ERAS in Cardiac Surgery: Wishful Thinking or Reality

Enhanced recovery after cardiac surgery (ERACS) is a multi-disciplinary approach to improve patient outcomes and reduce complications following cardiac surgery. The aim of ERACS protocol is to optimize pre-operative preparation, reduce surgical trauma, and minimize post-operative stress.The protocol has been shown to improve patient outcomes, including shorter hospital stays, lower rates of complications, and faster return to normal activities. It is important to note that ERACS is a multi-disciplinary approach, and requires close collaboration between surgeons, anaesthesiologists, nurses, and other healthcare professionals to ensure successful implementation. Anaesthesiologists play a crucial role in the ERACS protocol, as they are responsible for the management of the patient’s anaesthesia and pain management during and after surgery. In this paper provide an overview of the ERACS protocol from the perspective of an anaesthesiologist

Cytosorb® haemoadsorption: a potential game changer for patients needing myocardial surgical revascularisation

Cytosorb, an extracorporeal blood purification system, utilises the principles of haemoadsorption to remove low molecular weight substances from the blood, including multiple cytokines such as interleukin (IL)-1b, IL-6, IL-8, and tumour necrosis factor-α, and anti-platelet drugs aiming to improve clinical outcomes. Given the prominent role of pro-inflammatory cytokines in various inflammatory states, Cytosorb has seen growing application as a therapeutic immunomodulator including surgery. This review focuses on the effects of the use of Cytosorb in patients undergoing coronary artery bypass grafting (CABG) and the indications of removal of cytokines and anti-platelet agents such as ticagrelor. The evidence supports the feasibility and safety profile of Cytosorb, with no device-related adverse events reported in all studies. Initial studies suggest significant potential for Cytosorb in urgent or emergency CABG surgery to remove anti-platelet medication with promising benefits on clinical outcomes including fewer blood product transfusions, decreased length of intensive care unit stay, and lower re-sternotomy rates. Furthermore, a cost saving analysis indicated that intraoperative removal of ticagrelor with Cytosorb would be cost effective in the setting of emergency cardiac surgery. However, the evidence remains inconclusive when Cytosorb is used in elective CABG surgery for cytokine removal. Definite high quality clinical trials for both indications for Cytosorb in CABG surgery are needed to clarify if there is a clinically significant benefit in clinical outcomes. There is substantial trial activity for the application of Cytosorb in higher risk cardiac surgery to establish the place of Cytosorb in future treatment pathways in cardiac surgery

A sertéságazat helyzetének bemutatása (jövedelmezőség, hatékonyság)

Jelen tanulmányban a sertéságazat piaci helyzetét és jövedelemtermelő képességét vizsgáltuk, ehhez kapcsolódóan jártuk körbe az ágazatot. Az ágazati körkép után a sertéstartás jövedelemtermelő képességének bemutatására egy „jó színvonalú termelési gyakorlatot” kívántunk modellezni. Az Eredmények között bemutatásra került, hogy mi jellemzi a naturális ráfordításokat, a termelési költségeket, valamint ezek szerkezetét és összetételét. Megállapításra került, hogy a sertéshús előállítás összes költségének körülbelül kétharmadát a takarmányozási költségek teszik ki, így itt a költséghatékonyság javítása alapvető gazdasági cél. A termelés legfőbb nehézsége a folyamatosan változó felvásárlási ár, amely alapvetően meghatározza, hogy az adott vállalkozás nyereséget vagy veszteséget realizál. Az adatokból levezettük, hogy adott körülmények között hogyan alakulna egy virtuális üzem árbevétele, és megállapításra került, hogy a jelenlegi piaci árak mellett támogatás nélkül nem lehet a sertéságazatban jövedelmet elérni, a virtuális üzem kizárólag az ágazati támogatásnak köszönhetően tudott nyereséget realizálni. Végezetül kereszttábla elemzésekkel szemléltettük, hogyan befolyásolja a termelés hatékonyságát és gazdaságosságát a takarmány ára és a hízó értékesítési ára, illetve a takarmány ára és a takarmányozási együttható. Azt a megállapítást tehetjük, hogy a virtuális üzemünk nehéz helyzetben van, ugyanis ha a fajlagos takarmányhasznosítás minimálisan emelkedik (cp), vagy a takarmányárak növekednek (cp), mindkét esetben veszteséget realizál az üzem külön-külön is. A jelenlegi takarmányárak mellett érdemes fontolóra venni, hogy milyen kompromisszumot kötünk azzal kapcsolatban, hogy teljes mértékben az adott genetika igényeit kívánjuk kielégíteni, ezzel akár magas színvonalú takarmányhasznosulási és jó húsminőségi mutatókat elérve, vagy olcsóbb takarmányokat etetünk, amely a naturális mutatókat ronthatja, azonban költséghatékonyságban kedvezőbb szintet tudunk elérni

Volatile organic compound profiling to explore primary graft dysfunction after lung transplantation

Primary graft dysfunction (PGD) is a major determinant of morbidity and mortality following lung transplantation. Delineating basic mechanisms and molecular signatures of PGD remain a fundamental challenge. This pilot study examines if the pulmonary volatile organic compound (VOC) spectrum relate to PGD and postoperative outcomes. The VOC profiles of 58 bronchoalveolar lavage fluid (BALF) and blind bronchial aspirate samples from 35 transplant patients were extracted using solid-phase-microextraction and analyzed with comprehensive two-dimensional gas chromatography coupled to time-of-flight mass spectrometry. The support vector machine algorithm was used to identify VOCs that could differentiate patients with severe from lower grade PGD. Using 20 statistically significant VOCs from the sample headspace collected immediately after transplantation (\u3c 6 h), severe PGD was differentiable from low PGD with an AUROC of 0.90 and an accuracy of 0.83 on test set samples. The model was somewhat effective for later time points with an AUROC of 0.80. Three major chemical classes in the model were dominated by alkylated hydrocarbons, linear hydrocarbons, and aldehydes in severe PGD samples. These VOCs may have important clinical and mechanistic implications, therefore large-scale study and potential translation to breath analysis is recommended

The role of interleukin-1β as a predictive biomarker and potential therapeutic target during clinical ex vivo lung perfusion

BACKGROUND: Extended criteria donor lungs deemed unsuitable for immediate transplantation can be reconditioned using ex vivo lung perfusion (EVLP). Objective identification of which donor lungs can be successfully reconditioned and will function well post-operatively has not been established. This study assessed the predictive value of markers of inflammation and tissue injury in donor lungs undergoing EVLP as part of the DEVELOP-UK study. METHODS: Longitudinal samples of perfusate, bronchoalveolar lavage, and tissue from 42 human donor lungs undergoing clinical EVLP assessments were analyzed for markers of inflammation and tissue injury. Levels were compared according to EVLP success and post-transplant outcomes. Neutrophil adhesion to human pulmonary microvascular endothelial cells (HPMECs) conditioned with perfusates from EVLP assessments was investigated on a microfluidic platform. RESULTS: The most effective markers to differentiate between in-hospital survival and non-survival post-transplant were perfusate interleukin (IL)-1β (area under the curve = 1.00, p = 0.002) and tumor necrosis factor-α (area under the curve = 0.95, p = 0.006) after 30 minutes of EVLP. IL-1β levels in perfusate correlated with upregulation of intracellular adhesion molecule-1 in donor lung vasculature (R(2) = 0.68, p < 0.001) and to a lesser degree upregulation of intracellular adhesion molecule-1 (R(2) = 0.30, p = 0.001) and E-selectin (R(2) = 0.29, p = 0.001) in conditioned HPMECs and neutrophil adhesion to conditioned HPMECs (R(2) = 0.33, p < 0.001). Neutralization of IL-1β in perfusate effectively inhibited neutrophil adhesion to conditioned HPMECs (91% reduction, p = 0.002). CONCLUSIONS: Donor lungs develop a detectable and discriminatory pro-inflammatory signature in perfusate during EVLP. Blocking the IL-1β pathway during EVLP may reduce endothelial activation and subsequent neutrophil adhesion on reperfusion; this requires further investigation in vivo