RESUMEN
BACKGROUND: Spinal cord ischemia (SCI) resulting in paraplegia is a devastating complication associated with thoracic endovascular aortic aneurysm repair (TEVAR) whose incidence has significantly declined over time. In this review, we present our experience with a multidisciplinary clinical protocol for cerebrospinal fluid (CSF) drain management in patients undergoing TEVAR. Furthermore, we aimed to characterize complications of CSF drain placement in a large, single center experience of patients who underwent TEVAR. METHODS: This retrospective review is of patients undergoing TEVAR with and without CSF drain placement between January 2014 and December 2019 at a single institution. Patient demographics, hospital course, and drain-related complications were analyzed to assess the incidence of CSF drain-related complications. RESULTS: A total of 235 patients were included in this study, of which 85 received CSF drains. Eighty patients (94.1%) were placed by anesthesiologists, while 5 (5.9%) were placed under fluoroscopic guidance by interventional neurosurgery. The most common level of placement was L3-L4 in 38 (44.7%) cases followed by L4-L5 in 36 (42.4%) cases. The mean duration of CSF drain was 1.9 ± 1.4 days. Complications due to CSF drainage occurred in 5 (5.9%) patients and included partial retainment of catheter, subdural edema, epidural hematoma, headache, and bleeding near the drain site. The overall 30-day mortality rate was 5.5% and did not differ between those who received a CSF drain and those who did not (P = 0.856). The overall incidence of SCI resulting in paraplegia was 1.7% in the studied patients. CONCLUSIONS: A protocol-based CSF drainage program for spinal cord protection involves a multifaceted approach in identification and selection of patients meeting criteria for prophylactic drain placement, direct closed loop communication, and perioperative management by an experienced team. Despite the inherent advantages of CSF drain placement, it is not without complications, thus risk and benefit need to be weighed in context of the procedure and the patient with close communication and team approach.
Asunto(s)
Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular , Drenaje/instrumentación , Procedimientos Endovasculares , Paraplejía/prevención & control , Isquemia de la Médula Espinal/prevención & control , Anciano , Anciano de 80 o más Años , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Disección Aórtica/cirugía , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/mortalidad , Aneurisma Falso/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Aneurisma de la Aorta Torácica/cirugía , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Toma de Decisiones Clínicas , Protocolos Clínicos , Drenaje/efectos adversos , Drenaje/mortalidad , Endofuga/diagnóstico por imagen , Endofuga/mortalidad , Endofuga/cirugía , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Paraplejía/etiología , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Isquemia de la Médula Espinal/etiología , Factores de Tiempo , Resultado del Tratamiento , Úlcera/diagnóstico por imagen , Úlcera/mortalidad , Úlcera/cirugíaRESUMEN
BACKGROUND: Autophagy is an integral component of cellular homeostasis and metabolism. The exact mechanism of impaired autophagy in diabetes mellitus is unknown. Forkhead Box O3 (FOXO3α) is a key regulator of oxidative stress-related responses. We hypothesize FOXO3α is a direct upstream regulator of the autophagy pathway, and its upregulation is compromised in diabetic patients during stress of cardiopulmonary bypass (CPB). METHODS: The study enrolled 32 diabetic and 33 nondiabetic patients undergoing a cardiac surgical procedure on CPB. Right atrial tissue and serum samples were collected before and after CPB per protocol. A set of key components were quantitatively assessed and compared by microarray, immunoblotting, and immunohistochemistry studies. Data were analyzed using paired or unpaired student test. A P of <.05 or less was considered significant. RESULTS: Serum microarray showed FOXO3α was upregulated in the diabetic vs nondiabetic group after CPB (P = .033), autophagy-related 4B gene and Beclin 1 gene were greatly upregulated in the nondiabetic group (P = .028 and P = .002, respectively). On immunoblotting, there was upregulation of FOXO3α in the nondiabetic patients after CPB (P = .003). There were increased levels of Beclin-1, Bcl-2, and light chain 3B after CPB in the nondiabetic group only (P = .016, P = .005, P = .002, respectively). Sirtuin 1, Unc-51-like autophagy activating kinase 1 (ULK1), peroxisome proliferator-activated receptor gamma coactivator 1α (PGC1α), and mammalian target of rapamycin (mTOR) were not significantly changed in the nondiabetic group after CPB. CONCLUSIONS: Compared with nondiabetic patients, there was no significant upregulation of FOXO3α in diabetic patients, which could possibly explain the lack of upregulation of the autophagy process after CPB. FOXO3α could potentially serve as a therapeutic target to improve cellular homeostasis.
Asunto(s)
Puente Cardiopulmonar/efectos adversos , Diabetes Mellitus/genética , Proteína Forkhead Box O3/genética , Miocardio/metabolismo , Estrés Oxidativo/genética , ARN/genética , Regulación hacia Arriba , Anciano , Apoptosis , Autofagia , Diabetes Mellitus/metabolismo , Diabetes Mellitus/patología , Femenino , Proteína Forkhead Box O3/biosíntesis , Humanos , Immunoblotting , Masculino , Miocardio/patologíaRESUMEN
BACKGROUND: Ultrasound guidance has resulted in a continuous evolution in techniques for pain control for video-assisted thoracoscopic surgery (VATS). The objective of this study was to compare erector spinae plane block with intercostal block as multimodal analgesia to elucidate quality of postoperative pain control and preservation of pulmonary function after VATS. METHODS: A consecutive cohort of patients undergoing elective VATS was enrolled in the study and divided into erector spinae plane block and intercostal block groups. Spirometry and visual analog scale pain score exams were performed to measure forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), FEV1/FVC ratio, and forced expiratory flow in intervals of 25% to 75%. Chronic pain was assessed by reviewing surgical follow-up notes. RESULTS: Seventy-eight patients were included. Comparing the erector spinae plane block group with the intercostal block group found significant improvement in visual analog scale pain score (3.2 vs 6.4, P < .001), postanesthesia care unit length of stay (127.3 vs 189.5 minutes, P = .045), preservation in lung volume parameters at 2 hours (FVC: 40.5% vs 51.4%, P < .001; FEV1: 40.9% vs 53.8%, P < .001; and forced expiratory flow in intervals of 25%-75%: 39.7% vs 53.7%, P = .019) and at 24 hours (FVC: 37.8% vs 50.5%, P < .001; FEV1: 34.3% vs 51.9%, P < .001; forced expiratory flow in intervals of 25%-75%: 27.1% vs 56.3%, P < .001), respectively. CONCLUSIONS: Erector spinae plane block improves acute and chronic pain control and preserves lung function. Thus, it has the potential for enhanced recovery from VATS as part of a multimodal analgesia regimen.