Hypercoagulation is common before and after cardiac surgery
using CPB. Even during CPB in fully heparinised patients
hypercoagulation may be detected. Further investigation to
clear up this fenomenon are needed. TEG is usable method for
screening of hypercoagulable states during cardiac surgery.
Advanced technologies (e.g. platelet mapping) are needed to
explain reason of hypercoagulability.
Endothelial protein C receptor (EPCR) is a transmembrane glycoprotein primarily localised on vessel endothelium. EPCR binds protein C (PC) on the endothelial surface and presents it to the thrombin/thrombomodulin complex. Thrombin activates PC to APC, which exerts anticoagulant and anti-inflammatory effect. Proteolysis of membrane-bound EPCR releases soluble EPCR which can be detected in plasmatic circulation. This reaction indirectly correlates with thrombin generation and can be interpreted as marker of endothelial activation during cardiopulmonary bypass (CPB).
Aim: To compare assessment of fibrinogen by thromboelastography with the standard von Clauss method. Methods: Observational prospective study. Results: Thromboelastography provides direct and complex evaluation of the entire coagulation cascade based upon changes in blood viscosity. It affects both platelets and plasma components. New application of this method measures fibrinogen contribution to coagulation as opposed to fibrinogen antigen levels measured by immunoassay. Paired samples from 117 patients before cardiopulmonary bypass were compared. A moderate correlation was found between fibrinogen and functional fibrinogen with a Spearman correlation coefficient of 0.476. Conclusion: The functional fibrinogen test is a valid point-of-care method for fibrinogen assay with a moderate correlation to the standard method.
Background The vacuum-asssited closure has represented an encouraging treatment modality in treatment of surgical site infection in cardiac surgery, providing superior results compared with conventional treatment strategies, particularly in the treatment of deep sternal wound infection. Methods From November 2004 to January 2007, 40 patients, undergoing VAC therapy (VAC system, KCI, Austria, Hartmann-Rico Inc., Czech Republic) for surgical site infection following cardiac surgery, were prospectively evaluated. Four patients (10%) were treated for extensive leg-wound infection, 10 (25%) were treated for superficial sternal wound infection and 26 (65%) for deep sternal wound infection. The median age was 69.9 +/- 9.7 years and the median BMI was 33.2 +/- 5.0 kg/m2. Twenty-three patients (57%) were women and diabetes was present in 22 patients (55%). The VAC was employed after the previous failure of the conventional treatment strategy in 7 patients (18%). Results Thirty-eight patients (95%) were successfully healed. Two patients (5%) died, both of deep sternal infetion consequences. The overall length of hospitalization was 36.4 +/- 22.6 days. The median number of dressing changes was 4.6 +/- 1.8. The median VAC treatment time until surgical closure was 9.7 +/- 3.9 days. The VAC therapy was solely used as a bridge to the definite wound closure. Four patients (10%) with a chronic fistula were re-admitted with the range of 1 to 12 months after the VAC therapy. Conclusion The VAC therapy is a safe and reliable option in the treatment of surgical site infection in the field of cardiac surgery. The VAC therapy can be considered as an effective adjunct to convetional treatment modalities for the therapy of extensive and life-threatening wound infection following cardiac surgery, particurlarly in the group of high-risk patients.
Cíl: Zhodnotit, jakou měrou ovlivňuje diabetes mellitus hojení sternotomie u pacientů podstupujících revaskularizaci myokardu, v případě použití dvou mamárních tepen odebraných jako skelet.Metodika: Retrospektivně byl zhodnocen soubor 300 po sobě jdoucích nemocných s ICHS, kteří podstoupili plánovanou revaskularizaci myokardu. Vstupním kritériem byl věk do 70 let (včetně), ejekční frakce levé komory nad 40 % a hemodynamicky významná stenóza v povodí obou větví levé koronární tepny. Skupinu A tvořilo 150 operovaných, u kterých byla arteria thoracica interna použita bilaterálně, odebraná jako skelet bez okolních tkání, skupinu B tvořilo 150 operovaných s použitou jednou arteria thoracica interna, odebranou jako pedikl s okolními tkáněmi. Medián věku operovaných ve skupině A byl 59 let, medián věku operovaných ve skupině B byl 64 let. U všech pacientů bylo sledováno, zda se vyskytly poruchy hojení sternotomie hodnocené škálou 0 - zhojeno per primam, 1 - porucha hojení měkkých tkání, 2 - hluboký sternální infekt, současně se zhodnocením možných rizikových faktorů, se zaměřením na diabetes mellitus. Pro analýzu vlivu jednotlivých ukazatelů jako prediktorů pooperačních komplikací byla použita metoda multinomické logistické regrese.Výsledky: Ve skupině A bylo 37 nemocných s diabetes mellitus. Ve skupině B 77 nemocných s diabetes mellitus. Při analýze celého souboru 300 operovaných se diabetes mellitus jako významný prediktor poruchy hojení sternotomie neprojevil. Jako jediný významný prediktor byl prokázán věk. Bodový odhad poměru šancí (OR) = 1,044 a jeho 95% konfidenční interval (CI) je v rozmezí 1,037-1,052. Typ operace se jako významný prediktor neprojevil.V modelech pro každou skupinu A a B zvlášť nepůsobil diabetes mellitus ani věk jako statisticky významný prediktor. Analýza ve skupině A prokázala jediný významný prediktor, a to hyperlipidemii s OR = 4,971 (95% CI 1,228-20,124). Ve skupině B analýza žádný významný prediktor neodhalila.Závěr: Na základě našich výsledků lze potvrdit, že v případě odběru obou arteria thoracica interna jako skelet není diabetes mellitus významným prediktorem poruchy hojení sternotomie.
We sought to compare clinical outcomes, in-hospital mortality and 1-year survival of two different treatment modalities of deep sternal wound infection, topical negative pressure and the closed irrigation therapy.Retrospective analysis of 66 consecutive patients treated for deep sternal infection at our institution. A total of 28 patients (February 2002 through September 2004) underwent primarily closed irrigation therapy, and 34 patients (November 2004 through December 2007) had the application of topical negative pressure. Four patients (July 2004 through December 2004) who underwent a combination of both strategies were excluded from the study. Clinical and wound care outcomes were compared, focusing on therapeutic failure rate, in-hospital stay and the 1-year mortality of both treatment strategies.Topical negative pressure was associated with a significantly lower failure rate of the primary therapy (P<0.05), shortening of the intensive care unit stay (P<0.001), a particular decrease in the in-hospital stay (P<0.05) and the 1-year mortality (P<0.05) in comparison with closed irrigation therapy. Comparable overall length of the therapy, in-hospital stay and the risk of wire-related fistulas after chest reconstruction were found.Topical negative pressure is a superior method of treatment for deep sternal wound infection, which is based on lower therapeutic failure rate, significant decrease in-hospital stay, and the decrease of the 1-year mortality rate, compared with primarily applied closed irrigation.
Uvod: Plicni embolie patři na předni mista v kardiovaskularni mortalitě. Zvlastni misto patři problematice masivni embolizace do arteria pulmonalis se zhroucenim oběhu a indikaci pacienta k chirurgicke trombembolektomii. Variabilni etiologie a kombinace rizikových faktorů je v kazuistice dobře demonstrovana.
Popis připadu: Třicetileta pacientka po padu na kole s posttraumatickou rupturou jater, masivni hemoterapii, diseminovanou intravaskularni koagulaci, edemem mozku, komplikovanou masivni plicni embolii se selhanim oběhu, provedena chirurgicka trombembolektomie s evakuaci cetných trombotických mas.
Výsledky: Pacientka s nepřiznivou prognozou (velke ztraty krve, DIC, edem mozku, resuscitace, masivni plicni embolizace), byla po 16 dnech propustěna do domaciho osetřovani. Studie naznacuji dobrý výsledek chirurgicke trombembolektomie v připadě vcasne a vhodne indikace. Bostonska studie, 47 (100 %) operovaných pacientů, z nichž zemřeli 3 (6 %) pacienti, 2 s předoperacni srdecni zastavou, 12 (26 %) pacientů bylo předoperacně v kardiogennim soku, 6 (11 %) pacientů mělo srdecni zastavu, naznacuje cetnost provaděných trombembolektomii a uspěsnost teto terapie. Průměrna delka hospitalizace 11 dni (3–75 dni). Jednolete, respektive třilete přeživani uvadi v 86 %, respektive 83 %.
Zavěr: Pozitivni výsledek, tedy navrat pacientky do aktivniho života, byl možný diky multidisciplinarnimu přistupu, dobremu inicialnimu zajistěni a vhodne indikaci k chirurgicke trombembolektomii na specializovanem pracovisti.
Hydrogen sulfide is produced endogenously by a variety of enzymes involved in cysteine metabolism.Clinical data indicate that endogenous levels of hydrogen sulfide are diminished in various forms of cardiovascular diseases.The aim of the current study was to investigate the effects of hydrogen sulfide supplementation on cardiac function during reperfusion in a clinically relevant experimental model of cardiopulmonary bypass.Twelve anesthetized dogs underwent hypothermic cardiopulmonary bypass.After 60 minutes of hypothermic cardiac arrest, reperfusion was started after application of either saline vehicle (control, n = 6), or the sodium sulfide infusion (1 mg/kg/hour, n = 6).Biventricular hemodynamic variables were measured by combined pressure-volume-conductance catheters.Coronary and pulmonary blood flow, vasodilator responses to acetylcholine and sodiumnitroprusside and pulmonary function were also determined.Administration of sodium sulfide led to a significantly better recovery of left and right ventricular systolic function (P < 0.05) after 60 minutes of reperfusion.Coronary blood flow was also significantly higher in the sodium sulfide-treated group (P < 0.05).Sodium sulfide treatment improved coronary blood flow, and preserved the acetylcholine-induced increases in coronary and pulmonary blood (P < 0.05).Myocardial ATP levels were markedly improved in the sulfide-treated group.Thus, supplementation of sulfide improves the recovery of myocardial and endothelial function and energetic status after hypothermic cardiac arrest during cardiopulmonary bypass.These beneficial effects occurred without any detectable adverse hemodynamic or cardiovascular effects of sulfide at the dose used in the current study.
Prace podava přehled o roli tromboelastografie (TEG) v monitorovani hemostazy v perioperacnim obdobi v kardiochirurgii. Popisuje aktivaci hemostatickeho systemu během mimotělniho oběhu a teoreticke principy tromboelastografie. Podava souhrn literarnich udajů o monitorovani pacientů pomoci TEG v perioperacnim obdobi a jeho význam pro výběr optimalni terapie.
