Cardiac Surgical Intensive Care Research Articles

Correlation Analysis between Urinary Catheter Indwelling Time and Nosocomial Urinary Tract Infection.

Indwelling urinary catheter is closely associated with the occurrence of urinary tract infection (UTI). Herein, we further explored the correlation of urinary catheter indwelling time and UTI. Retrospectively, the medical data of nosocomial patients (n = 681) were collected during two quarters of April 2023 to June 2023 (the second quarter, 23.4-23.6, n = 330) and July 2023 to September 2023 (the third quarter, 23.7-23.9, n = 351). The baseline data and incidence of catheter-related UTI were analysed. The total hospitalisation days and indwelling urinary catheter days of patients in five departments were assessed, namely, coronary care unit (CCU), respiratory intensive care unit (RICU), surgical intensive care unit (SICU), neurology intensive care unit (NICU) and cardiac surgical intensive care unit (CSICU) departments. The correlation between hospitalisation days/indwelling urinary catheter days and the occurrence of UTI was evaluated by Spearman correlation analysis. In the CCU, RICU, SICU, NICU and CSICU departments, the number of patients was 463, 83, 29, 91 and 15, respectively. During 23.4-23.6, the incidence of catheter-associated UTI (CAUTI) was 0, 2.85, 6.12, 0 and 12.99 per 1000 urinary catheter days in CCU, RICU, SICU, NICU and CSICU, respectively. During 23.7-23.9, the incidence of CAUTI was 2.98, 6.13, 8.66, 0 and 0 per 1000 urinary catheter days in CCU, RICU, SICU, NICU and CSICU, respectively. Notably, hospitalisation days/indwelling urinary catheter days were positively correlated with the occurrence of CAUTI in each quarter (p < 0.05). There was a positive correlation between urinary catheter indwelling time and the occurrence of UTI.

Organization and structure of intensive care management of adult congenital heart disease in the United States

BackgroundThe growing number of adults with congenital heart disease has led to the formation of dedicated centers to provide specialized care. There is a paucity of published data on the organization, staffing, and resources available when adult congenital heart disease (ACHD) patients are hospitalized in intensive care settings. This study aims to describe the delivery of intensive care for ACHD patients in the United States and identify key differences between accredited centers or those pending accreditation and non-accredited Adult Congenital Heart Association (ACHA) centers. MethodsA web-based cross-sectional survey targeting centers with specialized ACHD programs was conducted. ResultsData were obtained from 48 of 96 centers (50%). Twenty-seven (56%) were accredited by the ACHA and 8 (17%) were pending accreditation. Surgical ACHD patients were primarily co-managed by cardiologists and intensivists (n = 11, 23%) and treated within an adult cardiac surgical intensive care unit (n = 34, 72%). Compared to non-accredited centers, ACHA accredited centers or those pending accreditation were more likely to offer daily rounds with ACHD providers (30, 86% vs. 6, 46%, p=<0.01), were more likely to support an ACHD fellowship training program (16, 46% vs. 0, 0%, p=<0.01); and were more likely to have durable mechanical support, such as ventricular assist devices (35, 100% vs. 8, 62%, p < 0.01). ConclusionThis survey reports current trends in organization, staffing, and resources available to ACHD patients requiring intensive care. ACHA accredited centers or those pending accreditation were more likely to have dedicated ACHD rounds, fellowship training programs, and access to durable mechanical support.

A machine learning-based prediction model for postoperative delirium in cardiac valve surgery using electronic health records

BackgroundPrevious models for predicting delirium after cardiac surgery remained inadequate. This study aimed to develop and validate a machine learning-based prediction model for postoperative delirium (POD) in cardiac valve surgery patients.MethodsThe electronic medical information of the cardiac surgical intensive care unit (CSICU) was extracted from a tertiary and major referral hospital in southern China over 1 year, from June 2019 to June 2020. A total of 507 patients admitted to the CSICU after cardiac valve surgery were included in this study. Seven classical machine learning algorithms (Random Forest Classifier, Logistic Regression, Support Vector Machine Classifier, K-nearest Neighbors Classifier, Gaussian Naive Bayes, Gradient Boosting Decision Tree, and Perceptron.) were used to develop delirium prediction models under full (q = 31) and selected (q = 19) feature sets, respectively.ResultThe Random Forest classifier performs exceptionally well in both feature datasets, with an Area Under the Curve (AUC) of 0.92 for the full feature dataset and an AUC of 0.86 for the selected feature dataset. Additionally, it achieves a relatively lower Expected Calibration Error (ECE) and the highest Average Precision (AP), with an AP of 0.80 for the full feature dataset and an AP of 0.73 for the selected feature dataset. To further evaluate the best-performing Random Forest classifier, SHAP (Shapley Additive Explanations) was used, and the importance matrix plot, scatter plots, and summary plots were generated.ConclusionsWe established machine learning-based prediction models to predict POD in patients undergoing cardiac valve surgery. The random forest model has the best predictive performance in prediction and can help improve the prognosis of patients with POD.

AI-Enhanced Predictive Modeling for Identifying Depression and Delirium in Cardiovascular Patients Scheduled for Cardiac Surgery.

Our study was conducted at a cardiac surgical intensive care unit. A total of 224 participants who were scheduled for elective coronary artery bypass graft surgery (CABG) were enrolled in the study. Prior to surgery, each patient underwent psychiatric evaluation to identify major depressive disorder (MDD) based on the DSM-5 criteria. An advanced data curation workflow was applied to eliminate outliers and inconsistencies and improve data quality. An explainable AI-empowered pipeline was developed, where sophisticated machine learning techniques, including the AdaBoost, random forest, and XGBoost algorithms, were trained and tested on the curated data based on a stratified cross-validation approach. Our findings identified a significant correlation between the biomarker "sRAGE" and depression (r = 0.32, p = 0.038). Among the applied models, the random forest classifier demonstrated superior accuracy in predicting depression, with notable scores in accuracy (0.62), sensitivity (0.71), specificity (0.53), and area under the curve (0.67). This study provides compelling evidence that depression in CVD patients, particularly those with elevated "sRAGE" levels, can be predicted with a 62% accuracy rate. Our AI-driven approach offers a promising way for early identification and intervention, potentially revolutionizing care strategies in this vulnerable population.

Percutaneous Dilatational Tracheostomy in a Cardiac Surgical Intensive Care Unit: A Single-Center Experience.

A significant proportion of cardiac surgery intensive care unit (CSICU) patients require long-term ventilation, necessitating tracheostomy placement. The goal of this study was to evaluate the long-term postoperative outcomes and complications associated with percutaneous dilatational tracheostomy (PDT) in CSICU patients. All patients undergoing PDT after cardiac, thoracic, or vascular operations in the CSICU between January 1, 2013 and January 1, 2021 were identified. They were evaluated for mortality, decannulation time, and complications including bleeding, infection, and need for surgical intervention. Multivariable regression models were used to identify predictors of early decannulation and the complication rate. Ninety-three patients were identified for this study (70 [75.3%] male and 23 [24.7%] female). Furthermore, 18.3% of patients had chronic obstructive pulmonary disease (COPD), 21.5% had history of stroke, 7.5% had end-stage renal disease, 33.3% had diabetes, and 59.1% were current smokers. The mean time from PDT to decannulation was 39 days. Roughly one-fifth (20.4%) of patients were on dual antiplatelet therapy and 81.7% had anticoagulation restarted 8 hours post-tracheostomy. Eight complications were noted, including 5 instances of bleeding requiring packing and 1 case of mediastinitis. There were no significant predictors of decannulation prior to discharge. Only COPD was identified as a negative predictor of decannulation at any point in time (hazard ratio, 0.28; 95% confidence interval, 0.08-0.95; p=0.04). Percutaneous tracheostomy is a safe and viable alternative to surgical tracheostomy in cardiac surgery ICU patients. Patients who undergo PDT have a relatively short duration of tracheostomy and do not have major post-procedural complications.

Improved clinical outcomes following introduction of an attending intensivist for patients admitted to the cardiac surgical intensive care unit after valvular heart surgery: a single-center experience.

Although numerous studies have documented the improved clinical outcomes of patients undergoing cardiac surgery following introduction of attending intensivist, most of these studies included heterogeneous patient populations. We aimed to investigate the impact of an attending intensivist on the clinical outcomes of patients admitted to the cardiac surgical intensive care unit (CSICU) following valvular heart surgery. Patients who underwent valvular heart surgery between January 2007 and December 2012 (control group, n=337) were propensity matched (1:1) between January 2013 and June 2017 (intensivist group, n=407). During the propensity score matching analysis, 285 patients were extracted from each group. Patients in the intensivist group underwent mechanical ventilation for a significantly shorter time than those in the control group (21.8±69.8 vs. 39.2±115.3 hours, P=0.021). More patients were extubated within 6 hours in the intensivist group than in the control group (53.7% vs. 42.8%, P=0.015). The incidence of ventilator-associated pneumonia (1.4% vs. 4.9%, P=0.031), cardiac arrest due to cardiac tamponade associated with post-cardiotomy bleeding (0.4% vs. 3.9%, P=0.002), and acute kidney injury (2.8% vs. 7.7%, P=0.011) in the intensivist group was significantly lower than that in the control group. The 30-day mortality rate of the intensivist group was significantly lower than that of the control group (2.1% vs. 6.7%, P=0.015). Critical care provided in the CSICU staffed by an attending intensivist is associated with a lower 30-day mortality rate and reduced incidence of postoperative complications.

Agreement between cardiac output estimation with a wireless, wearable pulse decomposition analysis device and continuous thermodilution in post cardiac surgery intensive care unit patients.

Pulse Decomposition Analysis (PDA) uses integration of the systolic area of a distally transmitted aortic pulse as well as arterial stiffness estimates to compute cardiac output. We sought to assess agreement of cardiac output (CO) estimation between continuous pulmonary artery catheter (PAC) guided thermodilution (CO-CCO) and a wireless, wearable noninvasive device, (Vitalstream, Caretaker Medical, Charlottesville, VA), that utilizes the Pulse Decomposition Analysis (CO-PDA) method in postoperative cardiac surgery patients in the intensive care unit. CO-CCO measurements were compared with post processed CO-PDA measurements in prospectively enrolled adult cardiac surgical intensive care unit patients. Uncalibrated CO-PDA values were compared for accuracy with CO-CCO via a Bland-Altman analysis considering repeated measurements and a concordance analysis with a 10% exclusion zone. 259.7h of monitoring data from 41 patients matching 15,583 data points were analyzed. Mean CO-CCO was 5.55L/min, while mean values for the CO-PDA were 5.73L/min (mean of differences +- SD 0.79 ± 1.11L/min; limits of agreement - 1.43 to 3.01L/min), with a percentage error of 37.5%. CO-CCO correlation with CO-PDA was moderate (0.54) and concordance was 0.83. Compared with the CO-CCO Swan-Ganz, cardiac output measurements obtained using the CO-PDA were not interchangeable when using a 30% threshold. These preliminary results were within the 45% limits for minimally invasive devices, and pending further robust trials, the CO-PDA offers a noninvasive, wireless solution to complement and extend hemodynamic monitoring within and outside the ICU.

Remimazolam: A New Ingress in Cardiac Surgical Intensive Care Unit

Remimazolam is a novel intravenous ultrashort acting benzodiazepine that has a potential for safe and effective sedative. This recent addition in anesthesia armamentarium has a great role in procedural sedation and general anesthesia which is well-approved. The main beauty of this drug is, if needed its effects can be reversed by flumazenil which allows prompt termination of sedation. Remimizolam has fast predictive effect and recovery time, high procedural success rate, and minor respiratory and hemodynamic fluctuation when used for procedural sedation and general anesthesia. Although has a great potential for sedation in patients admitted to intensive care unit (ICU), some randomized trials are necessary to prove its long-term efficacy and safety in patients admitted to ICU.

Cardiac surgery during the COVID-19 pandemic.

The COVID-19 pandemic had several specific as well as general implications on cardiac surgery. Acute respiratory distress made extracorporeal oxygenation necessary in asignificant number of patients and accordingly many patients were treated in anesthesiological and even more in cardiac surgical intensive care units, which left only alimited number of beds in the intensive care units available for elective surgery cases. Moreover, the necessary availability of intensive care beds for severely diseased COVID-19 patients in general posed afurther limit, as did the relevant number of diseased personnel. Specific emergency plans were developed for many heart surgery units, limiting the number of elective cases. Increasing waiting lists were of course stressful for numerous elective-surgery patients and the decreased number of heart operations also meant afinancial burden for many units.

Algorithm-based detection of acute kidney injury according to full KDIGO criteria including urine output following cardiac surgery: a descriptive analysis

BackgroundAutomated data analysis and processing has the potential to assist, improve and guide decision making in medical practice. However, by now it has not yet been fully integrated in a clinical setting. Herein we present the first results of applying algorithm-based detection to the diagnosis of postoperative acute kidney injury (AKI) comprising patient data from a cardiac surgical intensive care unit (ICU).MethodsFirst, we generated a well-defined study population of cardiac surgical ICU patients by implementing an application programming interface (API) to extract, clean and select relevant data from the archived digital patient management system. Health records of N = 21,045 adult patients admitted to the ICU following cardiac surgery between 2012 and 2022 were analyzed. Secondly, we developed a software functionality to detect the incidence of AKI according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria, including urine output. Incidence, severity, and temporal evolution of AKI were assessed.ResultsWith the use of our automated data analyzing model the overall incidence of postoperative AKI was 65.4% (N = 13,755). Divided by stages, AKI 2 was the most frequent maximum disease stage with 30.5% of patients (stage 1 in 17.6%, stage 3 in 17.2%). We observed considerable temporal divergence between first detections and maximum AKI stages: 51% of patients developed AKI stage 2 or 3 after a previously identified lower stage. Length of ICU stay was significantly prolonged in AKI patients (8.8 vs. 6.6 days, p < 0.001) and increased for higher AKI stages up to 10.1 days on average. In terms of AKI criteria, urine output proved to be most relevant, contributing to detection in 87.3% (N = 12,004) of cases.ConclusionThe incidence of postoperative AKI following cardiac surgery is strikingly high with 65.4% when using full KDIGO-criteria including urine output. Automated data analysis demonstrated reliable early detection of AKI with progressive deterioration of renal function in the majority of patients, therefore allowing for potential earlier therapeutic intervention for preventing or lessening disease progression, reducing the length of ICU stay, and ultimately improving overall patient outcomes.Graphical

Survey on the Updated German S3 Guideline for Intensive Care in Cardiac Surgery Patients.

The German guideline on intensive care treatment of cardiac surgical patients provides evidence-based recommendations on management and monitoring. It remains unclear if, respectively, to which degree the guidelines are implemented into the daily practice. Therefore, this study aims to characterize the implementation of guideline recommendations in German cardiac surgical intensive care units (ICUs). An internet-based online survey (42 questions, 9 topics) was sent to 158 German head physicians of cardiac surgical ICUs. To compare the effect over time, most questions were based on a previously performed survey (2013) after introduction of the last guideline update in 2008. A total of n = 65 (41.1%) questionnaires were included. Monitoring changed to increased provision of available transesophageal echocardiography specialists in 86% (2013: 72.6%), SvO2 measurement in 93.8% (2013: 55.1%), and electroencephalography in 58.5% (2013: 2.6%). The use of hydroxyethyl starch declined (9.4% vs. 2013: 38.7%), gelatin 4% presented the most administered colloid with 23.4% (2013: 17.4%). Low cardiac output syndrome was primarily treated with levosimendan (30.8%) and epinephrine (23.1%), while norepinephrine (44.6%) and dobutamine (16.9%) represented the most favored drug combination. The main way of distribution was web-based (50.9%), with increasing impact on therapy regimens (36.9% vs. 2013: 24%). Changes were found in all questioned sectors compared with the preceding survey, with persisting variability between ICUs. Recommendations of the updated guideline have increasingly entered clinical practice, with participants valuing the updated publication as clinically relevant.

Agreement between cardiac output estimation by multi-beat analysis of arterial blood pressure waveforms and continuous thermodilution in post cardiac surgery intensive care unit patients

We sought to assess agreement of cardiac output estimation between continuous pulmonary artery catheter (PAC) guided thermodilution (CO-CTD) and a novel pulse wave analysis (PWA) method that performs an analysis of multiple beats of the arterial blood pressure waveform (CO-MBA) in post-operative cardiac surgery patients. PAC obtained CO-CTD measurements were compared with CO-MBA measurements from the Argos monitor (Retia Medical; Valhalla, NY, USA), in prospectively enrolled adult cardiac surgical intensive care unit patients. Agreement was assessed via Bland-Altman analysis. Subgroup analysis was performed on data segments identified as arrhythmia, or with low CO (less than 5 L/min). 927 hours of monitoring data from 79 patients was analyzed, of which 26 had arrhythmia. Mean CO-CTD was 5.29 ± 1.14 L/min (bias ± precision), whereas mean CO-MBA was 5.36 ± 1.33 L/min, (4.95 ± 0.80 L/min and 5.04 ± 1.07 L/min in the arrhythmia subgroup). Mean of differences was 0.04 ± 1.04 L/min with an error of 38.2%. In the arrhythmia subgroup, mean of differences was 0.14 ± 0.90 L/min with an error of 35.4%. In the low CO subgroup, mean of differences was 0.26 ± 0.89 L/min with an error of 40.4%. In adult patients after cardiac surgery, including those with low cardiac output and arrhythmia CO-MBA is not interchangeable with the continuous thermodilution method via a PAC, when using a 30% error threshold.

Prediction of depression among patients with cardiovascular disease scheduled cardiac surgery using an AI-empowered pipeline

Abstract Introduction Several studies have demonstrated, that one in three patients with cardiovascular disease (CVD) suffers from depression, and depression increases the likelihood for cardiac morbidity and mortality in the CVD population by 2–3-fold, independently of traditional risk factors or gender. Purpose The aim of this work is to predict depression in patients with CVD. Methods The clinical study was conducted in the cardiac surgical intensive care unit of The Central Clinical Hospital, the Medical University of Lodz in Poland, among patients scheduled for elective coronary artery bypass graft surgery (CABG). 224 patients signed an informed consent form, met the inclusion criteria and were enrolled in the study. All the patients had chronic coronary syndromes. The inclusion criteria were: consecutive adult patients scheduled for CABG surgery or CABG surgery with cardiac valve repair or replacement (CVR). The study population was examined by a psychiatrist the day prior to the scheduled operation, a diagnosis of major depressive disorder (MDD) was established on the basis of DSM-5 criteria. A data curation pipeline was applied to automatically remove outliers and duplicated fields in the input dataset. An AI-empowered pipeline was developed to classify patients at higher risk for depression. Random downsampling with replacement was applied to deal with the increased class imbalance by taking into consideration two confound factors, namely the Mini Mental State Examination and Hemoglobin concentration &amp;lt;10mg/dl. The downsampling process was repeated K times. In each iteration, three bagging and boosting ML schemas were utilized for the classification task including the AdaBoost (adaptive boosting), Random Forests and Extreme Gradient boosting trees (XGBoost). To this end, a nested cross-validation process was applied for hyperparameter optimization and model validation, where: (i) a 3-fold cross-validation process was first applied to seek for the optimal set of hyperparameters based on the grid search approach by tuning core parameters, including the learning rate, number of estimators, and max depth, among others, and (ii) a stratified 5-fold cross-validation process was subsequently used to evaluate the performance of the best model from the previous stage by computing the classification accuracy, sensitivity, specificity, and area under the ROC curve (AUC). The performance evaluation results were averaged across the 5 folds and across the downsampling iterations. Shappley additive explanation analysis was finally applied to provide explainable risk factors for depression. Results sRAGE was significantly correlated with depression (r=0.32, p=0.038). The Random forests classifier presented the highest performance to predict depression (Accuracy: 0.71, Sensitivity: 0.71, Specificity: 0.75 and AUC: 0.74). Conclusions Depression can be predicted with 71% accuracy at patients with CVD and elevated sRAGE values. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): HORIZON2020

INFRARED THERMOGRAPHY-BASED BODY-SURFACE THERMAL INHOMOGENEITY MONITORING TO ASSESS THE SEVERITY OF HYPOPERFUSION IN CRITICALLY ILL PATIENTS.

Background: Uneven body-surface thermal distribution is a manifestation of hypoperfusion and can be quantified by infrared thermography. Our aim was to investigate whether body-surface thermal inhomogeneity could accurately evaluate the severity of patients at risk of hypoperfusion. Methods: This was a prospective cohort study in which infrared thermography images were taken from unilateral legs of critically ill patients at high risk of hypoperfusion in a cardiac surgical intensive care unit. For each patient, five body-surface thermal inhomogeneity parameters, including standard deviation (SD), kurtosis, skewness, entropy, and low-temperature area rate (LTAR), were calculated. Demographic, clinical, and thermal characteristics of deceased and living patients were compared. The risk of mortality and capillary refill time (CRT) were chosen as the primary outcome and benchmarking parameter for hypoperfusion, respectively. The area under the receiver operating characteristic curve (AUROC) was used to evaluate predictive accuracy. Results: Three hundred seventy-three patients were included, and 55 (14.7%) died during hospital stay. Of inhomogeneity parameters, SD (0.738) and LTAR (0.768) had similar AUROC to CRT (0.757) for assessing mortality risk. Besides, there was a tendency for LTAR (1%-3%-7%) and SD (0.81°C-0.88°C-0.94°C) to increase in normotensive, hypotensive, and shock patients. These thermal parameters are associated with CRT, lactate, and blood pressure. The AUROC of a combined prediction incorporating three thermal inhomogeneity parameters (SD, kurtosis, and entropy) was considerably higher at 0.866. Conclusions: Body-surface thermal inhomogeneity provided a noninvasive and accurate assessment of the severity of critically ill patients at high risk of hypoperfusion.

Bedside Chest Ultrasound in Postoperative Pediatric Cardiac Surgery Patients: Comparison With Bedside Chest Radiography

The primary objective was to study the degree of agreement between the chest ultrasound (CUS) studies and chest x-ray (CXR) studies in postoperative pediatric cardiac surgical patients regarding the diagnosis of thoracic abnormalities, and also to compare the diagnostic performance of CUS in reference to CXR for the detection of thoracic abnormalities. The secondary objective was to compare the necessity for interventions done on the basis of CUS and CXR findings in the postoperative setting. A prospective observational study. At a postoperative pediatric cardiac surgical intensive care unit in a tertiary-care center. One hundred sixty patients between the age of 2 months to 18 years undergoing elective cardiac surgery for various congenital heart diseases. After obtaining permission from the institutional ethics committee, 160 pediatric cardiac surgical patients were studied prospectively in the postoperative period. On the day of surgery (postoperative day [POD] 0), bedside CXR was done in the immediate postoperative period. After bedside CXR, CUS examination was performed and then interpreted by the principal investigator. The CXR was interpreted by the surgical team. Provisional diagnosis was made by the principal investigator and surgical team. Any intervention required was decided based on CXR or CUS findings or both. The procedure was repeated in the morning of POD 1. The degree of agreement between CUS studies and CXR studies in detecting abnormalities was evaluated by Cohen's kappa (k) statistics. The diagnostic performance of CUS was compared with that of CXR using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy. Overall, kappa analysis (k) showed substantial agreement between the findings of the CUS and CXR studies (k=0.749). The diagnostic performance of CUS, as compared with CXR, was found to have a sensitivity of 96.9%, specificity of 84.75%, PPV of 73.4%, NPV of 98.43%, and diagnostic accuracy of 88.44%. In 94 abnormal findings, the interventions were done based on CUS or CXR findings or both. Overall, there was a substantial agreement (k=0.787) between CUS and CXR regarding the necessity for interventions. The degree of agreement between CUS and CXR studies was substantial for atelectasis, interstitial edema, and diaphragmatic weakness. The degree of agreement between CUS and CXR studies was almost perfect for pneumothorax and fair for pleural effusion. More CUS studies detected intrathoracic pathologies than CXR studies. The CUS also detected abnormalities earlier than CXR and was found to be useful for the early institution of intervention therapy in patients with interstitial edema and atelectasis. It would be reasonable to conclude that CUS may be considered in some instances as an alternative to CXR.

Postoperative Hypothermia after Cardiac Surgery: A Retrospective Cohort Study of Incidence and Risk Factors

Background: Postoperative hypothermia (PH) may result in perioperative complications such as adverse cardiovascular events, coagulopathy with consecutive blood loss, and wound infection. Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) are at risk for hypothermia throughout the postoperative period. Objective: To determine the incidence and risk factors of PH in patients after open cardiac surgery. Materials and Methods: The present study was a retrospective cohort study of patients that underwent open cardiac or thoracic aortic surgery using CPB between January and December 2013. Patient characteristics, clinical data, and perioperative outcomes were abstracted and analyzed. PH was defined as body temperatures of less than 36℃ upon arrival at the cardiac surgical intensive care unit (CSICU). Postoperative outcomes including bleeding from the chest tube, postoperative inotropic support, ventilator days, CSICU length of stay, and mortality were reviewed. Results: Seven hundred sixty patients were included in the present study with 60.4% male, a mean age of 61.7 years, and 92.4% elective surgery with 96.3% first time surgery. The incidence of PH was 43.4%. Multiple logistic regression analysis demonstrated that factors associated with PH were increasing age (odds ratio 1.013 per year, 95% CI 1.002 to 1.023, p=0.020), female patients (odds ratio 1.40, 95% CI 1.03 to 1.89, p=0.032), deep hypothermia during CPB (odds ratio 2.33, 95% CI 1.26 to 4.30, p=0.007), and administration of more than 3L of intravenous fluid including crystalloids, colloids, and blood products, after separation of CPB until discharge from the operating room (OR) (odds ratio 1.52, 95% CI 1.09 to 2.12, p=0.014). Conclusion: Approximately 43.4% of the cardiac surgical patients develop hypothermia following open cardiac or thoracic aortic surgeries. Factors associated with PH were increasing age, female patients, deep hypothermia during CPB, and administration of more than 3L of intravenous fluid after separation of CPB until discharge from the OR. Keywords: Hypothermia; Postoperative; Cardiac surgical procedures; Cardiopulmonary bypass

Efficacy and safety of proton pump inhibitors versus histamine-2 receptor blockers in the cardiac surgical population: insights from the PEPTIC trial.

The comparative effectiveness and safety of proton pump inhibitors (PPIs) versus histamine-2 receptor blockers for stress ulcer prophylaxis in the cardiac surgical intensive care unit population is uncertain. Although the Proton Pump Inhibitors versus Histamine-2 Receptor Blockers for Ulcer Prophylaxis Therapy in the Intensive Care Unit (PEPTIC) trial reported a higher risk of mortality in the PPI arm with no difference in gastrointestinal bleeding, detailed information on surgical variables and clinically relevant surgical subgroups was not available. The analysis included all Canadian cardiac surgery patients enrolled in the PEPTIC trial. Data were electronically linked using unique patient identifiers to a clinical information system. Outcomes of interest included in-hospital mortality, gastrointestinal bleeding, Clostridium difficile infections, ventilator-associated conditions and length of stay. We studied 823 (50.6%) randomized to PPIs and 805 (49.4%) to histamine-2-receptor blockers. In the intention-to-treat analysis, there were no differences in hospital mortality [PPI: 4.3% vs histamine-2 receptor blockers: 4.8%, adjusted odds ratio (aOR) 0.97, 95% confidence interval (CI) 0.55-1.70], gastrointestinal bleeding (3.9% vs 4.8%, aOR 1.09, 95% CI 0.66-1.81), C. difficile infections (0.9% vs 0.1%, aOR 0.18, 95% CI 0.02-1.59), ventilator-associated conditions (1.6% vs 1.7%, aOR 0.92, 95% CI 0.85-1.00) or median length of stay (9.2 vs 9.8 days, adjusted risk ratio 1.06, 85% CI 0.99-1.13). No significant treatment differences were observed among subgroups of interest or per-protocol populations. In a secondary analysis of cardiac surgery patients enrolled in the PEPTIC trial in Canada, no differences in effectiveness or safety were observed between use of PPIs and histamine-2 receptor blockers for stress ulcer prophylaxis. anzctr.org.au identifier: ACTRN12616000481471.

Assessment of the effect of two regimens of milrinone infusion in paediatric patients with pulmonary artery hypertension undergoing corrective cardiac procedure: A prospective observational study.

The aim of the study was to compare the effect of two different regimens of milrinone in pediatric patients with pulmonary artery hypertension (PAH) undergoing corrective procedure. This randomized prospective study included 100 pediatric patients undergoing corrective cardiac surgeries. Group E: Milrinone was started as infusion 0.5 μg/kg/min without a loading dose after induction of anesthesia and continued as infusion 0.5-0.75 μg/kg/min in the pediatric cardiac surgical intensive care unit (PSICU). Group L: Milrinone was started as a loading dose 50 μg/kg over 10 min before weaning from cardiopulmonary bypass (CPB) followed by infusion 0.5-0.75 μg/kg/min in the PSICU. We compared heart rate, mean arterial blood pressure, central venous pressure, cardiac index (CI), mean pulmonary arterial pressure (MPAP), serum lactate level, urine output, vasoactive inotropic score, mechanical ventilation duration, and intensive care unit (ICU)- and hospital length of stay between the groups. There was an increase in mean arterial blood pressure, CI, and urine output in Group E compared to Group L (P < 0.05). MPAP, serum lactate level, and requirement of inotropes and vasopressors were lower in Group E compared to Group L (P < 0.05). Mechanical ventilation duration, ICU, and hospital length of stay were shorter in Group E than Group L (P < 0.05). Early use of milrinone in patients with PAH undergoing corrective cardiac surgeries improved CI and mean arterial pressure, decreased MPAP, improved urine output, decreased serum lactate level, and decreased requirement of inotropes and vasopressors after weaning from CPB compared to the milrinone bolus group.

The Outcomes of Tracheostomy in Pediatric Cardiac Surgical Patients

Abstract Objectives To describe the outcomes of postoperative tracheostomy and determine the predictors of survival. Design Prospective, observational study. Setting Cardiac surgical intensive care unit of a tertiary care hospital. Participants All pediatric patients below 10 years of age who underwent tracheostomy after cardiac surgery from January 2019 to December 2019. Different variables were compared between survivors and nonsurvivors. Intervention Tracheostomy. Results Among 1084 pediatric patients who underwent cardiac surgery during the study period, 41 (3.7%) received tracheostomy. Survival rate was 71%.Earlier, sternal closure (SC) (p = 0.04), acute kidney injury (AKI) (p = 0.001), serum C-reactive protein (CRP) (p = 0.007), duration of total parenteral nutrition (TPN) (p = 0.005) and days of feed interruption (FI) (p = 0.02), activated partial thromboplastin time (aPTT) before tracheostomy (p = 0.006), and bleeding from tracheostomy site (p = 0.02) were significantly low in the survivor group.Among the peritracheostomy variables taken at different time points, the levels of pH on tracheostomy day 1 (p = 0.03), serum lactate on tracheostomy day 2 (p = 0.01) and day 3 (p = 0.01), and random blood sugar (RBS) on tracheostomy day 3 (p = 0.04) were significantly lower in the survivor group.The arterial oxygen saturation (SaO2) on tracheostomy day 1 (p = 0.04) and the platelet count before tracheostomy (p = 0.02) were significantly higher in the survivor group. Conclusions Our study demonstrated a survival of 71% among the study cohort. Lesser duration of open sternum, lower incidence of AKI, less number of days on TPN and FI, lower posttracheostomy aPTT, bleeding, RBS, lactate, and higher pretracheostomy platelet count and posttracheostomy SaO2 were found to be the predictors of survival.

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.