Cardiac arrest from massive carbon dioxide embolism during endoscopic saphenous vein harvesting.
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ABSTRACT:
SUBMITTER: Kawabori M
PROVIDER: S-EPMC8302869 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Coronary artery bypass grafting is the most common cardiac surgical procedure performed worldwide and the long saphenous vein the most common conduit for this. When performed as an open vein harvest (OVH), the incision on each leg can be up to 85cm long, making it the longest incision of any routine procedure. This confers a high degree of morbidity to the procedure. Endoscopic vein harvest (EVH) methods were popularised over two decades ago, demonstrating significant benefits over OVH in terms of leg wound complications including surgical site infections. They also appeared to hasten return to usual activities and wound healing and became popular particularly in North America. Subgroup analyses of two trials designed for other purposes created a period of uncertainty between 2009-2013 while the impact of endoscopic vein harvesting on vein graft patency and major adverse cardiac events was scrutinised. Large observational studies debunked the findings of increased mortality in the short-term, allowing practitioners and governing bodies to regain some confidence in the procedure. A well designed, adequately powered, randomised controlled trial published in 2019 also definitively demonstrated that there was no increase in death, myocardial infarction or repeat revascularisation with endoscopic vein harvest. Endoscopic vein harvest is a Class IIa indication in European Association of Cardio-Thoracic Surgery (EACTS) and a Class I indication in International Society of Minimally Invasive Cardiac Surgery (ISMICS) guidelines.
| S-EPMC8024854 | biostudies-literature
Project description:Endoscopic vein harvest in preparation for coronary artery bypass surgery has become a preferred method of procuring saphenous vein. Several case reports have documented carbon dioxide (CO2) embolization with this procedure as well as CO2 embolization during other laparoscopic surgeries (Markar et al., 2010). Although uncommon, the potential for CO2 entrainment through an open vein or through absorption by vascular structures exists and should be recognized (Lin et al., 2003). We report a case of CO2 embolization during EVH for a 77-year-old patient who underwent CABG that was identified early by the cardiac surgeon through the indirect auscultation of a mill-wheel murmur after the pericardium was opened. This may be the first reported case of a murmur related to air emboli identified without the use of a precordial Doppler probe or a stethoscope. This diagnosis was further supported by TEE before systemic hypotension or cardiovascular collapse occurred.
| S-EPMC4906192 | biostudies-literature
Project description:ObjectivesThis survey sought to characterize the national prescribing patterns and barriers to the use of thrombolytic agents in the treatment of pulmonary embolism, with a specific focus on treatment during actual or imminent cardiac arrest.DesignA 19-question international, cross-sectional survey on thrombolytic use in pulmonary embolism was developed, validated, and administered. A multivariable logistic regression was conducted to determine factors predictive of utilization of thrombolytics in the setting of cardiac arrest secondary to pulmonary embolism.SettingInternational survey study.SubjectsPhysicians, pharmacists, nurses, and other healthcare professionals who were members of the Society of Critical Care Medicine.InterventionsNone.Measurements and main resultsThrombolytic users were compared with nonusers. Respondents (n = 272) predominately were physicians (62.1%) or pharmacists (30.5%) practicing in an academic medical center (54.8%) or community teaching setting (24.6%). Thrombolytic users (n = 177; 66.8%) were compared with nonusers (n = 88; 33.2%) Thrombolytic users were more likely to work in pulmonary/critical care (80.2% thrombolytic use vs 59.8%; p < 0.01) and emergency medicine (6.8% vs 3.5%; p < 0.01). Users were more likely to have an institutional guideline or policy in place pertaining to the use of thrombolytics in cardiac arrest (27.8% vs 13.6%; p < 0.01) or have a pulmonary embolism response team (38.6% vs 19.3%; p < 0.01). Lack of evidence supporting use and the risk of adverse outcomes were barriers to thrombolytic use. Working in a pulmonary/critical care environment (odds ratio, 2.36; 95% CI, 1.24-4.52) and comfort level (odds ratio, 2.77; 95% CI, 1.7-4.53) were predictive of thrombolytic use in the multivariable analysis.ConclusionsMost survey respondents used thrombolytics in the setting of cardiac arrest secondary to known or suspected pulmonary embolism. This survey study adds important data to the literature surrounding thrombolytics for pulmonary embolism as it describes thrombolytic user characteristic, barriers to use, and common prescribing practices internationally.
| S-EPMC7314323 | biostudies-literature
Project description:BackgroundTo compare the clinical outcomes, quality of saphenous vein (SV) grafts, and wound complications between endoscopic vein harvesting (EVH) technique and open vein harvesting (OVH) technique in patients with coronary artery bypass graft (CABG) surgery.MethodsWe reviewed one hundred patients with multi-vessel coronary artery disease who underwent elective CABG and agreed to preserve their SV specimens for study. Fifty patients (OVH group) underwent OVH, and the remaining (EVH group) underwent EVH. The median follow-up time was 12 months. Clinical outcomes, 1-year graft patency rates, endothelium integrity of SV grafts and wound complications were assessed.ResultsThe follow-up time was 12 [12-13] months. Recurrence of angina was observed in 5 patients, with 3 (6.1%) in EVH group and 2 (4%) in OVH group (P=0.68). The endothelium integrity of specimens before distension was similar in both the groups (EVH: 81.1%±6.11% vs. OVH: 80.8%±6.58%, P=0.83). After distension, the endothelium integrity was still similar (EVH: 70.7%±9.73%; OVH: 68.3%±9.60%; P=0.22). Grafts of 5 (11.6%) patients in EVH group were classified as occluded, and 4 (9.8%) patients in OVH group showed occlusion of SV grafts (P=1.0). After day 7, the postoperative leg pain was significantly milder in EVH group than OVH group (1.16±0.76 vs. 2.50±0.91, P<0.01).ConclusionsThese findings suggest that EVH is not associated with worse clinical outcomes or conduit quality. However, it may have advantage in wound healing.
| S-EPMC7330341 | biostudies-literature
Project description:ObjectivesTo obtain a suitable conduit from the lesser (short) saphenous system for use in coronary artery bypass surgery. We wanted to perform this while the patient was in the supine position as to not disrupt the standard operation, and at the same time, utilizing the endoscopic vein harvest technique with its obvious abilities to decrease vein harvest morbidity. We also theorized that through endoscopic techniques instead of the open technique we could harvest greater lengths of conduit, thus providing quality vein segments for additional grafts if needed.MethodsWe were able to perform endoscopic vein harvest while in the supine position with one unique centrally located incision that has not been previously described.ResultsThe lesser saphenous vein harvested in the described technique provided excellent conduit for our patients that were conduit poor. The endoscopic technique allowed increased length of harvested segments, by giving us the ability to travel under the gastrocnemius muscle with minimal morbidity as opposed to the open technique, where the traditional endpoint is the aforementioned muscle. Conduits were harvested successfully from 14 of 16 candidates. No wound infections or healing problems were experienced. Neurovascular integrity was maintained in all patients.ConclusionsEndoscopic vein harvest of the lesser saphenous vein with the patient in the supine position is safe, effective and affords conduits for a unique subset of patients undergoing coronary artery bypass grafting.
| S-EPMC3523626 | biostudies-literature
Project description:Massive pulmonary embolism (PE) frequently leads to cardiac arrest (CA) which carries an extremely high mortality rate. Although available, randomized trials have not shown survival benefits from thrombolytic use. Thrombolytics however have been used successfully during resuscitation in clinical practice in multiple case reports and in retrospective studies. Recent resuscitation guidelines recommend using alteplase for PE related CA; however they do not offer a standardized treatment regimen. The most consistently applied approach is an intravenous bolus of 50?mg tissue plasminogen activator (t-PA) early during cardiopulmonary resuscitation (CPR). There is no consensus on the subsequent dosing. We present a case in which two 50?mg boluses of t-PA were administered 20 minutes apart during CPR due to persistent hemodynamic compromise guided by bedside echocardiogram. The patient had an excellent outcome with normalization of cardiac function and no neurologic sequela. This case demonstrates the benefit of utilizing bedside echocardiography to guide administration of a second bolus of alteplase when there is persistent hemodynamic compromise despite achieving return of spontaneous circulation after the initial bolus, and there is evidence of persistent right ventricle dysfunction. Future trials are warranted to help establish guidelines for thrombolytic use in cardiac arrest to maximize safety and efficacy.
| S-EPMC5884296 | biostudies-literature
Project description:ObjectiveTo determine if arterial oxygen and carbon dioxide abnormalities in the first 24h after return of spontaneous circulation (ROSC) are associated with increased mortality in adult out-of-hospital cardiac arrest (OHCA).MethodsWe used data from the Resuscitation Outcomes Consortium (ROC), including adult OHCA with sustained ROSC ≥1h after Emergency Department arrival and at least one arterial blood gas (ABG) measurement. Among ABGs measured during the first 24h of hospitalization, we identified the presence of hyperoxemia (PaO2≥300mmHg), hypoxemia (PaO2<60mmHg), hypercarbia (PaCO2>50mmHg) and hypocarbia (PaCO2<30mmHg). We evaluated the associations between oxygen and carbon dioxide abnormalities and hospital mortality, adjusting for confounders.ResultsAmong 9186 OHCA included in the analysis, hospital mortality was 67.3%. Hyperoxemia, hypoxemia, hypercarbia, and hypocarbia occurred in 26.5%, 19.0%, 51.0% and 30.6%, respectively. Initial hyperoxemia only was not associated with hospital mortality (adjusted OR 1.10; 95% CI: 0.97-1.26). However, final and any hyperoxemia (1.25; 1.11-1.41) were associated with increased hospital mortality. Initial (1.58; 1.30-1.92), final (3.06; 2.42-3.86) and any (1.76; 1.54-2.02) hypoxemia (PaO2<60mmHg) were associated with increased hospital mortality. Initial (1.89; 1.70-2.10); final (2.57; 2.18-3.04) and any (1.85; 1.67-2.05) hypercarbia (PaCO2>50mmHg) were associated with increased hospital mortality. Initial (1.13; 0.90-1.41), final (1.19; 1.04-1.37) and any (1.01; 0.91-1.12) hypocarbia (PaCO2<30mmHg) were not associated with hospital mortality.ConclusionsIn the first 24h after ROSC, abnormal post-arrest oxygen and carbon dioxide tensions are associated with increased out of-hospital cardiac arrest mortality.
| S-EPMC5660655 | biostudies-literature
Project description:Due to increasing concentrations in the atmosphere, carbon dioxide has, in recent times, been targeted for utilisation (Carbon Capture Utilisation and Storage, CCUS). In particular, the production of CO from CO2 has been an area of intense interest, particularly since the CO can be utilized in Fischer-Tropsch synthesis. Herein we report that CO2 can also be used as a source of atomic oxygen that is efficiently harvested and used as a waste-free terminal oxidant for the oxidation of alkenes to epoxides. Simultaneously, the process yields CO. Utilization of the atomic oxygen does not only generate a valuable product, but also prevents the recombination of O and CO, thus increasing the yield of CO for possible application in the synthesis of higher-order hydrocarbons.
| S-EPMC8528036 | biostudies-literature
Project description:BackgroundCurrent consensus statements maintain that endoscopic vein harvesting (EVH) should be standard care in coronary artery bypass graft surgery, but vein quality and clinical outcomes have been questioned. The VICO trial (Vein Integrity and Clinical Outcomes) was designed to assess the impact of different vein harvesting methods on vessel damage and whether this contributes to clinical outcomes after coronary artery bypass grafting.MethodsIn this single-center, randomized clinical trial, patients undergoing coronary artery bypass grafting with an internal mammary artery and with 1 to 4 vein grafts were recruited. All veins were harvested by a single experienced practitioner. We randomly allocated 300 patients into closed tunnel CO2 EVH (n=100), open tunnel CO2 EVH (n=100), and traditional open vein harvesting (n=100) groups. The primary end point was endothelial integrity and muscular damage of the harvested vein. Secondary end points included clinical outcomes (major adverse cardiac events), use of healthcare resources, and impact on health status (quality-adjusted life-years).ResultsThe open vein harvesting group demonstrated marginally better endothelial integrity in random samples (85% versus 88% versus 93% for closed tunnel EVH, open tunnel EVH, and open vein harvesting; P<0.001). Closed tunnel EVH displayed the lowest longitudinal hypertrophy (1% versus 13.5% versus 3%; P=0.001). However, no differences in endothelial stretching were observed between groups (37% versus 37% versus 31%; P=0.62). Secondary clinical outcomes demonstrated no significant differences in composite major adverse cardiac event scores at each time point up to 48 months. The quality-adjusted life-year gain per patient was 0.11 (P<0.001) for closed tunnel EVH and 0.07 (P=0.003) for open tunnel EVH compared with open vein harvesting. The likelihood of being cost-effective, at a predefined threshold of £20 000 per quality-adjusted life-year gained, was 75% for closed tunnel EVH, 19% for open tunnel EVH, and 6% for open vein harvesting.ConclusionsOur study demonstrates that harvesting techniques affect the integrity of different vein layers, albeit only slightly. Secondary outcomes suggest that histological findings do not directly contribute to major adverse cardiac event outcomes. Gains in health status were observed, and cost-effectiveness was better with closed tunnel EVH. High-level experience with endoscopic harvesting performed by a dedicated specialist practitioner gives optimal results comparable to those of open vein harvesting.Clinical trial registrationURL: https://www.isrctn.com. International Standard Randomised Controlled Trial Registry Number: 91485426.
| S-EPMC5768238 | biostudies-literature
Project description:BACKGROUND:The saphenous vein is the most commonly used conduit for coronary artery bypass grafting (CABG). Wound healing complications related to saphenous vein harvesting are common, with reported surgical site infection rates ranging from 2 to 20%. Patients' risk factors, perioperative hygiene routines, and surgical technique play important roles in wound complications. Here we describe the perioperative routines and surgical methods of Swedish operating theatre (OT) nurses and cardiac surgeons. METHODS:A national cross-sectional survey with descriptive design was conducted to evaluate perioperative hygiene routines and surgical methods associated with saphenous vein harvesting in CABG. A web-based questionnaire was sent to OT nurses and cardiac surgeons at all eight hospitals performing CABG surgery in Sweden. RESULTS:Responses were received from all hospitals. The total response rate was 62/119 (52%) among OT nurses and 56/111 (50%) among surgeons. Chlorhexidine 5 mg/mL in 70% ethanol was used at all eight hospitals. The OT nurses almost always (96.8%) performed the preoperative skin disinfection, usually for three to 5 minutes. Chlorhexidine was also commonly used before dressing the wound. Conventional technique was used by 78.6% of the surgeons, "no-touch" by 30.4%, and both techniques by 9%. None of the surgeons used endoscopic vein harvesting. Type of suture and technique used for closing the wound differed markedly between the centres. CONCLUSIONS:In this article we present insights into the hygiene routines and surgical methods currently used by OT nurses and cardiac surgeons in Sweden. The results indicate both similarities and differences between the centres. Local traditions might be the most important factors in determining which procedures are employed in the OT. There is a lack of evidence-based hygiene routines and surgical methods.
| S-EPMC6950860 | biostudies-literature