These observations support the belief that transesophageal echocardiographic monitoring in the intensive care unit is associated with higher interobserver agreement in diagnosing and excluding significant causes of hemodynamic instability for postoperative cardiac surgical patients.

Diastolic function is receiving more attention since echocardiographic measurements were developed and have become widely available. The importance and significance of diastolic dysfunction (DD) observed before cardiac surgery and its relationship with adverse outcomes, such as difficult separation from cardiopulmonary bypass (CPB), have not been fully explored. In this study, we hypothesize that DD can be a predictor for the need of inotropic support to successfully separate from CPB. Ninety-two consecutive patients underwent surgery during the study period. Twenty-six patients were excluded. From the remaining 66 patients, 52 had coronary artery bypass grafting alone and 14 combined procedures, valvular surgery, and reoperations (redo). Systolic and diastolic function was evaluated by two experts blinded as to the clinical data except for the age. The evaluation of diastolic function was done according to published guidelines. The demographic, echocardiographic, and hemodynamic variables were entered in a logistic regression analysis to determine which variables were independent predictors of difficult separation from CPB and the need for postoperative vasoactive support. DD was present in 20 patients (30%). Patients with DD had lower weight (P = 0.046), less frequent coronary artery bypass grafting alone (P = 0.0004), more myocardial infarction before surgery (P = 0.02), higher regional wall motion score index (P = 0.0002), and larger left ventricle (P = 0.03). Total CPB time (P = 0.004) and ischemic time (P = 0.007) were longer in the DD group. Patients with DD required more frequent inotropic support at the end of surgery (P = 0.006) and up to 12 h after surgery (P = 0.003). Multivariate logistic regression identified female sex, DD, and total CPB time as predictive of difficult weaning and inotropic requirements up to 12 h after surgery.

Inhaled epoprostenol reduces pulmonary pressure and improves right ventricular stroke work in patients with pulmonary hypertension undergoing cardiac surgery. A dose of 60 microg is hemodynamically safe, and its effect is completely reversed after 25 minutes. We did not observe any evidence of platelet dysfunction or an increase in surgical bleeding after administration of inhaled epoprostenol.

Moderate and severe LVDD and RVDD can be identified with very good reproducibility, and both degrees of diastolic dysfunction are associated with DSB.

Purpose: To determine the relative impact of each category-based TEE indication according to the ASA guidelines. Methods: In 851 patients undergoing cardiac surgery, TEE clinical indications were classified as category I or II according to the ASA guidelines. Category I indications are patients in which TEE is considered useful and category II are those where TEE is potentially useful but indications are less clear. All TEE examinations were reviewed by two anesthesiologists with advanced training in TEE. For each patient, the clinical impact of TEE in the clinical management was assessed using five criteria: 1) change of medical therapy; 2) change in the surgical procedure; 3) confirmation of a suspected diagnosis; 4) positioning of an intravascular device, and 5) substitute to a pulmonary artery catheter (PAC).Results: TEE had greater utility in category I than in category II indications (15/53 (28%) vs 110/798 (14%) respectively) (P < 0.01). The nature of the clinical impact was as follows: modification of medical therapy in 67/125 (53%), modification of planned surgical intervention in 38/125 (30%), confirmation of a diagnosis in 34/125 (27%). The impact on therapy was higher in complex surgical procedures (39%) than in valvular replacement (19%) (P < 0.01) and coronary artery bypass surgery (10%) (P < 0.001).Conclusions: Our findings validate the usefulness of the ASA practice guidelines demonstrating a greater impact of TEE on clinical management for category I indications than for category II. TEE also had a greater clinical impact in complex surgical procedures and in valvular replacement.Objectif : Déterminer l'effet relatif de l'indication de l'ETO basée sur chacune des catégories relevant des recommandations ASA.Méthode : Chez 851 patients devant subir une intervention chirurgicale cardiaque, les indications cliniques de l'ETO ont été classées en catégorie I ou II selon les recommandations de l'ASA. Dans la catégorie I, ce sont les patients pour qui l'ETO est considérée utile et dans la catégorie II, ceux pour qui l'ETO est probablement utile, les indications n'étant pas aussi claires. Tous les examens d'ETO ont été révisés par deux anesthésiologistes de formation poussée en ETO. Les répercussions cliniques de l'ETO sur le traitement clinique de chaque patient ont été évaluées selon cinq critères: 1) la modification du traitement médical 2) un changement de technique chirurgicale 3) la confirmation d'un diagnostic présumé 4) la mise en place d'un appareil intravasculaire 5) un substitut au cathéter de l'artère pulmonaire (CAP).Résultats : L'ETO a présenté une plus grande utilité avec les indications de catégorie I qu'avec celles de caté-gorie II (15/53 (28 %) vs 110/798 (14 %) respectivement) (P < 0,01). La nature de l'effet clinique a été : une modification de traitement médical chez 67/125 (53 %), un changement d'intervention chirurgicale chez 38/125 (30 %), la confirmation d'un diagnostic chez 34/125 (27 %). Les conséquences sur le traitement ont été plus grandes pour des interventions chirurgicale...

PVP monitoring can accurately estimate CVP under various conditions encountered in the operating room and in the ICU.

Phonomyography can be used to determine neuromuscular block at the corrugator supercilii muscle. In comparison with acceleromyography, phonomyography tends to measure a longer onset with more pronounced maximum effect and shorter recovery of neuromuscular block.

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