IntroductionPost-cardiac surgery delirium is a severe complication. The circadian rhythm of melatonin secretion has been shown to be altered postoperatively.Aim of the studyIt was hypothesized that restoring normal sleeping patterns with a substance that is capable of resynchronizing circadian rhythm such as exogenous administration of melatonin may possibly reduce the incidence of postoperative delirium.Material and methodsThis paper represents a prospective clinical observational study. Two consecutive groups of 250 consecutive patients took part in the study. Group A was the control group and group B was the melatonin group. In group B, the patients received prophylactic melatonin treatment. The main objectives were to observe the incidence of delirium, to identify any predictors of delirium, and to compare the two groups based on the delirium incidence.ResultsThe incidence of delirium was 8.4% in the melatonin group vs. 20.8% in the control group (p = 0.001). Predictors of delirium in the melatonin group were age (p = 0.001) and higher EuroSCORE II value (p = 0.001). In multivariate analysis, age and EuroSCORE II value (p = 0.014) were predictors of postoperative delirium. Comparing the groups, the main predictors of delirium were age (p = 0.001), EuroSCORE II value (p = 0.001), cardio-pulmonary bypass (CPB) time (p = 0.001), aortic cross-clamping (ACC) time (p = 0.008), sufentanil dose (p = 0.001) and mechanical ventilation (p = 0.033).ConclusionsAdministration of melatonin significantly decreases the incidence of postoperative delirium after cardiac surgery. Prophylactic treatment with melatonin should be considered in every patient scheduled for cardiac surgery.
Predmet výskumu: Delírium po kardiochirurgických operáciách predstavuje závažnú komplikáciu. Klinická štúdia mala za úlohu posúdiť včasné rizikové faktory delíria a identifi kovať, ktoré z nich by mohli byť potenciálne modifi kované za účelom optimalizovania perioperačného manažmentu. Metodika: Pôvodná práca predstavuje prospektívnu klinickú observačnú štúdiu. Štúdia pozostáva z 250 po sebe nasledujúcich pacientov. Operačné postupy, spôsob vedenia anestézie ako aj pooperačný manažment pacientov boli realizované štandardným spôsobom. Incidencia a rizikové faktory pooperačného delíria boli analyzované v prvom kroku použitím analýzy s jednou premennou. Premenné považované za klinicky významné boli následne použité v analýze s viacerými premennými za účelom identifi kovania nezávislých rizikových faktorov delíria. Prítomnosť delíria bola hodnotená pomocou skórovacej škály-The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)-každých 12 hodín po operácii. Výsledky: Pooperačné delírium sa rozvinulo u 52 pacientov (20,8 %). Analýza s použitím jednej premennej potvrdila, že pokročilý vek (p = 0,0001), vyššia hodnota EuroSCORE II (p = 0,0001), dlhšie trvanie mimotelového obehu (p = 0,0001), dlhšie trvajúce naloženie aortálnej svorky (p = 0,0001) a dávka sufentanilu (p = 0,010) boli signifi kantne asociované so vznikom pooperačného delíria. Podávanie benzodiazepínov sa ukázalo ako intermediárny prediktor pooperačného delíria (p = 0,055). Zhrnutie: Pokročilý vek, vyššia hodnota EuroSCORE II, dlhšie trvanie mimotelového obehu a dlhšie naloženie aortálnej svorky, vyššie dávky sufentanilu podané v priebehu anestézie predstavujú všetko rizikové faktory vzniku pooperačného delíria. Jediným modifi kovateľným rizikovým faktorom pooperačného delíria bola dávka podaného sufentanilu, ktorá súvisela s dĺžkou trvania samotnej operácie. Nové preventívne stratégie a podanie nižšej dávky sufentanilu počas samotnej operácie, ako aj použitie iných opiátových prípravkov by malo byť preskúmané a v prípade priaznivých výsledkov aplikované do praxe za účelom zníženia výskytu pooperačného delíria.
Introduction:Non-valvular atrial fibrillation is a common problem in the elderly, occurring in 2% to 4% of the population > 60 years of age and it is one of the most common causes of embolic systemic events.We report a case of intracardiac thrombosis mimicking myxoma as a complication of atrial fibrillation associated with a prothrombotic state. Case Report:A 60 year old patient was presented with a right atrial mass and a 3 vessel coronary artery disease. The patient had been sufferring from persistent atrial fibrillation. In the past he had a transitory ischemic attack and a lower leg embolism and also he did not receive any anticoagulation therapy.He underwent coronary angiography which showed 3 vessels coronary artery disease. Transthoracic echocardiogram showed a freefloating right atrial mass of size 7.0 x1.1 cm with a highly embolic potential suggesting myxoma or thrombus and is shown in figure 1.Patient underwent an emergency surgery. After institution of the cardiopulmonary bypass he underwent surgical exploration of the right heart chambers and pulmonary arteries with pulmonary embolectomy. No thrombi were found in the right atrium and ventricle but were found in the main, right and left pulmonary artery. He underwent a left internal thoracic artery by-pass graft to left anterior descending artery and a great saphenous vein by-pass graft to the marginal branch. The postoperative course was uneventful. The pulmonary embolism was subclinical. Gross examination of the operative specimen showed pieces of fresh thrombi which were confirmed later also by a histologic examination, and are shown in figure 2. Right Atrial Thrombus Mimicking Myxoma with Subclinical Pulmonary EmbolismA search for a hypercoagulable state revealed normal thrombin, prothrombin and partial thromboplastin times, normal antitrhombin III, protein C and S and homocystein levels. Screening for anticardiolipin antibodies and lupus anticoagulant were negative. Genetic analysis showed heterozygous mutations of FXII
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