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Objective: To inform the design of a pivotal randomized controlled trial of prophylactic intra-aortic balloon counterpulsation (IABC) in patients undergoing coronary artery bypass graft (CABG) at high risk of postoperative low cardiac output syndrome (LCOS)., Design: Inception cohort study., Setting: A total of 13 established cardiac centers in Australia, Canada, New Zealand, and the United Kingdom., Participants: Adult patients were eligible for inclusion if they were listed for CABG surgery and had 2 or more LCOS risk factors (low ejection fraction, severe left main coronary artery disease, redo sternotomy, unstable angina)., Interventions: Outcomes of interest were a composite outcome of in-hospital mortality, postoperative acute myocardial infarction (AMI), acute kidney injury (AKI), or stroke as well as 6-month vital status and quality of life using the EuroQol 5-dimensional questionnaire (EQ5D)., Measurements and Main Results: The study included 136 participants over a 29-month period. Overall, in-hospital and 6-month mortality occurred in 7 (5%) and 11 (8%) participants, respectively. The composite outcome occurred in 60 (44%). The mean increase in EQ5D summary index at 6 months was 0.10 (standard deviation 0.24, p = 0.01). Perioperative AMI, AKI, or stroke significantly decreased the odds of a clinically meaningful improvement in quality of life (odds ratio 0.32; 95% confidence interval 0.13-0.79; p = 0.014). Preoperative IABC was used in 39 participants and did not predict postoperative outcomes., Conclusions: The study identified a group of patients at risk of LCOS in whom CABG surgery was associated with a substantial burden of perioperative morbidity. Preoperative IABC use was variable, supporting the need for further research., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: To determine whether preoperative endothelial dysfunction provides risk stratification for perioperative renal injury in patients undergoing noncardiac surgery. The relationship between perioperative renal injury and myocardial injury after noncardiac surgery (MINS) was explored secondarily., Design: An observational study., Setting: Two academic medical centers., Participants: A total of 218 patients scheduled to undergo intermediate or high-risk noncardiac surgery., Interventions: None., Measurements and Main Results: Endothelial dysfunction was identified preoperatively by a Reactive Hyperemia-Peripheral Arterial Tonometry (RH-PAT) index. Renal injury was defined by peak delta serum creatinine (ΔSCr) or creatinine-based kidney disease: Improving global outcomes acute kidney injury (AKI) criteria within 7 days postoperatively. MINS was defined by peak troponin ≥0.04 µg/L within 3 days postoperatively. AKI occurred in 22 patients (10.1%). Median RH-PAT index within the study cohort was 1.64 (range 1.03-4.96) and did not differ between patients with or without AKI. When adjusted for covariates, there was no association between RH-PAT index and either AKI or peak ΔSCr. MINS occurred in 32 patients (14.7%) and was associated independently with the outcome of AKI (odds ratio [OR], 3.7; 95% confidence interval [CI], 1.2-10.8; p = 0.02) and peak ΔSCr (β-regression coefficient 23; 95% CI, 9-37; p = 0.002). Co-occurrence of AKI and MINS portended a marked increase in 30-day mortality (OR, 43; 95% CI, 6-305; p = 0.001) and delayed time to discharge (hazard ratio, 0.27; 95% CI, 0.13-0.54; p = 0.001)., Conclusions: For patients undergoing noncardiac surgery, preoperative endothelial function assessed by noninvasive peripheral arterial tonometry was not associated with perioperative AKI. Perioperative renal injury was associated strongly with MINS, and this may represent a mechanism by which AKI increases adverse outcomes., (Crown Copyright © 2015. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the accuracy and clinical utility of a continuous arterial blood gas (ABG) monitor during lung transplantation., Design: Prospective, observational cohort study., Setting: University hospital., Participants: Eleven patients undergoing bilateral sequential lung transplantation (BSLTx)., Interventions: Repeated ABG sampling., Measurements and Main Results: Agreement was measured by the bias (limits of agreement): pH, 0.006 (-0.10 to 0.10); PaO2, -22 mmHg (-130 to 86 mmHg); and PaCO2, -1.6 mmHg (-13.4 to 10.2 mmHg). Sensitivity and specificity of the Paratrend 7 (Biomedical Sensors, Ltd, Malvern, PA) PaO2 measurements (to detect PaO2 < 100 mmHg) were 84.6% and 97.6%, respectively., Conclusion: Continuous ABG monitoring with the Paratrend 7 shows sufficiently good agreement with laboratory blood gas analysis during BSLTx and thus is a convenient alternative to intermittent laboratory blood gas measurement. Because of the potential for significant (and sometimes rapid) acid-base disturbances, continuous ABG monitoring may have a role during most lung transplantation procedures.

Objectives: To investigate the relationship between excessive endogenous production of nitric oxide (NO) and the low systemic vascular resistance (SVR) syndrome after cardiac surgery., Design: Prospective, case-control. Cases defined by low SVR postoperatively (< 750 dyn/s/cm-5), and matched with controls (> 900 dyn/s/cm-5)., Setting: Cardiothoracic intensive care unit (ICU) in a tertiary care hospital., Participants: Forty-four patients after cardiac surgery., Interventions: Collection of plasma and urine samples after identification., Measurements and Main Results: Plasma and urine nitrate concentrations were measured as an index of endogenous NO production. Hemodynamic, inotropic, and outcome data were collected. Median nitrate concentrations did not differ between cases and controls (plasma, 58 mumol/L, v 62 mumol/L, p = 0.43; urine, 399 mumol/L v 404 mumol/L, p = 0.38). Times to extubation and intensive care unit (ICU) discharge were prolonged in patients with low SVR (17.8 hours v 8.7 hours, p = 0.021; 2.5 days v 1.2 days, p = 0.019, respectively)., Conclusions: No association between "low SVR syndrome" and endogenous NO production was found. Patients with low SVR after cardiac surgery required a longer period of inotropic and ventilator support, with delay in discharge from the ICU. The risk and cost implications of this syndrome support further research.

Objectives: To review the experience of anesthesia for bilateral sequential lung transplantation (BSLTx) and describe factors associated with outcome., Design: Case series., Setting: University hospital., Participants: Sixty-four adult patients undergoing BSLTx., Interventions: Descriptive and inferential statistical analysis., Measurements and Main Results: Details of anesthetic technique, patient, and perioperative characteristics are presented. Mean (SD) lung allograft ischemic times were 320 (81) minutes for the first lung and 446 (93) minutes for the second lung. Mean (SD) duration of surgery was 8.5(2) hours, and median time to extubation was 28 hours. There was a reduction in the use of cardiopulmonary bypass, from 10 of 19 (53%) in 1992 to 1993 to 10 of 45 (22%) in 1994 to 1996, p = 0.016. There was an association between time to extubation and duration of surgery (Spearman rank correlation, p = 0.33, p = 0.008), but no association with intraoperative fluid administration (p = 0.18, p = 0.16), or inotrope requirements (p = 0.06, p = 0.65). Predictors of in-hospital mortality were preoperative renal impairment (p = 0.034), early reoperation (p = 0.005), and delay in extubation (p = 0.013); and for 12-month mortality was patient age (p = 0.01). The actuarial survival rates were 90%, 73%, and 58% at 30 days, 1 year, and 2 years, respectively., Conclusions: Anesthesia for BSLTx is a most challenging procedure, for which maintenance of tissue oxygenation and right ventricular perfusion are essential. Recent advances include use of inhaled nitric oxide, ventilator management that reduces dynamic hyperinflation, and permissive hypercapnia. Analysis of outcome from a large case series such as this enables the anesthesiologist to be more aware of the important features of anesthesia for BSLTx, as well as identify potential areas of improvement.

Objective: To document changes in serum lipids and glucose with a propofol infusion technique for cardiac surgery., Design: Prospective cohort., Setting: University teaching hospital., Participants: 22 elective cardiac surgical patients., Interventions: Frequent venous blood sampling., Measurements and Main Results: Serum lipids and glucose were measured at 10 time periods perioperatively, from preinduction until 4 hours post-cardiopulmonary bypass. Plasma propofol concentrations were also measured in 10 of these patients. There was a significant increase in glucose (P < 0.0005) and decreases in cholesterol (P < 0.0005), high-density lipoprotein (P = 0.004), and low-density lipoprotein (P < 0.0005); there was no significant change in triglycerides (P = 0.39). The propofol infusion resulted in acceptable plasma levels throughout the procedure and allowed early extubation in the intensive care unit, after a mean (SD) of 7.14 (5.9) hours. There was a strong correlation between triglyceride and propofol levels at most time periods (r = 0.38 to 0.98)., Conclusions: This study demonstrates that a propofol infusion technique does not result in elevation of serum lipids and supports its increased popularity in maintenance of anesthesia for cardiac surgery.