Adult Cardiac Surgery Patients Research Articles

The Effects of Propafenone on Postoperative Atrial Fibrillation in Adult Patients Undergoing Cardiac Surgery: A Meta-Analysis of Randomized Controlled Trials

Background. Previous research has only conducted a restricted amount of investigations on the effectiveness of propafenone in preventing and treating of atrial fibrillation (AF) after cardiac surgery. Hence, a comprehensive evaluation and meta-analysis were performed to evaluate the effectiveness and safety of propafenone in individuals undergoing cardiac surgery for postoperative atrial fibrillation (POAF). Methods. A meta-analysis of randomized controlled trials was conducted. Until September 15th, 2023, various databases were searched. The main focal points consisted of the presence of POAF, transition from AF to sinus rhythm, and reappearance of AF. The odds ratios (ORs) for treatment effects on dichotomous variables were calculated. Results. The analysis of data included 9 controlled trials that were randomized and had 1014 patients. The findings indicated that propafenone has a significant impact on reducing the occurrence of POAF in adult patients who undergo cardiac surgery (OR, 0.52; 95% CI: 0.30, 0.89; P=0.02). In addition, it was observed that propafenone significantly increase the rate of conversion to sinus rhythm from AF within 20 min (OR, 5.39; 95% CI: 2.25, 12.91; P=0.0002) and 1 hour (OR, 2.89; 95% CI: 1.50, 5.57; P=0.002) after administration. Surprisingly, the administration of propafenone treatment did not have a significant impact on the rate of conversion to sinus rhythm from AF within 24 hours (OR, 0.63; 95% CI: 0.38, 1.04; P=0.07) after administration. Conclusions. The present study suggests that the postoperative administration of propafenone to adult cardiac surgery patients is both safe and effective for preventing and treating POAF.

Days alive and out of hospital for adult female and male cardiac surgery patients: a population-based cohort study

BackgroundResearch shows women experience higher mortality than men after cardiac surgery but information on sex-differences during postoperative recovery is limited. Days alive and out of hospital (DAH) combines death, readmission and length of stay, and may better quantify sex-differences during recovery. This main objective is to evaluate (i) how DAH at 30-days varies between sex and surgical procedure, (ii) DAH responsiveness to patient and surgical complexity, and (iii) longer-term prognostic value of DAH.MethodsWe evaluated 111,430 patients (26% female) who underwent one of three types of cardiac surgery (isolated coronary artery bypass [CABG], isolated non-CABG, combination procedures) between 2009 – 2019. Primary outcome was DAH at 30 days (DAH30), secondary outcomes were DAH at 90 days (DAH90) and 180 days (DAH180). Data were stratified by sex and surgical group. Unadjusted and risk-adjusted analyses were conducted to determine the association of DAH with patient-, surgery-, and hospital-level characteristics. Patients were divided into two groups (below and above the 10th percentile) based on the number of days at DAH30. Proportion of patients below the 10th percentile at DAH30 that remained in this group at DAH90 and DAH180 were determined.ResultsDAH30 were lower for women compared to men (22 vs. 23 days), and seen across all surgical groups (isolated CABG 23 vs. 24, isolated non-CABG 22 vs. 23, combined surgeries 19 vs. 21 days). Clinical risk factors including multimorbidity, socioeconomic status and surgical complexity were associated with lower DAH30 values, but women showed lower values of DAH30 compared to men for many factors. Among patients in the lowest 10th percentile at DAH30, 80% of both females and males remained in the lowest 10th percentile at 90 days, while 72% of females and 76% males remained in that percentile at 180 days.ConclusionDAH is a responsive outcome to differences in patient and surgical risk factors. Further research is needed to identify new care pathways to reduce disparities in outcomes between male and female patients.

Efficacy of ultrasound-guided pecto-intercostal fascial block and transversus thoracis muscle plane block for postoperative analgesia in cardiac surgery in adult patients: A randomized study

ABSTRACT Background Insufficient management of postoperative pain is a notable issue encountered by individuals after open-heart operations. The study aimed to evaluate the effect of ultrasound-guided pecto-intercostal fascial block (PIFB) and transversus thoracis muscle plane (TTB) on the analgesic efficacy in adult patients undergoing open-heart operations and the duration of mechanical ventilation (MV). Methods A randomized double-blind controlled trial was conducted on a cohort of 90 adult patients with elective open-heart surgery, namely valve replacement, with midline sternotomy. Patients were divided into three groups of similar size. The first group (control group) received conventional systemic analgesia alone, while the second group received bilateral TTB and the third group received bilateral PIFB, using ultra-sound guided technique. Results A significant reduction in NRS (Numeric Rating Scale) values was observed in both the TTB group and the PIFB group as compared to the control group at zero, three and 6-hour postoperative. The PIFB and TTB group exhibited an important delay in the initiation of first rescue analgesia, as well as a reduction in the overall intake of fentanyl for rescue purposes during a twenty-four-hour period. Additionally, the TTB group and the PIFB group demonstrated considerably shorter durations of mechanical ventilation as compared to the control group. Conclusions The utilization of ultrasound TTB and PIFB demonstrated efficacy in providing postoperative analgesia compared to the control group. This was evidenced by the less requirement for additional analgesic medication, reducing postoperative pain scores and a shorter duration of mechanical ventilation.

The protocol of enhanced recovery after cardiac surgery in adult patients: A stepped wedge cluster randomized trial

BackgroundThe Enhanced Recovery After Cardiac Surgery is a bundle of measurements from preoperative to postoperative phases to improve patients’ recovery. MethodsThis study is a multicenter, stepwise design, cluster randomized controlled trial. 3600 patients presenting during control and intervention periods are eligible if they are aged from 18 to 80 years old awaiting elective cardiac surgery with cardiopulmonary bypass (CPB). 5 centers are randomly assigned to staggered start dates for one-way crossover from the control phase to the intervention phase. In the intervention periods, patients will receive ERAS strategy including preoperative, intraoperative and postoperative approaches. During the control phase, patients receive usual care. The primary outcome consists of major adverse cardiac and cerebrovascular events (MACCEs), postoperative pulmonary complications (PPCs), and acute kidney injury (AKI). DiscussionThis study aims to compare the application of ERAS management protocol and traditional management protocol in adult cardiac surgery under extracorporeal circulation.

Quantitative assessment of carotid ultrasound diameter measurements in the operating room: a comparable analysis of long-axis versus rotated and tilted orientation

Objective. Carotid ultrasound (US) has been studied as a non-invasive alternative for hemodynamic monitoring. A long-axis (LA) view is traditionally employed but is difficult to maintain and operator experience may impact the diameter estimates, making it unsuitable for monitoring. Preliminary results show that a new, i.e. rotated and tilted (RT) view is more robust to motion and less operator-dependent. This study aimed to quantitatively assess common carotid diameter estimates obtained in a clinical setting from an RT view and compare those to corresponding estimates obtained using other views. Approach. Carotid US measurements were performed in 30 adult cardiac-surgery patients (26 males, 4 females) with short-axis (SA), LA, and RT probe orientations, the first being used as a reference for measuring the true vessel diameter. Per 30 s acquisition, the median and spread in diameter values were computed, the latter representing a measure of robustness, and were statistically compared between views. Main results. The median (IQR) over all the patients of the median diameter per 30 s acquisition was 7.15 (1.15) mm for the SA view, 7.03 (1.51) mm for the LA view, and 6.99 (1.72) mm for the RT view. The median spread in diameter values was 0.18 mm for the SA view, 0.16 mm for the LA view, and 0.18 mm for the RT view. There were no statistically significant differences between views in the median diameter values (p = 0.088) or spread (p = 0.122). Significance. The RT view results in comparable and equally robust median carotid diameter values compared to the reference. These findings open the path for future studies investigating the use of the RT view in new applications, such as in wearable ultrasound devices.

Procalcitonin for the diagnosis of postoperative bacterial infection after adult cardiac surgery: a systematic review and meta-analysis

Background and aimsPatients undergoing cardiac surgery are subject to infectious complications that adversely affect outcomes. Rapid identification is essential for adequate treatment. Procalcitonin (PCT) is a noninvasive blood test that could serve this purpose, however its validity in the cardiac surgery population is still debated. We therefore performed a systematic review and meta-analysis to estimate the accuracy of PCT for the diagnosis of postoperative bacterial infection after cardiac surgery.MethodsWe included studies on adult cardiac surgery patients, providing estimates of test accuracy. Search was performed on PubMed, EmBase and WebOfScience on April 12th, 2023 and rerun on September 15th, 2023, limited to the last 10 years. Study quality was assessed with the QUADAS-2 tool. The pooled measures of performance and diagnostic accuracy, and corresponding 95% Confidence Intervals (CI), were calculated using a bivariate regression model. Due to the variation in reported thresholds, we used a multiple-thresholds within a study random effects model for meta-analysis (diagmeta R-package).ResultsEleven studies were included in the systematic review, and 10 (2984 patients) in the meta-analysis. All studies were single-center with observational design, five of which with retrospective data collection. Quality assessment highlighted various issues, mainly concerning lack of prespecified thresholds for the index test in all studies. Results of bivariate model analysis using multiple thresholds within a study identified the optimal threshold at 3 ng/mL, with a mean sensitivity of 0.67 (0.47–0.82), mean specificity of 0.73 (95% CI 0.65–0.79), and AUC of 0.75 (IC95% 0.29–0.95). Given its importance for practice, we also evaluated PCT’s predictive capability. We found that positive predictive value is at most close to 50%, also with a high prevalence (30%), and the negative predictive value was always > 90% when prevalence was < 20%.ConclusionsThese results suggest that PCT may be used to help rule out infection after cardiac surgery. The optimal threshold of 3 ng/mL identified in this work should be confirmed with large, well-designed randomized trials that evaluate the test’s impact on health outcomes and on the use of antibiotic therapy.PROSPERO Registration number CRD42023415773. Registered 22 April 2023.Graphical abstract

Risk stratification model in predicting mortality among adult cardiac surgery patients and its application in Indonesia: A review

Risk stratification model in predicting mortality among adult cardiac surgery patients and its application in Indonesia: A review

Agitation during anaesthetic emergence: An observational study of adult cardiac surgery patients in two Australian intensive care units

BackgroundAnaesthetic emergence agitation among adult patients being recovered after open cardiac and/or thoracic aorta surgery has not been described. ObjectivesThe objective of this study was to characterise emergence agitation in terms of incidence, clinical features, and consequences in a cohort of cardiac surgery patients being recovered in the intensive care unit (ICU). MethodsA prospective, observational pilot study was implemented.Over a 5-week period, the study was conducted in two metropolitan hospitals in Victoria, Australia.The cohort comprised all patients admitted to the ICUs aged ≥18 years, who had undergone cardiac surgery via an open sternotomy with general anaesthetic, and whose emergence was directly observed.Emergence agitation was defined as a Richmond Agitation and Sedation Scale score of ≥+2. ResultsFifty patients were observed. Emergence agitation occurred in 24/50 (48%) of patients. Patients with emergence agitation experienced more clinical consequences than patients with calm emergence, including a significantly greater number of episodes of airway compromise (12/24, 50%, p < 0.001); ventilator dyssynchrony (23/24, 96%, p = 0.004); and hypertension (13/24, 54%, p = 0.004). Significant treatment interference (potentially dangerous patient movements such as pulling tubes) occurred with 23/24 patients (96%, p < 0.0001). Patients who underwent emergence agitation required significantly more interventions during anaesthetic emergence than patients who underwent a calm emergence. Interventions included extra nursing measures (16/24, 67%, p = 0.001) administration of sedative and/or opioid intravenous boluses (22/24, 92%, p = 0.001) and vasoactive agents (15/24, 63%, p = 0.05). ConclusionsIn patients recovering from cardiac surgery in the ICU, emergence agitation was clinically important. Immediate interventions were required to prevent and manage complications.

Risk of fluid accumulation after cardiac surgery

ObjectivePatients undergoing heart surgery are at high risk of postoperative fluid accumulation due to long procedures and cardiopulmonary bypass. In the present study, we sought to investigate the prevalence of postoperative fluid accumulation and its relation to adverse events in patients undergoing cardiac surgery. MethodsCAREBANK is prospective, single-center cohort study focusing on the adverse events after cardiac surgery. The study population was divided into 2 groups based on 5% postoperative weight gain. All the in-hospital adverse events are registered on the database. The end points of the present study were length of hospital stay, length of intensive care unit stay, occurrence of new-onset atrial fibrillation after hospital major bleeding episodes major cardiac events, cerebrovascular events, and death. Three-month and 1-year follow-up data also include all major adverse events. ResultsAltogether 1001 adult cardiac surgery patients were enrolled. The most frequent operations were coronary artery bypass grafting (56.3%). Five hundred fifty-four out of 939 (59.0%) patients had ≥5% weight gain during index hospitalization. Patients with a weight gain ≥5% were more likely to be women, have lower body mass index, had heart failure, and more often had preoperative atrial fibrillation. In-hospital period fluid accumulation was associated with reoperation due bleeding and longer total hospital stay. At 3 months' follow-up, weight gain 5% or more was associated with increased occurrence of new-onset atrial fibrillation, this was not reflected in the occurrence of strokes, transient ischemic attacks, or myocardial infarctions. ConclusionsPostoperative fluid excess is associated with adverse outcomes in cardiac surgery. Women, low-weight patients, and patients with cardiac failure or atrial fibrillation are prone to perioperative fluid accumulation.

Impact of intraoperative blood products, fluid administration, and persistent hypothermia on bleeding leading to reexploration after cardiac surgery

ObjectiveRisk factors for severe postoperative bleeding after cardiac surgery remain multiple and incompletely elucidated. We evaluated the impact of intraoperative blood product transfusions, intravenous fluid administration, and persistently low core body temperature (CBT) at intensive care unit arrival on risk of perioperative bleeding leading to reexploration. MethodsWe retrospectively queried our tertiary care center's Society of Thoracic Surgeons Institutional Database for all index, on-pump, adult cardiac surgery patients between July 2016 and September 2022. Intraoperative fluid (crystalloid and colloid) and blood product administrations, as well as perioperative CBT data, were harvested from electronic medical records. Linear and nonlinear mixed models, treating surgeon as a random effect to account for inter-surgeon practice differences, were used to assess the association between above factors and reexploration for bleeding. ResultsOf 4037 patients, 151 (3.7%) underwent reexploration for bleeding. Reexplored patients experienced remarkably greater postoperative morbidity (23% vs 6%, P < .001) and 30-day mortality (14% vs 2%, P < .001). In linear models, progressively increasing IV crystalloid administration (adjusted odds ratio, 1.11, 95% confidence interval, 1.03-1.19) and decreasing CBT on intensive care unit arrival (adjusted odds ratio, 1.20; 95% confidence interval, 1.05-1.37) were associated with greater risk of bleeding leading to reexploration. Nonlinear analysis revealed increasing risk after ∼6 L of crystalloid administration and a U-shaped relationship between CBT and reexploration risk. Intraoperative blood product transfusion of any kind was not associated with reexploration. ConclusionsWe found evidence of both dilution- and hypothermia-related effects associated with perioperative bleeding leading to reexploration in cardiac surgery. Interventions targeting modification of such risk factors may decrease the rate this complication.

Determining sex-specific preoperative haemoglobin levels associated with intraoperative red blood cell transfusion in cardiac surgery: a retrospective cohort study

BackgroundAnaemic cardiac surgery patients are at greater risk of intraoperative red blood cell transfusion. This study questions the application of the World Health Organization population-based anaemia thresholds (haemoglobin <120 g L−1 in non-pregnant females and <130 g L−1 in males) as appropriate preoperative optimisation targets for cardiac surgery. MethodsA retrospective cohort study was conducted on adults ≥18 yr old undergoing cardiopulmonary bypass surgery. Logistic regression was applied to define sex-specific preoperative haemoglobin concentrations with reduced probability of intraoperative red blood cell transfusion for cardiac surgery patients. ResultsData on 4384 male and 1676 female patients were analysed. Binarily stratified multivariable logistic regression odds of receiving intraoperative red blood cell transfusion increased in cardiac surgery patients >45 yr old (odds ratio [OR] 1.84; 95% confidence interval [CI] 1.33–2.55), surgery urgency <30 days (OR 2.03; 95% CI 1.66–2.48), combined coronary artery bypass grafting and valve surgery, or other surgery types (OR 2.24; 95% CI 1.87–2.67), and female sex (OR 1.92; 95% CI 1.62–2.28). The odds decreased by 8.4% with each 1 g L−1 increase in preoperative haemoglobin (OR 0.92; 95% CI 0.91–0.92). Logistic regression predicted females required a preoperative haemoglobin concentration of 133 g L−1 and males 127 g L−1 to have a 15% probability of intraoperative transfusion. ConclusionsThe World Health Organization female anaemia threshold of haemoglobin <120 g L−1 disproportionately disadvantages female cardiac surgery patients. A preoperative haemoglobin concentration ≥130 g L−1 in adult cardiac surgery patients would minimise their overall probability of intraoperative red blood cell transfusion to <15%.

Cardiac surgery-associated acute kidney injury and perioperative plasma viscosity: is there a relationship?

Plasma viscosity (PV) is a key factor in microcirculatory flow resistance and capillary perfusion during hemodilution, we hypothesized a possible relationship between cardiac surgery-associated acute kidney injury (CSA-AKI) and PV. We conducted a prospective, observational, single-center study on 50 adult cardiac surgery patients with cardiopulmonary bypass (age 64 years, male sex 80%, baseline serum creatinine 1.04mg/dL). We assessed perioperative characteristics, management, short-term outcomes, blood analysis, PV, serum creatinine, and diuresis. CSA-AKI was identified using KDIGO criteria. Data were collected at 10 time points during the first perioperative week. CSA-AKI occurred in 17 patients (34%): 12 (24%) stage 1, 1 (2%) stage 2, and 4 (8%) stage 3. Most patients (88%) developed CSA-AKI within 48h post-surgery. Patients with CSA-AKI had higher body mass index (BMI), more frequent chronic kidney disease (CKD), and lower hemoglobin and hematocrit levels. The median baseline PV for the entire cohort was 1.50 cP on EDTA and 1.37 cP on citrate. No significant differences in PV levels were found between patients with CSA-AKI and normal kidney function, both at baseline and at the 48-h. Logistic and Cox regression analyses showed no significant relationship between PV and CSA-AKI. However, CSA-AKI was related to increased BMI, lower hemoglobin and hematocrit levels, and pre-existing CKD. The present study found no significant association between PV and CSA-AKI. Nevertheless, more research is needed to validate this finding and to investigate the role of PV in other clinical settings.

Re-Dosing del Nido cardioplegia in adult cardiac surgery: Perfusion characteristics and outcomes--Is there an optimal redosing strategy?

del Nido cardioplegia is utilized for myocardial protection in adult patients undergoing cardiac surgery; however, no standardized re-dosing protocol exists. We describe perfusion characteristics and clinical outcomes in adult cardiac surgery patients who were re-dosed with del Nido cardioplegia. Chart review was performed for adult patients undergoing cardiac surgery (specific inclusion/exclusion criteria below) who received exactly two doses of del Nido cardioplegia from 2012 to 2019; n = 542 patients. The main outcome was a composite endpoint comprised of operative mortality, myocardial infarction, post-operative cardiac support device (CSD), and postoperative decrease in ejection fraction (EF), which was analyzed via multivariable logistic regression (MVLR). A secondary analysis evaluated postoperative vasoactive-inotropic scores (VIS) via gamma log link regression (GLLR) as a more physiologic indication of myocardial recovery. MVLR demonstrated that increased total cardiopulmonary bypass (CPB) time was associated with a positive composite outcome (p < .001), whereas time between doses (p = .237) and the volume of each dose was not (p = .626). GLLR also demonstrated that prolonged CBP, decreased EF, congestive heart failure at time of surgery, and low hematocrit at the start of the surgery were all associated with higher VIS. In this retrospective study, variations in re-dosing strategy for del Nido cardioplegia do not affect postoperative outcomes and increased CPB time is associated with increased operative mortality, myocardial infarction, need for post-operative CSDs, and reduced postoperative EF, and increased VIS, irrespective of the re-dosing strategy. Further studies are warranted to to identify additional patient and operative characteristics that predispose to complications.

Association of pulmonary artery catheter with in-hospital outcomes after cardiac surgery in the United States: National Inpatient Sample 1999–2019

To examine associations of pulmonary artery catheter (PAC) use with in-hospital death and hospital length of stay (days) overall and within subgroups of hospitalized cardiac surgery patients. Secondary analyses of 1999–2019 National Inpatient Sample data were performed using 969,034 records (68% male, mean age: 65 years) representing adult cardiac surgery patients in the United States. A subgroup of 323,929 records corresponded to patients with congestive heart failure, pulmonary hypertension, mitral/tricuspid valve disease and/or combined surgeries. We evaluated PAC in relation to clinical outcomes using regression and targeted maximum likelihood estimation (TMLE). Hospitalized cardiac surgery patients experienced more in-hospital deaths and longer stays if they had ≥ 1 subgroup characteristics. For risk-adjusted models, in-hospital deaths were similar among recipients and non-recipients of PAC (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.96, 1.12), although PAC was associated with more in-hospital deaths among the subgroup with congestive heart failure (OR 1.14, 95% CI 1.03, 1.26). PAC recipients experienced shorter stays than non-recipients (β = − 0.40, 95% CI − 0.64, − 0.15), with variations by subgroup. We obtained comparable results using TMLE. In this retrospective cohort study, PAC was associated with shorter stays and similar in-hospital death rates among cardiac surgery patients. Worse clinical outcomes associated with PAC were observed only among patients with congestive heart failure. Prospective cohort studies and randomized controlled trials are needed to confirm and extend these preliminary findings.

Remote monitoring following adult cardiac surgery: A paradigm shift?

BackgroundThe Perfect Care (PC) initiative engages, educates, and enrolls adult cardiac surgery patients into a transformational program that includes an app for appointment scheduling, tracking biometric data and patient-reported outcomes, audiovisual visits, and messaging, paired with a digital health kit (consisting of a fitness tracker, scale, and sphygmomanometer). PC aims to reduce postoperative length of stay (LOS) as well as 30-day readmission and mortality. MethodsThis was a retrospective review of patients who underwent coronary artery bypass (CAB), valve, or combined CAB and valve procedures at either of the 2 participating hospitals between April 2018 and March 2022. Patients who participated in the PC quality improvement initiative were compared to propensity-matched controls (1:1 matching). The evaluation focused on postoperative LOS and a novel composite measure comprising 30-day readmission and mortality. ResultsRemote monitoring (PC) was associated with a shorter postoperative LOS, lower combined rate of 30-day readmission and mortality, and less variation compared to matched non-PC controls. ConclusionsIntegrated improvements in postoperative remote monitoring of adult cardiac surgery patients may reduce time in the hospital and post-acute care facilities. Future prioritized efforts include the development of additional, personalized biometric monitoring devices, use of biometric data to augment risk assessment, and investigation of the value of remote monitoring on various patient risk profiles to address potential disparities in care.

A primer for the student joining the adult cardiac surgery service tomorrow: Primer 1 of 7

A primer for the student joining the adult cardiac surgery service tomorrow: Primer 1 of 7

Outcome Comparison Between Insulin-Dependent and Non Insulin-Dependent Patients after Open Adult Cardiac Surgery

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Insulin-dependent diabetic patients usually have poor glycemic control and higher risk of complications than non-insulin-dependent diabetic patients. However, the difference in clinical outcomes between these two groups of patients who underwent open cardiac surgery was not established. Therefore, this study compares the short-term outcome of insulin vs non-insulin-dependent diabetic patients after open cardiac surgery in a large-scale study.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The study design was a retrospective cohort. All adults who underwent open cardiac surgery between January 1&lt;sup&gt;st&lt;/sup&gt; 2016-December 31&lt;sup&gt;st&lt;/sup&gt; 2020 in 4 tertiary hospitals in Indonesia were included in the study. From a total of 4.931 samples included in the study, 3.753 patients were non-diabetic (Group I) and 1.178 were diabetic (Group II). Group II was divided into subgroup IIA (930 non-insulin-dependent) and subgroup IIB (248 insulin-dependent). The main outcome was in-hospital mortality of open cardiac surgery patients.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Result:&lt;/strong&gt; In-hospital mortality between group I and II had no significant difference (6.8% vs 5.7%; p = 0.188), as well as IIA and IIB (5.6% vs 6%; p = 0.782). Multivariate analysis demonstrated that diabetes did not increase mortality of open cardiac surgery (OR 0.665; p = 0.021). In-hospital mortality of subgroup IIB was higher than subgroup IIA, but insulin therapy did not increase the risk of in-hospital mortality (OR 1.259; p = 0.464).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; Both insulin-dependent and non-insulin-dependent diabetes mellitus were not the predictors of poor short-term outcomes for open adult cardiac surgery patients.&lt;/p&gt;

Albumin Infusion and Blood Loss After Cardiac Surgery

BackgroundIn the recent ALBICS (ALBumin In Cardiac Surgery) trial, 4% albumin used for cardiopulmonary bypass priming and volume replacement increased perioperative bleeding compared with Ringer acetate. In the present exploratory study, albumin-related bleeding was further characterized. MethodsRinger acetate and 4% albumin were compared in a randomized, double-blinded fashion in 1386 on-pump adult cardiac surgery patients. The study end points for bleeding were the Universal Definition of Perioperative Bleeding (UDPB) class and its components. ResultsThe UDPB bleeding grades were higher in the albumin group than the Ringer group: “insignificant” (albumin vs Ringer: 47.5% vs 62.9%), “mild” (12.7% vs 8.9%), “moderate” (28.7% vs 24.4%), “severe” (10.2% vs 3.2%), and “massive” (0.9% vs. 0.6%; P < .001). Patients in the albumin group received red blood cells (45.2% vs 31.5%; odds ratio [OR], 1.80; 95% CI, 1.44-2.24; P < .001), platelets (33.3% vs 21.8%; OR, 1.79; 95% CI, 1.41-2.28; P < .001), and fibrinogen (5.6% vs 2.6%; OR, 2.24; 95% CI, 1.27-3.95; P < .05), and underwent resternotomy (5.3% vs 1.9%; OR, 2.95; 95% CI, 1.55-5.60, P < .001) more often than patients in the Ringer group. The strongest predictors of bleeding were albumin group allocation (OR, 2.18; 95% CI, 1.74-2.74) and complex (OR, 2.61; 95% CI, 2.02-3.37) and urgent surgery (OR, 1.63; 95% CI, 1.26-2.13). In interaction analysis, the effect of albumin on the risk of bleeding was stronger in patients on preoperative acetylsalicylic acid. ConclusionsPerioperative administration of albumin, compared with Ringer’s acetate, resulted in increased blood loss and higher UDBP class. The magnitude of this effect was similar to the complexity and urgency of the surgery.

Chest X-ray Overuse in Cardiothoracic Intensive Care Unit per American College of Radiology Criteria

BackgroundA routine chest radiograph (CXR) is frequently incorporated into postoperative clinical pathways. Whereas prior studies evaluated CXR use for specific indications, overall CXR "stewardship" within cardiothoracic surgery remains undescribed. We characterized CXR use within a cardiothoracic intensive care unit (ICU) and quantified X-ray–driven changes in patient management. MethodsAll CXRs performed during 3 months in the cardiothoracic ICU of an academic 900-bed tertiary care hospital were retrospectively reviewed. Attending radiologist CXR reports and clinical history from ordering providers were manually reviewed to classify CXRs as indicated or not indicated by American College of Radiology (ACR) Appropriateness Criteria. Multiple resident-level providers further reviewed CXRs to determine whether the image demonstrated any actionable or unexpected findings. ResultsBetween October 1, 2021, and January 3, 2022, 1273 CXRs were performed on adult cardiac and general thoracic surgery patients; the most common indication was routine daily (55.9%), followed by support device monitoring (12.4%) and new ICU transfer (10.4%). Only 34.3% of performed CXRs met ACR Appropriateness Criteria; 65.7% did not (P = .002). Only 3.8% of not indicated CXRs had actionable or significant findings vs 13.0% of indicated CXRs (P = .02). Of the 32 not indicated CXRs with actionable findings, 37.5% recommended endotracheal tube repositioning and 28.1% recommended other line or tube repositioning. ConclusionsCXRs are overused in the cardiothoracic ICU according to ACR Appropriateness Criteria. CXRs performed outside these guidelines have significantly fewer actionable or meaningful findings. Optimizing CXR use can improve resource utilization and efficiency in care of cardiothoracic surgical patients.

Technologic Transformation of Perioperative Cardiac Care and Outcomes

BackgroundThe “Perfect Care” initiative engages, educates, and enrolls adult cardiac surgery patients into a comprehensive program that incorporates remote perioperative monitoring (RPM). This study investigated the impact of RPM on postoperative length of stay, 30-day readmission and mortality, and other outcomes. MethodsThis quality improvement project compared outcomes in 354 consecutive patients who underwent isolated coronary artery bypass and who were enrolled in RPM between July 2019 and March 2022 at 2 centers against outcomes in propensity-matched control patients from a pool of 1301 patients who underwent isolated coronary artery bypass from April 2018 to March 2022 without RPM. Data were extracted from The Society of Thoracic Surgeons Adult Cardiac Surgery Database, and outcomes were analyzed according to its definitions. RPM used perioperative standard practice routines, a digital health kit for remote monitoring, a smartphone application and platform, and nurse navigators. Propensity scores were generated with RPM as the outcome measure, and a 2:1 match was generated using a nearest-neighbor matching algorithm. ResultsPatients who underwent isolated coronary artery bypass and who were participating in RPM showed a statistically significant, 15.4% (1 day) reduction in postoperative length of stay (P < .0001) and a 44% reduction in 30-day readmission and mortality (P < .039) compared with matched control patients. Significantly more RPM participants were discharged directly home instead of to a facility (99.4% vs 92.0%; P < .0001). ConclusionsThe RPM platform and associated efforts to engage and monitor adult cardiac surgery patients remotely is feasible, is embraced by patients and clinicians, and transforms perioperative cardiac care by significantly improving outcomes and reducing variation.