A relatively new uncalibrated arterial pressure waveform cardiac output (CO) measurement technique is the Pulsioflex-ProAQT® system. Aim of this study was to validate this system in cardiac surgery patients with a specific focus on the evaluation of a difference in the radial versus the femoral arterial access, the value of the auto-calibration modus and the ability to show fluid-induced changes. In twenty-five patients scheduled for ascending aorta, aortic arch replacement, or both we measured CO simultaneously by transpulmonary thermodilution (COtd) and by using the ProAQT® system connected to the radial (COpR), as well as the femoral artery catheter (COpF). Hemodynamic data were assessed at predefined time points; from incision until 16 h after ICU admission. In total 175 (radial) and 179 (femoral) pairs of CO measurement were collected. The accuracy of COpR/COpF was evaluated showing a mean bias of −0.31 L/min (±2.9 L/min) and -0.57 L/min (± 2.8 L/min) with percentage errors of 49 and 46% respectively. Trending ability of the ProAQT® device was evaluated; the four quadrant concordance rates in the radial and femoral artery were 74 and 75% and improved to 77 and 85% after auto-calibration. The mean angular biases in the radial and femoral artery were 6.4° and 6.0° and improved to 5° and 3.3° after auto-calibration. The polar concordance rates in the radial and femoral artery were 65 and 70% and improved to 76 and 84% after auto-calibration. Considering the fluid-induced changes in stroke volume(SV), the coefficient of correlation between the changes in SVtd and SVp was 0.57 (p < 0.01) in the radial artery and 0.60 (p < 0.01) in the femoral artery. The ProAQT® system can be of additional value if the clinician wants to determine fluid responsiveness in cardiac surgery patients. However, the ProAQT® system provided inaccurate CO measurements compared to transpulmonary thermodilution. The trending ability was poor for COpR but moderate for COpF. Auto-calibration of the system did not improve accuracy of CO measurements nor did it improve the prediction of fluid responsiveness. However, the trending ability was improved by auto-calibration, possibly by correcting a drift over a longer time period.

Background Medication administration errors (MAEs) are a major cause of morbidity and mortality. An updated barcode medication administration (BCMA) technology on infusion pumps is implemented in the operating rooms to automate double check at a syringe exchange. Objective The aim of this mixed-methods before-and-after study is to understand the medication administrating process and assess the compliance with double check before and after implementation. Methods Reported MAEs from 2019 to October 2021 were analysed and categorised to the three moments of medication administration: (1) bolus induction, (2) infusion pump start-up and (3) changing an empty syringe. Interviews were conducted to understand the medication administration process with functional resonance analysis method (FRAM). Double check was observed in the operating rooms before and after implementation. MAEs up to December 2022 were used for a run chart. Results Analysis of MAEs showed that 70.9% occurred when changing an empty syringe. 90.0% of MAEs were deemed to be preventable with the use of the new BCMA technology. The FRAM model showed the extent of variation to double check by coworker or BCMA. Observations showed that the double check for pump start-up changed from 70.2% to 78.7% postimplementation (p=0.41). The BCMA double check contribution for pump start-up increased from 15.3% to 45.8% (p=0.0013). The double check for changing an empty syringe increased from 14.3% to 85.0% (p<0.0001) postimplementation. BCMA technology was new for changing an empty syringe and was used in 63.5% of administrations. MAEs for moments 2 and 3 were significantly reduced (p=0.0075) after implementation in the operating rooms and ICU. Conclusion An updated BCMA technology contributes to a higher double check compliance and MAE reduction, especially when changing an empty syringe. BCMA technology has the potential to decrease MAEs if adherence is high enough.

Objectives To determine the impact of a rotational thromboelastometry (ROTEM)-guided transfusion protocol on the use of blood products, patient outcomes, coagulation factor concentrates, and costs. Design A single-center retrospective cohort study. Setting A tertiary university hospital. Patients Adults undergoing proximal aortic surgery with deep hypothermic circulatory arrest. Intervention ROTEM-guided transfusion protocol compared with clinically-guided transfusion. Measurements and Main Results Two hundred seventeen patients were included; seventy-one elective and 24 emergency patients in the clinically-guided group, and 59 elective and 63 emergency patients in the ROTEM-guided transfusion protocol group. In the ROTEM-guided transfusion protocol group, a significant reduction in transfusion of red blood cells (5 [3-8] v 2 [0-4], p < 0.001), platelet concentrate (2 [2-3] v 1 [1-2], p < 0.001), and plasma (1,980 mL [1,320-3,300] v 800 mL [0-1,000], p < 0.001) was seen in elective surgery. Emergency patients received fewer red blood cells (7 [5-10] v 5 [2-10], p = 0.040), platelet concentrate (3 [2-4] v 2 [2-3], p = 0.023), and plasma (3,140 mL [1,980-3,960] v 1,000 mL [0-1,400], p < 0.001). Prothrombin complex concentrate and fibrinogen concentrate were increased significantly in elective and emergency patients. The surgical reexploration for bleeding rate was decreased in elective patients 33.8% v 5.1%. Conclusion The implementation of a ROTEM-guided transfusion protocol might have the potential to decrease blood product transfusion and may improve patient outcomes.

Background: Femoral cannulation is commonly used in minimally invasive cardiac surgery to establish extracorporeal circulation. We present a case with a finding that should be evaluated when screening candidates for minimally invasive cardiac surgery. Case summary: A 57-year-old male patient was scheduled for minimally invasive repair of the mitral and tricuspid valve and a MAZE procedure. During surgery there was difficulty advancing the venous cannula inserted in the right femoral vein. On transoesophageal echocardiography a guidewire advanced from the femoral vein was observed entering the right atrium from the superior vena cava. Despite inserting a second venous cannula in the jugular vein, venous drainage was insufficient for minimal invasive surgery. The approach was converted to a median sternotomy with bicaval cannulation. Re-examination of the preoperative computed tomography (CT) scan showed an interrupted inferior vena cava (IVC) with azygos continuation. Discussion: In patients with major venous malformations such as the interrupted IVC with azygos continuation a full sternotomy is the preferred approach. The venous system should be evaluated when screening candidates for minimally invasive mitral valve surgery with preoperative CT. Additional cues to suspect interruption of the IVC are polysplenia and a broad superior mediastinal projection on the chest radiograph, mimicking a right paratracheal mass.

Background: Clamshell thoracotomy is the traditional approach for bilateral sequential lung transplantation (LuTx), despite considerable morbidity. The bilateral anterolateral thoracotomy without sternal division is proposed as an alternative, less invasive method. Since this technique is more surgically challenging, the aim of this study was to evaluate the more favorable surgical approach. Methods: Adult patients undergoing LuTx between 2010 and 2022 were included in this single‐center retrospective cohort study. Multivariable regression analyses were performed to assess the effect of surgical approach on mortality, operative outcomes, and complications. Results: A total of 249 patients (anterolateral thoracotomy: n = 132, clamshell: n = 117) were included. Recipients in the anterolateral thoracotomy group were older, on the waiting list for a shorter period of time, classified less often as highly urgent, and differed in their indications for LuTx. After multivariable correction, operating and ischemic times were longer for patients in the anterolateral thoracotomy group. However, patients with an anterolateral thoracotomy incision had less intraoperative extracorporeal circulation (ECC) use, blood loss, and need for transfusion. While survival was similar, ICU and hospital stay, and duration of mechanical ventilation were shorter. Patients in the anterolateral thoracotomy group also had significantly less wound‐related complications. The use of intraoperative ECC, which was much higher in the clamshell group, seemed to play an important role in these differences in outcomes. Conclusion: Performing LuTx through the less invasive anterolateral thoracotomy is a favorable alternative to the clamshell incision. Despite increased technical difficulty and a limited increase in operating and ischemic times, survival is similar, but the anterolateral thoracotomy patients had significantly less peri‐ and post‐operative complications and a faster recovery.

Blood transfusion is often necessary during and after lung transplantation surgery. Point-of-care guided bleeding strategies, such as rotational thromboelastometry (ROTEM), can reduce blood transfusion in cardiovascular surgery. This study aimed to assess the effect of ROTEM-guided bleeding management on the need for allogenic blood transfusion, prohemostatic medication, and clinical outcomes in lung transplantation patients. This single-center retrospective cohort study compared patients receiving bilateral lung transplantation between 2010-2014 and 2017-2020. The first cohort was treated with a clinically guided bleeding strategy and the second cohort with a ROTEM-guided bleeding strategy. Multivariable regression analyses were performed to determine the effects on primary outcomes. A total of 167 (66 clinically guided vs 101 ROTEM-guided) patients were included for analysis. Baseline, intraoperative, and postoperative characteristics were mostly similar, but differed regarding the number of patients with cystic fibrosis, use of cardiopulmonary bypass, and surgical technique. The ROTEM-guided group received significantly less median red blood cells (7 [3; 13] vs 4 [1; 9] units, p < 0.01), platelet concentrate (2 [0; 3] vs 0 [0; 2] units, p = 0.01), and plasma volume (2,310 [1,320; 3,960] vs 800 [0; 1,600] ml, p < 0.01). In multivariable regression analysis, implementation of the ROTEM strategy only remained significantly associated with a decreased use of plasma volume. Cardiopulmonary bypass significantly increased allogenic blood transfusion needs. Moreover, more prothrombin complex concentrate, fibrinogen concentrate, and less tranexamic acid were used in the ROTEM-guided group. ROTEM-guided bleeding management reduces plasma transfusion in bilateral lung transplant surgery and cardiopulmonary bypass seems to increase transfusion needs.