Population Of Cardiac Surgery Patients Research Articles

The pathophysiology and management of depression in cardiac surgery patients

BackgroundDepression is common in the cardiac surgery population. This contemporary narrative review aims to explore the main pathophysiological disturbances underpinning depression specifically within the cardiac surgery population. The common non-pharmacological and pharmacological management strategies used to manage depression within the cardiac surgery patient population are also explored.MethodsA total of 1291 articles were identified through Ovid Medline and Embase. The findings from 39 studies were included for qualitative analysis in this narrative review.ResultsDepression is associated with several pathophysiological and behavioral factors which increase the likelihood of developing coronary heart disease which may ultimately require surgical intervention. The main pathophysiological factors contributing to depression are well characterized and include autonomic nervous system dysregulation, excessive inflammation and disruption of the hypothalamic–pituitary–adrenal axis. There are also several behavioral factors in depressed patients associated with the development of coronary heart disease including poor diet, insufficient exercise, poor compliance with medications and reduced adherence to cardiac rehabilitation. The common preventative and management modalities used for depression following cardiac surgery include preoperative and peri-operative education, cardiac rehabilitation, cognitive behavioral therapy, religion/prayer/spirituality, biobehavioral feedback, anti-depressant medications, and statins.ConclusionThis contemporary review explores the pathophysiological mechanisms leading to depression following cardiac surgery and the current management modalities. Further studies on the preventative and management strategies for postoperative depression in the cardiac surgery patient population are warranted.

Acquisition of New Philips Affiniti 30 Vascular Color Doppler Ultrasound Device - Cost Benefit Analysis to Reduce Cardiosurgical Patients' Treatment.

Cerebrovascular accidents (CVI) are considered the second most serious complication in cardiac surgery patients with a frequency of 10%. By preventing complications of surgical treatment, using a Color Doppler ultrasound (CDU) device, in the population of cardiac surgery patients, the unplanned costs of prolonged postoperative treatment would be reduced. To prove that the acquisition and use of the newly developed CDU device "Affinit 30" is completely economical, profitable and medically justified. Numerical parameters of the treatment of cardiovascular patients were analyzed (number of procedures, number of days in the intensive care unit, cost of additional consultative services of the clinic for radiology and neurology), and the calculated economic value of the potential investment, as well as the cost of preventing surgical complications, by purchasing and installing a new modern CDU device. The profitability of the investment was assessed using the economic parameters Net Present Value (NPV) of the investment, Internal rate of return (IRR) and Profitability Index (PI). A mathematical calculation with the given parameters yields NPV = 948,850 KM and IRR of 273% when applied to the given parameters. The PI value is 12.6, which matches the previously calculated NPV and IRR values. The acquisition and use of the newly developed CDU device "Affinit 30" is economically profitable and medically justified. This is shown by the calculated values of the economic parameters Net Present Value of the investment (NPV), Internal rate of return (IRR) and the Profitability Index (PI).

Analysing and improving preoperative medication management in cardiac surgery.

The objective of this study was to analyse the preoperative medication management within the cardiac surgery patient population and measure the effectiveness of an interprofessional intervention in routine care. A jointly developed preoperative medication management was implemented in routine care on multiple levels (inclusion in admission letter to primary care, hotline for inquiries, pocket cards for physicians and correspondence with referring centres). The effectiveness was evaluated by analysing preoperative management before and after implementation. The primary endpoint was the number of drugs managed correctly according to the guidelines after implementation. Secondary endpoints consisted amongst others of bleeding on the intensive care unit, re-thoracotomy, postoperative infarction and cerebrovascular complications. Additionally, possible associations between the correct management and different variables were investigated by multivariate analysis. After the implementation, the number of drugs managed correctly according to guidelines increased from 54.0 to 73.5% (P< .001). The effect was more prominent for direct oral anticoagulants and prophylactic aspirin where the guideline adherence increased from 29.2 to 74.5% and from 78.6 to 95.1%, respectively. No difference was seen for sodium-glucose transporter-2 inhibitors, metformin, vitamin-K antagonists and dual-antiplatelet therapy. Secondary endpoints showed no safety signals with regard to bleeding or thrombotic events. In multivariate analysis, the intervention was effective (odds ratio 2.17, 95% confidence interval [1.32-3.62]) after adjusting for possible confounders. An interprofessional programme was effective to improve preoperative medication management in cardiac surgery patients. Sodium-glucose transporter-2 inhibitors, metformin and direct oral anticoagulants appear to be especially at risk for incorrect management before cardiac surgery with possible adverse events.

Relationship between multimorbidity and prevalence of frailty syndrome in patients qualified for elective cardiac surgery.

Abstract Funding Acknowledgements Type of funding sources: None. Intorduction Frailty syndrome (FS) and multimorbidity are closely related but separate constructs that are associated with higher risk of death, higher rehospitalization rates, disability, and reduced quality of life. Identification of multimorbidity and FS in the cardiac surgery patient population appears to be important in terms of the qualification process, incidence of perioperative risk, and optimization of patient status before the cardiac surgery procedure. Purpose Analysis of the relationship between multimorbidity and FS in patients qualified for elective cardiac surgery. Methods The study included 100 patients ≥ 65 years of age (40 women and 60 men, mean age M±SD =71.69±4). The study included elderly patients qualified for elective cardiac surgery (coronary artery bypass grafting, valvular surgery or combined surgery). In the study group frailty was identified with the use of standardized research tools including those for one-dimensional and multidimensional assessment (FRAIL scale, Frailty Phenotype, 5-meter gaid speed, Tilburg Frailty Indicator, Tilburg Frailty Indicator - TFI). The presence of more than 3 chronic diseases was considered as multimorbidity. A significance level of 0.05 was assumed in the analysis, so all p&amp;lt;0.05 values were interpreted as indicating significant relationships. Results Multimorbidity was reported in 88% of patients qualified for cardiac surgery. The prevalence of FS varied according to the screening tool used.Based on FRAIL was reported in 27% of patients, based on Frailty Phenotype in 17% of patients, based on 5-meter gaid speed in 43% of patients, and based on TFI in 63% of patients. In patients with multimorbidity FS was significantly more frequent than in patients without frailty syndrome, which was confirmed by FRAIL (96.3% vs. 60.0%; p-=0.003) and TFI questionnaire (95.2% vs. 75.7%; p=0.008) scores. Conclusions 1. Most elderly patients qualified for elective cardiac surgery procedures are characterized by multimorbidity. 2 Multimorbidity is associated with a higher prevalence of FS in both unidimensional and multidimensional assessment. 3 This phenomenon requires further study, especially with regard to the occurrence of outcomes in this patient population.

Increased postoperative myeloperoxidase concentration associated with low baseline antioxidant capacity as the risk factor of delirium after cardiac surgery

Background Though risk factors of postoperative delirium are well described, its pathophysiology is still undiscovered. The primary objective of the current study is to assess whether increased pre- and postoperative myeloperoxidase (MPO) levels are associated with postoperative delirium in the population of cardiac surgery patients. The secondary objective is to evaluate the correlation between MPO levels and serum antioxidant capacity (AC). Methods The patients’ cognitive status was assessed one day preoperatively with the use of the Mini-Mental State Examination Test and the Clock Drawing Test. A diagnosis of major depressive disorder and anxiety disorders was established based on DSM-5 criteria. Blood samples for MPO and AC levels were collected both pre- and postoperatively. The Confusion Assessment Method for the Intensive Care Unit was used to screen for a diagnosis of delirium. Results Delirium occurred in 34% (61 of 177) of patients. Multivariable logistic regression analysis revealed that increased postoperative MPO concentration was independently associated with postoperative delirium development, and negatively correlated with lower baseline serum AC. Conclusions Cardiac surgery patients with less efficient antioxidative mechanisms experience a higher postoperative peak of serum MPO, which in turn may predispose to postoperative delirium development. KEY MESSAGES MPO is a lysosomal enzyme with strong pro-oxidative and pro-inflammatory properties. Cardiac surgery patients who have increased concentration of postoperative MPO are at significantly higher risk of postoperative delirium development. This higher level of postoperative MPO is negatively correlated with baseline antioxidant capacity (AC). It can be hypothesized that individuals with decreased baseline AC experience a higher peak of MPO post-surgery due to less efficient antioxidative mechanisms, which in turn contributes to postoperative delirium development.

Delirium and depression in cardiac surgery: A comprehensive review of risk factors, pathophysiology, and management.

Mental health and wellbeing continue to gain more attention as they are inextricably associated with clinical outcomes, particularly quality of life. Many medical ailments and major surgeries affect patients' mental health, including depression and delirium. The objective of this manuscript was to comprehensively review and critically examine the literature pertaining to cardiac surgery, depression, and delirium. This is a narrative review article. We performed our search analysis by using the following key words: "Cardiac Surgery", "Depression", "Delirium", "Clinical outcomes", and "Mental Health". Search analysis was done on MedLine PubMed, accessing indexed peer-reviewed publications. Cardiac Surgery is a life-altering intervention indicated to improve morbidity and mortality in patients with cardiovascular diseases. Psychiatric conditions before and after cardiac surgery worsen patient prognosis and increase mortality rate. Specifically, preoperative depression increases postoperative depression and is associated with impaired functional status, slow physical recovery, and an increased readmission rate. Although the exact pathophysiology between depression and cardiovascular disease (CVD) is unknown, several pathways have been implicated. Unmanaged depression can also lead to other psychological conditions such as delirium. Like depression, the exact association between delirium and CVD is not well understood, but believed to be multifactorial. Herein, we provide a comprehensive review of the links between depression, delirium, and cardiovascular surgery. We critically examine the current data that pertains to the pathophysiology of these debilitating mental health issues in the context of cardiac surgery. Finally, we summarize the various treatment options available for managing depression and delirium in the cardiac surgery patient population.

Tissue oxygen saturation changes and postoperative complications in cardiac surgery: a prospective observational study

BackgroundCardiac surgery with extracorporeal circulation (ECC) can induce microvascular dysfunction and tissue hypoperfusion. We hypothesized that the alterations in near-infrared spectroscopy (NIRS)-derived parameters would be associated with post-operative complications in cardiac surgery patients.MethodsProspective observational study performed at two University Hospitals. Ninety patients undergoing cardiac surgery with ECC were enrolled. The NIRS sensor was applied on the thenar eminence. A vascular occlusion test (VOT, 3-min ischemia) was performed at baseline (t0), at Intensive Care Unit (ICU) admission (t1), 3 (t2) and 6 (t3) hours later. Baseline tissue oxygen saturation (StO2), oxygen extraction rate and microvascular reactivity indices were calculated.ResultsIn the first hours after cardiac surgery, StO2 tended to increase (86% [80–89] at T3 versus 82% [79–86] at T0, p = ns), while both tissue oxygen extraction and microvascular reactivity tended to decrease, as indicated by increasing occlusion slope (− 8.1%/min [− 11.2 to − 7] at T3 versus − 11.2%/min [− 13.9 to − 7.9] at T0, p = ns) and decreasing recovery slope (1.9%/sec [1.1–2.9] at T3 versus 3.1%/sec [2.3–3.9] at T0, p = ns). No substantial differences were found in NIRS-derived variables and their changes over time between patients with complications and those without complications.ConclusionsPeripheral tissue oxygen extraction and microvascular reactivity were reduced during the first hours after cardiac surgery. NIRS-derived parameters were not able to predict complications in this population of cardiac surgery patients.

Trends and Outcomes of Cardiovascular Surgery in Patients With Opioid Use Disorders

Persistent opioid use is currently a major health care crisis. There is a lack of knowledge regarding its prevalence and effect among patients undergoing cardiac surgery. To characterize the national population of cardiac surgery patients with opioid use disorder (OUD) and compare outcomes with the cardiac surgery population without OUD. In this retrospective population-based cohort study, more than 5.7 million adult patients who underwent cardiac surgery (ie, coronary artery bypass graft, valve surgery, or aortic surgery) in the United States were included. Pregnant patients were excluded. Propensity matching was performed to compare outcomes between cardiac surgery patients with OUD (n = 11 359) and without OUD (n = 5 707 193). The Nationwide Inpatient Sample database was queried from January 1998 to December 2013. Data were analyzed in January 2018. Persistent opioid use and/or dependence. In-hospital mortality, complications, length of stay, costs, and discharge disposition. Among the 5 718 552 included patients, 3 887 097 (68.0%) were male; the mean (SD) age of patients with OUD was 47.67 (13.03) years and of patients without OUD was 65.53 (26.14) years. The prevalence of OUD among cardiac surgery patients was 0.2% (n = 11 359), with an 8-fold increase over 15 years (0.06% [262 of 437 641] in 1998 vs 0.54% [1425 of 263 930] in 2013; difference, 0.48%; 95% CI of difference, 0.45-0.51; P < .001). Compared with patients without OUD, patients with OUD were younger (mean [SD] age, 48 [0.30] years vs 66 [0.05] years; P < .001) and more often male (70.8% vs 68.0%; P < .001), black (13.7% vs 4.8%), or Hispanic (9.1% vs 4.8%). Patients with OUD more commonly fell in the first quartile of median income (30.7% vs 17.1%; P < .001) and were more likely to be uninsured or Medicaid beneficiaries (48.6% vs 7.7%; P < .001). Valve and aortic operations were more commonly performed among patients with OUD (49.8% vs 16.4%; P < .001). Among propensity-matched pairs, the mortality was similar between patients with vs without OUD (3.1% vs 4.0%; P = .12), but cardiac surgery patients with OUD had an overall higher incidence of major complications (67.6% vs 59.2%; P < .001). Specifically, the risks of blood transfusion (30.4% vs 25.9%; P = .002), pulmonary embolism (7.3% vs 3.8%; P < .001), mechanical ventilation (18.4% vs 15.7%; P = .02), and prolonged postoperative pain (2.0% vs 1.2%; P = .048) were significantly higher. Patients with OUD also had a significantly longer length of stay (median [SE], 11 [0.30] vs 10 [0.22] days; P < .001) and cost significantly more per patient (median [SE], $49 790 [1059] vs $45 216 [732]; P < .001). The population of patients with persistent opioid use or opioid dependency undergoing cardiac surgery has increased over the past decade. Cardiac surgery in patients with OUD is safe but is associated with higher complications and cost. Patients should not be denied surgery because of OUD status but should be carefully monitored postoperatively for complications.

Validation of the Fitbit Flex in an Acute Post-Cardiac Surgery Patient Population.

Purpose: This study examined the validity of the Fitbit Flex activity monitor for step count and distance walked among post-cardiac surgery patients. Method: Participants (n=20) from a major urban cardiac surgery centre were recruited 1-2 days before hospital discharge. The Fitbit Flex step count and distance walked outputs and video recording of each participant performing the 6-minute walk test were collected. Fitbit Flex output was compared with criterion measures of manual step count obtained from the video recording and manual measurement of distance walked. Statistical analysis compared the output and criterion measures using paired sample t-tests, Pearson correlation coefficients, Lin's concordance correlations, and Bland-Altman plots. Sub-analysis compared slower walking (<0.8 m/s; n=11) and faster walking (≥0.8 m/s; n=8) group speeds (1 participant was excluded from analysis). Results: Steps counted and distance walked were significantly different between the Fitbit Flex outputs and criterion measures (p<0.05). The Fitbit Flex steps counted and distance walked showed moderate association with manual measure steps counted (r=0.67) and distance walked (r=0.45). Lin's concordance coefficients revealed a lack of agreement between the Fitbit Flex and the criterion measurement of both steps counted (concordance correlation coefficient [CCC]=0.43) and distance walked (CCC=0.36). The percentage of relative error was -18.6 (SD 22.7) for steps counted and 25.4 (SD 45.8) for distance walked. Conclusions: The Fitbit Flex activity monitor was not a valid measure of step count and distance walked in this sample of post-cardiac surgery patients. The lack of agreement between outputs and criterion measures suggests the Fitbit Flex alone would not be an acceptable clinical outcome measure for monitoring walking progression in the early postoperative period.

Colloids in Cardiac Surgery—Friend or Foe?

The right choice of fluid replacement still is a matter of debate. Recently, two large-scale studies on the use of hydroxyethyl starches (HES) in the intensive care setting have been published, which have caused a huge shift in the daily practice of volume therapy. These results have been applied to patients outside intensive care. The aim of this study was to evaluate the impact this change has had on the outcomes in a large population of cardiac surgery patients, with a focus on the type of colloid infusion. A prospective, registered, observational study, using propensity score matching. Cohort study from 3 university hospitals using a common registry. The study comprised 17,742 patients who were referred for cardiac surgery from 2007 to 2014. Patients were divided in groups according to perioperative fluid replacement with either crystalloids or colloids. The colloid group was further divided into HES or human albumin (HA). Analyses were based on the following 3 subsections: HES versus crystalloids, HA versus crystalloids, and HES versus HA, with use of propensity score matching or direct matching of cases. Primary outcome parameters were 30-day and 6-month mortality, new postoperative renal replacement therapy, and new cardiac ischemic events. The groups were fully comparable in individual analyses. The use of HES had no impact on new dialysis and 30-day mortality. A Cox proportional regression analysis showed that HES had no impact on 6-month mortality and new postoperative ischemic events. When comparing HA with crystalloid use, a significantly increased risk in crude analysis was demonstrated on all outcome parameters; and when comparing HA with HES, a significantly higher risk was observed in HA patients in mortality parameters and new postoperative, but after adjustment, only the risk of new postoperative dialysis persisted. This study underlined the difficulties in establishing hardcore outcome data, even in large cohort studies. The findings seemed to diminish the magnitude of risk when using HES in cardiac surgery patients and seriously questioned the choice of HA when a plasma expander is needed.

Risk predictors of infection and mortality in population of cardiac surgery patients on ecmo therapy

The main hazardous events in the population of cardiac surgery patients on veno-arterial extracorporeal membrane oxygenation therapy (va-ECMO) are occurrence of infection and death.

Pancreatic stone protein predicts postoperative infection in cardiac surgery patients irrespective of cardiopulmonary bypass or surgical technique.

IntroductionWe investigated the role of pancreatic stone protein (PSP) in predicting the occurrence of infection in the postoperative course of cardiac surgery patients. Several biomarkers indicating the presence of inflammation and infection are available in the clinical routine; yet, their utility in the postoperative course of patients following cardiac surgery remains uncertain. Moreover, cardiopulmonary bypass, also referred to as “on-pump surgery”, increases the susceptibility to an exaggerated inflammatory state. However, the impact of such extracorporeal circulation on circulating PSP levels remains poorly understood.MethodsIn a prospective cohort of unselected patients undergoing cardiac surgery, we set out to elucidate the diagnostic accuracy of serum PSP levels as opposed to canonical biomarkers (CRP, WBC) of inflammation to discriminate between the presence of infection and surgical trauma,. In addition, we investigated whether the biomarkers were influenced by the surgical technique employed, i.e. on-pump vs. off-pump and minimally invasive surgery vs. sternotomy. Levels of circulating PSP and routine inflammatory biomarkers (CRP, WBC) were measured in samples taken from 120 patients at baseline as well as at postoperative day 1–3.ResultsUnivariate analysis showed that among the biomarkers investigated, only PSP levels had discriminatory power to differentiate infection from surgical trauma in the postoperative course of the entire cohort of patients following cardiac surgery. With regard to cardiac surgical interventions, there was no significant association between the absence or presence of extracorporeal circulation and PSP levels. However, there was a significant difference in the slope of the rise of postoperative PSP between minimally invasive surgery as opposed to patients subjected to sternotomy.ConclusionIn an unselected population of cardiac surgery patients, post-operative serum PSP levels were significantly associated with the presence of infection in both the on-pump and off-pump setting. Of note, the surgical technique employed (sternotomy vs. minimally invasive approach) had a significant impact on postoperative PSP levels.

The assessment of the T102C polymorphism of the 5HT2a receptor gene, 3723G/A polymorphism of the NMDA receptor 3A subunit gene (GRIN3A) and 421C/A polymorphism of the NMDA receptor 2B subunit gene (GRIN2B) among cardiac surgery patients with and without delirium

ObjectiveThe studies regarding the role of genes polymorphism in development of postoperative delirium are extremely rare. Therefore, we investigated the potential association of polymorphism in 5HT2a receptor gene and N-methyl-d-aspartate (NMDA) receptor 3A and 2B subunits genes with postoperative delirium. MethodWe conducted a prospective, nested, case–control study. For analysis, 3723G/A (rs3739722) polymorphism in the GRIN3A gene, 421C/A (rs3764028) polymorphism in the GRIN2B gene and T102C (rs6313) polymorphism in the 5HT2A gene were selected. ResultsGenetic analysis confirmed that there were significant differences in genotype frequencies for 3723G/A between delirium patients and controls. No other significant associations were observed. Moreover, according to the multivariate conditional logistic regression analysis the presence of AG haplotype of GRIN3A gene was independently associated with postoperative delirium. ConclusionsThese findings suggest that the genetic variations of NR3A subunit of NMDA receptor may be a predisposing factor to delirium among the Polish population of cardiac surgery patients.

NP020 Revising the morbidity and mortality process in a community based regional cardiac care program: A nurse led initiative to improve the quality of care in the cardiac surgery patient population

Mortality within the cardiac surgery patient population is a well-studied concept; recently, the evidence has discussed that nearly thirty percent of those patients who died after undergoing coronary artery bypass grafting were preventable. This finding emphasizes that further system improvements must be implemented to deflect gaps in care that lead to negative outcomes. Historically, morbidity and mortality (MM the purpose of the MM it will identify an approach taken to revise the M&M process in a community-based cardiac surgery program. In addition, the presentation will identify stakeholders, tools and resources used to complete the quality of care strategy. Finally, a case presentation will highlight lessons learnt and final yields from the initiative.

Ventilator-Associated Pneumonia Among Cardiac Surgery Patients: What More Can We Do for Prevention?

PURPOSE: Despite extensive efforts and campaigns, infections continue to plague intensive care units. Ventilator associated pneumonia (VAP) is associated with relatively high mortality and morbidity rates and significantly increases length of stay in the ICU. Furthermore VAP is now considered a non-reimbursable complication with an estimated cost per patient range of $11, 897-$150,841. The purpose of this study was to explore our cardiac surgery patient population to discern which clinical variables may be modifiable to reduce the number of patients who develop VAP despite rigid implementation of the VAP prevention bundle.

A novel survival model of cardioplegic arrest and cardiopulmonary bypass in rats: a methodology paper

BackgroundGiven the growing population of cardiac surgery patients with impaired preoperative cardiac function and rapidly expanding surgical techniques, continued efforts to improve myocardial protection strategies are warranted. Prior research is mostly limited to either large animal models or ex vivo preparations. We developed a new in vivo survival model that combines administration of antegrade cardioplegia with endoaortic crossclamping during cardiopulmonary bypass (CPB) in the rat.MethodsSprague-Dawley rats were cannulated for CPB (n = 10). With ultrasound guidance, a 3.5 mm balloon angioplasty catheter was positioned via the right common carotid artery with its tip proximal to the aortic valve. To initiate cardioplegic arrest, the balloon was inflated and cardioplegia solution injected. After 30 min of cardioplegic arrest, the balloon was deflated, ventilation resumed, and rats were weaned from CPB and recovered. To rule out any evidence of cerebral ischemia due to right carotid artery ligation, animals were neurologically tested on postoperative day 14, and their brains histologically assessed.ResultsThirty minutes of cardioplegic arrest was successfully established in all animals. Functional assessment revealed no neurologic deficits, and histology demonstrated no gross neuronal damage.ConclusionThis novel small animal CPB model with cardioplegic arrest allows for both the study of myocardial ischemia-reperfusion injury as well as new cardioprotective strategies. Major advantages of this model include its overall feasibility and cost effectiveness. In future experiments long-term echocardiographic outcomes as well as enzymatic, genetic, and histologic characterization of myocardial injury can be assessed. In the field of myocardial protection, rodent models will be an important avenue of research.

Positive Heparin-Platelet Factor 4 Antibody Complex and Cardiac Surgical Outcomes

Given the large number of patients undergoing cardiac operations annually, it is important to identify populations at high risk for adverse outcomes. This observational study was conducted to determine the incidence of preoperative heparin-platelet factor 4 (HPF4) antibodies and to assess the associated risk of postoperative adverse outcomes in a nonselected cardiac surgery patient population. Between March 2002 and December 2004, 1114 (92%) of 1209 patients undergoing cardiac surgery with heparin were tested in an unselected manner for HPF4 antibodies. Main outcome measures were HPF4 antibody seropositivity and fatal and nonfatal adverse clinical outcomes after cardiac surgery. Of those screened, 60 (5.4%) of 1114 had positive HPF4 antibodies preoperatively. These patients had longer mean postoperative length of stay (14.0 days versus 9.8 days, p = 0.05), a higher incidence of prolonged (> or = 96 hours) mechanical ventilation (20.3% versus 9.2%, p = 0.02), acute limb ischemia (5.1% versus 0.9%, p = 0.03), renal complications including dialysis (20.3% versus 10.5%, p = 0.03), and gastrointestinal complications (15.3% versus 5.9%, p = 0.01). Stepwise logistic regression analysis showed positive HPF4 antibody status to be an independent predictor for adverse outcome and was associated with a higher risk for renal complications, including dialysis (adjusted odds ratio 2.2; 95% confidence interval, 1.1 to 4.3), than was diabetes. In this large patient series, the presence of HPF4 antibodies before surgical heparin administration was an independent and clinically significant risk factor for postoperative adverse events after cardiac surgery. An optimal preoperative cardiac surgery risk profile should include HPF4 antibody status.

Thoracic Epidural Analgesia after Cardiac Surgery

Thoracic Epidural Analgesia after Cardiac Surgery

Clinical Effects of Hyperglycemia in the Cardiac Surgery Population: The Portland Diabetic Project

To determine the outcome effects of hyperglycemia, and its pharmacologic reduction with continuous intravenous insulin infusions (CII) in the cardiac surgery patient population. The Portland Diabetic Project is a prospective, non-randomized, observational study of 5,510 consecutive diabetic cardiac surgery patients treated between January 1987 and November 2005. This study was the first to reveal that hyperglycemia in the first 3 postoperative days is independently predictive of mortality (P<0.0001), deep sternal wound infection (P= 0.0001), and increased length of stay (P<0.002) in diabetic cardiac surgery patients. Conversely, CII, designed to achieve predetermined target glucose levels, was shown to independently reduce the risks of death and deep sternal wound infection by 60% and 77%, respectively (P<0.001 for both). Target glucose levels <150 mg/dL and a 3-day postoperative duration of CII therapy are both important variables that determine the impact of the CII therapy on improved outcomes. Perioperative hyperglycemia in cardiac surgery patients adversely alters mortality, length of stay, and infection rates. Three days of CII eliminates the incrementally increased risks of these complications previously seen in diabetic patients.

Prolonged Intensive Care Unit Stay in Cardiac Surgery: Risk Factors and Long-Term-Survival

Risk factors have been found for prolonged intensive care unit (ICU) stay in cardiac surgery patients in only a few studies; conflicting results have been described. The focus of this study was twofold: first, to evaluate preoperative, intraoperative, and postoperative risk factors for ICU stay greater than 3 days in a cardiac surgery patient population; second, to evaluate long-term survival in cardiac surgery patients with prolonged ICU stay. Records from 2,683 cardiac surgery patients were retrospectively evaluated. Univariate and multivariate analyses for risk factors were performed for an ICU stay greater than 3 days. Thereafter, 2,563 patients were enrolled in a follow-up study for an observational time of 3 years after surgery. Mortality was dependent on renal, respiratory, and heart failure, as well as age, elevated APACHE II scores, and reexploration. Long-term survival analyses demonstrated a significantly lower survival in patients with longer ICU stay. However, the 6-month to 3-year long-term survival was comparable with survival in patients without prolonged ICU stay. Because of the increasing acuity of patients needing cardiac surgery, it is important to identify those at risk for a prolonged ICU course. It is therefore of paramount interest to implement measures throughout their entire hospital stay that would maximize organ function to improve survival and resource utilization.