis of the chronology of the thrombocytopenia and also of the clinical and biological context. The authors report the observation of a case of additional thrombocytopenia after cardiovascular surgery under extracorporeal circulation, detailing the diagnostic modalities and describing the different usual clinical and biological characteristics of platelet changes induced by extracorporeal circulation.

Open-label randomized controlled trial of ultra-low tidal ventilation without extracorporeal circulation in patients with COVID-19 pneumonia and moderate to severe ARDS: study protocol for the VT4COVID trial

Background Acute respiratory distress syndrome (ARDS) is a severe complication of COVID-19 pneumonia, with a mortality rate amounting to 34–50% in moderate and severe ARDS, and is associated with prolonged duration of invasive mechanical ventilation. Such as in non-COVID ARDS, harmful mechanical ventilation settings might be associated with worse outcomes. Reducing the tidal volume down to 4 mL kg−1 of predicted body weight (PBW) to provide ultra-low tidal volume ventilation (ULTV) is an appealing technique to minimize ventilator-inducted lung injury. Furthermore, in the context of a worldwide pandemic, it does not require any additional material and consumables and may be applied in low- to middle-income countries. We hypothesized that ULTV without extracorporeal circulation is a credible option to reduce COVID-19-related ARDS mortality and duration of mechanical ventilation. Methods The VT4COVID study is a randomized, multi-centric prospective open-labeled, controlled superiority trial. Adult patients admitted in the intensive care unit with COVID-19-related mild to severe ARDS defined by a PaO2/FiO2 ratio ≤ 150 mmHg under invasive mechanical ventilation for less than 48 h, and consent to participate to the study will be eligible. Patients will be randomized into two balanced parallels groups, at a 1:1 ratio. The control group will be ventilated with protective ventilation settings (tidal volume 6 mL kg−1 PBW), and the intervention group will be ventilated with ULTV (tidal volume 4 mL kg−1 PBW). The primary outcome is a composite score based on 90-day all-cause mortality as a prioritized criterion and the number of ventilator-free days at day 60 after inclusion. The randomization list will be stratified by site of recruitment and generated using random blocks of sizes 4 and 6. Data will be analyzed using intention-to-treat principles. Discussion The purpose of this manuscript is to provide primary publication of study protocol to prevent selective reporting of outcomes, data-driven analysis, and to increase transparency. Enrollment of patients in the study is ongoing. Trial registration ClinicalTrials.govNCT04349618. Registered on April 16, 2020

Haemodynamics Support during Surgical Myocardial Revascularisation in Patients with Systolic Left Ventricular Dysfunction

Coronary heart disease remains a leading cause of death worldwide, and coronary bypass surgery -- the treatment standard in haemodynamically significant multivessel and/or trunk coronary stenosis. Intraoperative haemodynamics support during coronary artery bypass grafting (CABG) in patients with reduced ejection fraction currently remains controversial. Manifold evidence favours CABG with no extracorporeal circulation in higher risk patients to avoid the system’s frequent complications of blood transfusion, renal failure, bleeding, wound infection, cerebrovascular events and humoral disturbances. On the other hand, CABG with extracorporeal circulation and heart arrest allows a bloodless operating field and complete revascularisation in most, often very complex, cases. The complication rate and outcome in beating-heart surgery are reckoned to depend directly on the relevant surgeon’s and clinic experience, which makes many relinquish the technique due to a limited history of skill. This essay overviews the current state of the art, discussions of recent systematic studies on intraoperative haemodynamics support in patients with reduced left ventricular ejection fraction and touches upon the importance of surgeon’s experience for the operation outcome.