Cardiac Surgical Intensive Care Unit Research Articles

Topical application of tranexamic acid reduces postoperative bleeding in open-heart surgery: myth or fact?

To determine the efficacy of topical application of Tranexamic acid in controlling postoperative bleeding in open-heart surgery. Double blind randomized control trial. Departments of Cardiac Surgery and Intensive Care of Armed Forces Institute of Cardiology and National Institute of Heart Diseases (AFIC-NIHD), Rawalpindi, Pakistan, from May to October 2011. A total of 100 consecutive adult patients fulfilling the inclusion criteria undergoing elective on-pump cardiac surgeries were randomly divided in groups 'A' and 'B'. A study solution that contained 2.5 g of Tranexamic acid in 250 ml normal saline in group-A and equal amount of normal saline (placebo) in group-B was poured in the pericardial cavity over the mediastinal tissues before sternal closure. Postoperative bleeding was measured in both groups for 24 hours in the cardiac surgical ICU. Efficacy of Topical Tranexamic Acid / Placebo was measured in terms of mean postoperative bleeding in ml. Kindly again include these lines which seem to have been omitted in the final proof. There was significant difference in the mean postoperative bleeding within 24 hours among the two groups 340.1 ± 112.4 ml in Tranexamic acid group vs. 665 ± 187.28 ml in placebo group (p < 0.001). Patients who did not have topical Tranexamic acid before chest closure had a significantly higher postoperative bleeding. Topical Tranexamic acid application is an effective and economical way for controlling non-surgical bleeding in patients undergoing cardiac surgery with cardiopulmonary bypass.

Analysis of object surface cleanness and relative factors in cardiac surgical ICU

Objective To assess the effect of existing cleaning methods applied in cardiac surgical intensive care unit, analyze potential danger and provide evidence to support clean processes in the future. Methods Each patient′s bed unit was defined as a sample and the frequency of hand-to-bed contact and the extent of patient-to-bed contact were assessed.Totals of 15 monitoring surface on each sheet were taken after sterilization within 24 hours and the Relative Light Units(RLU) of the monitoring surface values were compared with Adenosine Triphosphate (ATP) bioluminescence techniques. Results RLU values were more than 500 on bedside table surface, bed block, ECG buttons, micro pump surface, pressurized infusion ball surface and crank bed. RLU values were between 250 and 500 on nurses′ small table surface, breathing machine buttons, rulers and stethoscope surface. RLU values were less than 250 on treatment plate, footboard, pump lines and vacuum tube surface. Conclusions Hand hygiene plays a significant role in daily life. It is important to strengthen routine hand hygiene publicity and education, and monitoring and supervision can be used as an effective measure to improve the surface cleanliness of objects. Key words: ICU; Adenosine triphosphate bioluminescence techniques; Cleanliness

Near-Infrared Spectroscopy Hemoglobin Index Measurement During Fluid Challenge: A Prospective Study in Cardiac Surgery Patients

Little is known about changes in near-infrared spectroscopy-derived tissue hemoglobin index (HbI). The authors tested the hypothesis that absolute values and changes in brain hemoglobin index (HbIb) and skeletal muscle hemoglobin index (HbIm) could differ from the reference arterial hemoglobin (Hb) during fluid challenge. A prospective, monocenter observational study. A 16-bed cardiac surgical intensive care unit in a teaching university hospital. Fifty consecutive adult patients. Investigation before and after a fluid challenge. Simultaneous comparative Hb, HbIb and HbIm data points were collected from a blood-gas analyzer and the EQUANOX device (Nonin Medical Inc., Plymouth, MN). Correlations were determined by linear regression. No significant relationship was found between absolute values of Hb and HbIb before (R(2)= 0.04, p = 0.627) and after (R(2) = 0.00006, p = 0.956) fluid challenge. No significant relationship was found between absolute values of Hb and HbIm before (R(2)= 0.030, p = 0.226) and after (R(2) = 0.05, p = 0.117) the fluid challenge. No significant relationship was found between changes in Hb and HbIb (R(2)= 0.26, p = 0.263) and between changes in Hb and HbIm (R(2) = 0.001, p = 0.801) after the fluid challenge. Bland-Altman analysis showed a poor concordance between changes in Hb and HbIb, and changes in Hb and HbIm, with large limits of agreement. HbIb and HbIm cannot be used to provide continuous noninvasive estimation of Hb, and trends in HbIb and HbIm cannot be considered as noninvasive surrogates for the trend in Hb after cardiac surgery.

Evaluation of adjusted central venous blood gases versus arterial blood gases of patients in post-operative paediatric cardiac surgical intensive care unit.

Background and Aims:Central venous catheters are in situ in most of the intensive care unit (ICU) patients, which may be an alternative for determining acid-base status and can reduce complications from prolonged arterial cannulation. The aim of this study was to examine the reliability between adjusted central venous blood gas (aVBG) and arterial blood gas (ABG) samples for pH, partial pressure of carbon-di-oxide (pCO2), bicarbonate (HCO3−), base excess (BE) and lactates in paediatric cardiac surgical ICU.Methods:We applied blood gas adjustment rule, that is aVBG pH = venous blood gas (VBG) pH +0.05, aVBG CO2 = VBG pCO2 - 5 mm Hg from the prior studies. In this study, we validated this relationship with simultaneous arterial and central venous blood obtained from 30 patients with four blood sample pairs each in paediatric cardiac surgical ICU patients.Results:There was a strong correlation (R i.e., Pearson's correlation) between ABG and aVBG for pH = 0.9544, pCO2 = 0.8738, lactate = 0.9741, HCO3− = 0.9650 and BE = 0.9778. Intraclass correlation co-efficients (ICCs) for agreement improved after applying the adjustment rule to venous pH (0.7505 to 0.9454) and pCO2 (0.4354 to 0.741). Bland Altman showed bias (and limits of agreement) for pH: 0.008 (−0.04 to + 0.057), pCO2: −3.52 (–9.68 to +2.65), lactate: −0.10 (−0.51 to +0.30), HCO3−: −2.3 (–5.11 to +0.50) and BE: −0.80 (−3.09 to +1.49).Conclusion:ABG and aVBG samples showed strong correlation, acceptable mean differences and improved agreement (high ICC) after adjusting the VBG. Hence, it can be promising to use trend values of VBG instead of ABG in conjunction with a correction factor under stable haemodynamic conditions.

Methicillin-Resistant Staphylococcus Species in a cardiac surgical intensive care unit

Objective. Multi-drug resistant bacterial infections, in particular when Methicillin-Resistant Staphylococcus Aureus (MRSA) is involved, have become a relevant problem in both general and specialized intensive care units. The aim of this study was to identify the epidemiology of MRSA infections in a Cardiac Surgical Intensive Care Unit, to assess their impact on mortality and to identify predictors of MRSA infection and mortality in this population.Design and settings. A 7-year observational study in a cardiac surgery teaching center.Participants. Eight thousand, one hundred and sixty-two microbiological samples were obtained from 7,313 patients who underwent cardiac surgery in the study period.Interventions. None.Variables of interest and main results. Twenty-eight patients (0.38%) had MRSA infection. The most frequent site of MRSA isolation was from bronchoalveolar samples. Hospital mortality was 50% in patients with MRSA infection and 2% in patients without MRSA infection (p<0.001).Few preoperative independent predictors of MRSA infection and hospital mortality were found at multivariate analysis. Outcomes were found to be most influenced by perioperative variables. MRSA infection was the strongest predictor of mortality, with an odds ratio of 20.5 (95% CI 4.143-101.626).Conclusions. Methicillin-resistant Staphylococcus aureus infections following cardiac surgery still have a strong impact on the patients’ outcome. More efforts should be directed toward the development of new risk analysis models that might implement health care practices and might become precious instruments for infection prevention and control.

A standard handoff improves cardiac surgical patient transfer: operating room to intensive care unit.

Patient handoffs are high-risk times associated with sentinel events. Effective handoff processes may enhance patient safety and team member communication. This study assesses the impact of a standardized protocol for handoffs from the cardiac surgery operating room to intensive care unit (ICU). Using a prospective pre-post study design, a formalized handoff process was developed including critical handoff elements and a standardized handoff procedure, script, and checklist. Data were collected from 60 handoff observations (30 pre and 30 post), evaluating 52 unique parameters, and survey of providers on perspectives of the handoff process. Results were compared by chi-square test, two sample t-test, or nonparametric Mann-Whitney test. Statistical significance was defined as P ≤ .05. Provider's perspectives showed improved satisfaction with the standardized handoff process through improved responses in 19 of 22 survey items (P < .001). Median time until ventilator connection, ICU monitor transfer, first cardiac index, and chest radiograph were reduced after implementation. Completion of handoff process components also improved after implementation for 36 of 47 nontime parameters. A standard checklist-driven handoff process can dramatically improve key data transmission and reduce time of critical patient care steps during the high-risk period of patient handoff in a cardiac surgical ICU.

Hospital Bed Type, the Electronic Medical Record, and Safe Bed Elevation in the Intensive Care Setting.

In mechanically ventilated patients, head of bed (HOB) elevation above 30° decreases the risk of ventilator-associated pneumonia. The research team studied (a) compliance with proper HOB elevation in their cardiac surgical intensive care unit, (b) the accuracy of HOB angles recorded in the electronic medical record (EMR), and (c) the effect of bed type on (a) and (b). Nurses were polled to discover how HOB angles were measured in practice. HOB angles were compliant in 80% of observations. Compliance was more frequent in beds with side-of-bed angle indicators (SBI) than beds with under-bed angle indicators (UBI; 88% vs 77%, P = .04). Charting in the EMR was accurate in 50% of SBI bed observations but only 20% of UBI bed observations (P < .0001). Sixty-seven percent of nurses used the SBI; 27% used the UBI; 6% used estimation alone. Though compliance was suboptimal, compliance and EMR accuracy were significantly associated with bed type. Bedside indicators are underutilized.

The impact of an algorithm on the optimization of beta-blockers after cardiac surgery.

To evaluate the impact of a simple written algorithm of early postoperative beta-blocker administration on daily practices. A prospective, single center observational study. A 16-bed cardiac surgical intensive care unit in a university teaching hospital. One hundred twenty-five consecutive adult patients chronically treated with beta-blockers and scheduled for conventional cardiac surgery. Two successive 4-month phases: Phase 1 = uncontrolled early postoperative beta-blocker administration (n = 73) and phase 2 = beta-blocker administration by an institutional written algorithm using incremental doses of bisoprolol and/or esmolol (n = 52). The main endpoint was the number of patients receiving beta-blockers on the morning of postoperative day 1. Secondary endpoints were the number of patients receiving beta-blockers on the morning of postoperative day 1 and reaching the targeted therapeutic goal and the incidence of postoperative atrial fibrillation in the intensive care unit. A 79% increase in the number of patients receiving beta-blockers on the morning of postoperative day 1 (42% v 75%, p<0.001) was observed during the second phase of the study. The number of patients receiving beta-blockers on the morning of postoperative day 1 and reaching the targeted therapeutic goal was increased significantly by 127% (33% v 75%, p<0.001). The incidence of atrial fibrillation was similar between both phases of the study: 37% versus 31%, p = 0.567. A simple written algorithm markedly improved early postoperative continuation of beta-blockers in chronically treated patients undergoing conventional cardiac surgery.

Glasgow Coma Scale for outcome prediction after cardiac surgery: is it applicable?

The Glasgow Coma Scale (GCS) is used commonly for assessing patients' neurologic condition and outcome in intensive care units (ICUs); however, its reliability in cardiac surgical patients has been questioned. It has been claimed that active sedation is the cause of its unsuitability for these patients. This study aimed to compare the accuracy of GCS in cardiac surgical patients with and without active sedation to find out if the inapplicability of GCS in surgical patients is related to active sedation. This was an observational cohort study. The study was conducted in a cardiac surgical intensive care unit between January 1, 2007 and December 31, 2009. All consecutive adult cardiac surgical patients were included in this study. All types of cardiac surgical procedures performed during the study period were included without any exceptions. The study population was divided into 2 groups: sedated and non-sedated. GCS was calculated daily for the first 7 postoperative days. The authors developed a new 4-point neurologic descriptor (ND): (1) neurologically free, (2) ICU psychosis, (3) actively sedated, and (4) documented focal neurologic deficits. The accuracy of both scales (GCS and ND) at predicting ICU mortality was compared by replacing the GCS in the Sequential Organ Failure Assessment (SOFA) score with the new ND, producing a modified SOFA. GCS was not an accurate outcome predictor in non-sedated or sedated patients. The ND was superior to GCS. Correspondingly, the modified SOFA showed a significantly higher accuracy of ICU-mortality prediction than the original SOFA. Regardless of active sedation, GCS is not accurate at outcome prediction for cardiac surgical patients. The suggested ND is a simple and more accurate risk stratification variable in cardiac surgical ICUs.

Use of acid suppression medications in postoperative cardiac surgical intensive care unit patients

Background Acid suppression medications are routinely used in general intensive care unit patients for prevention of stress-related gastric mucosal bleeding. Their use has been extrapolated to include elective postoperative cardiac surgical patients. The evidence for their use in this group of patients remains inconclusive (Shin and Abah, Interact Cardiovasc Thorac Surg, 2012; 14: 622-8). Aim To audit the use of acid suppression therapy in postoperative cardiac surgical patients as inpatients and after discharge, and ascertain whether these patients experienced postoperative gastrointestinal bleeding. Method A retrospective chart review was undertaken, focusing on cases of cardiac surgical intensive care patients to investigate the use of stress ulcer prophylaxis and the occurrence of post-surgical gastrointestinal bleeding. The continuation of therapy after discharge was also audited. Results The cases of 78 patients were included in the audit: all received stress ulcer prophylaxis, and no patients experienced gastrointestinal bleeding postoperatively. In all, 27% of these patients were dispensed acid suppression therapy without a valid indication at the time of discharge. Conclusions It cannot be conclusively determined if the absence of postoperative gastrointestinal bleeding was due to the administration of prophylaxis. An alternative explanation is that stress ulcers were not likely to occur in this cohort of patients. Despite not having any indication for continuation of acid suppression, 20 patients were discharged with these medications.

Status of cardiac surgical intensive care medicine in Germany during 2013: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery.

This report summarizes the results of a voluntary survey designed to assess the current situation of cardiac surgical intensive care medicine in Germany in 2013. standardized questionnaire concerning detailed information about structural characteristics of cardiac surgical intensive care units (ICUs) was sent to all German departments performing cardiac surgery. Participation quota resp. response rate was 100%. Compared with previous surveys since 1998, the total number of available intensive care capacities for patients after cardiac surgery increased to 1,404 beds, whereas the proportion of cardiac surgical ICUs decreased to 59% with a simultaneous increase of interdisciplinary ICUs. The proportion of cardiac surgeons acting as director of an ICU declined to 36%. The physicians' teams were predominantly interdisciplinary (74%). More than half of the directors were board-certified intensivists (54%), with a peak of 81% in ICUs run by cardiac surgeons. Human resources development in the ICU showed divergent trends with an increase of physicians and a decrease of nurses. Half of all ICUs (50%) and two-thirds of cardiac surgical ICUs (65%) offer an accredited training program for intensive care medicine. The results of this survey corroborate that intensive care medicine represents a substantial and important part of cardiac surgery. However, efforts are necessary to keep this attitude alive for the future.

Red blood cell transfusion practices in two surgical intensive care units: a mixed methods assessment of barriers to evidence-based practice.

Despite evidence supporting restrictive red blood cell (RBC) transfusion thresholds and the associated clinical practice guidelines, clinical practice has been slow to change in the intensive care unit (ICU). Our aim was to identify barriers to conservative transfusion practice adherence. A mixed-methods study involving observation of prescriber (i.e., physicians, physician assistants, nurse practitioners) and bedside nurse daily bedside rounds, provider survey, and medical record abstraction was conducted in one cardiac surgical ICU (CSICU) and one surgical ICU (SICU) in an academic hospital in Baltimore, Maryland. Of 52 patient encounters observed during bedside rounds, 38 (73%) involved patients without evidence of active bleeding or cardiac ischemia. Surveys were completed by 52 (93%) of the 56 providers participating in rounds. Prescribers in the CSICU and SICU (87 and 90%, respectively) indicated the ideal pretransfusion hemoglobin (Hb) to be not more than 7 g/dL in nonbleeding and/or nonischemic patients compared to a minority of nurses (8% [p = 0.002] and 42% [p = 0.015], respectively). Prescribers and nurses in both ICUs overestimated the typical pretransfusion Hb in their units (CSICU, p < 0.001; SICU, p = 0.019). During rounds, providers infrequently explicitly discussed Hb monitoring or transfusion thresholds (33%) despite most (60%) reporting significant variation in transfusion thresholds between individual prescribers. Our study identified several provider and system barriers to evidence-based transfusion practices including knowledge differences, overly optimistic estimates of current practice, and heterogeneous transfusion practice in each ICU. Further work is necessary to develop targeted interventions to improve evidence-based RBC transfusion practices.

Delirium in the cardiac surgical ICU.

Evidence is emerging that delirium is associated with both short-term and long-term morbidity and mortality. This review highlights the epidemiology, outcomes, prevention and treatment strategies associated with delirium after cardiac surgery. The incidence of delirium after cardiac surgery is estimated to be 26-52%, with a significant percentage being hypoactive delirium. It is clear that without an appropriate structured test for delirium, the incidence of delirium will be underrecognized clinically. Delirium after cardiac surgery is associated with poor outcomes, including increased long-term mortality, increased risk of stroke, poor functional status, increased hospital readmissions and substantial cognitive dysfunction for 1 year following surgery. The effectiveness of prophylactic antipsychotics to reduce the risk of delirium is controversial, with data from recent small studies in noncardiac surgery potentially showing a benefit. Although antipsychotic medications are often used to treat delirium, the evidence that antipsychotics in cardiac surgery patients reduce duration of delirium or improve long-term outcomes following delirium is poor. Clinicians in the ICU must recognize the impact of delirium in predicting long-term outcomes for patients. Further research is needed in determining interventions that will be effective in preventing and treating delirium in cardiac surgical setting.

Tracheostomy After Cardiac Surgery: Timing of Tracheostomy as a Risk Factor for Mortality

The optimal timing for tracheostomy after cardiac surgery in patients undergoing prolonged ventilation is controversial. The aim of this study was to assess the effect of tracheostomy timing on short- and long-term mortality of these patients. Retrospective study of prospectively collected data. Cardiac surgical intensive care unit (ICU) in a tertiary-care, university-affiliated hospital. All patients undergoing tracheostomy after cardiac surgery between September 2004 and March 2013 were included. The authors compared the outcome in 2 groups of patients according to the timing of tracheostomy: Group I, early-intermediate tracheostomy (0-14 days) and Group II, late tracheostomy (≥15 days). During the study period, 6,069 patients underwent cardiac surgery; among them, 199 patients (3.26%) received a tracheostomy. There were 90 patients in Group I and 109 patients in Group II. There was no significant difference in the severity of the patients' illness between the groups. The mortality rate at 3 months, 6 months, 1 year, and 2 years was 37%, 48%, 56%, and 58% in Group I, respectively, and 58%, 70%, 74%, and 77% in Group II, respectively (p< 0.01). Early-intermediate (0-14 days) tracheostomy after cardiac surgery in patients requiring prolonged mechanical ventilation was associated with reduced mortality compared with late tracheostomy (≥15 days).

A prospective randomized comparative study between two different milrinone regimens in adult patients with pulmonary hypertension undergoing cardiac surgery

Context Milrinone is an inodilator commonly used to improve myocardial function and to decrease pulmonary hypertension. Aim The aim of this study was to compare two different regimens of milrinone administration in adult cardiac surgery patients with pulmonary hypertension. Setting and design A prospective, randomized, comparative study was conducted in Madinah Cardiac Center, Almadinah Almonourah, Saudi Arabia. Material and methods The study included 100 adult patients undergoing cardiac surgery with mean pulmonary artery pressure greater than 25 mmHg, as estimated preoperatively by Doppler echocardiography. The patients were classified randomly into two groups (n = 50): group A and group B. In group A, milrinone was started by infusion at a rate of 0.5 μg/kg/min without a loading dose at the beginning of CPB and continued postoperatively at a rate of 0.5-0.75 μg/kg/min in the cardiac surgical ICU. In group B, milrinone was given as a loading dose of 50 μg/kg over 10 min before weaning from CPB followed by infusion at a rate of 0.5-0.75 μg/kg/min postoperatively in the cardiac surgical ICU. Statistical analysis used Data were statistically described in terms of mean ΁ SD or frequencies and percentages, when appropriate, using the paired t-test. Measurements and main results Early milrinone using significantly decreased pulmonary artery pressure and pulmonary and systemic vascular resistances; it increased the right ventricular fractional area change, cardiac index, and urine output; and it decreased the serum lactate, pharmacological and mechanical supports, and ICU and hospital length of stay (P < 0.05). ConclusionThe early administration of milrinone in adult cardiac surgery was associated with better hemodynamic effect, and it decreased the need for pharmacological supports. In addition, it was associated with shorter ICU and hospital length of stay without any side effects related to milrinone.

Choosing wisely - when to mend a broken heart with ECMO?

Refractory cardiac shock in the cardiac surgical intensive care unit confers significant morbidity and mortality. Extracorporeal membrane oxygenation (ECMO) has become a common intervention for refractory cardiogenic shock when other therapies have failed. However, it is difficult to predict who will benefit from this costly, resource-intensive, but potentially life-saving technology. Here, we discuss the utility of a novel biomarker, serum butylcholinesterase, in determining survival in patients supported with ECMO following cardiac surgery.

Use of picture archiving and communication system for imaging of radiological films in cardiac surgical intensive care unit

Use of picture archiving and communication system for imaging of radiological films in cardiac surgical intensive care unit

Echocardiography-Based Hemodynamic Management in the Cardiac Surgical Intensive Care Unit

INTRAOPERATIVE TRANSESOPHAGEAL echocardiography (TEE) is well established within the cardiac operating room. Confirmation of the preoperative diagnosis is sought and additional relevant information is communicated to the surgeon. Following the procedure, the results of surgery are examined together with any complications, and information from echocardiography is used to optimize hemodynamic status. As the patient moves to the cardiac critical care unit and the TEE probe is removed, this information is no longer available.

Rapid clinical evaluation: an early warning cardiac surgical scoring system for hand-held digital devices *

The purpose of this study was to develop a new scoring system for the prompt recognition of clinical deterioration and early treatment in postoperative cardiac surgical patients. All consecutive adult patients undergoing cardiac surgery between 1st January 2007 and 31st December 2010 were included. The new score was calculated daily until intensive care unit (ICU) discharge. The score consists of 11 variables representing six different organ systems. Performance was assessed using receiver-operating characteristic (ROC) curves and calibration tests. A total of 5207 patients with a mean age of 67.2 ± 10.9 years were admitted to the ICU after cardiac surgery. The operations performed covered the whole spectrum of cardiac surgery. ICU mortality was 5.9%. The mean length of ICU stay was 4.6 ± 7.0 days. The new score had an excellent discrimination with areas under the ROC curves between 0.91 and 0.96. Calibration was also excellent reflected by observed/expected mortality ratios ranging between 1.0 and 1.26. The new score is a simple and reliable scoring system to assess organ dysfunction in cardiac intensive care patients. It is designed especially for personal digital assistants to simplify and accelerate the process of risk stratification in cardiac surgical ICUs.

Cardiac Surgical ICU Care: Eliminating “Preventable” Complications

The goal of this article is to provide an outline of the latest advances in critical care that pertain to the open heart surgery patient, pinpointing initiatives that would enable physicians and institutions to successfully implement guidelines, protocols, checklists, and initiatives that have been shown to improve patient safety.