S32 ORAL ABSTRACT PRESENTATIONS / Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) S1–S33

Discussion: We found that oxygen delivery, partly related to a plasma (FFP) was being transfused to optimise coagulation, as
low haematocrit, was a predictor for DDRF. In contrast, well as metamizol. Immediate management of anaphylaxis
oxygen delivery was not associated with PPSC, which may (epinephrine, aggressive fluid therapy, corticosteroids and
be related to a higher mean DO₂ overall. antihistamines) was started stopping all the suspected triggers
(FFP, metamizol).
REFERENCE: 1. Ranucci M, Romitti F, Isgrò G, et al. During external cardiac massage, massive bleeding
Oxygen delivery during cardiopulmonary bypass and acute appeared through the thoracic drainage tubes and plasma-
renal failure after coronary operations. Ann Thorac Surg. free management according to our institutional protocol was
2005; 80: 2213-2220. started. Emergency resternotomy was performed in the ICU
due to cardiac tamponade and ineffective CPR. A bleeding
Table 1: Multivariate Regression Risk Analysis for Kidney Failure
point in the aorta was repaired successfully. A total of 10 red
Risk Factor DDRF PPSC packed blood cells, 4g of fibrinogen concentrate, 1200 IU of
prothombin complex concentrate and 2 pools of platelets were
Regression p- Regression p-value
transfused, achieving patient stabilisation after 40 min of CPR.
Coefficient value Coefficient
Once again, the patient was transferred to the operating room
Re-operation NS NS 0.105 o0.001 for surgical revision.
MAP 0.062 0.002 0.108 o0.001 The levels of plasma total tryptase after the reaction were
CPB duration 0.007 0.001 0.146 o0.001 not elevated, neither histamine, latex or complement factors.
Nadir haematocrit -0.278 0.001 -0.118 o0.001
Nadir 30 minutes 0.010 0.027 NS NS
Patient was discharged from hospital two months later, after
mean DO2 overcoming multiple postoperative complications. At the
moment, the delayed immunological study is still outstanding.
DDRF ¼ dialysis dependent renal; PPSC ¼ postoperative peak serum
creatinine; MAP ¼ Mean Arterial Pressure; CPB ¼ Cardiopulmonary bypass; Discussion: Serious allergic events occurring during
DO2 ¼ Oxygen Delivery anaesthesia and the peri-operative period are rare, but can
rapidly evolve into life-threatening situations if not recognised
PP29 and managed promptly. In the postoperative period after
cardiac surgery the immediate diagnosis of anaphylaxis can
Cardiac arrest due to anaphylactic shock after cardiac be difficult, particularly as sudden cardiovascular collapse is
surgery with massive bleeding and cardiac tamponade follow- also observed in situations of cardiogenic shock, major
ing cardiopulmonary resuscitation: case report bleeding, cardiac tamponade, vasoplegia or severe
arrhythmias. Nevertheless anesthesiologists should not forget
Mireia Rodríguez Prieto, M García Alvarez, A Parera Ruiz, about the rare diagnosis of anaphylaxis. While transthoracic
T Koller, V Moral echocardiography is performed, the patient’s body should be
uncovered to check for cutaneous manifestations. With a high
Hospital Santa Creu i Sant Pau, Department of Anaesthesiol- level of clinical suspicion early and specific management of
ogy, Barcelona, Spain anaphylaxis should be started. In this case it is possible that
high levels of triptase were not detected because of total
Introduction: Anaphylaxis is a severe and life-threatening replacement of circulating blood volume due to massive
systemic hypersensitivity reaction. Perioperative anaphylaxis transfusion.
is reported in up to 1/13.000 anaesthetic procedures.
Hypotension related to anaesthetic agents, inability of the
anaesthetised patient to communicate early symptoms and that PP30
the patient is covered can contribute to delayed diagnosis with
terrible consequences. Neuromuscular ultrasound as a promising tool in the diagnose
of diaphragmatic paralysis after cardiac surgery
Case report: We report a case of a 76-year old man admitted
to ICU after elective valvular heart surgery. Immediate María del Mar Felipe1, M García-Álvarez1, L Zapata2,
postoperative follow-up was complicated by hemodynamic J Galán1
instability due to a major bleeding requiring surgical revision.
1
After re-admission to ICU, the patient stayed hemodynamically Hospital Sant Pau, Department of Anaesthesiology, Barce-
stable with low doses of vasoactive and inotropic drugs with no lona, Spain
2
evidence of bleeding or myocardial dysfunction. Unexpectedly, Hospital Sant Pau, Department of Intensive Care, Barcelona,
the patient developed refractory hypotension and subsequent Spain
cardiac arrest (asystole). Cardiopulmonary resuscitation (CPR)
was started. When we uncovered the chest of the patient to Introduction: Diaphragm dysfunction is a potential factor for
perform urgent transthoracic echocardiography generalised postoperative pulmonary complications leading to prolonged
flushing and hives were noticed. At that point fresh frozen mechanical ventilation and failed extubation after cardiac
 ORAL ABSTRACT PRESENTATIONS / Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) S1–S33
surgery (1). A prompt diagnosis is crucial for starting with
therapeutic strategies as soon as possible.
Different structural and functional techniques such as chest
radiographs, fluoroscopy, computed tomography, dynamic
magnetic resonance and electromyography are available; each
one has its strengths and weaknesses (1,2).
Neuromuscular ultrasound has emerged as a non-invasive
technique useful in the structural and functional assessment of
the diaphragm. It is considered as a fast, reliable, cheap and
safe method using no ionising radiation to study the structure
and function of the diaphragm (1).
After cardiac surgery, imaging protocols should be devel-
oped and validated to standardise the ultrasonography assess-
ment of the diaphragm (3).
Method: We report a case of a 74-year-woman admitted to
Intensive Care Unit (ICU) after myocardial revascularization
with combined aortic and mitral valve replacements who
developed after extubation a progressive and unexplained
tachypnea and orthopnea, more marked in the supine
position and accompanied by respiratory secretions.
Chest X-rays were not conclusive. Initial lung ultrasonogra-
phy revealed a pattern of consolidation. Antibiotic therapy was
started as pneumonia was suspected but there was no improve-
ment in the amount of dyspnoea. We decided to perform a
neuromuscular ultrasound to evaluate the diaphragm.
Result: Neuromuscular ultrasound revealed a right
diaphragmatic paralysis. This finding with no need for any
other invasive or expensive method, gave us her diagnosis. We
contacted our pneumologist and we started noninvasive
S33
ventilation (NIV) which resulted in a clear improvement.
The patient was finally discharged to ward on NIV.
Discussion: Postoperative diaphragmatic dysfunction due
hypothermia, traction or cauterising of the phrenic nerve
during the surgery is under-diagnosed because of its varied
and often non-specific presentation, such as unexplained
respiratory distress, asymmetric breathing pattern or an
elevated diaphragm on chest radiographs (1,2,3). In the
presence of any of these symptoms, checking diaphragm
function should be mandatory.
Utrasonography is a promising technique for the evaluation
of the structure and dynamic function of the diaphragm,
perhaps the future chosen technique. It is accurate,
reproducible, relatively easy to learn, portable, which is
very important for critically ill patients on mechanical
ventilation (1)
Ventilator weaning protocols involving diaphragmatic para-
meters to predict success of extubation should be developed
and tested (1,3).
REFERENCES: 1. Neuromuscular ultrasound for evaluation
of the diaphragm. Sarwal A et al. Muscle nerve. 2013 March,
47(3): 319-329
2. Diagnosis of abnormal diaphragm motion after cardi-
othoracic surgery: Ultrasound performance by a cardiac
intensivist vs. fluoroscopy. Sanchez de Toledo J et al.
Congenit Heart Dis. 2010 Nov-Dec; 5(6): 565-572
3. Sonographic measurement of diaphragmatic motion after
coronary artery bypass surgery. Fedullo SJ et al. Chest 1992
Dec; 102(6): 1683-1686