Adult Cardiac Surgery Patients Research Articles

Role of Hypothermia in Adult Cardiac Surgery Patients: A Systematic Review and Meta-analysis

To review studies that assessed systemic hypothermia as an organ protection strategy in adults undergoing cardiac surgery with cardiopulmonary bypass. A systematic review and meta-analysis. Randomized controlled trials, irrespective of blinding, language, publication status, and date of publication, were identified by searching the Cochrane Central register of Controlled Trials, MEDLINE, and Embase until November 2020. Risk of bias assessment was performed according to Cochrane methodology. Treatment effects were expressed as risk ratios and 95% confidence intervals. Heterogeneity was expressed as I2. Systemic hypothermia. Forty-eight trials enrolling 6,690 patients were included in the analysis. Methodologic quality of the studies included was low, mostly due to insufficient allocation concealment or blinding. Random-effects meta-analysis did not resolve uncertainty as to the risks and benefits for hypothermia versus normothermia for key primary and secondary outcomes, including mortality (1.21, 0.94 to 1.56, I2=0%) and brain injury (0.87, 0.67 to 1.14, I2=0%). Sensitivity analyses restricted to trials at low risk of important bias demonstrated higher mortality with hypothermia (1.70, 1.05 to 2.75, I2=0%), with little or no treatment effect on brain injury (1.01, 0.69 to 1.49, I2=0%). There was no interaction between cardioplegia temperature and the effects of cardiopulmonary bypass temperature on outcomes. There was insufficient evidence to assess the effects of hypothermia in noncoronary artery bypass graft surgery. The existing evidence for an organ-protective effect of hypothermia in adult cardiac surgery is of low quality and inconsistent.

The value of bioactive adrenomedullin and dipeptidyl peptidase 3 to predict short-term unfavourable outcomes after cardiac surgery: A prospective cohort study.

Adrenomedullin (ADM) is a key regulator of endothelial barrier function and vascular tone. Dipeptidyl peptidase 3 (DPP3) is a protease involved in the degradation of several cardiovascular mediators. Increased levels of bioactive ADM (bio-ADM) and circulating DPP3 (cDPP3) were found to predict short-term outcome in cardiogenic shock patients. To investigate the unknown temporal profiles of bio-ADM and cDPP3 and their association with short-term outcome following cardiac surgery. Prospective observational study of 203 adult cardiac surgery patients admitted to the intensive care unit (ICU) postoperatively. Plasma bio-ADM and cDPP3 levels were measured at ICU admission (day 1) and on days 2 and 3. Biomarker prediction of prolonged vasopressor dependency (>3 days), acute kidney injury (AKI) and prolonged ICU length of stay (ICU-LOS) (>3 days). bio-ADM and cDPP3 levels displayed distinct temporal profiles following cardiac surgery. cDPP3 levels were highest on day 1 and strongly correlated with surgical complexity and duration but subsequently normalised on day 2 in most patients. In contrast, bio-ADM levels on day 1 were within the normal range but subsequently increased. Day 2 bio-ADM levels were strongly associated with study outcomes: the area under the receiver-operating curves (AUROC) were 0.82 (95% CI, 0.72 to 0.92) for prolonged vasopressor dependency, 0.87 (0.81 to 0.92) for AKI and 0.82 (0.75 to 0.90) for prolonged ICU-LOS (all P < 0.0001). cDPP3 levels on day 2 also predicted these outcomes, albeit to a lesser extent, with AUROCs of 0.73 (95% CI, 0.64 to 0.81) for prolonged vasopressor dependency, 0.69 (0.61 to 0.77) for AKI and 0.70 (0.62 to 0.79) for prolonged ICU-LOS (all P < 0.0001). Following cardiac surgery, increased bio-ADM levels are strongly associated with unfavourable short-term outcomes, whereas cDPP3 levels are mainly related to surgery complexity and duration. On the basis of these findings, ADM-modulating therapies may have beneficial effects in cardiac surgery patients whereas DPP3-targeted therapies should be reserved for patient categories with higher baseline disease severity.

Relation between Prolonged Cardiopulmonary Bypass Time in Cardiac Surgery in Adult Patients and Post-Operative Acute Kidney Injury

Abstract Background Cardiac-surgery associated acute kidney injury (CSA-AKI) remains an important and frequent complication in patients undergoing cardiac surgery and is associated with a poor short- and long-term prognosis. The incidence for CSA-AKI according to Acute Kidney Injury Network criteria (AKIN) varies between 3% and 50%. CSA-AKI requiring temporary renal replacement therapy (RRT) occurs in 5% to 20% of these patients and is associated with a high mortality rate. Objective To detect the relation between prolonged cardiopulmonary bypass time in cardiac surgery and the incidence of post-operative acute kidney injury. Patients and Methods This is an observational retrospective study conducted on (80) adult patients who underwent elective cardiac surgery at Aswan Heart Centre (Magdi Yacoub Foundation) after the approval of the Ethical Medical Committee of Aswan Heart Centre. Results Results of the statistical analysis of the present study showed that mean CPB duration was prolonged in the AKI group of patients (155 min) than the non-AKI group of patients (129 min). Conclusion Prolonged cardiopulmonary bypass duration may be an independent risk factor for acute kidney injury post cardiac surgery in adult patients.

POST-OPERATIVE PAIN AND ANALGESIC USE FOR CARDIAC SURGERY WITH MEDIAN STERNOTOMY

<h3>BACKGROUND</h3> Inadequate pain control after median sternotomy leads to reduced mobilization, increased respiratory complications, and longer hospital stays. Typically, post-operative pain is controlled by opioid analgesics that may have significant respiratory and gastrointestinal side effects. Parasternal intercostal neuraxial block (PSB) has emerged as part of a multimodal strategy to control pain after median sternotomy. However, the effect of this intervention on post-op pain and analgesic use has not been fully established. <h3>METHODS AND RESULTS</h3> We conducted a meta-analysis to assess the effect of PSB on post-op pain and analgesic use in adult cardiac surgery patients undergoing median sternotomy. PubMed, Embase, Google Scholar and the Cochrane database were searched with the following search strategy: ((post-operative pain) or (pain relief) OR (analgesics) or (analgesia) or (nerve block) or (regional block) or (local block) or (regional anesthesia) or (local anesthetic) or (parasternal block) and (sternotomy)) and (humans[filter]). Inclusion criteria were: cardiac surgery, median sternotomy, age>18 and parasternal block (continuous and single dose), and exclusion criteria were: non-cardiac surgery, non-parasternal nerve blocks, use of NSAIDS in parasternal infusion. Quality assessment was performed by 3 independent reviewers via the Cochrane risk of bias assessment tool. Of 1165 total citations, 16 were found to be relevant. These were all double blinded RCTs: 7 RCTs with a total of 2223 patients reported post-op pain scores in an extractable format and 11 RCTs (N=2155) reported post-op analgesia use after PSB (Table 1). For post-op analgesia use, morphine equivalent doses were calculated for all studies and post-op pain scores were standardized to a 10-point visual analog scale for comparison between studies; both these were reported as total opioid use or cumulative score ranging from 24h to 72h post-op. All data analyses were run using a random effects model, using a restricted maximum likelihood estimation, analyzing standardized mean differences with 95% CI's. For studies which only reported median and IQR, standard deviation was estimated by IQR/1.35. Following median sternotomy both post-op pain (SMD -0.49 [-0.92,-0.06]) and post-op morphine equivalent use (SMD -1.68 [-3.11, -0.25]) were significantly less in the PSB group (Fig. 1). <h3>CONCLUSION</h3> A parasternal nerve block strategy significantly reduces post-op pain and opioid analgesic use. While there was heterogeneity between the RCTs in the amount, type of anesthetic and the use of single vs continuous dosing and the type of control used (Table 1), our analysis suggests that PSB is effective in reducing post-op pain in cardiac surgery patients.

A pilot randomized clinical trial of cryopreserved versus liquid-stored platelet transfusion for bleeding in cardiac surgery: The cryopreserved versus liquid platelet-New Zealand pilot trial.

Platelets for transfusion have a shelf-life of 7 days, limiting availability and leading to wastage. Cryopreservation at -80°C extends shelf-life to at least 1 year, but safety and effectiveness are uncertain. This single centre blinded pilot trial enrolled adult cardiac surgery patients who were at high risk of platelet transfusion. If treating clinicians determined platelet transfusion was required, up to three units of either cryopreserved or liquid-stored platelets intraoperatively or during intensive care unit admission were administered. The primary outcome was protocol safety and feasibility. Over 13 months, 89 patients were randomized, 23 (25.8%) of whom received a platelet transfusion. There were no differences in median blood loss up to 48 h between study groups, or in the quantities of study platelets or other blood components transfused. The median platelet concentration on the day after surgery was lower in the cryopreserved platelet group (122 × 103 /μl vs. 157 × 103 /μl, median difference 39.5×103 /μl, p= 0.03). There were no differences in any of the recorded safety outcomes, and no adverse events were reported on any patient. Multivariable adjustment for imbalances in baseline patient characteristics did not find study group to be a predictor of 24-h blood loss, red cell transfusion or a composite bleeding outcome. This pilot randomized controlled trial demonstrated the feasibility of the protocol and adds to accumulating data supporting the safety of this intervention. Given the clear advantage of prolonged shelf-life, particularly for regional hospitals in New Zealand, a definitive non-inferiority phase III trial is warranted.

Dextran-based priming solution during cardiopulmonary bypass attenuates renal tubular injury-A secondary analysis of randomized controlled trial in adult cardiac surgery patients.

Acute kidney injury (AKI) is a well-known complication after cardiac surgery and cardiopulmonary bypass (CPB). In the present secondary analysis of a blinded randomized controlled trial, we evaluated the effects of a colloid-based versus a conventional crystalloid-based prime on tubular injury and postoperative renal function in patients undergoing cardiac surgery with CPB. Eighty-four adult patients undergoing cardiac surgery with CPB were randomized to receive either a crystalloid- or colloid- (dextran 40) based CPB priming solution. The crystalloid solution was based on Ringer-Acetate plus mannitol. The tubular injury biomarker, N-acetyl-b-D-glucosaminidase (NAG), serum creatinine and diuresis were measured before, during and after CPB. The incidence of AKI was assessed according to the KDIGO criteria. The urinary-NAG/urinary-creatinine ratio rose in both groups during and after CPB, with a more pronounced increase in the crystalloid group (p=.038). One hour after CPB, the urinary-NAG/urinary-creatinine ratio was 88% higher in the crystalloid group (4.7±6.3 vs. 2.5±2.7, p=.045). Patients that received the dextran 40-based priming solution had a significantly lower intraoperative diuresis (p<.001) compared to the crystalloid group. The incidence of AKI was 18% in the colloid and 22% in the crystalloid group (p=.66). Postoperative serum creatinine did not differ between groups. In patients undergoing cardiac surgery with CPB, colloid-based priming solution (dextran 40) induced less renal tubular injury compared to a crystalloid-based priming solution. Whether a colloid-based priming solution will improve renal outcome in high-risk cardiac surgery, or not, needs to be evaluated in future studies on higher risk cardiac surgery patients.

Accuracy, Precision, and Trending Ability of Perioperative Central Venous Oxygen Saturation Compared to Mixed Venous Oxygen Saturation in Unselected Cardiac Surgical Patients

To determine whether central venous oxygen saturation (ScvO2) measurements could be used interchangeably with mixed venous oxygen saturation (SvO2) measurements in adult cardiac surgery patients. A single-center prospective observational study. A university hospital. Eighty-five adult patients undergoing cardiac surgery. The study authors compared the oxygen saturations in 590 pairs of venous blood samples drawn from the pulmonary artery catheter (PAC) at three different time points during surgery and four different time points in the intensive care unit. They compared samples obtained from the distal pulmonary artery line (SvO2) to those drawn from the proximal central venous line of the PAC (ScvO2) with the Bland-Altman test and the four-quadrant method. The mean bias between SvO2 and ScvO2 was -1.9 (95% confidence interval [CI], -2.3 to -1.5) and the limits of agreement (LOA) were -11.5 to 7.6 (95% CI, -12.5 to -10.7 and 6.8-8.5, respectively). The percentage error (PE) was 13.2%. Based on the four-quadrant plot, only 50% of the measurement pairs were in agreement, indicating deficient trending ability. ScvO2 values showed acceptable accuracy as the mean bias was low. The precision was inadequate; although the PE was acceptable, the LOA were wide. Trending ability was inadequate. The authors cannot recommend the use of ScvO2 values interchangeably with SvO2 measurements in the management of adult cardiac surgery patients.

Del Nido cardioplegia in adult cardiac surgery: analysis of myocardial protection and post-operative high-sensitivity Troponin T.

del Nido cardioplegia has been adopted for use in adult cardiac surgery, despite a lack of robust randomised evidence supporting equivalence or superiority to conventional hyperkalaemic blood cardioplegia. We investigated the clinical surrogates of myocardial protection, and performed an extensive analysis of post-operative high-sensitivity Troponin T (hs-TnT) values in a general adult cardiac surgery population receiving del Nido, in comparison to a historical hyperkalaemic blood cohort. 171 consecutive patients of a single surgeon from between November 2018 and June 2020 received del Nido, and were compared to a historical cohort of 326 patients between January 2016 and November 2018 who received hyperkalaemic blood cardioplegia. Clinical markers of myocardial protection were compared, as were hs-TnT values at 6, 12, 24, and 72-h post-operatively. Equivalence between groups was determined using the two one-sided tests procedure. There was no difference between the groups in the incidence of post-operative low cardiac output state, inotropic support, or myocardial infarction. Del Nido patients had less defibrillation requirement, and more spontaneous resumption of normal sinus rhythm. High-sensitivity Troponin T values were similar at all time-points including in a coronary artery bypass graft subgroup, and in those patients with elevated pre-operative hs-TnT. In a broad cohort of adult cardiac surgery patients, including those undergoing coronary artery bypass surgery and those with recent myocardial infarction, del Nido provides equivalent myocardial protection and clinical outcomes when compared to hyperkalemic blood cardioplegia. Post-operative high-sensitivity Troponin T values were also equivalent between the groups.

Effective Collaboration Towards Positive Perioperative Outcomes for the Cardiac Surgery Patient in the Preoperative Phase of Care

<h3>Background Information</h3> The pre-procedure clinic in our academic medical center provides preoperative evaluation and surgical preparation for patients. Nurses in the clinic care for complex patients and support multiple surgical specialties, including cardiac surgery. Workflows related to this subset of patients, specifically identification of blood type and antibodies, presented a particular challenge for the clinic and cardiac surgery patients were not always ready for the operating room (OR) on the day of surgery. There was a negative impact on on-time first case starts (OTFS), cardiac surgery staff utilization, and, most importantly, patient satisfaction when delays occurred the morning of surgery due to positive antibodies and the need for additional work up to prepare blood availability for surgery. <h3>Objectives of Project</h3> The project aims were to: 1) provide an efficient outpatient pre-operative 30-day blood band process in the pre-procedure evaluation clinic for the adult cardiac surgery patient as partners in care with the cardiac surgery service and 2) establish a mutually beneficial work flow between perioperative services and cardiac surgery staff to minimize downstream OR delays. <h3>Process of Implementation</h3> A consultative group guided perioperative services leadership to improve internal processes. Collaboration with the cardiac surgery clinic and patient administrative services staff was crucial for project success. The project team developed and implemented a cardiac surgery internal workflow for preoperative management and the team revised outpatient registration workflows. All patient care technicians in the pre-procedure evaluation clinic received education for preoperative 30-day blood band lab procurement and associated form storage. <h3>Statement of Successful Practice</h3> This poster illustrates that there had been an upward trend in meeting the divisional OTFS goal of ≥ 75%. As of 10/31/19, ≥ 80% of cardiac surgery first cases started on time as compared to only 55% of cases started on time in July 2019. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Perinanesthesia nurses can improve the care of their patients by employing performance innovation concepts to break down barriers to ensure multidisciplinary success. By engaging multiple perioperative disciplines, providers, and members of the patient care delivery team, both patient care and organizational goals can be met. The option of 30 day blood bands is expanding to other surgical services to avoid delays the morning of surgery.

The Effect of COVID-19 on Adult Cardiac Surgery in the United States in 717 103 Patients

BackgroundCOVID-19 has changed the world as we know it, and the United States continues to accumulate the largest number of COVID-related deaths worldwide. There exists a paucity of data regarding the effect of COVID-19 on adult cardiac surgery trends and outcomes on regional and national levels. MethodsThe Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried from January 1, 2018, to June 30, 2020. The Johns Hopkins COVID-19 database was queried from February 1, 2020, to January 1, 2021. Surgical and COVID-19 volumes, trends, and outcomes were analyzed on a national and regional level. Observed-to-expected ratios were used to analyze risk-adjustable mortality. ResultsThe study analyzed 717 103 adult cardiac surgery patients and more than 20 million COVID-19 patients. Nationally, there was a 52.7% reduction in adult cardiac surgery volume and a 65.5% reduction in elective cases. The Mid-Atlantic region was most affected by the first COVID-19 surge, with 69.7% reduction in overall case volume and 80.0% reduction in elective cases. In the Mid-Atlantic and New England regions, the observed-to-expected mortality for isolated coronary bypass increased as much as 1.48 times (148% increase) pre-COVID rates. After the first COVID-19 surge, nationwide cardiac surgical case volumes did not return to baseline, indicating a COVID-19–associated deficit of cardiac surgery patients. ConclusionsThis large analysis of COVID-19–related impact on adult cardiac surgery volume, trends, and outcomes found that during the pandemic, cardiac surgery volume suffered dramatically, particularly in the Mid-Atlantic and New England regions during the first COVID-19 surge, with a concurrent increase in observed-to-expected 30-day mortality.

Standardized Assessment of Global activities in the Elderly scale in adult cardiac surgery patients

BackgroundDifferent instruments have been used to assess ability to perform everyday functional activities, such as activities of daily living (ADL) and instrumental activities of daily living (IADL). No measures of functional activity have been validated in cardiac surgery. We assessed the reliability and validity of the Standardized Assessment of Global activities in the Elderly (SAGE) scale. MethodsWe undertook an observational sub-study of VISION Cardiac Surgery. Patients were assessed post-discharge after cardiac surgery using SAGE and comparator measures to determine convergent validity. A blinded independent assessor administered SAGE by phone within 7 days to determine test–retest reliability. We sought to demonstrate a correlation of ≥0.5 between SAGE and each corresponding measure. We also sought to define the SAGE score corresponding to severe functional disability, defined using the World Health Organisation Disability Assessment Schedule (WHODAS). ResultsThere were 152 patients included. Inter-rater reliability was excellent (intra-class correlation coefficient=0.99; 95% confidence interval [CI], 0.98–0.99). Convergent validity was evident, ranging from adequate for the overall SAGE score (0.54; 95% CI, 0.42–0.65) to very good for the SAGE mobility sub-score (0.80; 95% CI, 0.73–0.85). SAGE was initially poorly correlated with the IADL index (–0.24) but increased to –0.60 after post-hoc adjustment of SAGE scoring. A SAGE score ≥7 was associated with severe functional disability and occurred in 42/152 (27.6%) of patients. ConclusionThese results demonstrate the reliability and validity of the SAGE scale as a measure of global function in patients discharged home after cardiac surgery. Clinical trial registrationNCT01842568.

Number and Type of Blood Products Are Negatively Associated With Outcomes After Cardiac Surgery

BackgroundThe association between blood transfusion and adverse outcome is documented in cardiac surgery. However, the incremental significance of each unit transfused, whether red blood cell (RBC) or non-RBC, is uncertain. This study examined the relationship of patient outcomes with the type and number of blood product units transfused. MethodsStatewide data from 24 082 adult cardiac surgery patients were included. The relationship with blood transfusion was assessed for morbidity and 30-day mortality using total number of RBC and non-RBC units transfused, specific type of non-RBC units, and different combinations of transfusion (only RBC, only non-RBC, RBC + non-RBC). Multivariable logistic regressions examined these associations. ResultsMedian age was 66 years (30% female patients), and 51% of patients received a transfusion (31%-66% across hospitals). Risk-adjusted analyses found each blood product unit was associated with 9%, 7%, and 4% greater odds for 30-day mortality, major morbidity, and minor morbidity, respectively (all P < .001). Odds for 30-day mortality were 13% greater with each RBC unit (P < .001) and 6% greater for each non-RBC unit (P < .001). Each unit of fresh frozen plasma (P < .001) and platelets (P < .001) increased the odds for 30-day mortality, but no effect was found for cryoprecipitate (P = .725). Odds for 30-day mortality were lower for non-RBC–only (odds ratio, 0.52; P = .030) and greater for RBC + non-RBC (odds ratio, 2.98; P < .001) compared with RBC-only transfusion. ConclusionsIndependent of center variability on transfusion methods, each additional unit transfused was associated with increased odds for complications, with RBC transfusion carrying greater risk compared with non-RBC. Comprehensive evidence-based clinical approaches and coordination are needed to guide each blood transfusion event after cardiac surgery.

The additional use of methylene blue has a decatecholaminisation effect on cardiac vasoplegic syndrome after cardiac surgery

BackgroundPostoperative vasoplegia with minimal responsiveness to vasopressors is common after cardiac surgery. Called cardiac vasoplegic syndrome (CVS), it is caused by multiple factors. Treating CVS involves a high dose of fluids and catecholamines, however high doses of catecholamines and fluids are associated with serious side effects. There is evidence that new therapeutic strategies can lead to a reduction in norepinephrine doses and mortality in CVS. Specifically, the use of non-adrenergic vasopressors such as methylene blue (MB) can be beneficial.MethodsWe retrospectively analyzed the electronic records of 8716 adult cardiac surgery patients from November 2008 to December 2016. Medication, hemodynamic and outcome parameter data were analyzed for CVS until discharge. We determined CVS according to the following parameters: a postoperative onset of ≤24 h, a reduced mean arterial pressure (MAP) of < 70 mmHg, a dose of norepinephrine ≥0.8 mg*h− 1 and a continuously increasing need for catecholamine, without ventricular dysfunction.ResultsWe identified 513 patients with CVS. Perioperative risk factors were higher in patients treated with methylene blue (MB). Before MB administration patients had a significantly higher dose of norepinephrine, and MAP increased after MB administration. Norepinephrine could be reduced after MB administration and MAP remained stable at the same level even after the reduction of norepinephrine.ConclusionsCVS patients have a severe systemic disease accompanied by significant operative stress and a high catecholamine requirement. The administration of MB in addition to standard treatment for CVS in the first 24 h was accompanied by an increase in MAP followed by a decrease in vasopressor requirement, indicating that early MB administration can be beneficial.

Early Thromboembolic Stroke Risk of Postoperative Atrial Fibrillation Following Cardiac Surgery

The authors aimed to study the association between postoperative atrial fibrillation (POAF) and thromboembolic stroke and to determine risk factors for thromboembolic stroke after cardiac surgery. The authors performed a secondary analysis from a randomized controlled trial (GRIP-COMPASS). The patients with thromboembolic stroke were compared with those without thromboembolic stroke, and the difference in the incidence of POAF between these groups was assessed. Odds ratios (OR) were calculated using logistic regression analyses. Brain imaging was studied for the occurrence of thromboembolic stroke during hospital admission, and POAF was monitored for seven days. To assess which characteristics were associated with occurrence of thromboembolic stroke, stepwise backward regression analysis was performed. All adult consecutive cardiac surgery patients admitted postoperatively to the intensive care unit. Academic tertiary care medical center. None. Of the 910 patients included in this study, 26 patients (2.9%) had a thromboembolic stroke during hospital admission. The incidence of POAF during the first seven days after cardiac surgery in those with thromboembolic stroke was 65%, compared with 39% in those without thromboembolic stroke: adjusted OR 3.01 (95% confidence interval, 1.13-8.00). POAF, a history of peripheral vascular disease, a higher EuroSCORE, and a longer duration of surgery were associated with thromboembolic stroke. POAF within seven days after cardiac surgery was associated with a three-fold increased risk for a thromboembolic stroke during hospital admission. Expeditious treatment of POAF may, therefore, reduce early stroke risk after cardiac surgery.

International Survey on Calcium Use when Weaning from Cardiopulmonary Bypass

The objective: to evaluate the international practice of using calcium salts when weaning from cardiopulmonary bypass after cardiac surgery in adult patients.Design: a multiple-choice survey about the current practice of calcium salts use when weaning from cardiopulmonary bypass based on the SurveyMonkey platform.Participants: cardiac surgical hospitals around the world.Estimation and main results. Totally 112 emails were sent to Russian and foreign centers inviting them to participate in the survey. 100 centers from 32 countries replied to this request. Generally, the majority of centers (88%) administer calcium salts during surgery with cardiopulmonary bypass, and in 71 (71%) centers out of 100, calcium salts are used to improve hemodynamics. Among 88 centers that use calcium salts during surgery, 66% (58/88) of respondents use calcium chloride, 22% (19/88) use calcium gluconate, and 12% (11/88) use both drugs. Most centers (55 (77%) out of 71) use doses of 5 to 15 mg/kg as a bolus or infusion for 1 min.Conclusion: Our survey shows that the majority of cardiac surgery centers use calcium in adult cardiac surgery patients especially during weaning from cardiopulmonary bypass. There is variability in the type of drug, dose, and route of administration.

Survey of Physiotherapy Practice in Ontario Cardiac Surgery Intensive Care Units.

Purpose: This article describes current physiotherapy practice for critically ill adult patients requiring prolonged stays in critical care (>3 d) after complicated cardiac surgery in Ontario. Method: We distributed an electronic, self-administered 52-item survey to 35 critical care physiotherapists who treat adult cardiac surgery patients at 11 cardiac surgical sites. Pilot testing and clinical sensibility testing were conducted beforehand. Participants were sent four email reminders. Results: The response rate was 80% (28/35). The median reported number of cardiac surgeries performed per week was 30 (interquartile range [IQR] 10), with a median number of 14.5 (IQR 4) cardiac surgery beds per site. Typical reported caseloads ranged from 6 to 10 patients per day per therapist, and 93% reported that they had initiated physiotherapy with patients once they were clinically stable in the intensive care unit. Of 28 treatments, range of motion exercises (27; 96.4%), airway clearance techniques (26; 92.9%), and sitting at the edge of the bed (25; 89.3%) were the most common. Intra-aortic balloon pump and extracorporeal membrane oxygenation appeared to limit physiotherapy practice. Use of outcome measures was limited. Conclusions: Physiotherapists provide a variety of interventions to critically ill cardiac surgery patients. Further evaluation of the limited use of outcome measures in the cardiac surgical intensive care unit is warranted.

Comparison of Clinical Scoring Tools to Predict Heparin-Induced Thrombocytopenia in Cardiac Surgery

The 4Ts and HIT-Expert Probability (HEP) scoring tools for heparin-induced thrombocytopenia (HIT) have not been validated in cardiac surgery patients, and the reported sensitivity and specificity of the Post-Cardiopulmonary Bypass (CPB) scoring tool vary widely in the 2 available analyses. It remains unclear which of the available scoring tools most accurately predicts HIT in this population. Forty-nine HIT-positive patients who underwent on-pump cardiac surgery within a 6-year period were loosely matched to 98 HIT-negative patients in a 1:2 case-control design. The 4Ts, HEP, and CPB scores were calculated for each patient. Sensitivity and specificity of each tool were calculated using standard cut-offs. The Youden method was utilized to determine optimal cut-offs within receiver operating characteristic (ROC) curves of each score, after which sensitivities and specificities were recalculated. Using standard cut-offs, the sensitivities for the CPB, HEP, and 4Ts scores were 100%, 93.9%, and 69.4%, respectively. Specificities were 51%, 49%, and 71.4%, respectively. The AUC of the scoring tool ROC curves were 0.961 for the CPB score, 0.773 for the HEP score, and 0.805 for the 4Ts score. Using the Youden method-derived optimal cut-off of ≥3 points on the CPB score, sensitivity remained 100% with improved specificity to 88.9%. The CPB score is the preferred HIT clinical scoring tool in adult cardiac surgery patients, whereas the 4Ts score performed less effectively. A cut-off of ≥ 3 points on the CPB score could increase specificity while preserving high sensitivity, which should be validated in a prospective evaluation.

The assessment of patients undergoing cardiac surgery for Covid-19: Complications occurring during cardiopulmonary bypass.

The outbreak of the novel coronavirus pandemic (COVID-19) has resulted in dramatic changes to the conduct of surgery both from a patient management perspective and in protecting healthcare providers. The current study reports on the status of COVID-19 infections in patients presenting for cardiac surgery with cardiopulmonary bypass (CPB) on circuit complications. A tracking process for monitoring the presence of COVID-19 in adult cardiac surgery patients was integrated into a case documentation system across United States hospitals where out-sourced perfusion services were provided. Assessment included infection status, testing technique employed, surgery status and CPB complications. Records from 5612 adult patients who underwent cardiac surgery between November 1, 2020 and January 18, 2021 from 176 hospitals were reviewed. A sub-cohort of coronary artery bypass graft patients (3283) was compared using a mixed effect binary logistic regression analysis. 4297 patients had negative test results (76.6%) while 49 (0.9%) tested positive for COVID-19, and unknown or no results were reported in 693 (12.4%) and 573 (10.2%) respectively. Coagulation complications were reported at 0.2% in the negative test results group versus 4.1% in the positive test result group (p < 0.001). Oxygenator gas exchange complications were 0.2% in the negative test results group versus 2.0% in the positive test results group (p = 0.088). Coronary artery bypass graft patients with a positive test had significantly higher risk for any CPB complication (p = 0.003) [OR 10.38, CI 2.18–49.53] then negative test patients [OR 0.01, CI 0.00–0.20]. The present study has shown that patients undergoing cardiac surgery with CPB who test positive for COVID-19 have higher CPB complication rate than those who test negative.

Risk factors for vasoplegia after coronary artery bypass and valve surgery

Vasoplegia denotes a state of low tissue perfusion characterized by hypotension, tachycardia, and low systemic vascular resistance. This state results in increased mortality and morbidity following cardiac surgery. A better understanding of the associated risk factors will guide the surgical team in patient management. The aim of this study is to determine which risk factors are involved in its emergence. This prospective observational study included adult cardiac surgery patients between February - September 2018 at a single cardiothoracic surgery center. Patients were evaluated for cardiac contractility, surgical drainage, inotrope, and vasopressor requirement perioperatively. The groups were compared for demographic, echocardiographic, and operative variables. Variables significant in univariate analysis were carried on to binary logistic regression for risk factor analysis. A total of 31 patients were vasoplegic among a total of 487 included patients, resulting in a 6.37% incidence. In the vasoplegia group, chronic kidney failure, use of angiotensin-converting enzyme (ACE) inhibitors, use of angiotensin receptor blockers, and use of diuretics were more frequent, cardiopulmonary bypass (CPB) and aortic cross-clamp durations were longer, and mean Euroscore II was higher. Vasoplegia was more frequent in valve surgery and resternotomy patients. CPB duration, use of ACE inhibitors, use of angiotensin receptor blockers, and chronic renal failure were independent risk factors. Patients with long CPB duration, preoperative use of ACE inhibitors or Angiotensin receptor blockers, and a history of renal failure requiring dialysis are under increased risk of vasoplegia. Vasoplegia necessitates large-scale studies for a better understanding of its risk factors.

Dexmedetomidine reduces the incidence of postoperative delirium after cardiac surgery: a meta-analysis of randomized controlled trials

BackgroundThe role of dexmedetomidine in preventing postoperative delirium (POD) after cardiac surgery remains controversial because of several recent trials with negative results. We aimed to perform an updated meta-analysis of randomized controlled trials (RCTs) to clarify this controversy.MethodsRCTs investigating the perioperative administration of dexmedetomidine in cardiac surgery were retrieved from PubMed, Web of Science, and the Cochrane library until August,27,2020. Two researchers independently screened the literature, collected the data and evaluated the bias risk of the included studies. The meta-analysis was performed with the RevMan 5.3.ResultsA total of 15 studies including 2813 patients were included in the study. A pooled result showed that dexmedetomidine could reduce the risk of POD in adult population underwent cardiac surgery (OR 0.56, 95%CI 0.36–0.89, P = 0.0004, I2 = 64%). The subgroup analysis demonstrated that the protective effect of dexmedetomidine was only present in the patients injected with dexmedetomidine after surgery but not from the start of surgery, in the adult patients without specific age limitation but not in the elderly, and in the studies in comparison with other sedatives but not with placebo. There were no statistical differences when analyzing the secondary outcomes including hypotension (OR 1.13; 95% CI 0.54–2.37, P < 0.00001, I2 = 85%), bradycardia (OR 1.72; 95% CI 0.84–3.53, P = 0.04, I2 = 58%) and atrial fibrillation (OR 0.87; 95% CI 0.70–1.08, P = 0.43, I2 = 0).ConclusionsDexmedetomidine can reduce the incidence of POD compared to other sedatives and opioids after cardiac surgery in adult patients. The proper population and timing for perioperative use of dexmedetomidine after cardiac surgery remain to be further investigated.