Cardiovascular and Thoracic Anesthesia
Lung-protective ventilation during cardiac surgery: Lung-protective ventilation strategies use low tidal volume (TV), low driving pressure, and positive end-expiratory pressure (PEEP). In a retrospective study of nearly 4700 patients undergoing cardiac surgery with cardiopulmonary bypass (CPB), lung-protective ventilation was associated with fewer postoperative pulmonary complications (pneumonia, prolonged postoperative mechanical ventilation, need for reintubation, and/or poor oxygenation with arterial oxygen tension [PaO2]/fraction of inspired oxygen [FiO2] ratio <100 mmHg) compared with other ventilation strategies. A sensitivity analysis revealed that use of driving pressure <16 mmHg alone, but not PEEP or low TV, was also independently associated with fewer pulmonary complications. Although elevated driving pressure may simply be a marker (rather than a cause) of lung injury, we maintain this pressure <16 mmHg as a component of lung-protective ventilation after CPB.
Monitoring standards for adults undergoing cardiopulmonary bypass: Guidelines for monitoring standards in adults undergoing cardiopulmonary bypass (CPB) were jointly released by the European Association for Cardio-Thoracic Surgery (EACTS), European Association of Cardiothoracic Anaesthesiology (EACTA), and European Board of Cardiovascular Perfusion (EBCP). These include confirmation of adequate pump flow with continuous flow measurements on the arterial line, as well as continuous monitoring of arterial line pressure in the CPB circuit (pre-oxygenator and post-oxygenator), arterial blood gases, mixed venous oxygen saturation (SvO2), oxygenator arterial outlet temperature, and, when available, exhaust concentrations of volatile anesthetic agents. Other necessary monitoring includes intermittent or continuous monitoring of hemoglobin or hematocrit and potassium, as well as frequent (approximately every 30 minutes) monitoring of glucose, electrolytes, and urine output.
Use of point-of-care viscoelastic coagulation tests to guide transfusion therapy during cardiac surgery: Decisions for blood product transfusion in surgical patients with bleeding and coagulopathy are guided by tests of hemostasis as a component of goal-directed protocols. The Society of Cardiovascular Anesthesiologists released a practice advisory for management of perioperative bleeding in cardiac surgical patients that recommends point-of-care (POC) viscoelastic coagulation tests to guide transfusion therapy. Such POC tests (eg, thromboelastography [TEG], rotational thromboelastometry [ROTEM]) allow rapid assessment of coagulopathy and response to interventions (eg, transfusions or administration of hemostatic agents). When available, we recommend POC viscoelastic tests to assess hemostasis during cardiac surgery; conventional coagulation tests are also recommended as additional or alternative assessment tools.
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