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Hemodynamic conditions with reduced systemic vascular resistance commonly are observed in patients undergoing cardiac surgery and may range from moderate reductions in vascular tone, as a side effect of general anesthetics, to a profound vasodilatory syndrome, often referred to as vasoplegic shock. Therapy with vasopressors is an important pillar in the treatment of these conditions. There is limited guidance on the appropriate choice of vasopressors to restore and optimize systemic vascular tone in patients undergoing cardiac surgery. A panel of experts in the field convened to develop statements and evidence-based recommendations on clinically relevant questions on the use of vasopressors in cardiac surgical patients, using a critical appraisal of the literature following the GRADE system and a modified Delphi process. The authors unanimously and strongly recommend the use of norepinephrine and/or vasopressin for restoration and maintenance of systemic perfusion pressure in cardiac surgical patients; despite that, the authors cannot recommend either of these drugs with respect to the risk of ischemic complications. The authors unanimously and strongly recommend against using dopamine for treating post-cardiac surgery vasoplegic shock and against using methylene blue for purposes other than a rescue therapy. The authors unanimously and weakly recommend that clinicians consider early addition of a second vasopressor (norepinephrine or vasopressin) if adequate vascular tone cannot be restored by a monotherapy with either norepinephrine or vasopressin and to consider using vasopressin as a first-line vasopressor or to add vasopressin to norepinephrine in cardiac surgical patients with pulmonary hypertension or right-sided heart dysfunction. [ABSTRACT FROM AUTHOR]

In minimally invasive surgical ablation for atrial fibrillation during video-assisted thoracoscopy surgery, one-lung ventilation (OLV) with a double- lumen tube is commonly employed. In contrast with the majority of thoracic procedures, the patient lies supine; thus, the protective effect of gravity is lost and intrapulmonary shunt remains high. To decrease intrapulmonary shunt and to increase oxygenation, many strategies are utilized: high inspiratory fraction of oxygen (F I O 2), positive end-expiratory pressure on the ventilated lung, and continuous positive airway pressure (CPAP) on the deflated lung. The authors performed a prospective, single- center, randomized study to evaluate the effect of additional CPAP in the nonventilated lung on oxygen delivery during surgical ablation for atrial fibrillation via video-assisted thoracoscopy in the supine position. University hospital Centro Cardiologico Monzino IRCCS, Milano, Italy. Twenty-two patients scheduled for minimally invasive surgical ablation for atrial fibrillation. The patients underwent pressure-controlled ventilation, adjusting inspiratory pressure to obtain a tidal volume of 7 mL/kg while keeping F I O 2 constantly 1.0, a respiratory rate to maintain arterial partial pressure of carbon dioxide (PaCO 2) between 35 and 40 mmHg, and positive end-expiratory pressure of 5 cmH 2 O. During OLV, inspiratory pressure was reduced to obtain a tidal volume of 5 mL/kg, maintaining F I O 2 of 1.0, a respiratory rate to maintain PaCO 2 between 35 and 40 mmHg with capnothorax of 10 cmH 2 O. The patients were then randomized into the CPAP group (CPAP 10 cmH 2 0 on deflated lung) and NO CPAP group. Inotropic agents (dopamine or dobutamine) were used if cardiac index fell below 1.5 L/min/m2. Twenty-two patients were enrolled, randomized, and completed the study. Median age was 62 years. The difference in arterial partial pressure of oxygen between the 2 groups was shy of significance, p = 0.16. Cardiac index progressively increased during OLV until the end of the procedure in both groups (p < 0.01) and was maintained above 1.5 mL/min/m2 during the whole study time. Arterial oxygen content remained stable during the entire procedure in both groups (p = 0.27). Oxygen delivery index (DO 2 I) increased significantly during the procedure (p < 0.01); nevertheless, the difference in DO 2 I between the CPAP and NO CPAP group was nonsignificant (p = 0.61). Intrapulmonary shunt (Q s /Q t) increased during OLV (p < 0.01 for the time effect) and remained high until total lung ventilation was reintroduced. No difference in Q s /Q t was observed between the CPAP and NO CPAP groups (p = 0.98). Similarly, mean pulmonary artery pressure increased significantly during OLV and remained high at the end of the procedure in both groups (time effect p < 0.01). During OLV for atrial fibrillation surgical ablation in the supine position, CPAP on the deflated lung seemed to be ineffective to reduce Q s /Q t or to increase arterial partial pressure of oxygen and DO 2 I, provided cardiac output was maintained above 1.5 L/min/m2. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to determine if there is a direct relationship between the duration of cardiopulmonary bypass (CPB time [CPBT]) and postoperative morbidity and mortality in patients undergoing cardiac surgery. Design: Retrospective study. Setting: Cardiac surgery unit, university hospital. Participants: Five thousand six patients, New York Heart Association classes 1 through 4, who underwent cardiac surgery between January 2002 and March 2008. Interventions: All patients were subjected to CPB. Measurements and Main Results: The mean CPBT was 115 minutes (median 106). One hundred thirty-one patients (2.6%) died during the same hospitalization. The postoperative median blood loss was 600 mL. Reoperations for bleeding occurred in 193 patients (3.9%), and 1,001 patients received 3 or more units of red blood cells. There were 108 patients (2.2%) with neurologic sequelae, 391 patients (7.8%) with renal complications, 37 patients (0.7%) with abdominal complications, and 184 patients (3.7%) with respiratory complications. Seventy-two patients (1.4%) had an infective complication, and 80 patients (1.6%) had a postoperative multiorgan failure. The multivariate analysis confirmed the role of CPBT, considered in 30-minute increments, as an independent risk factor for postoperative death (odds ratio [OR] = 1.57, p < 0.0001), pulmonary (OR = 1.17, p < 0.0001), renal (OR 1.31, p < 0.0001), and neurologic complications (OR = 1.28, p < 0.0001), multiorgan failure (OR = 1.21, p < 0.0001), reoperation for bleeding (OR = 1.1, p = 0.0165), and multiple blood transfusions (OR = 1.58, p < 0.0001). Conclusions: Prolonged CPB duration independently predicts postoperative morbidity and mortality after cardiac surgery. [Copyright &y& Elsevier]

Objectives: To assess if 2 different anesthesia strategies, high-thoracic epidural anesthesia (HTEA) plus inhalation anesthesia and total intravenous anesthesia (TIVA) with sufentanil/propofol had different influence on outcomes of coronary artery bypass graft (CABG) surgery patients. Design: Retrospective comparison of outcomes between HTEA and TIVA patients using propensity score pair-wise matching of patients. Setting: A university teaching hospital. Participants: A study of 1,473 consecutive patients undergoing elective CABG surgery; of these, 476 (32%) received HTEA combined with inhalation anesthesia, whereas 997 (68%) underwent TIVA alone. Interventions: The patients undergoing CABG surgery were offered the epidural-inhalation anesthetic approach. Measurements and Main Results: Propensity matching yielded 389 pairs of patients. Patients were well matched in preoperative and operative features. Postoperative mortality, myocardial infarction, stroke, acute renal failure rates, and intensive care unit (ICU) stay were not statistically different in HTEA and TIVA groups. On the other hand, patients treated with HTEA had shorter ventilation times (5.8 ± 3.11 v 6.9 ± 5.0 hours, HTEA and TIVA, respectively, p < 0.001); in addition, vasoconstrictors were more frequently used in cases of HTEA, whereas vasodilators were mainly used with TIVA both intra- and postoperatively. No neurologic complications related to the use of HTEA were observed. Conclusions: HTEA and TIVA provided similar early outcomes after CABG surgery, and there were no major differences between these 2 strategies in the average risk CABG patient populations. Although HTEA did not cause neurologic problems and yielded a significant reduction in time to extubation, a consistent benefit over standard techniques could not be shown. [Copyright &y& Elsevier]

Background: Conventional on-pump coronary artery bypass grafting (CABG) is associated with a systemic inflammatory response and by an increased production of reactive oxygen species, whereas off-pump coronary artery bypass grafting (OPCAB) is thought to be accompanied by less oxidative stress. Urinary isoprostane iPF2α-III is a new marker reflecting oxidative stress; it has emerged as the most reliable marker of oxidative stress status in vivo. This study was designed to ascertain whether OPCAB compared with CABG represents a surgical strategy that avoids oxidative stress. To this end urinary isoprostanes and other established oxidative stress markers were measured during the first 24 hours after CABG and OPCAB. Methods: Fifty low-risk coronary patients were randomly assigned to CABG or OPCAB. Urinary isoprostane iPF2α-III levels, plasma levels of free malondialdehyde, and total antioxidant status were measured before, during, and up to 24 hours after surgery. Results: In OPCAB iPF2α-III excretion remained unchanged throughout the study. As expected, in CABG iPF2α-III levels significantly increased during surgery and returned at baseline 24 hours later. Free malondialdehyde behaved similarly, with no change in OPCAB and sharp increases during CABG. Conversely, total antioxidant status showed a sharp drop during CABG, followed by a slow recovery, whereas a significantly lower drop occurred in OPCAB. Conclusions: In this randomized study in low-risk coronary patients, OPCAB revealed less perioperative oxidative stress, as reflected by lack of excretion of iPF2α-III in urine, by lack of increase of plasma free malondialdehyde, and by lower decreases in plasma total antioxidant status. [Copyright &y& Elsevier]