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P-67 Which is better to stabilize circulation and improve oxygen delivery during paediatric cardiac surgery, olprinone or milrinone?
FREE POSTER SESSIONS 1
S61
Department of Anaesthesiology and Pain Medicine, Department of Cardiology, University Hospital, University of Bern, Bern, Switzerland
Introduction. The objective was to evaluate the difference between sedation versus general anaesthesia in the percutaneous replacement of the aortic valve.
Introduction. Transcatheter aortic valve implantation (TAVI) is becoming an alternative to surgery for high-risk patients with severe aortic valve stenosis. Monitored anaesthesia care (MAC) is an option for transfemoral TAVI. We studied respiratory and post-sedative adverse events during and up to 72 hr after TAVI performed in MAC with a combination of propofol and ketamine. Method. With IRB approval, anaesthesia and postanaesthesia care records of consecutive TAVI performed in MAC in 20082009 were analysed retrospectively. Anaesthesia instrumentation consisted of SpO2, ECG, O2 (face mask), capnography, invasive arterial and CVP monitoring. Patients were sedated with a combination of propofol and ketamine with respective concentrations of 0.78% (7.8 mg/mL) and 0.23% (2.3 mg/mL). Post– TAVI assessment included SpO2, nursing records on confusion, delirium or disorientation with GCSⱕ14, nausea and/or vomiting (PONV). Data are median (min-max). Results. Analysis included 83 of 86 patients undergoing TAVI in MAC (84⫾4 yr; previous cardiac surgery, 10/83; CHD, 22/83). We excluded 3 patients converted to general anaesthesia (GA) during TAVI due to procedural complications. During MAC, patients received doses of propofol 16 g kg-1 min-1 (2.3–38), and ketamine 4.8 g kg-1 min-1 (0.7–11). Pre-MAC SpO2 was 95% (89 –99) at room air; during MAC, nadir SpO2 was 98% (74-100). Minimum respiratory rate was 17 breaths/min (7-30). One patient required bronchodilator for bronchospasm and one conversion to GA due to ischaemic leg pain. In postprocedural care, nadir SpO2 was 91% (80 –96); transient disorientation or delirium was recorded in 28/83 (34%). PONV was documented in 23/83 (28%), and treated with antiemetics in 21/83 patients. Conclusion. A MAC concept using the sedative-analgesic combination of propofol and ketamine was successfully used for TAVI. Airway patency, respiratory drive and oxygenation were well maintained during the procedure. Incidence of PONV and disorientation appear lower than published for geriatric patients following GA or cardiac surgery.
Method. Ninety patients underwent percutaneous aortic valve replacement in a two year period. Eleven patients were given general anaesthesia (propofol 2 mg/kg iv., fentanyl 100 g iv., cisatracurium 0.1 mg/kg iv.) and maintenance with a continuous infusion of propofol at low doses with additional boluses of an opioid (fentanyl). Seventy-nine pts received local anaesthesia and mild sedation with midazolam 0.05 mg/kg allowing spontaneous breathing. Management included basic anaesthetic monitoring, antibiotic prophylaxis with ampicillina-sulbactam 3 g iv. 30 minutes before the start of the procedure, a central line in the femoral vein and a left femoral arterial line. Balloon aortic valvuloplasty (BAV) was performed under rapid right ventricular pacing (150-180 bpm). The goal of BAV is to dilate the aortic valve annulus and seat the prosthesis by a retrograde approach through the femoral artery or if this is impossible because of atherosclerosis or previous vascular surgery, a surgical approach through the subclavian artery.
2
P-66 Percutaneous aortic valve replacement: anaesthesia management Aldo Manzato, Mario Frontini, Salvatore Curello, Claudia Fiorina, Federica Ettori, Elena Porteri Spedali Civili, Brescia, Italy
Results. Indications have been limited to elderly patients with a prohibitively high surgical risk for valve replacement because of excessive comorbidities (logistic EuroSCORE middle value was 24). There was a 97.8% procedural success with a mortality to 30 days of 7.7% (7/90). Complications during the procedure were 1 death from end stage cardiomyopathy, 1 stroke, 1 endstage pulmonary fibrosis, 1 hepatic coma, 2 respiratory failures, 1 multiple organ failure, 1 fracture of the valvular annulus, 1 cardiac tamponade, 1 pulmonary embolism, 1 intestinal obstruction, 1 pulmonary cancer and 2 unknown causes of death. There were second or third degree AV block in 31 patients (34%) with implantation of a pacemaker. 11 patients bled from the femoral artery, 5 requiring surgical repair. Discussion. During our initial experience we used general anaesthesia because we thought that it could provide major stability and improve the tolerability of the procedure. We used transoesophageal echocardiography every time. Subsequently, with some experience, we used only mild sedation with spontaneous respiration and transthoracic echocardiography. Conclusions. This procedure is useful in patients with excessive comorbidities and a prohibitively high surgical risk for valve replacement. It can be performed with sedation and spontaneous breathing and maintains haemodynamic and respiratory stability.
Poster Session VIII – Paediatric and Adult Cardiac & Thoracic Anaesthesia P-67 Which is better to stabilize circulation and improve oxygen delivery during paediatric cardiac surgery, olprinone or milrinone? Satoshi Kurokawa, Yuko Tomita, Shihoko Iwata, Minoru Nomura Tokyo Women’s Medical University, Tokyo, Japan Introduction. A multicentre trial demonstrated that high-dose milrinone (Mil) led to significant reductions in the development of low output syndrome and mortality after paediatric cardiac surgery. Meanwhile, our group has previously shown that a phos-
phodiesterase inhibitor olprinone (Olp) stabilizes the circulation and improves oxygen delivery after separation from cardiopulmonary bypass (CPB) during paediatric cardiac surgery. The aim of the current study is to compare how Olp and Mil affect haemodynamics and oxygen delivery. Method. Randomly selected 29 patients were given Olp in a non-blinded manner. Twenty one patients given Mil during the study period were the reference. Venous oxygen saturation (ScvO2), cerebral tissue oxygen index (TOI), and cerebral regional tissue oxygen saturation (rSO2) were monitored. An infusion of either Olp (0.3 g kg-1 min-1) or Mil (0.5 g kg-1 min-1) was started immediately after the release of aortic cross-clamping without a loading dose. Haemodynamic data and oximetric
S62
FREE POSTER SESSIONS
data (ScvO2, TOI and rSO2) were collected and the oxygen excess factor (⍀) was calculated at termination of CPB and at 15, 30, 60, 90, and 120 minutes after separation from CPB. Statistical analysis was performed by repeated ANOVA, paired t-test and two-way ANOVA. P⬍0.05 was considered significant. Results. Parameters of cardiac function and lung condition were comparable between Olp and Mil groups. In the biventricular repair (33 patients), neither agent had any influences on HR and CVP. Both agents tended to increase BP and the increase reached statistical significance at 120 min in the Olp group (16.3⫾19.8%). Dopamine dose was significantly tapered from 60 min only in the Olp group (Olp 4.0⫾1.2 vs. Mil 5.0⫾1.6 g kg-1 min-1 at 60min). No significant differences between the groups were found from the parameter comparisons. ScvO2, ⍀, and TOI tended to increase in the Olp group from 15-30 min, but not significantly. In Fontan-type operations (17 patients), the changes in haemodynamic parameters were similar to those in the biventricular repair in both groups. Conclusion. Olp and Mil were both similarly effective in stabilizing the circulation and improving oxygen delivery. Among the biventricular repair cases, Olp was more effective than Mil in permitting the tapering of concomitantly used inotrope doses. P-68 The safety and efficacy of early extubation after paediatric cardiac surgery Gulsun Guven, Gunseli Abay, Numan Ali Riza Karaci, Gunseli Uyar, Sevim Canik
Ali
Aydemir,
Siyami Ersek Thoracic and Cardiovascular Surgery Center, Istanbul, Turkey Introduction. Early extubation after congenital heart surgery has been described. However, prolonged postoperative mechanical ventilation in the intensive care unit (ICU) remains common practice in many centres. This study was undertaken to determine the feasibility of early extubation of children after surgical repair of congenital heart lesions. Method. We performed a prospective study of 100 patients aged 0-16 years (median 5.5 yr) who underwent congenital heart surgery. All patients were managed as potential candidates for early extubation. 50 patients were extubated within 6 hr (Group I) and 50 patients were extubated between 7-24 hr after surgery (Group II). The criteria for extubation were adequate spontaneous ventilation, haemodynamic stability, normothermia and adequate haemostasis. The two groups were compared by patient age, weight, status on arrival in the paediatric ICU (including haemodynamics, pH, PaCO2, SaO2, base excess, haematocrit and lactate level at 0, 6th and 12th hr). Mann Whitney-U-test was used for statistical analysis (P⬍0.05). Results. Patients extubated late were younger and smaller. There were no significant differences of haemodynamics between the two groups. In the early extubation group, cardiopulmonary bypass (CPB) time and aortic cross-clamp (XCL) time were shorter (P⬍0.05). Use of inotropic agents was lower in group I. PaCO2 after extubation was higher in the early extubation group and pH was lower (P⬍0.01) but this mild to moderate respiratory acidosis was transient and required no specific treatment. One patient required re-intubation in group I. The length of ICU stay (27.97 ⫾ 10.40 vs. 48.38 ⫾ 32.27 hr) and hospital stay (6.51 ⫾ 1.08 vs. 9.14 ⫾ 3.76 days) for the early extubation group were significantly shorter (P⬍0.01). Discussion. This study supports that in selected paediatric cardiac patients, early extubation can be performed safely, with a low rate of
failed extubation [1]. This technique reduces ICU and hospital stay without increasing postoperative complications. The strongest independent risk factors for failure of this strategy included younger age, smaller weight, longer CPB and aortic XCL time. REFERENCE 1. Meissner U, Scharf J, Dötsch J, et al. Very early extubation after open-heart surgery in children does not influence cardiac function. Pediatr Cardiol 2008; 29: 317-20. P-69 Extra corporeal life support makes cardiac intervention and advanced radiologic examinations possible in cardiac arrest Anne Frost, Bodil Steen Rasmussen, Jan Ravkilde, Benedict Kjærgaard
Kerstin
Krüger,
Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark Introduction. Extra corporeal life support (ECLS) with a mobile system is an option in the treatment of cardiac arrest of unknown origin [1]. The underlying cause of cardiac arrest is often not clear and a correct diagnosis may require advanced radiologic examinations and therapeutic procedures for initiation of a life saving treatment. Method. Fifty-eight patients suffering cardiac arrest receiving CPR were treated with ECLS. Fifteen patients needed further examinations of CT scans, pulmonary angiography and/or invasive cardiologic interventions. These advanced examinations were performed with intravenous contrast and 15 to 25 seconds arrest of ECLS makes it possible to fill the heart and vessels sufficiently to perform angiography. Results. The underlying diagnosis in the 15 patients were pulmonary embolism (n⫽6), accidental hypothermia (n⫽2), myocardial infarction (n⫽2), WPW syndrome (n⫽1), sepsis (n⫽1), disseminated intravascular coagulation (n⫽2), and high voltage accident (n⫽1). Five of the 15 patients who needed advanced examinations survived. Overall, 22 of the 58 patients treated with ECLS survived. Discussion. This study shows that it is possible to make advanced radiological and cardiological examinations in patients suffering cardiac arrest of unknown origin with the use of ECLS. These advanced examinations and intervention were important parts of the resuscitation and survival of 5 patients and in the other investigated 10 patients, the results of the examinations greatly influenced the choice of treatment. Even though the overall survival rate was only one third, none could have survived without ECLS. Thus, ECLS is life saving and associated with acceptable outcomes when severity of illness is considered. REFERENCE 1. Kjaergaard B, Frost A, Rasmussen BS, et al. Cardiac interventions and advanced radiologic examinations are possible in cardiac arrest with extra corporeal life support. Resuscitation 2011; in press. P-70 Predictors of risk factors related to the development of hepatic dysfunction following open heart surgery Ayse Baysal, Buket Ozyaprak, Ismail Ozkaynak, Tuncer Kocak Kartal Kosuyolu Training and Research Hospital, Kartal/Istanbul, Turkey
S61
Department of Anaesthesiology and Pain Medicine, Department of Cardiology, University Hospital, University of Bern, Bern, Switzerland
Introduction. The objective was to evaluate the difference between sedation versus general anaesthesia in the percutaneous replacement of the aortic valve.
Introduction. Transcatheter aortic valve implantation (TAVI) is becoming an alternative to surgery for high-risk patients with severe aortic valve stenosis. Monitored anaesthesia care (MAC) is an option for transfemoral TAVI. We studied respiratory and post-sedative adverse events during and up to 72 hr after TAVI performed in MAC with a combination of propofol and ketamine. Method. With IRB approval, anaesthesia and postanaesthesia care records of consecutive TAVI performed in MAC in 20082009 were analysed retrospectively. Anaesthesia instrumentation consisted of SpO2, ECG, O2 (face mask), capnography, invasive arterial and CVP monitoring. Patients were sedated with a combination of propofol and ketamine with respective concentrations of 0.78% (7.8 mg/mL) and 0.23% (2.3 mg/mL). Post– TAVI assessment included SpO2, nursing records on confusion, delirium or disorientation with GCSⱕ14, nausea and/or vomiting (PONV). Data are median (min-max). Results. Analysis included 83 of 86 patients undergoing TAVI in MAC (84⫾4 yr; previous cardiac surgery, 10/83; CHD, 22/83). We excluded 3 patients converted to general anaesthesia (GA) during TAVI due to procedural complications. During MAC, patients received doses of propofol 16 g kg-1 min-1 (2.3–38), and ketamine 4.8 g kg-1 min-1 (0.7–11). Pre-MAC SpO2 was 95% (89 –99) at room air; during MAC, nadir SpO2 was 98% (74-100). Minimum respiratory rate was 17 breaths/min (7-30). One patient required bronchodilator for bronchospasm and one conversion to GA due to ischaemic leg pain. In postprocedural care, nadir SpO2 was 91% (80 –96); transient disorientation or delirium was recorded in 28/83 (34%). PONV was documented in 23/83 (28%), and treated with antiemetics in 21/83 patients. Conclusion. A MAC concept using the sedative-analgesic combination of propofol and ketamine was successfully used for TAVI. Airway patency, respiratory drive and oxygenation were well maintained during the procedure. Incidence of PONV and disorientation appear lower than published for geriatric patients following GA or cardiac surgery.
Method. Ninety patients underwent percutaneous aortic valve replacement in a two year period. Eleven patients were given general anaesthesia (propofol 2 mg/kg iv., fentanyl 100 g iv., cisatracurium 0.1 mg/kg iv.) and maintenance with a continuous infusion of propofol at low doses with additional boluses of an opioid (fentanyl). Seventy-nine pts received local anaesthesia and mild sedation with midazolam 0.05 mg/kg allowing spontaneous breathing. Management included basic anaesthetic monitoring, antibiotic prophylaxis with ampicillina-sulbactam 3 g iv. 30 minutes before the start of the procedure, a central line in the femoral vein and a left femoral arterial line. Balloon aortic valvuloplasty (BAV) was performed under rapid right ventricular pacing (150-180 bpm). The goal of BAV is to dilate the aortic valve annulus and seat the prosthesis by a retrograde approach through the femoral artery or if this is impossible because of atherosclerosis or previous vascular surgery, a surgical approach through the subclavian artery.
2
P-66 Percutaneous aortic valve replacement: anaesthesia management Aldo Manzato, Mario Frontini, Salvatore Curello, Claudia Fiorina, Federica Ettori, Elena Porteri Spedali Civili, Brescia, Italy
Results. Indications have been limited to elderly patients with a prohibitively high surgical risk for valve replacement because of excessive comorbidities (logistic EuroSCORE middle value was 24). There was a 97.8% procedural success with a mortality to 30 days of 7.7% (7/90). Complications during the procedure were 1 death from end stage cardiomyopathy, 1 stroke, 1 endstage pulmonary fibrosis, 1 hepatic coma, 2 respiratory failures, 1 multiple organ failure, 1 fracture of the valvular annulus, 1 cardiac tamponade, 1 pulmonary embolism, 1 intestinal obstruction, 1 pulmonary cancer and 2 unknown causes of death. There were second or third degree AV block in 31 patients (34%) with implantation of a pacemaker. 11 patients bled from the femoral artery, 5 requiring surgical repair. Discussion. During our initial experience we used general anaesthesia because we thought that it could provide major stability and improve the tolerability of the procedure. We used transoesophageal echocardiography every time. Subsequently, with some experience, we used only mild sedation with spontaneous respiration and transthoracic echocardiography. Conclusions. This procedure is useful in patients with excessive comorbidities and a prohibitively high surgical risk for valve replacement. It can be performed with sedation and spontaneous breathing and maintains haemodynamic and respiratory stability.
Poster Session VIII – Paediatric and Adult Cardiac & Thoracic Anaesthesia P-67 Which is better to stabilize circulation and improve oxygen delivery during paediatric cardiac surgery, olprinone or milrinone? Satoshi Kurokawa, Yuko Tomita, Shihoko Iwata, Minoru Nomura Tokyo Women’s Medical University, Tokyo, Japan Introduction. A multicentre trial demonstrated that high-dose milrinone (Mil) led to significant reductions in the development of low output syndrome and mortality after paediatric cardiac surgery. Meanwhile, our group has previously shown that a phos-
phodiesterase inhibitor olprinone (Olp) stabilizes the circulation and improves oxygen delivery after separation from cardiopulmonary bypass (CPB) during paediatric cardiac surgery. The aim of the current study is to compare how Olp and Mil affect haemodynamics and oxygen delivery. Method. Randomly selected 29 patients were given Olp in a non-blinded manner. Twenty one patients given Mil during the study period were the reference. Venous oxygen saturation (ScvO2), cerebral tissue oxygen index (TOI), and cerebral regional tissue oxygen saturation (rSO2) were monitored. An infusion of either Olp (0.3 g kg-1 min-1) or Mil (0.5 g kg-1 min-1) was started immediately after the release of aortic cross-clamping without a loading dose. Haemodynamic data and oximetric
S62
FREE POSTER SESSIONS
data (ScvO2, TOI and rSO2) were collected and the oxygen excess factor (⍀) was calculated at termination of CPB and at 15, 30, 60, 90, and 120 minutes after separation from CPB. Statistical analysis was performed by repeated ANOVA, paired t-test and two-way ANOVA. P⬍0.05 was considered significant. Results. Parameters of cardiac function and lung condition were comparable between Olp and Mil groups. In the biventricular repair (33 patients), neither agent had any influences on HR and CVP. Both agents tended to increase BP and the increase reached statistical significance at 120 min in the Olp group (16.3⫾19.8%). Dopamine dose was significantly tapered from 60 min only in the Olp group (Olp 4.0⫾1.2 vs. Mil 5.0⫾1.6 g kg-1 min-1 at 60min). No significant differences between the groups were found from the parameter comparisons. ScvO2, ⍀, and TOI tended to increase in the Olp group from 15-30 min, but not significantly. In Fontan-type operations (17 patients), the changes in haemodynamic parameters were similar to those in the biventricular repair in both groups. Conclusion. Olp and Mil were both similarly effective in stabilizing the circulation and improving oxygen delivery. Among the biventricular repair cases, Olp was more effective than Mil in permitting the tapering of concomitantly used inotrope doses. P-68 The safety and efficacy of early extubation after paediatric cardiac surgery Gulsun Guven, Gunseli Abay, Numan Ali Riza Karaci, Gunseli Uyar, Sevim Canik
Ali
Aydemir,
Siyami Ersek Thoracic and Cardiovascular Surgery Center, Istanbul, Turkey Introduction. Early extubation after congenital heart surgery has been described. However, prolonged postoperative mechanical ventilation in the intensive care unit (ICU) remains common practice in many centres. This study was undertaken to determine the feasibility of early extubation of children after surgical repair of congenital heart lesions. Method. We performed a prospective study of 100 patients aged 0-16 years (median 5.5 yr) who underwent congenital heart surgery. All patients were managed as potential candidates for early extubation. 50 patients were extubated within 6 hr (Group I) and 50 patients were extubated between 7-24 hr after surgery (Group II). The criteria for extubation were adequate spontaneous ventilation, haemodynamic stability, normothermia and adequate haemostasis. The two groups were compared by patient age, weight, status on arrival in the paediatric ICU (including haemodynamics, pH, PaCO2, SaO2, base excess, haematocrit and lactate level at 0, 6th and 12th hr). Mann Whitney-U-test was used for statistical analysis (P⬍0.05). Results. Patients extubated late were younger and smaller. There were no significant differences of haemodynamics between the two groups. In the early extubation group, cardiopulmonary bypass (CPB) time and aortic cross-clamp (XCL) time were shorter (P⬍0.05). Use of inotropic agents was lower in group I. PaCO2 after extubation was higher in the early extubation group and pH was lower (P⬍0.01) but this mild to moderate respiratory acidosis was transient and required no specific treatment. One patient required re-intubation in group I. The length of ICU stay (27.97 ⫾ 10.40 vs. 48.38 ⫾ 32.27 hr) and hospital stay (6.51 ⫾ 1.08 vs. 9.14 ⫾ 3.76 days) for the early extubation group were significantly shorter (P⬍0.01). Discussion. This study supports that in selected paediatric cardiac patients, early extubation can be performed safely, with a low rate of
failed extubation [1]. This technique reduces ICU and hospital stay without increasing postoperative complications. The strongest independent risk factors for failure of this strategy included younger age, smaller weight, longer CPB and aortic XCL time. REFERENCE 1. Meissner U, Scharf J, Dötsch J, et al. Very early extubation after open-heart surgery in children does not influence cardiac function. Pediatr Cardiol 2008; 29: 317-20. P-69 Extra corporeal life support makes cardiac intervention and advanced radiologic examinations possible in cardiac arrest Anne Frost, Bodil Steen Rasmussen, Jan Ravkilde, Benedict Kjærgaard
Kerstin
Krüger,
Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark Introduction. Extra corporeal life support (ECLS) with a mobile system is an option in the treatment of cardiac arrest of unknown origin [1]. The underlying cause of cardiac arrest is often not clear and a correct diagnosis may require advanced radiologic examinations and therapeutic procedures for initiation of a life saving treatment. Method. Fifty-eight patients suffering cardiac arrest receiving CPR were treated with ECLS. Fifteen patients needed further examinations of CT scans, pulmonary angiography and/or invasive cardiologic interventions. These advanced examinations were performed with intravenous contrast and 15 to 25 seconds arrest of ECLS makes it possible to fill the heart and vessels sufficiently to perform angiography. Results. The underlying diagnosis in the 15 patients were pulmonary embolism (n⫽6), accidental hypothermia (n⫽2), myocardial infarction (n⫽2), WPW syndrome (n⫽1), sepsis (n⫽1), disseminated intravascular coagulation (n⫽2), and high voltage accident (n⫽1). Five of the 15 patients who needed advanced examinations survived. Overall, 22 of the 58 patients treated with ECLS survived. Discussion. This study shows that it is possible to make advanced radiological and cardiological examinations in patients suffering cardiac arrest of unknown origin with the use of ECLS. These advanced examinations and intervention were important parts of the resuscitation and survival of 5 patients and in the other investigated 10 patients, the results of the examinations greatly influenced the choice of treatment. Even though the overall survival rate was only one third, none could have survived without ECLS. Thus, ECLS is life saving and associated with acceptable outcomes when severity of illness is considered. REFERENCE 1. Kjaergaard B, Frost A, Rasmussen BS, et al. Cardiac interventions and advanced radiologic examinations are possible in cardiac arrest with extra corporeal life support. Resuscitation 2011; in press. P-70 Predictors of risk factors related to the development of hepatic dysfunction following open heart surgery Ayse Baysal, Buket Ozyaprak, Ismail Ozkaynak, Tuncer Kocak Kartal Kosuyolu Training and Research Hospital, Kartal/Istanbul, Turkey