The coronavirus disease 2019 (COVID-19) pandemic continues to affect healthcare services. As elective cardiac surgical services resume, clinicians will encounter COVID-19-recovered patients for cardiac surgery. The hyperimmune pathophysiology of COVID-19 and exposure to the inflammation of cardiac surgery, cardiopulmonary bypass, mechanical ventilation, blood transfusion, and perioperative infections could lead to exacerbated responses, exemplified by systemic inflammatory response syndrome and cascade to multiorgan dysfunction syndromes. The authors present a patient with coronary artery disease undergoing off-pump coronary artery bypass surgery after the institutional protocol of two COVID-19 reverse-transcriptase polymerase chain reaction tests reported negative. Intraoperatively, unexplained hypoxemia was observed, which warranted cardiopulmonary bypass support to complete the grafting. After multiple attempts of failed weaning, intra-aortic balloon pump and high inotropes helped to wean. The patient had a stormy postoperative course, with low oxygenation, bleeding, low-cardiac-output syndrome, rhabdomyolysis of lower limb muscles, requiring multiple blood and blood product transfusion, and renal replacement therapy. Despite the corrective measures, severe hyperkalemia and cardiac arrest ensued. IgG antibodies to the severe acute respiratory distress syndrome coronavirus-2 virus were tested considering the unexplained hypoxemia. A “convalescent COVID-19” patient with “first hit” at primary infection, encountering a “second hit” of surgery and perioperative insults, might have a hyperimmune response. This “second hit” hypothesis should be considered when COVID-19 convalescent (COVID-19 symptomatic or asymptomatic) patients undergo cardiac surgery and present with unusual complications.
You may also like
The Impact of Slow Rewarming on Inotropy, Tissue Metabolism, and “After Drop” of Body Temperature in Pediatric Patients
Therefore, this study was performed to build a rewarming strategy aiming to improve the cardiac performance, minimize the early after-drop in both core and foot temperatures, and to achieve early achievement of homeostasis.
Blood Conservation and Hemostasis in Cardiac Surgery: A Survey of Practice Variation and Adoption of Evidence-Based Guidelines
The survey demonstrated widespread adoption of several best practices, including the tolerance of lower hemoglobin transfusion triggers, use of antifibrinolytics, minimization of hemodilution, and use of red cell salvage. The survey also confirms that gaps remain in preoperative anemia management and the use of transfusion algorithms supplemented with POC hemostasis testing. Serial use of this survey can be used to identify barriers to implementation and audit the effectiveness of interventions described in this article. This instrument could also help harmonize local, regional, and national efforts and become an essential component of an implementation strategy for PBM in cardiac surgery.
Pericardial fluids or Cardiopulmonary Bypass-Is There a Major Culprit for Changes in Coagulation and Inflammation?
Direct recirculation of pericardial fluids rather than conventional CPB itself causes major intraoperative changes of some coagulation markers. Pericardial blood loss with direct recirculation should be kept to a minimum to avoid unnecessary activation of coagulation.