Cardiosurgery Patients Research Articles

Risk factors for surgical site infection following cardiac surgery in a region endemic for multidrug resistant organisms

ObjectivesTo identify risk factors for surgical site infections following cardiosurgery in an area endemic for multidrug resistant organisms. DesignSingle-center, historical cohort study including patients who underwent cardiosurgery during a 6-year period (2014–2020). SettingJoint Commission International accredited, multiorgan transplant center in Palermo, Italy. Main outcome measuresSurgical site infection was the main outcome. ResultsOn a total of 3609 cardiosurgery patients, 184 developed surgical site infection (5.1 %). Intestinal colonization with multidrug resistant organisms was more frequent in patients with surgical site infections (69.6 % vs. 33.3 %; p < 0.001). About half of surgical site infections were caused by Gram-negative bacteria (n = 97; 52.7 %). Fifty surgical site infections were caused by multidrug resistant organisms (27.1 %), with extended-spectrum Beta-lactamase-producing Enterobacterales (n = 16; 8.7 %) and carbapenem-resistant Enterobacterales (n = 26; 14.1 %) being the predominant resistance problem. However, in only 24 of surgical site infections caused by multidrug resistant organisms (48 %), mostly carbapenem-resistant Enterobacterales (n = 22), a pathogen match between the rectal surveillance culture and surgical site infections clinical culture was demonstrated. Nevertheless, multivariate logistic regression analysis identified a rectal swab culture positive for multidrug resistant organisms as an independent risk factor for SSI (odds ratio 3.95, 95 % confidence interval 2.79–5.60). Other independent risk factors were female sex, chronic dialysis, diabetes mellitus, previous cardiosurgery, previous myocardial infarction, being overweight/obese, and longer intubation time. ConclusionIn an area endemic for carbapenem-resistant Enterobacterales, intestinal colonization with multidrug resistant organisms was recognized as independent risk factor for surgical site infections. Implications for clinical practiceNo causal relationship between colonization with resistant pathogens and subsequent infection could be demonstrated. However, from a broader epidemiological perspective, having a positive multidrug resistant organisms colonization status appeared a risk factor for surgical site infections. Therefore, strict infection control measures to prevent cross-transmission remain pivotal (e.g., nasal decolonization, hand hygiene, and skin antisepsis).

Effectiveness of early respiratory and inhalation therapy on the respiratory status of cardiosurgery patients with COPD exacerbation

Effectiveness of early respiratory and inhalation therapy on the respiratory status of cardiosurgery patients with COPD exacerbation

Early extubation protocol post-coronary artery bypass graft &amp; open heart surgery

Fast-tracking in cardiac care refers to the complex intervention including early extubation, care during anesthesia, mobilization and hospital discharge to reduce perioperative morbidity, costs, and length of stay in the intensive care unit and the hospital. This review was designed to evaluate early extubation protocols, the differences in early and late extubation, the safety and efficacy of early extubation among the patients in surgical intensive care after coronary artery bypass graft (CABG) surgery. The analyzed studies showed many significant differences in the mortality and postoperative complications of time-directed extubation practices and low dose-based general anesthesia in patients with low to moderate risk undergoing early extubation (fast-track) and the conventional care methods. Different fast-track interventions could diminish extubation time, costs, and the length of hospital stay. However, several factors including patient’s stay in the intensive therapy ward vs general ward, patient selection, skills and experience of the staff, and fast-track anesthesia methods could be considered to perform safe fast-tracking in patients undergoing cardiac surgery. On the other hand, to achieve this safety for high-risk cardiosurgery patients multidisciplinary coordination is needed.

Structural changes of brain vessels in cardiosurgery patients with postoperative stroke

Hypoxic-ischemic lesions of the brain of cardiac surgery patients as a leading factor in stroke have been studied. The importance of prolonged thrombosis, embolism, which exacerbate the general degenerative changes in the central nervous system is recognized.&#x0D; The aim of the research – to study the morphological changes of the vessels of the brain of cardiac surgery patients with postoperative stroke on the background of hypoxic-ischemic complications.&#x0D; Materials and methods. Pieces of cerebral vessels were subjected to microscopic examination. Histological sections were stained according to Van Gieson.&#x0D; Results and their discussion. The study of the structure of the vessels of the brain of persons who were in the group intact to neurological pathology control, showed the presence of anatomical and functional changes that are fully consistent with the sex-age norms of postnatal human ontogenesis.&#x0D; The drugs of the clinical observation group contained signs of pathological changes characteristic of hypoxic-ischemic disorders. It is obvious that their appearance and intensification contributed to the development of ischemic stroke. Structural and functional changes mainly concerned the vascular walls, their layers, paravasal spaces, the blood system as a liquid phase, in fact. Endothelial layer with signs of desquamation. Endothelial cells are characterized by signs of hyperchromia of the nuclei, the shift of the latter in the direction of one of the poles of the cells, the appearance of heterochromatin. Contacts between cells are weakened, defects are visible in the surface layer. Perovascular edema, which is formed in the case of increased permeability, leads to a certain isolation of individual vessels from the surrounding tissues, followed by the development of hypoxia. Defects of the wall layers lead to the activation of the migratory properties of platelets, encourage the appearance of megakaryocytes, erythrocyte thrombi, which are in close contact with the endothelial layer of blood vessels. On histological specimens, brick-red blood clots abundantly cover the damaged inner layer of vascular walls, sometimes completely filling their openings. Over time, defects in the layers of the walls are accompanied by thrombosis, inflammation, edema.&#x0D; Conclusions. Hypoxic-ischemic brain lesions in cardiac surgery patients play a leading role in stroke. Priority is given to hypoxia, which contributes to ischemia, trophic disorders, atrophy, necrosis, necrobiotic changes. The latter are the organic basis of pathogenetic patterns of focal cerebral infarction (with progressive destruction of brain cells, its vessels, the development of prolonged thrombosis, embolism, increased general degenerative changes in the central nervous system)

Leading morphological dominants of stroke as a basis for the morbid psychotype in cardiosurgical patients with postoperative hypoxic-ischemic injuries

Leading morphological dominants of stroke as a basis for the morbid psychotype in cardiosurgical patients with postoperative hypoxic-ischemic injuries

Can the Vulnerable Elders-13 Survey (VES-13) scale replace the EuroSCORE scale in predicting complications in patients over 60 years of age undergoing cardiac surgery?

IntroductionBefore the operation each cardiosurgery geriatric patient is assessed by the Vulnerable Elders-13 Survey (VES-13) and European System for Cardiac Operative Risk Evaluation (EuroSCORE) scales.AimTo compare the applicability of the VES-13 and EuroSCORE scale in the assessment of postoperative risk among operated patients > 60 years old qualified most often for coronary artery bypass grafting.Material and methodsVES-13 is a questionnaire containing 13 questions, including patient’s age and a health self-assessment. The EuroSCORE includes age, sex and cardiological assessment and vascular changes, respiratory diseases, neurological and nephrological disorders. In both scales the risk of death is high when the patient has > 6 points. The study included 100 patients ≥ 60 (60.83 ±6.18) years old who were divided into subgroups with < 6 points and ≥ 6 points.ResultsThe number of VES-13 points = 3.06 ±2.25, EuroSCORE = 5.50 ±3.19. In patients > 75 years old VES score was 4.32 ±2.6 vs. 2.707 ±2.02 and EuroSCORE 8.09 ±3.02 vs. 4.77 ±2.83. The most frequent postoperative complication was atrial fibrillation. The most frequent complications were the following: death (5%), delirium (3.64%), bleeding (3.54%), stroke (3.54%), renal failure (3.32%), pacemaker implantation (3.28%), difficult healing of the wound (2.64%), intestinal ischemia (2.56%). The correlation between the VES-13 and EuroSCORE was moderate.ConclusionsIn cardiosurgery patients who obtained before the operation ≥ 6 points on the VES-13 or EuroSCORE the risk of postoperative complications is high. VES-13 and EuroSCORE cannot be used interchangeably because the correlation is at a medium level.

Анатомическое обоснование выбора места пункции и введения центрального венозного катетера у кардиохирургических пациентов

Анатомическое обоснование выбора места пункции и введения центрального венозного катетера у кардиохирургических пациентов

Chlorhexidine-Based Oral Care and Ventilator-Associated Pneumonia

Ventilator-associatedpneumonia (VAP) is amongthemost frequently occurring infections among critically ill patients, and its development is associatedwith poor patient prognosis. As such, VAP has been an important topic of clinical research in intensivecaremedicine,pulmonology, infectiousdiseases, and clinicalmicrobiology. Yet, aftermore than 30 years of clinical studies on diagnosis, treatment, and prevention, a myriad of uncertainties remain. Among the many challenges that confront our efforts to effectively treat VAP is that there is currently no reliable gold standard fordiagnosis.Diagnosis is essentiallybasedonacombinationof clinical symptoms,microbiological test results, and radiological interpretations. These criteria, even in combination, are highly subjective and have suboptimal specificity. Subjective diagnosis of VAP hampers unbiased evaluation of the efficacy of preventive measures in unblindedstudies and increases the riskof assessmentbiaswhen VAP rates are used as a quality metric. Poor specificity of the diagnosis leads to unnecessary antibiotic use and its associatedharms.Ofnote, thediagnostic approachwithbetter specificity, ie, bronchoscopic procedures combinedwith quantitative microbiological cultures, is hardly used because it is invasive and expensive. The other sizable challenge in VAP management is that the evidence for preventive strategies is less robust than it appears on first examination. For instance, most guidelines recommend semirecumbent patient positioning. However, this recommendation is based on a prematurely interrupted controlled trial of 87 patients, in which the beneficial effects of the semirecumbent position could not be separated from the detrimental effects of continuous gastric feeding in control patients randomized to a complete supine position.1 The only other randomized trial of this intervention in intensive care unit (ICU) patients questioned the feasibility of the 45° position and failed to demonstrate a benefit from the 30° position.2 Some guidelines also recommend topical antimicrobial prophylaxis, such as selective decontamination of the digestive tract andselectiveoropharyngealdecontamination.These treatments have been associatedwith statistically significant reductions in the incidence of VAP inmany randomized trials and with improved patient outcome in settings with low levels of antibiotic resistance.3 Yet, absence of evidence of benefit in settings with higher levels of antibiotic resistance and fear of selection for antibiotic resistancehavepreventedwidespread adoption of these measures. There is greater consensus for theuseof chlorhexidinegluconate oropharyngeal care as a strategy for VAP prevention, in part because of its perceived safety, both for individual patients andwith respect to avoiding antibiotic resistance.However, althoughchlorhexidine iswidelyusedandhasbeen identified as an important process of high-quality care by the Institute forHealthcare Improvement, theevidence that it prevents VAP or improves patient outcome isweaker than for selective decontamination. In this issue of JAMA Internal Medicine, Klompas and coworkers4 question the effectiveness and safetyof chlorhexidineoral care inpatients receivingmechanicalventilation inthe ICU. This conclusion is based on the results of a new metaanalysis of 16 randomized trials evaluating this intervention in 1868 cardiosurgical patients (3 studies) and 1762 intensive care patients (13 studies).This stratifiedmeta-analysis suggests that chlorhexidine oral care is effective in cardiosurgery patients, whogenerallyundergo intubationandventilationonly forshort periodsaftersurgery,butnotamongintensivecarepatients,who generally undergo intubation for a longer period. In the intensive care patients, the authors found only statistically nonsignificanteffectsonthepreventionofVAP; inopen-label trials the summary risk ratio (RR) was 0.61 (95% CI, 0.35-1.04) and in double-blind trials the RR was 0.88 (95% CI, 0.66-1.16). Furthermore, there was a statistically nonsignificant result of increasedmortalityamong intensivecarepatients randomized to receivechlorhexidineoralcare(RR,1.13[95%CI,0.99-1.29]),with some evidence of a dose-response effect. Related article page 751 Chlorhexidine Oral Care andMechanical Ventilation Original Investigation Research

Адаптивный феномен ишемического посткондиционирования сердца. Перспективы клинического применения

Analysis of experimental data indicates that aging, metabolic syndrome may be serious obstacle against realization of cardioprotective effect of postconditioning. The moderate hypercholesterolemia, postinfarction cardiosclerosis and cardiac hypertrophy do not abolish protective effect of postconditioning in experimental animals. The issue whether diabetes mellitus and arterial hypertension affect an efficacy of postconditioning is a subject of discussion. Clinical investigations testify on cardioprotective impact of postconditioning in patients with acute myocardial infarction and cardiosurgery patients. At the same time, it is remained unclear when after coronary artery occlusion postconditioning exhibits cardioprotective effect. It is remained unknown how do affect aging, diabetes mellitus, metabolic syndrome, arterial hypertension, myocardial hypertrophy, cardiac postinfarction remodeling and efficacy postconditioning in clinical praxis. It is required a further clinical investigations turning the development pharmacological approaches to prophylaxis of reperfusion injury of the heart.

XRFA-SR studies of the distribution of macro and microelements in myocardium and vessel samples from cardiosurgery patients

Studies of the disbalance of chemical elements in myocardium of patients with an ischemic heart disease and aortic aneurysm are very important in order to reveal the predictors of irreversible changes in damaged tissues. X-Ray fluorescence analysis using synchrotron radiation (XRFA-SR) allows us to perform direct nondestructive many-element analysis of samples with a small mass. Samples of this kind fragments of tissues taken during surgery (biopsy), whose mass is up to 1 mg. Normalization of the peak areas of elements to the peak area of incoherent scattering allowed us to take into account the nonidentity of the geometries of samples and standards at surface densities of the radiator from 153 to 45 mg/cm2 for excitation energies of 17 keV. The scattering characteristics of the matrices of the biological references used and the muscular tissue samples were evaluated from the ratios of the peak areas of coherent and incoherent scatterings and the changes in these ratios induced by varying the excitation quantum energy from 16 keV to 22 keV. These methodological approaches were used for determining the contents of chemical elements in human myocardium and vessel tissues in studying pathogenesis of different cardiovascular diseases and the potential of cardiosurgical correction in patients with aortic aneurysm and dissection.

Routine clinical laboratory tests correspond to increased serum levels of 3-hydroxy fatty acids, markers of endotoxins, in cardiosurgery patients

Endotoxemia developing during cardiosurgery as elevated endotoxin concentrations in patient's serum may prevail over 24 h after operation. A major reason is thought to be increased gut permeability resulting in endotoxin and bacterial leakage. In this study we aimed to measure endotoxin levels on samples obtained during and after cardiovascular procedures and compare them with clinical observations and laboratory test results. 3-Hydroxy fatty acids (3-OH FAs) of 10-18 carbon chain length, chemical markers of endotoxin (lipopolysaccharide), were determined in patient sera by gas chromatography-mass spectrometry-based analysis. RESULTS were compared with routine laboratory tests: blood morphology, urine, ALT, AST, bilirubin, kidney parameters, clotting parameters, and gasometry. Of a total of 16 patients, 5 patients (group I) showed increased serum 3-OH FA levels and 11 patients (group II) did not show any change in 3-OH FA levels 24 h after operation. All group I patients revealed leukocytosis, two developed post-operative anemia. Significantly different changes were observed: the initial, pre-operative 3-OH FA levels were similar for both groups, while group I patients showed increased levels of all the studied 3-OH FAs during the operation (p</=0.05), and 3-OH C14 and 3-OH C16 remained elevated 24 h after the operation. Cardiosurgery may strongly promote gut endotoxin translocation to the blood in some patients. Prolonged leukocytosis, deep anemia, and increased liver dysfunction markers may indicate the need for observation of possible endotoxemia development. It is recommended to monitor the endotoxin level and/or endotoxemia markers in cardiosurgery patients.

Comparative Analysis of Changes in the Rheological Properties of Blood at Stages of Treatment of Cardiosurgery Patients

It is shown that a heat operation under the conditions of artificial circulation exerts a marked influence on the rheological properties of blood and has a characteristic hemorheological picture during and after the operation. In this case, the value of the flow limit τ0 is a hemorheological criterion reflecting the adequacy of the surgical correction of a cardiovascular pathology and the efficiency of the intensive therapy measures, which should be taken into account when such patients are treated.

Quantitative measurement of heat shock proteins in cardiosurgery patients following cardioplegic arrest

Quantitative measurement of heat shock proteins in cardiosurgery patients following cardioplegic arrest