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J Thorac Cardiovasc Surg 1994;107:487-0498
© 1994 Mosby, Inc.

Cardiopulmonary Bypass, Myocardial Management, and Support Techniques

Clinically relevant diaphragmatic dysfunction after cardiac operations

Créteil, France

From Réanimation Médicaler, Service de Chirugie Cardiaque, INSERM U296, Université Paris XII, Hôspital Henri Mondor, Creteil, France.

Received for publication April 13, 1992. Accepted for publication July 7, 1993. Address for reprints: Laurent Brochard, MD, Réanimation Médicale, Hôpital Henri Mondor, 94010 Creteil, France.

Abstract

Phrenic nerve injury and diaphragmatic dysfunction can be induced by cardiac operation. The clinical consequences are not well-established. We evaluated 13 consecutive patients over a 2-year period with unexplained and prolonged difficulties in weaning from mechanical ventilation. The mean time of measurement from the operation day was 31 ± 19 days (range 8 to 78). With the same technique we also evaluated 12 control patients: four patients at day 1 after cardiac operation while they were still intubated; four normally convalescing patients at day 7 or 8 after cardiac operation; and four patients who required prolonged mechanical ventilation because of another identified cause after cardiac operation. Diaphragmatic function was evaluated at the bedside from esophageal and gastric pressure measurements. A low or negative ratio of gastric pressure swing to transdiaphragmatic pressure swing, indicative of diaphragm dysfunction, was found in all 13 patients (mean -0.39 ± 0.64). The difference between the 13 patients and all control groups was found to be highly significant. Transdiaphragmatic pressure measured during a maximal voluntary inspiratory effort and transdiaphragmatic pressure measured during a short, sharp sniff were markedly diminished (28 ± 18 cm H₂O and 13 ± 15 cm H₂O, respectively) in the 13 patients, significantly different from values in the four control patients studied at day 7 or 8. Transdiaphragmatic pressure measured after magnetic stimulation in four patients was also markedly reduced (7 ± 5 cm H₂O) as compared with normal theoretic values. Aminophylline infusion had no effect on any of these parameters. In one of two patients evaluated a second time, about 5 weeks later, a marked improvement was observed. Estimating the prevalence of clinically relevant diaphragmatic dysfunction, we found it to be 0.5% when no topical cooling was used and 2.1% when iced slush with no insulation pad was added for myocardial protection (p < 0.005). The most striking finding was that the clinical course of the 13 patients was marked by severe intercurrent events, including cardiorespiratory arrest after early tracheal extubation in 5 patients, nosocomial pneumonia in 11, prolonged mechanical ventilation in all (58 ± 41 days), and a fatal outcome in 3. We conclude that prolonged postoperative diaphragmatic dysfunction may cause severe life-threatening complications after cardiac operation and can be limited to some extent by avoiding the use of iced slush topical cooling of the heart. (J THORAC CARDIOVASC SURG 1994;107:487-98)

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