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Background The management of anticoagulation for mechanical heart valves during pregnancy poses a unique challenge. Mechanical valve thrombosis is a devastating complication for which surgery is often the treatment of choice. However, cardiac surgery for prosthetic valve dysfunction in pregnant patients confers a high risk of maternofetal morbidity and mortality. Case summary A 39-year-old woman in her first pregnancy at 30 weeks gestation presented to hospital with a mechanical mitral valve thrombosis despite therapeutic anticoagulation with low-molecular-weight heparin. She underwent an emergent caesarean section followed immediately by a bioprosthetic mitral valve replacement. This occurred after careful planning and organization on the part of a large multidisciplinary team. Discussion A proactive, rather than reactive, approach to the surgical management of a mechanical valve thrombosis in pregnancy will maximize the chances of successful maternal and fetal outcomes.

Purpose Reduction of right ventricular (RV) function after cardiac surgery has been shown to impact outcomes. Conventional indices for right ventricular dysfunction are validated using transthoracic echocardiogram (TTE) which has limited use compared to transesophageal echocardiogram (TEE) in the perioperative settings. The aim of this study was to assess the agreement of RV systolic function assessment with TEE compared to TTE and assess the association of echocardiographic parameter with hemodynamic indices of RV dysfunction. Method This was a single center prospective observational study in an academic institution. Fifty adult patients undergoing elective cardiac surgery were included. TTE, TEE and stroke volume measurements pre-cardiopulmonary bypass (CPB) and post-CPB were performed. The variables of interest were anatomical M-mode tricuspid annular plane systolic excursion (AMM-TAPSE), fractional area change (FAC), tricuspid annular velocity (S’) and myocardial performance index (MPI). Results FAC and AMM-TAPSE measured at the mid-esophageal 4 chamber view had substantial agreement with the TTE acquired parameters (Lin’s concordance correlation coefficient (CCC) = 0.76, 95%CI 0.59-0.86 and CCC = 0.85, 95%CI 0.76-0.91). S’ was significantly underestimated by TEE (CCC = 0.07, 95%CI -0.04-0.19) and MPI showed moderate agreement (CCC = 0.45 95%CI 0.19-0.65). Despite the significant changes in echocardiographic parameters, there were no corresponding changes in stroke volume (SV) or pulmonary artery pulsatility index at the post-CPB period. Conclusions TEE acquired FAC and AMM-TAPSE had substantial agreement with pre-operative TTE values and no significant differences between the pre-CPB and post-CPB period. Systolic RV echocardiographic parameters decreased post-CPB but this was not accompanied by significant hemodynamic changes.

Left ventricular noncompaction (LVNC) is described as a cardiomyopathy with an increase in left ventricle trabeculations and recesses. We report a rare case of persistent pregnancy-acquired LVNC cardiomyopathy and review the anesthetic peripartum management strategies. A 33-year-old parturient was followed closely by the high-risk obstetric service for her second pregnancy. She had an unresolved LVNC cardiomyopathy that was diagnosed during her first pregnancy for which she had a caesarean section. Her symptoms included occasional palpitations and dyspnea. She was started on metoprolol and enoxaparin. A successful caesarean section was performed at 37 weeks gestation under regional anesthesia. Echocardiograms prior to and during the second pregnancy demonstrated persistence of the LV hypertrabeculations, LV systolic dysfunction, and a left ventricular ejection fraction (LVEF) of 35%. Pregnancy-induced LV hypertrabeculations occur in a significant proportion of women, but most cases spontaneously resolve completely. Favorable maternal and fetal outcomes require multidisciplinary care and careful selection of the anesthetic technique and drugs that maintain stable hemodynamics.

Background Hyperinsulinemic normoglycemia augments myocardial glucose uptake and utilization. We tested the hypothesis that hyperinsulinemic normoglycemia reduces 30-day mortality and morbidity after cardiac surgery. Methods This dual-center, parallel-group, superiority trial randomized cardiac surgical patients between August 2007 and March 2015 at the Cleveland Clinic, Cleveland, Ohio, and Royal Victoria Hospital, Montreal, Canada, to intraoperative glycemic management with (1) hyperinsulinemic normoglycemia, a fixed high-dose insulin and concomitant variable glucose infusion titrated to glucose concentrations of 80 to 110 mg · dl–1; or (2) standard glycemic management, low-dose insulin infusion targeting glucose greater than 150 mg · dl–1. The primary outcome was a composite of 30-day mortality, mechanical circulatory support, infection, renal or neurologic morbidity. Interim analyses were planned at each 12.5% enrollment of a maximum 2,790 patients. Results At the third interim analysis (n = 1,439; hyperinsulinemic normoglycemia, 709, standard glycemic management, 730; 52% of planned maximum), the efficacy boundary was crossed and study stopped per protocol. Time-weighted average glucose concentration (means ± SDs) with hyperinsulinemic normoglycemia was 108 ± 20 versus 150 ± 33 mg · dl–1 with standard glycemic management, P < 0.001. At least one component of the composite outcome occurred in 49 (6.9%) patients receiving hyperinsulinemic normoglycemia versus 82 (11.2%) receiving standard glucose management (P < efficacy boundary 0.0085); estimated relative risk (95% interim-adjusted CI) 0.62 (0.39 to 0.97), P = 0.0043. There was a treatment-by-site interaction (P = 0.063); relative risk for the composite outcome was 0.49 (0.26 to 0.91, P = 0.0007, n = 921) at Royal Victoria Hospital, but 0.96 (0.41 to 2.24, P = 0.89, n = 518) at the Cleveland Clinic. Severe hypoglycemia (less than 40 mg · dl–1) occurred in 6 (0.9%) patients. Conclusions Intraoperative hyperinsulinemic normoglycemia reduced mortality and morbidity after cardiac surgery. Providing exogenous glucose while targeting normoglycemia may be preferable to simply normalizing glucose concentrations.

Cardiac surgery triggers an inflammatory stress response, leading to protein catabolism, a process that even high-dose insulin therapy alone cannot reverse. To determine whether hyperinsulinemic-normoglycemic clamp and perioperative amino acid (AA) supplementation improves whole body protein balance, 20 patients scheduled for elective coronary artery bypass grafting surgery were randomly assigned to have intra- and postoperative hyperinsulinemic-normoglycemic clamp, with or without intravenous AA supplementation. Primed continuous infusions of [6,6-2H2]glucose and l-[1-13C]leucine were used to quantify whole body protein and glucose metabolism before and after surgery. Adipose tissue and serum cytokines were also analyzed to measure their responsiveness to the anabolic effect of AA administration. During hyperinsulinemic-normoglycemic clamp, AA supplementation successfully stimulated whole body protein synthesis, resulting in a positive whole body protein balance after surgery (insulin: −13.6 ± 4.5 vs. insulin + AA: 2.1 ± 5.4 μmol·kg−1·h−1, P < 0.001). Endogenous glucose production was equally suppressed in both groups (insulin: 0.0 ± 3.8 vs. insulin + AA 1.6 ± 1.6 μmol·kg−1·min−1, P = 0.230). AA supplementation led to significant changes in serum and tissue IL-6 (insulin: 246.6 ± 111.2 vs. insulin + AA: 124.5 ± 79.3 pg/ml, P = 0.011). In conclusion, hyperinsulinemic-normoglycemic clamp technique, together with AA supplementation, can induce an anabolic state after open-heart surgery, as quantified by a positive whole body protein balance.

Introduction Few bioprosthetic valved conduits for aortic root surgery are commercially available. Long-term Warfarin therapy (mechanical), potential root calcification (xeno- or homograft valves), and the need for additional ascending aorta grafts are concerns associated with currently used valved conduits. A simplified, self-assembled bioroot conduit comprising currently available materials that facilitates future intervention and exhibits advantages of a bioprosthesis was used. Methods From November 2015 to January 2017, 17 consecutive patients underwent urgent or elective aortic root surgery. A bioroot conduit, constructed using 28 or 30 mm of sinus of Valsalva Gelweave tube graft and a 3 to 5 mm smaller bioprosthetic Trifecta valve sewn into the sinus of Valsalva base, was preconstructed in the operating room before sternotomy. The size of the valved conduit was based on the distal ascending aorta or proximal arch and not aortic annular dimension. The bioroot was sutured to the native aortic annulus at the level of the bottom skirt of the Valsalva graft without contacting the sewing cuff of the bioprosthetic valve. Results All patients survived the operation and were discharged home without long-term anticoagulation therapy. The mean age was 65 ± 12 years, and 13 patients were male. The cardiopulmonary bypass duration was 169 ± 84 minutes, and the cross-clamp (XC) duration was 110 ± 32 minutes. The operation was elective in 12 patients, urgent/emergent in five, and redo in three. Conclusion A simplified self-assembled bioroot Bentall conduit is appropriate for aortic root reconstruction. Use of a patient-tailored valved conduit will not prolong the cardiac ischemic time and will facilitate future valve replacement.

Hyperinsulinemic normoglycemia augments myocardial glucose uptake and utilization. We tested the hypothesis that hyperinsulinemic normoglycemia reduces 30-day mortality and morbidity after cardiac surgery.This dual-center, parallel-group, superiority trial randomized cardiac surgical patients between August 2007 and March 2015 at the Cleveland Clinic, Cleveland, Ohio, and Royal Victoria Hospital, Montreal, Canada, to intraoperative glycemic management with (1) hyperinsulinemic normoglycemia, a fixed high-dose insulin and concomitant variable glucose infusion titrated to glucose concentrations of 80 to 110 mg · dl; or (2) standard glycemic management, low-dose insulin infusion targeting glucose greater than 150 mg · dl. The primary outcome was a composite of 30-day mortality, mechanical circulatory support, infection, renal or neurologic morbidity. Interim analyses were planned at each 12.5% enrollment of a maximum 2,790 patients.At the third interim analysis (n = 1,439; hyperinsulinemic normoglycemia, 709, standard glycemic management, 730; 52% of planned maximum), the efficacy boundary was crossed and study stopped per protocol. Time-weighted average glucose concentration (means ± SDs) with hyperinsulinemic normoglycemia was 108 ± 20 versus 150 ± 33 mg · dl with standard glycemic management, P0.001. At least one component of the composite outcome occurred in 49 (6.9%) patients receiving hyperinsulinemic normoglycemia versus 82 (11.2%) receiving standard glucose management (Pefficacy boundary 0.0085); estimated relative risk (95% interim-adjusted CI) 0.62 (0.39 to 0.97), P = 0.0043. There was a treatment-by-site interaction (P = 0.063); relative risk for the composite outcome was 0.49 (0.26 to 0.91, P = 0.0007, n = 921) at Royal Victoria Hospital, but 0.96 (0.41 to 2.24, P = 0.89, n = 518) at the Cleveland Clinic. Severe hypoglycemia (less than 40 mg · dl) occurred in 6 (0.9%) patients.Intraoperative hyperinsulinemic normoglycemia reduced mortality and morbidity after cardiac surgery. Providing exogenous glucose while targeting normoglycemia may be preferable to simply normalizing glucose concentrations.

The incidence of delayed graft function in patients undergoing kidney transplantation remains significant. Optimal fluid therapy has been shown to decrease delayed graft function after renal transplantation. Traditionally, the perioperative volume infusion regimen in this patient population has been guided by central venous pressure as an estimation of the patient’s volume status and mean arterial pressure, but this is based on sparse evidence from mostly retrospective observational studies. Excessive volume infusion to the point of no further fluid responsiveness can damage the endothelial glycocalyx and is no longer considered to be the best approach. However, achievement of adequate flow to maintain sufficient tissue perfusion without maximization of cardiac filling remains a challenge. Novel minimally invasive technologies seem to reliably assess volume responsiveness, heart function and perfusion adequacy. Prospective comparative clinical studies are required to better understand the use of dynamic analyses of flow parameters for adequate fluid management in kidney transplant recipients. We review perioperative fluid assessment techniques and discuss conventional and novel monitoring strategies in the kidney transplant recipient.

We investigated the effect of insulin administered as part of a hyperinsulinemic-normoglycemic clamp on protein metabolism after coronary artery bypass grafting (CABG) surgery. Eighteen patients were studied, with nine patients in the control group receiving standard metabolic care and nine patients receiving insulin (5 mU·kg−1·min−1). Whole body glucose production, protein breakdown, synthesis, and oxidation were determined using stable isotope tracer kinetics (l-[1-13C]leucine, [6,6-2H2]glucose) before and 6 h after the procedure. Plasma amino acids, cortisol, and lactate were also measured. Endogenous glucose production (preoperatively 10.0 ± 1.6, postoperatively 3.7 ± 2.5 μmol·kg−1·min−1; P = 0.0001), protein breakdown (preoperatively 105.3 ± 9.8, postoperatively 85.2 ± 9.2 mmol·kg−1·h−1; P = 0.0005) and synthesis (preoperatively 88.7 ± 8.7, postoperatively 72.4 ± 8.4 mmol·kg−1·h−1; P = 0.0005) decreased in the presence of hyperinsulinemia, whereas both parameters remained unchanged in the control group. A positive correlation between endogenous glucose production and protein breakdown was observed in the insulin group ( r2 = 0.385). Whole body protein oxidation and balance decreased after surgery in patients receiving insulin without reaching statistical significance. In the insulin group the plasma concentrations of 13 of 20 essential and nonessential amino acids decreased to a significantly greater extent than in the control group. In summary, supraphysiological hyperinsulinemia, while maintaining normoglycemia, decreased whole body protein breakdown and synthesis in patients undergoing CABG surgery. However, net protein balance remained negative.

A prolonged seated time after intrathecal injection of hyperbaric bupivacaine and morphine is related to the incidence of hypotension during Cesarean delivery, but results in a high incidence of pain during peritoneal closure. We conducted this study to determine the effect of the addition of intrathecal fentanyl on the relationship between seated time and hypotension and intraoperative analgesia requirements. Women undergoing Cesarean delivery were randomized to receive an intrathecal injection of either 11.25 or 15 mg of hyperbaric bupivacaine with morphine 150 µg and fentanyl 15 µg using a combined spinal-epidural technique. The seated duration following intrathecal injection was assigned using up-down methodology. If the preceding patient was hypo- or normotensive, the next patient sat for 15 sec more or less, respectively. A systolic blood pressure < 80% of the preoperative value was defined as hypotension; a standardized anesthetic was administered, and the presence of pain during the procedure was recorded. Isotonic regression of pooled adjacent violators was used to determine the time at which 50% of each group would avoid hypotension (i.e., the median effective seated time). There were 15 patients in each group. The median seated time was 129 sec (95% confidence interval [CI], 116 to 150) for the 11.25-mg group and 459 sec (95% CI, 444 to 471) for the 15-mg group. Only one (3%) of the 30 patients in the study had pain on peritoneal closure, and this was successfully treated with intravenous fentanyl. We have determined the seated time required following intrathecal injection of hyperbaric bupivacaine, morphine, and fentanyl to prevent hypotension in 50% of patients undergoing Cesarean delivery. www.clinicaltrials.gov , NCT01896960. Registered 2 July 2013.

Extending the time a parturient is left sitting after induction of spinal anesthesia (i.e., the seated time) has had varying success in decreasing hypotension at Cesarean delivery. This may be due to the current lack of information concerning the dose-response relationship of seated time and rates of hypotension.Term parturients scheduled for Cesarean delivery were randomized to receive 11.25 or 15.0 mg of 0.75% intrathecal hyperbaric bupivacaine, and they remained seated after injection for a length of time determined by an up-down sequential method. They were then placed in a wedged position and their blood pressure was measured every minute. Pre-delivery hypotension was considered present if there was a 20% from baseline drop in systolic blood pressure. The seated time at which 50% of parturients avoided pre-delivery hypotension (median effective seated time) was determined with isotonic regression.Fifty patients were studied. For the 11.25-mg and 15.0-mg groups, the median effective seated time (95% confidence interval [CI]) was 130 sec (95% CI 117 to 150) and 385 sec (95% CI 381 to 396), respectively.There exists a seated time after intrathecal injection of hyperbaric bupivacaine where 50% of parturients do not experience hypotension. This seated time increases with an increased dose of bupivacaine. Further work is required to determine the full relationship between seated time and hypotension for other doses of anesthetic and to investigate the clinical utility of this technique for prevention of hypotension. This trial was registered at www.clinicaltrials.gov (NCT01561274).

c a m HYPERGLYCEMIA CAN OCCUR as part of the catabolic response to stress.1,2 Acute hyperglycemia is associated with a poor outcome and increased mortality under a variety of clinical conditions, most notably myocardial infarction, stroke, and major surgical tissue trauma.3-6 Data from hosital admissions indicate that nondiabetic patients with ewly diagnosed hyperglycemia have an increased risk of eath.7,8 However, the evidence supporting a link between diabetes mellitus (DM) and increased mortality in critically ill and surgical patients is not as strong.9-13 This may be caused partly by the underdiagnosis of DM and, thereby, falsely labeling diabetic patients as “nondiabetic.”11,13 Glycated hemoglobin, a marker of long-term glucose control, is a promising test to understand the complex relationship among glycemia, diabetes, and outcomes.14 It may allow the differentiation of patients with stress hyperglycemia from those with DM on admission and help the clinician to categorize patients metabolically. Furthermore, using glycated hemoglobin may allow for the improvement of glycemic control before surgery and, thus, potentially reduce postoperative morbidity. The authors reviewed the current literature regarding the association between hemoglobin A1c (HbA1c) and outcomes in the critically ill and surgical patient populations.

Albumin plasma concentrations are being used as indicators of nutritional status and hepatic function based on the assumption that plasma levels reflect the rate of albumin synthesis. However, it has been shown that albumin levels are not reliable markers of albumin synthesis under a variety of clinical conditions including inflammation, malnutrition, diabetes mellitus, liver disease, and surgical tissue trauma. To date, only a few studies have measured albumin synthesis in surgical and critically ill patients. This review summarizes the findings from these studies, which used different tracer methodology in various surgical or critically ill patient populations. The results indicate that the fractional synthesis rate of albumin appears to decrease during surgery, followed by an increase during the postoperative phase. In the early postoperative phase, albumin fractional synthesis rate can be stimulated by perioperative nutrition, if enough amino acids are being provided and if nutrition is being initiated before the operation. The physiologic meaning of albumin synthesis after surgery, however, still needs to be further clarified.

Objective We tested the hypothesis that the anabolic effect of hypocaloric, isonitrogenous nutrition in patients undergoing colorectal surgery depends on the patient's preoperative catabolic state. Background Although there is evidence to suggest that total parenteral nutrition more effectively spares protein in depleted than in nondepleted cancer patients, the influence of preoperative catabolism on the anabolic effects of hypocaloric nutrition in patients undergoing elective surgery is unknown. Methods Seventeen patients undergoing colorectal surgery received intravenous infusion of glucose with amino acids. Feeding was administered over 72 hours, from 24 hours before until 48 hours after surgery. Glucose provided 50% of the patient's measured resting energy expenditure. Amino acids provided 20% of the resting energy expenditure. Whole-body leucine balance (difference between the incorporation of leucine into protein = protein synthesis and endogenous leucine release = proteolysis) was determined using L-[1-(13)C]leucine kinetics before and 2 days after surgery. We analyzed the association between the postoperative increase in leucine balance and the following factors: preoperative leucine balance, protein breakdown, weight loss, oxygen consumption, circulating concentrations of glucose, free fatty acids, insulin, glucagon, cortisol, albumin, age, duration of surgery, and blood loss. Results Of 6 potentially relevant variables, 4 (weight loss, protein breakdown, albumin, and cortisol) were removed because they were not significant during the stepwise linear regression procedure. Leucine balance and age were the remaining 2 factors that remained with the final regression model: Δleucine balance = 19.1 - (0.20 × age [years]) - (0.58) × leucine balance(preOP)). Conclusions We demonstrate a significant association between the degree of preoperative catabolism, the patient's age, and the anabolic effect of hypocaloric nutrition (ClinicalTrials.gov registration ID: NCT01414946).

Objective To test the hypothesis that the intravenous administration of high doses of insulin while maintaining normoglycemia (GIN therapy) improves myocardial function after coronary artery bypass graft (CABG) surgery. Design A prospective, randomized clinical trial. Setting A university hospital. Participants Forty patients undergoing elective CABG surgery. Interventions Patients were randomized to the GIN or control group. Applying the principles of the hyperinsulinemic-normoglycemic clamp technique in the GIN group, insulin was administered at 5 mU/kg/min during surgery. Glucose 20% was infused at a rate adjusted to maintain blood glucose (BG) between 4.0 and 6.0 mmol/L. Patients in the control group received insulin on a sliding scale, also aiming at normoglycemia. Measurements and Main Results Systemic hemodynamic parameters included heart rate, mean arterial pressure, pulmonary artery wedge pressure, vascular resistance index, and cardiac index (CI). Left ventricular function was assessed by transesophageal echocardiography using the myocardial performance index (MPI) as a parameter of global left ventricular function, the fractional area change (FAC) for systolic function, and flow propagation velocity for diastolic function before and after surgery. All patients receiving GIN therapy were hyperinsulinemic (3,474 ± 1,204 pmol/L) and normoglycemic, showing a lower mean BG concentration (4.9 ± 0.5 mmol/L) than patients in the control group (8.2 ± 2.0 mmol/L). Patients receiving GIN therapy had an increased CI after surgery compared with the control group (p = 0.005). The GIN therapy was associated with improved MPI and FAC values when compared with standard care. Also, there was no difference in the parameters indicating left ventricular diastolic function. Conclusions Intraoperative GIN therapy improves global and systolic left ventricular function after CABG surgery.

Although the effects of insulin on glucose homeostasis are well recognized in surgical patients, its effect on perioperative protein metabolism has received little attention. The purpose of this study was to examine the effect of high-dose insulin therapy on the plasma concentrations of amino acids (AAs) in patients undergoing coronary artery bypass grafting surgery. We studied 20 nondiabetic patients scheduled for elective coronary artery bypass grafting surgery. Patients were randomly allocated to receive either standard metabolic care (target glycemia 6.0-10.0 mmol/L, control group, n = 10) or high-dose insulin therapy (insulin group, n = 10). Insulin was administered at 5 mU·kg(-1)·min(-1) beginning at skin incision. Simultaneously, 20% dextrose was infused at a variable rate adjusted to maintain glycemia between 4.0 and 6.0 mmol/L. Plasma AAs, glucose, cortisol, and insulin were measured immediately before surgery and at sternal closure. Differences in mean values were assessed by Student t test. Plasma concentrations of all AAs decreased in the insulin group, with 15 of 22 AAs, including all branched-chain AAs, being significantly lower at sternal closure when compared with the control group. At the end of surgery, plasma glucose concentration was significantly lower in the insulin group (4.2 ± 0.6 vs 7.3 ± 1.0 mmol/L, P = .0001), whereas plasma cortisol levels did not show any difference between groups. High-dose insulin therapy resulted in a significant reduction in plasma AAs, particularly branched-chain AAs, during cardiac surgery.

Coronary artery bypass grafting (CABG) is complicated by ischemia-reperfusion injury jeopardizing myocyte survival.The aim of the study was to investigate whether glucose and insulin administration, while maintaining normoglycemia (GIN therapy) using a hyperinsulinemic-normoglycemic clamp technique, is cardioprotective in patients undergoing CABG.We conducted a randomized controlled trial at a tertiary care university teaching hospital.We studied 99 patients undergoing elective CABG.Patients were randomly assigned to receive either GIN from the beginning of surgery until 24 h after CABG (GIN, n = 49) or standard metabolic care (control, n = 50).We measured plasma concentrations of cardiac troponin I and free fatty acids, cardiac function as assessed by transesophageal echocardiography, glycogen content, glycogen synthase activity, and the expression of AMP-activated protein kinase (AMPK) and protein kinase B (AKT) in cardiomyocytes.Patients receiving GIN therapy showed an attenuated release of cardiac troponin I (P0.05) and improved myocardial function (P0.05). Systemic free fatty acid concentrations were suppressed (P0.05), whereas intracellular glycogen content and glycogen synthase activity were not altered. The AMPK activity remained unchanged during ischemia in the GIN group, whereas it increased in the control group (P0.05). Enhanced AKT phosphorylation before ischemia was observed (P0.05) in the presence of GIN. However, there was no evidence for AKT-dependent AMPK inhibition.GIN therapy protects the myocardium and inhibits ischemia-induced AMPK activation.

Objective The incidence of diabetes mellitus (DM) is increasing worldwide; however, its diagnosis is often delayed. Identifying patients with abnormal fasting blood glucose (FBG) levels preoperatively may have important implications for immediate and long-term outcomes. The aim of the present study was to determine the prevalence of impaired fasting glucose (IFG) and provisional diagnosis of DM (PDD) with potential risk factors in patients presenting for elective surgery. Methods We measured FBG in consecutive adult patients undergoing elective non-cardiac surgery from September 2006 to August 2007. Patient age, sex, body mass index, and FBG were collected in the morning of their scheduled intervention. FBG was classified according to the World Health Organization categorization. Patients with a history of DM were excluded from the final analysis. The prevalence of IFG and PDD and odds ratio for risk factors were calculated. Results Four hundred ninety-three patients without a prior diagnosis of DM were sampled; 19.3% (95 of 493) had IFG and 6.5% (32 of 493) had PDD. Male subjects had a greater risk of PDD than female subjects (odds ratio 2.5, 95% confidence interval 1.2–5.5, P = 0.017). Increased body mass index was not a risk factor for IFG or PDD. The prevalence of IFG but not of PDD had a tendency to increase with age after 40 y. Conclusion More than 25% of patients without a prior diagnosis of DM presenting for elective surgery had increased FBG levels. Obtaining this information may initiate not only an earlier detection of DM in some patients but also affect acute perioperative management and outcomes.

Background— Management of severe ischemic mitral regurgitation remains difficult with disappointing early and intermediate-term surgical results of valve repair. Methods and Results— Forty-four patients with severe (4+) Carpentier type IIIb ischemic mitral regurgitation underwent mitral valve repair, with or without surgical revascularization, by posterior leaflet extension with a patch of bovine pericardium and a remodeling annuloplasty. Serial echocardiography was performed preoperatively, intraoperatively, and postoperatively to assess mitral valve competence. The postoperative functional status of patients was assessed. The average Parsonnet score was 38±13. Thirty-day mortality was 11%, and late mortality was 14%. Mean follow-up was 38 months. The actuarial freedom from moderate or severe recurrent mitral regurgitation was 90% at 2 years, whereas 90% of patients were in New York Heart Association class I at 2 years. Conclusion— Posterior leaflet extension with annuloplasty of the mitral valve for severe type IIIb ischemic regurgitation is a safe, effective method that provides good early and intermediate-term competence of the mitral valve and therefore good functional status.

An 82-yr-old male (who consented to this report) was scheduled to undergo aortic valve replacement for aortic stenosis and coronary artery bypass surgery. After induction of general anesthesia, an 8.5 Fr percutaneous sheath introducer (Arrow International, PA, USA) was inserted into the right internal jugular vein under ultrasound guidance. A 7.5 Fr pulmonary artery catheter (PAC) (Biosensors International, Singapore) was then threaded through the sheath to 54 cm without difficulty and without wedging. A routine postoperative chest x-ray showed what appeared to be a semi-loop of the PAC in the right ventricle with the distal tip in the main pulmonary artery. On postoperative day 1, resistance was encountered on removal of the PAC, and a subsequent chest x-ray confirmed a knot at the distal end of the introducer sheath (Figure). As a result, the introducer sheath and PAC were removed via a transverse jugular venotomy under general anesthesia, and the patient was discharged home on postoperative day 5 without further complications. Many previous reports have described various knotted intravascular devices, including arteriography catheters, central venous infusion catheters, guidewires, pacemaker electrodes, and PACs. Ours is a novel report describing a knotted introducer sheath with a PAC within it. Management of knotted intravascular devices includes percutaneous techniques performed in the interventional radiology suite or surgical intervention. The initial postoperative chest x-ray showing a semi-loop formation in the right ventricle should have triggered removal of the PAC under fluoroscopic guidance using an appropriate guidewire. This may have prevented the subsequent need for surgery.

Emergence agitation can occur following recovery from general anaesthesia. The patient may exhibit aggressive behaviour, disorientation, agitation and restlessness. Untreated, this complication may result in significant morbidity. We report two cases where droperidol was successfully used in the management of severe emergence agitation. In the first case, droperidol was administered to prevent the occurrence of postoperative agitation in a patient known to suffer from this condition following previous general anaesthetics. In the second case, droperidol was used to treat emergence agitation in a morbidly obese patient with a difficult airway who was aggressive and difficult to restrain. Both of these patients remained calm and co-operative, with stable cardio-respiratory parameters, following the administration of droperidol and showed no further signs of agitation. We suggest that droperidol is an effective medication that may be used to prevent and treat severe emergence agitation due to its rapid sedative effect and minimal cardio-respiratory depression.

To describe the cardiovascular effects of neuraxial blockade in a heart transplant patient.A 69-yr-old 70-kg male underwent orthotopic heart transplant (bicaval anastomosis technique) for ischemic cardiomyopathy. Five months after transplantation, the patient underwent a transurethral bladder tumour resection under spinal anesthesia. Two millilitres of bupivacaine 0.75% (15 mg) were injected intrathecally at L(3-4) and the patient remained seated for approximately 20 sec prior to assuming the lithotomy position. Subsequently, both blood pressure (BP) and heart rate (HR) diminished gradually (BP and HR immediately pre-spinal: 113 mmHg (mean arterial pressure) and 92 beats x min(-1), respectively; nadir BP and HR: 94 mmHg (16.8% decrease) 30 min postspinal and 73 beats x min(-1) (20.7% decrease) 40 min postspinal, respectively). HR and mean BP were highly correlated (r = 0.9410, P0.0001, R(2) = 0.8854). The dermatome level of neuraxial anesthesia, determined by sensitivity to pin prick, was T(8) (five minutes) and T(6) (ten minutes) postinjection of spinal anesthetic. Control patients (n = 10) undergoing elective urological procedures with identical anesthesia management demonstrated very similar cardiovascular responses.Although cardiac transplant patients may tolerate neuraxial anesthesia admirably, a fall in HR may ensue which theoretically could have important physiological consequences. It is argued that the change in HR in the transplanted patient was mediated by mechanisms intrinsic to the transplanted heart and/or by reduced catecholamine secretion from the adrenal medulla. It is emphasized that HR changes observed in cardiac transplant patients do not necessarily imply reinnervation of the transplanted organ.

ObjectiveThe hyperglycemic response to surgery may be a risk factor for cognitive dysfunction. We hypothesize that strict maintenance of normoglycemia during cardiac surgery preserves postoperative cognitive function.MethodsAs part of a larger randomized, single-blind, interventional efficacy study on the effects of hyperinsulinemic glucose control in cardiac surgery (NCT00524472), consenting patients were randomly assigned to receive combined administration of insulin and glucose, titrated to preserve normoglycemia (3.5–6.1 mmol L−1; experimental group), or standard metabolic care (blood glucose 3.5–10 mmol L−1; control group), during open heart surgery. The patients’ cognitive function was assessed during three home visits, approximately two weeks before the operation, and two months and seven months after surgery. The following tests were performed: Rey Auditory Verbal Learning Task (RAVLT for verbal learning and memory), Digit Span Task (working memory), Trail Making A & B (visuomotor tracking and attention), and the Word Pair Task (implicit memory). Questionnaires measuring specific traits known to affect cognitive performance, such as self-esteem, depression, chronic stress and social support, were also administered. The primary outcome was to assess the effect of hyperinsulinemic-normoglycemic clamp therapy versus standard therapy on specific cognitive parameters in patients receiving normoglycemic clamp, or standard metabolic care.ResultsTwenty-six patients completed the study with 14 patients in the normoglycemia and 12 patients in the control group. Multiple analysis of covariance (MANCOVA) for the RAVLT showed a significant effect for the interaction of group by visit (F = 4.07, p = 0.035), and group by visit by recall (F = 2.21, p = 0.04). The differences occurred at the second and third visit. MANCOVA for the digit span task, trail making and word pair association test showed no significant effect.ConclusionsPreserving intraoperative normoglycemia by intravenous insulin and glucose may prevent the impairment of memory function, both short and long-term, after cardiac surgery. published

Introduction La dexamethasone (DX) est un corticosteroide synthetique recommande en prophylaxie des nausees et vomissements postoperatoires. En dehors du contexte perioperatoire, la DX inhibe la reponse inflammatoire et l’axe hypothalomo-hypophyso-surrenalien (HHS). Cependant, il existe peu de donnees sur ses effets perioperatoires. Nous avons emis l’hypothese qu’une dose antiemetique de DX inhiberait l’activation normale de l’axe HHS postoperatoire et diminuerait la reponse inflammatoire. Materiel et methodes Nous avons mene une etude randomisee a double insu, controlee contre placebo sur des femmes de classe ASA I ou II subissant une laparotomie gynecologique elective. Les patientes atteintes de cancer ou de diabete, prenant des corticosteroides ou ayant recu des transfusions sanguines ont ete exclues. L’approbation du comite local d’ethique et le consentement eclaire de chaque patiente ont ete obtenus. Les patientes ont ete randomisees en trois groupes et ont recu, immediatement apres l’induction de l’anesthesie generale, de la DX 0 mg (groupe 1), 4 mg (groupe 2) ou 8 mg (groupe 3) IV. Le reste des soins perioperatoires a ete standardise. Les patientes ont ete evaluees par questionnaire et par prises de sang avant l’operation et a 6 h, 24 h et 48 h apres l’operation. Le resultat primaire etait le niveau de cortisol a 24 h. Les resultats secondaires incluaient les niveaux d’ACTH, de glucose, de proteine C reactive (CRP), d’IL-6, d’IL-10 et l’hemogramme. Nous avons egalement evalue les scores de nausees et de douleur postoperatoires ainsi que les evenements indesirables durant l’hospitalisation. Resultats Sur les 63 patientes recrutees, 8 ont ete exclues suite a des transfusions sanguines et 1 suite a un diagnostic de cancer. Les caracteristiques de base etaient similaires dans les trois groupes. Les niveaux de cortisol etaient significativement diminues dans les groupes 2 et 3 par rapport au groupe 1 a 6 h (moyenne ± DS en nmol/L 402,3 ± 235,8 vs 486,8 ± 240,2 vs 744,7 ± 339,0, p p p p p Fig. 1 et 2 ). Discussion La DX perioperatoire a dose antiemetique cause une attenuation de l’activation de l’axe HHS comme en temoignent des niveaux de cortisol et d’ACTH diminues. Elle modifie significativement la reponse inflammatoire en diminuant la cytokine pro-inflammatoire IL-6 et en augmentant la cytokine anti-inflammatoire IL-10. Ces influences pourraient avoir des implications cliniques, entre autres sur les risques d’infections postoperatoires, la guerison des plaies ou les phenomenes metastatiques.

To investigate the association between preoperative left ventricular ejection function (LVEF) and whole-body insulin sensitivity during cardiac surgery.A prospective, non-randomized trial.A tertiary care hospital setting.Patients undergoing elective cardiac surgery.Consenting, non-diabetic patients scheduled for elective cardiac surgery requiring cardiopulmonary bypass (CPB) were assigned either to a group with normal LVEF (EF≥55%) or one with low LVEF (EF≤45%) as assessed by coronary angiography. Insulin sensitivity was assessed by the hyperinsulinemic-normoglycemic clamp technique before and towards the end of CPB. The association between LVEF and insulin sensitivity was tested using Student t-test.One hundred forty patients were studied, with 48 patients in the low and 92 patients in the normal LVEF group. Patient demographics were similar in both groups except for preoperative LVEF (p0.001). Before CPB, patients with normal LVEF showed higher insulin sensitivity when compared to patients with low LVEF (p = 0.04). Insulin sensitivity decreased towards the end of CPB (p0.001) in both groups, resulting in similar values.Poor preoperative left ventricular function is associated with reduced insulin sensitivity before the onset of CPB in cardiac surgery.

Albert R Moore, William Li Pi Shan, Roupen Hatzakorzian Department of Anaesthesia, McGill University Health Centre, Royal Victoria Hospital, Montreal, Quebec, Canada Background: Retrospective studies have associated early epidural analgesia with cesarean delivery, but prospective studies do not demonstrate a causal relationship. This suggests that there are other variables associated with early epidural analgesia that increase the risk of cesarean delivery. This study was undertaken to determine the characteristics associated with early epidural analgesia initiation. Methods: Information about women delivering at 37 weeks or greater gestation with epidural analgesia, who were not scheduled for cesarean delivery, was extracted from the McGill Obstetric and Neonatal Database. Patients were grouped into those who received epidural analgesia at a cervical dilation of ≤3 cm and >3 cm. Univariable and multivariable logistic regression was used to determine the maternal, neonatal, and labor characteristics that increased the risk of inclusion in the early epidural group. Results: Of the 13,119 patients analyzed, multivariable regression demonstrated odds ratios (OR) of 2.568, 5.915 and 10.410 for oxytocin augmentation, induction, and dinoprostone induction of labor (P < 0.001). Increasing parity decreased the odds of early epidural analgesia (OR 0.780, P < 0.001), while spontaneous rupture of membranes (OR 1.490) and rupture of membranes before labor commenced (OR 1.288) were also associated with early epidural analgesia (P < 0.001). Increasing maternal weight (OR 1.049, P = 0.002) and decreasing neonatal weight (OR 0.943, P < 0.001) were associated with increasing risk of early epidural analgesia. Conclusion: Labor augmentation and induction, nulliparity, rupture of membranes spontaneously and before labor starts, increasing maternal weight, and decreasing neonatal weight are associated with early epidural analgesia. Many of these variables are also associated with cesarean delivery. Keywords: early epidural analgesia, labor, pain, analgesia, outcomes

Takotsubo cardiomyopathy (TC) is described as transient ventricular dysfunction following emotional or physical trauma. A few reports have described patients with TC in association with various circumstances of thyrotoxicosis. We report an unusual case of TC in a patient with a large retrosternal goiter and normal thyroid function. We speculate that TC was triggered by compromise of tracheal flow induced by the goiter.A 68-yr-old woman without primary heart disease presented with cardiorespiratory collapse requiring ventilatory and cardiovascular support, including placement of an intra-aortic balloon pump. She was diagnosed with a severe form of TC based on characteristic echocardiography findings and clinical course. Within less than a week, her myocardial function completely normalized. The patient was later found to have a large retrosternal goiter compressing her trachea, though her thyroid function was normal. A total thyroidectomy was eventually performed, and she made a full recovery. Subsequently, the patient was found to have a positive JAK2 mutation for a myeloproliferative disorder.Takotsubo cardiomyopathy may be regarded as the final common pathway of cardiac dysfunction triggered by various stress conditions, in this case, a large retrosternal goiter not associated with thyrotoxicosis and likely exacerbated by severe leukocytosis related to a myeloproliferative disorder.

As Dr Messas et al point out in their letter about our article,1 surgeons should attempt to restore function when addressing mitral regurgitation. The mitral valve is complex, and more than 1 cause of mitral regurgitation can be present at any one time. Carpentier’s classification was revolutionary because it was the first functional classification that truly allowed surgeons to identify and use repair techniques that would render the valve competent independently from the pathogenesis of the regurgitation. Carpentier …

Objective Previous attempts to achieve tight glucose control in surgical patients were associated with a significant incidence of hypoglycemia. The purpose of this study was to evaluate the efficacy of perioperative glucose and insulin administration while maintaining normoglycemia using a hyperinsulinemic-normoglycemic clamp technique. Methods We studied 70 non-diabetic and 40 diabetic patients undergoing cardiac procedures. Before induction of anesthesia, insulin was administered at 5 mU · kg −1 · min −1 . Blood glucose (BG) concentrations were determined every 15–30 min. Dextrose 20% was infused at a rate adjusted to maintain BG within 3.5–6.1 mmol/L. At the end of surgery, insulin infusion was decreased to 1 mU · kg −1 · min −1 and continued for 24 h. The mean ± standard deviation of BG and the percentage of BG values within the target range were calculated perioperatively. Episodes of severe hypoglycemia, i.e., BG Results The mean BG remained within target at all times. Normoglycemia in non-diabetic patients was achieved in 92.8% of measurements during and in 83.2% after surgery. In diabetic patients 87.4% of values were within target intraoperatively and 76.7% after surgery. The rate of severe hypoglycemia was 2.7% (three patients). In non-diabetic patients the incidence of severe hypoglycemia was 0.2% of measurements during and 0.1% after surgery. Diabetic patients showed only one episode of severe hypoglycemia after surgery (0.1%). Conclusion Perioperative use of a hyperinsulinemic-normoglycemic clamp technique established and maintained normoglycemia in patients undergoing cardiac surgery with little risk of hypoglycemia.

Presenter un cas inhabituel ďatteinte des voies aeriennes superieures chez une patiente atteinte de la maladie de Graves. Nous avons pense que cette complication relevait, en partie, du traitement inadequat de ľhyperthyroidie. Une femme de 26 ans atteinte de la maladie de Graves a subi une thyroidectomie totale. Ľintubation fibroscopique vigile a ete tentee a cause ďun goitre important et ďorthopnee. Un œdeme des voies aeriennes superieures empechait le passage ďun tube endotracheal renforce de 7,5 mm. La patiente a ete intubee eveillee avec un tube endotracheal regulier de 7,5 mm sous laryngoscopie directe au-dessus ďune bougie de Eschmann. Elle a ete extubee dans la salle ďoperation a ľaide ďun tube ďechange. Deux heures plus tard, un stridor s’est developpe et une obstruction des voies aeriennes. Elle a ete difficilement reintubee sous laryngoscopie directe a cause ďun œdeme. Des signes de thyrotoxicose apparus a ce moment ont ete traites medicalement. Au troisieme jour postoperatoire, elle a subi une tracheostomie apres ľechec de ľextubation. Les voies aeriennes superieures etaient œdemateuses et le mouvement des cordes vocales minimal. Au neuvieme jour, la tracheostomie a ete reduite et la patiente a quitte ľhopital. Les cordes vocales etaient toujours œdematiees et peu mobiles. Trois semaines plus tard, la corde vocale droite bougeait normalement et la corde vocale gauche, faiblement. La canule de tracheostomie a ete retiree. Les patients atteints ďhyperthyroidie non controlee et ďun goitre important secondaires a la maladie de Graves peuvent avoir un œdeme des voies respiratoires superieures. Il faut penser a la possibilite ďobstruction et planifier une approche rigoureuse pour chaque etape de ľhospitalisation afin de traiter cette situation potentiellement dangereuse.

To the Editor, We read with interest the article by Abdelmalak et al. published recently in the Journal. Using retrospective registry data, the authors report the prevalence of undiagnosed diabetes in a large cohort of patients undergoing non-cardiac surgery. We commend the authors for their work on such a sizeable study population but would like to comment on three issues raised in the manuscript. First, the authors based the diagnosis of impaired fasting glucose (IFG) and diabetes mellitus (DM) on their patients’ most recent plasma glucose value prior to surgery; however, it remains unclear if the study patients were fasting at the time of blood glucose measurements and, if they were, for how long. The American Diabetes Association (ADA) criterion for the diagnosis of DM using fasting plasma glucose requires a fasting period of at least eight hours. Hence, not knowing the duration of fasting makes it difficult to differentiate between elevated, impaired, and normal fasting glucose. Second, the ADA stipulates that any method used to diagnose IFG or DM should be repeated at a later date to rule out laboratory error. Although this step was acknowledged by the authors, we would like to emphasize that a variable length of fasting as well as stress-induced changes in glycemia likely account for some of the abnormal plasma glucose levels found in this study. Measurement of hemoglobin A1c in future studies may further clarify the diagnosis. It is well documented that a large portion of adults with type 2 diabetes are unaware of their condition. This article does not state the actual manner in which each patient’s diabetic status was determined. It is not uncommon for patients with confirmed diabetic blood glucose levels not to consider themselves diabetic when being interviewed. It is therefore likely that a database registry underestimates the prevalence of DM, and this may account for a portion of the 10% DM reported in this study. We performed a prospective study in almost 500 patients (fasting [ eight hours) before surgery and showed that 26% of previously undiagnosed patients demonstrated blood glucose levels in the IFG or DM range. Similar to Abdelmalak et al.’s findings, male sex and older age were associated with a higher risk of hyperglycemia. Our study population, however, had a lower mean body mass index. We agree with the authors that pre-surgical identification of IFG and DM may be useful for predicting and influencing postoperative outcomes. We understand the inherent limitations of retrospective data analyses but caution against the premature labelling of patients as prediabetic and diabetic.