Serratus Anterior Plane Block for Apical TAVR in an Awake Patient

International audienc

Vasopressor-Sparing Strategies in Patients with Shock: A Scoping-Review and an Evidence-Based Strategy Proposition

Despite the abundant literature on vasopressor therapy, few studies have focused on vasopressor-sparing strategies in patients with shock. We performed a scoping-review of the published studies evaluating vasopressor-sparing strategies by analyzing the results from randomized controlled trials conducted in patients with shock, with a focus on vasopressor doses and/or duration reduction. We analyzed 143 studies, mainly performed in septic shock. Our analysis demonstrated that several pharmacological and non-pharmacological strategies are associated with a decrease in the duration of vasopressor therapy. These strategies are as follows: implementing a weaning strategy, vasopressin use, systemic glucocorticoid administration, beta-blockers, and normothermia. On the contrary, early goal directed therapies, including fluid therapy, oral vasopressors, vitamin C, and renal replacement therapy, are not associated with an increase in vasopressor-free days. Based on these results, we proposed an evidence-based vasopressor management strategy

Early veno arterial PCO2 difference is associated with outcome in peripheral veno arterial extracorporeal membrane oxygenation

Abstract Background: Veno arterial membrane oxygenation (VA ECMO) is increasingly used for cardiogenic failure. However, hemodynamic targets for adequate resuscitation remain a challenge. The PCO 2 gap and the ratio between PCO 2 gap and the arteriovenous difference in oxygen (PCO 2 gap/Da–vO 2 ) are marker of peripheral hypoperfusion. We hypothesized that the PCO 2 gap and the PCO 2 gap/Da–vO 2 ratio might be useful parameters in VA ECMO patients. Methods: We conducted an observational prospective study between September 2015 and February 2017. All consecutive patients >18 years of age who had been treated with peripheral VA ECMO for cardiac failure were included. We compared 2 groups of patients: patients who died of any cause under VA ECMO or in the 72h following VA ECMO weaning (early death group) - and patients who survived VA ECMO weaning more than 72h (surviving group). Blood samples were drawn from arterial and venous VA ECMO cannulas at H0 and H6. The ability of PCO 2 gap and PCO 2 gap/Da–vO 2 to discriminate between early mortality and surviving was studied using ROC curves analysis. Results: We included 20 patients in surviving group and 29 in early death group. The PCO 2 gap was higher in the early death group at H6 (7.4 [5.7–10.1] vs. 5.9 [3.8–9.2], p < 0.01). AUC for PCO 2 gap at H6 was 0.76 (0.61–0.92), with a cut-off of 6.2 mmHg. The PCO 2 gap/Da–vO 2 was higher in the early death group at H0 (2.1 [1.5–2.6] vs. 1.2 [0.9–2.4], p < 0.01) and at H6 (2.1 [1.3–2.6] vs. 1.0 [0.8–1.7], p < 0.01). AUC for PCO 2 gap/Da–vO 2 at H0 and H6 were 0.79 and 0.73 respectively; the cut-off value was 1.4. Conclusions: The PCO 2 gap and the PCO 2 gap/Da–vO2 ratio are associated with early death in patients who undergo VA ECMO

Determinants of Arterial Pressure of Oxygen and Carbon Dioxide in Patients Supported by Veno-Arterial ECMO

Background: The present study aimed to assess the determinants of arterial partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2) in the early phase of veno-arterial extracorporeal membrane oxygenation (VA ECMO) support. Even though the guidelines considered both the risks of hypoxemia and hyperoxemia during ECMO support, there are a lack of data concerning the patients supported by VA ECMO. Methods: This is a retrospective, monocentric, observational cohort study in a university-affiliated cardiac intensive care unit. Hemodynamic parameters, ECMO parameters, ventilator settings, and blood gas analyses were collected at several time points during the first 48 h of VA ECMO support. For each timepoint, the blood samples were drawn simultaneously from the right radial artery catheter, VA ECMO venous line (before the oxygenator), and from VA ECMO arterial line (after the oxygenator). Univariate followed by multivariate mixed-model analyses were performed for longitudinal data analyses. Results: Forty-five patients with femoro-femoral peripheral VA ECMO were included. In multivariate analysis, the patients&rsquo; PaO2 was independently associated with QEC, FDO2, and time of measurement. The patients&rsquo; PaCO2 was associated with the sweep rate flow and the PpreCO2. Conclusions: During acute VA ECMO support, the main determinants of patient oxygenation are determined by VA ECMO parameters

Serratus anterior plane block for minimal invasive heart surgery

Abstract Background Minimal invasive heart surgery (MIHS) presents several benefits, but provides intense and prolonged post-operative pain. Our objective was to compare efficacy of serratus anterior plane block (SAPB) with continuous wound infiltration (CWI) for management of post-operative pain following MIHS. Methods It’s retrospective, monocentric study between November 2016 to April 2017. The study was performed at the University hospital of Dijon, Burgundy, France. All patients scheduled for MIHS was included. Data was collected retrospectively. During this period, 20 patients had SAPB and 26 had CWI. SAPB was performed before extubation with a single injection of 0.5 mg/kg of ropivacaïne (5 mg/ml). In the CWI group, catheter was inserted in the subcutaneous space by the surgeon at the end of the procedure. A 10 ml bolus of ropivacaïne (7.5 mg/mL) was followed by a continuous infusion (2 mg/ml) between 7 and 12 ml/h for 48 h. Morphine consumption and visual analog score (VAS) were recorded for 48 h. Length of stay in intensive care unit and hospital was also collected. Results Morphine consumption and VAS score were significantly lower in SAPB group (p < 0.01). Length of stay in intensive care and hospital was significantly was decreased in SAPB group. Conclusion SAPB appears effective in reducing postoperative MIHS pain

Risk Factors of Bleeding in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation

International audienc

<p>A single dose of tramadol in continuous wound analgesia with levobupivacaine does not reduce post-sternotomy pain: a randomized controlled trial</p>

International audienc

Oesophageal–pericardial and atrio-oesophageal fistula complicating a pulmonary vein isolation procedure

A 66-year-old man with a history of catheter ablation for atrial fibrillation presented with purulent cardiac tamponade, revealing an atrio-oesophageal fistula. He underwent successful endoscopic management. A few days later, the patient fell into a sudden coma due to multiple cerebral air embolisms, resulting from a fistula between the esophagus and the right superior pulmonary vein

Épidémiologie, facteurs et complications associée à l’utilisation de noradrénaline en chirurgie cardiaque avec circulation extracorporelle : une étude observationnelle française multicentrique et prospective

International audienceBackgroundThe present study was designed to describe the prevalence of norepinephrine use, the factors associated with its use, and the incidence of postoperative complications according to norepinephrine use, in patients undergoing cardiac surgery with cardiopulmonary bypass.MethodWe performed a prospective, multicenter, observational study in 4 University-affiliated medico-surgical cardiovascular units. We analyzed all patients treated with cardiac surgery after excluding pre-ECMO surgery, LVAD implantation, heart transplantation and intraoperative hemorrhage.ResultsOf 9316 patients screened during the study period, 2862 were included and 2510 were analyzed. Among them, 1549 (61%) were treated with norepinephrine with a median maximal dose of 0.11 [0.06–0.2] μg/kg/min–1 and a median duration of 10 h [2–24]. Norepinephrine was most often started in the operating room before cardiopulmonary bypass. The multiple regression logistic analysis identified several modifiable (haematocrit, maintenance of beta-blocker, cardiopulmonary bypass time, glucose-insulin-potassium, Custodiol cardioplegia, Delnido cardioplegia, and fibrinogen transfusion) and non-modifiable factors (age, ASA score, chronic high blood pressure, coronary disease, dyslipidemia, right ventricular dysfunction, left ventricular dysfunction, active endocarditis, and valvular aortic surgery) associated with norepinephrine use. Mortality, morbidity (neurological and renal complications, death) and length of stay in the ICU were higher in patients treated with norepinephrine.ConclusionNorepinephrine is often used in cardiac surgical patients but for < 24 h with a low dose. Many preoperative and surgical factors are associated with norepinephrine use. Patients supported by norepinephrine have a higher incidence of major postoperative events.ContexteL’objectif de cette étude était de décrire la prévalence de l’utilisation de la noradrénaline, les facteurs associés à son utilisation, et l’incidence des complications postopératoires en fonction de son utilisation ou non, chez les patients opérés d’une chirurgie cardiaque avec circulation extracorporelle (CEC).MéthodeNous avons réalisé une étude prospective, multicentrique et observationnelle dans 4 unités médicochirurgicales cardiovasculaires de CHU. Nous avons analysé tous les patients de chirurgie cardiaque après avoir exclu les patients avec une ECMO avant la chirurgie, l’implantation d’un LVAD (définir), la transplantation cardiaque et l’hémorragie peropératoire.RésultatsSur les 9316 patients éligibles pendant la période de l’étude, 2862 ont été inclus et 2510 ont été analysés. La noradrénaline a été utilisée chez 1549 (61 %) patients avec une dose maximale médiane de 0,11 (0,06–0,2) μg/kg–1 min–1 et une durée médiane de 10 heures (2–24). La noradrénaline a le plus souvent été administrée au bloc opératoire, avant la CEC. L’analyse par régression logistique multiple a identifié plusieurs facteurs modifiables (hématocrite, maintien du bêta-bloquant, durée de CEC, glucose-insuline-potassium, la cardioplégie Custodiol, la cardioplégie Delnido et la transfusion de fibrinogène) et non modifiables (âge, score ASA, hypertension artérielle chronique, maladie coronarienne, dyslipidémie, insuffisance cardiaque droite, insuffisance cardiaque gauche, endocardite active et chirurgie valvulaire aortique) associés à l’utilisation de la noradrénaline. La mortalité, la morbidité (complications neurologiques et rénales, décès) et la durée du séjour en unité de soins intensifs étaient plus élevées chez les patients traités par noradrénaline.ConclusionLa noradrénaline est souvent utilisée chez les patients en chirurgie cardiaque, mais à faible dose pendant moins de 24 heures. De nombreux facteurs préopératoires et chirurgicaux sont associés à l’utilisation de la noradrénaline. Les patients traités par noradrénaline présentaient une incidence plus élevée d’événements postopératoires majeurs