Cardiovascular Surgical Patients Research Articles

Inhaled nitric oxide and postoperative outcomes in cardiac surgery with cardiopulmonary bypass: A systematic review and meta-analysis

Cardiac surgeries under cardiopulmonary bypass (CPB) are complex procedures with high incidence of complications, morbidity and mortality. The inhaled nitric oxide (iNO) has been frequently used as an important composite of perioperative management during cardiac surgery under CPB. We conducted a meta-analysis of published randomized clinical trials (RCTs) to assess the effects of iNO on reducing postoperative complications, including the duration of postoperative mechanical ventilation, length of intensive care unit (ICU) stay, length of hospital stay, mortality, hemodynamic improvement (the composite right ventricular failure, low cardiac output syndrome, pulmonary arterial pressure, and vasoactive inotropic score) and myocardial injury biomarker (postoperative troponin I levels). Subgroup analyses were performed to assess the effect of modification and interaction. These included iNO dosage, the timing and duration of iNO therapy, different populations (children and adults), and comparators (other vasodilators and placebo or standard care). A comprehensive search for iNO and cardiac surgery was performed on online databases. Twenty-seven studies were included after removing the duplicates and irrelevant articles. The results suggested that iNO could reduce the duration of mechanical ventilation, but had no significance in the ICU stay, hospital stay, and mortality. This may be attributed to the small sample size of the most included studies and heterogeneity in timing, dosage and duration of iNO administration. Well-designed, large-scale, multicenter clinical trials are needed to further explore the effect of iNO in improving postoperative prognosis in cardiovascular surgical patients.

Perioperative Plasma in Addition to Red Blood Cell Transfusions Is Associated With Increased Venous Thromboembolism Risk Postoperatively.

Perioperative red blood cell (RBC) transfusions increase venous thromboembolic (VTE) events. Although a previous study found that plasma resuscitation after trauma was associated with increased VTE, the risk associated with additional perioperative plasma is unknown. A US claims and EHR database (TriNetX Diamond Network) was queried. We compared surgical patients who received perioperative plasma and RBC to patients who received perioperative RBC but not plasma. Subanalyses included (1) all surgeries (n = 48,580) and (2) cardiovascular surgeries (n = 38,918). Propensity score matching was performed for age at surgery, ethnicity, race, sex, overweight and obesity, type 2 diabetes, disorders of lipoprotein metabolism, essential hypertension, neoplasms, nicotine dependence, coagulopathies, sepsis, chronic kidney disease, liver disease, nonsteroidal anti-inflammatory analgesics, platelet aggregation inhibitors, anticoagulants, hemoglobin level, outpatient service utilization, and inpatient services; surgery type was included for "all surgeries" analyses. Outcomes included 30-day mortality, postoperative VTE, pulmonary embolism (PE), and disseminated intravascular coagulation (DIC). After matching the surgical cohorts, compared to only RBC, plasma + RBC was associated with higher risk of postoperative mortality (4.52% vs 3.32%, risk ratio [RR]: 1.36 [95% confidence interval, 1.24-1.49]), VTE (3.92% vs 2.70%, RR: 1.36 [1.24-1.49]), PE (1.94% vs 1.33%, RR: 1.46 [1.26-1.68]), and DIC (0.96% vs 0.35%, RR: 2.75 [2.15-3.53]). Among perioperative cardiovascular patients, adding plasma to RBC transfusion was associated with similar increased risk. When compared with perioperative RBC transfusion, adding plasma was associated with increased 30-day postoperative mortality, VTE, PE, and DIC risk among surgical and cardiovascular surgical patients. Reducing unnecessary plasma transfusion should be a focus of patient blood management to improve overall value in health care.

Cardiovascular disease classification based on a multi-classification integrated model

<abstract> <p>Cardiovascular disease (CVD) has now become the disease with the highest mortality worldwide and coronary artery disease (CAD) is the most common form of CVD. This paper makes effective use of patients' condition information to identify the risk factors of CVD and predict the disease according to these risk factors in order to guide the treatment and life of patients according to these factors, effectively reduce the probability of disease and ensure that patients can carry out timely treatment. In this paper, a novel method based on a new classifier, named multi-agent Adaboost (MA_ADA), has been proposed to diagnose CVD. The proposed method consists of four steps: pre-processing, feature extraction, feature selection and classification. In this method, feature extraction is performed by principal component analysis (PCA). Then a subset of extracted features is selected by the genetics algorithm (GA). This method also uses the novel MA_ADA classifier to diagnose CVD in patients. This method uses a dataset containing information on 303 cardiovascular surgical patients. During the experiments, a four-stage multi-classification study on the prediction of coronary heart disease was conducted. The results show that the prediction model proposed in this paper can effectively identify CVDs using different groups of risk factors, and the highest diagnosis accuracy is obtained when 45 features are used for diagnosis. The results also show that the MA_ADA algorithm could achieve an accuracy of 98.67% in diagnosis, which is at least 1% higher than the compared methods.</p> </abstract>

The short-term efficacy of high flow nasal oxygen therapy on cardiovascular surgical patients: a randomized crossover trial

BackgroundOxygen therapy after extubation in the intensive care unit (ICU) is essential in order to maintain adequate oxygenation, especially in patients who have undertaken cardiovascular surgery. A Venturi mask (VM) has been routinely used as an oxygen therapy in the ICU. Recently, however, the high flow nasal cannula (HFNC) has become available, and this device can deliver up to 60 L/min of humidified oxygen. The aim of this study is to evaluate the short-term efficacy between HFNC and VM in cardiovascular surgical patients.MethodsForty patients who underwent cardiovascular surgery were randomized to either protocol A (HFNC followed by VM) or protocol B (VM followed by HFNC). After 60-minutes of use with either device, arterial blood gas analysis was performed, and the PaO2/FiO2 ratio (PFR) was calculated. Simultaneously, physiological data (respiratory rate, heart rate, mean arterial pressure, continuous cardiac index, and mixed venous oxygen saturation) were recorded. During this procedure, FiO2 and gas flow were maintained at a fixed rate. These variables were compared by using the paired t-test, and a p value < 0.05 was considered significant. All data were expressed as mean (standard deviation).ResultsThirty-five patients (17 from protocol A and 18 from protocol B) were enrolled, and 5 patients were excluded from analysis in accordance with the exit criteria. PaO2 was significantly higher in the HFNC group than in the VM group [101.7 (25.9) vs. 91.8 (23.0), mean difference 9.87 (18.5), 95% confidence interval 3.5 to 16.2, p = 0.003]. Moreover, PFR was significantly higher in the HFNC group than in the VM group [265.9 (81.4) vs. 238.7 (68.5), p = 0.002]. Moreover, PaCO2 was significantly lower in the HFNC group than in the VM group [33.8 (3.5) vs. 34.7 (2.9), p = 0.033]. The respiratory rate was significantly lower in the HFNC group than in the VM group [18 (4) vs. 21 (4), p = 0.006], and no significant differences were seen in any of the other parameters.ConclusionsCompared to VM, HFNC ameliorated oxygenation function and decreased patients’ effort in breathing. The hemodynamic state did not differ between HFNC and VM. Therefore, HFNC can be used safely in cardiovascular surgical patients.Trial registrationThis trial was registered with the UMIN Clinical Trials Registry (ID UMIN000016572).

Risk factors for femoral-to-radial artery pressure gradient after weaning from cardiopulmonary bypass: a historical cohort study.

After weaning from cardiopulmonary bypass (CPB), the radial artery pressure is frequently lower than the central pressure as reflected by femoral pressure. This discrepancy may cause improper blood pressure management. In this study, we aimed to evaluate the risk factors related to developing a significant postbypass femoral-to-radial pressure gradient, including the incidence of complications related to femoral pressure monitoring. From January 2017 to May 2021, we studied consecutive adult cardiovascular surgical patients undergoing CPB in a historical cohort study. Patients were divided into two groups according to developing a significant femoral-to-radial pressure gradient, which was defined as a difference of ≥ 25 mm Hg for systolic pressure or ≥ 10 mm Hg for mean pressure, lasting ≥ 5 minutes for 30 minutes after CPB weaning. Factors associated with a significant pressure gradient and femoral pressure monitoring-related complications were analyzed. Among 2,019 patients, 677 (34%) showed a significant postbypass femoral-to-radial pressure gradient. Multivariable logistic regression analysis revealed the following factors related to the pressure gradient development: age (adjusted odds ratio [aOR] for an increase in 10 years, 1.09; 95% confidence interval [CI], 1.04 to 1.09; P < 0.001), body surface area (BSA) (aOR for an increase in 1 m2, 0.12; 95% CI, 0.07 to 0.21; P < 0.001), aortic cross-clamping time (aOR for an increase in 30 minutes, 1.05; 95% CI, 1.03 to 1.08; P < 0.001), and intraoperative epinephrine use (aOR, 1.55; 95% CI, 1.23 to 1.95; P < 0.001). The femoral pressure monitoring-related complications were observed in 11/2,019 (0.5%) patients. Our study showed that old age, smaller BSA, prolonged aortic cross-clamping time, and intraoperative epinephrine use were associated with developing a significant postbypass femoral-to-radial pressure gradient in cardiovascular surgery. Considering monitoring-related complications occurred very infrequently, it might be helpful to monitor both radial and femoral pressure simultaneously in patients with these risk factors for appropriate blood pressure management. Nevertheless, further studies are needed to confirm our findings because our results are limited by a retrospective design and residual confounding factors.

Mechanical Circulatory Support in Cardiovascular Surgical Patients: Single Center Practice and Experience.

In view of the role of mechanical circulatory support in patients with severe cardiac insufficiency during perioperative period, we searched the relevant articles on mechanical circulatory support at Fuwai Hospital, and analyzed the indications and complications of different mechanical circulatory support methods. Relevant studies were identified by computerized searches of PubMed, Ovid, Embase, Cochrane Library, Wanfang Data, VIP Data, Chinese BioMedical Literature & Retrieval System (SinoMed), and China National Knowledge Infrastructure (CNKI), using search words ("intra-aortic balloon counter pulsation" OR "IABP" OR "extracorporeal membrane oxygenation" OR "ECMO" OR "ventricular assist device" OR "VAD") AND ("Fuwai" OR "fuwai"). All studies concerning the application of IABP, ECMO, and VAD at Fuwai Hospital were included, exclusion criteria included: (1) studies published as review, case report or abstract; (2) animal or cell studies; (3) duplicate publications; (4) studies lacking information about outcomes of interest. A total of 36 literatures were selected for analysis. The specific mechanical circulatory support methods of ECMO and VAD retrieved from the studies were VA-ECMO and LVAD. The number of cases using IABP, ECMO, LVAD was 1968, 972, 67; and the survival rate was 80.4%, 54.9%, 56.7%, respectively. The major complications of IABP, ECMO and LVAD were hemorrhage (1.2%, 35.9% and 14.5%), infection (3.7%, 12.7% and 9.7%), acute kidney injury (9.1%, 29.6% and 6.5%), the secondary complications were limb ischemia, neurological events, cardiovascular events and thrombosis. The present study suggested that, IABP, ECMO and VAD, either alone or in combination, were effective and safe mechanical circulation support when managing cardiovascular surgical patients with severe hemodynamic instability at Fuwai Hospital.

Predictors of Rehabilitation Referral Among Cardiovascular Surgical Patients.

ObjectiveCardiovascular disease (CVD) continues to be the leading cause of mortality globally. Cardiac rehabilitation (CR) programs act by modifying the evolution of CVD and mortality; however, CR programs are under-used. The aim was to determine the profile of patients that received rehabilitation after cardiac surgery.Patients and MethodsA retrospective observational study was conducted from January 2017 to December 2017 at a single center. The study sample was chosen among patients admitted to the Intensive Care Unit of the Hospital Gregorio Marañón/Gregorio Marañón General University Hospital. Socio-demographic and clinical variables were collected.ResultsIn the present study, 336 patients underwent cardiac surgery of which 63.8% were men and 87.1% had ≥1 cardiovascular risk factors. Of the total cohort, 24.7% were operated for ischemic heart disease, 47.9% valvulopathy, 11% underwent combined surgery, 3.6% cardiac transplantation, 6.5% aneurysms, and 3.9% congenital disease. In-hospital respiratory rehabilitation was prescribed to all patients. Only 4.8% of the patients received motor rehabilitation and 13.8% were referred to CR. We found higher referral rates among patients with more cardiovascular risk factors, <65 years of age, and those undergoing coronary surgery and heart transplantation. Age, ischemic heart disease, and overweight were independent predictors of CR referral.ConclusionThe benefit of CR programs after cardiac surgery is widely described; however, the referral rate to CR remains low. It is crucial to optimize referral protocols for these patients.

Does preoperative sleep quality and distress tolerance levels in cardiovascular surgery patients affect postoperative intensive care processes?

Objective: This study was conducted to observe the effects of pre-operative sleep and distress intolerance levels on post-operative of cardiovascular surgery patients. Method: This is a descriptive study. The study population consisted of 120 patients who met the inclusion criteria and accepted to participate in this research. The data were collected by using tools such as the the demographic data form which was developed by the researchers, Pittsburgh Sleep Quality Index(PSQI), Insomnia severity Index(ISI) and distress ınterolerance index(DII), and applied through face to face interviews with the patients. The multivariate analysis of variance were used in the analysis of the data. Results: This study was 120 patients, comprising 82(68.3%) males and 38(31.7%) females. According to PSQI, 77.5% of patients have a poor sleep quality. Those with good sleep quality were found to have a lower total score (37.630)>=5 poor sleep quality than the total score (31.731) of the DII. According to the PSQI, as the sleep quality decreases, the intensive care unit (ICU) stay time is increasing (23.8%, p = 0.009). Conclusion: Compared to normal population, cardiovascular surgical patients have higher levels of poor sleep quality and distressing intolerance. We found a positive correlation between impaired sleep quality and distressed intolerance levels.

Changes In Admission Types of Cardiovascular Surgical Patients Between Covid-19 Waves

Changes In Admission Types of Cardiovascular Surgical Patients Between Covid-19 Waves

Diabetic Control Agents and Their Impact on Cardiac Surgery Patients: A Clinical Overview.

Chronic hyperglycemia is associated with poor cardiovascular surgical outcomes due to microvascular and macrovascular complications. This is a major concern as over one third of cardiovascular surgical patients have diabetes mellitus which greatly increases their risk of experiencing adverse cardiovascular events. A literature review was performed to identify articles discussing the effects of anti-diabetic medications (ADMs) on cardiovascular outcomes and surgical mortality and morbidity rates. Optimizing perioperative glucose levels remains a key factor in producing good surgical outcomes. In addition, recognizing gender differences, increasing patient satisfaction, and implementing dedicated diabetic teams all improve surgical mortality and morbidity rates in the diabetic population.

Description of Pharmacogenomic Testing Among Patients Admitted to the Intensive Care Unit After Cardiovascular Surgery.

Pharmacogenomic (PGx) testing has the potential to provide information on specific drug-metabolizing enzymes that may lead to an absence, reduction, or increase in medication effect in patients. There is a paucity of prospective studies examining PGx testing in the intensive care unit (ICU) setting. To (1) obtain a PGx panel in a sample of cardiovascular (CV) surgical patients with a planned ICU stay and identify phenotypes, and (2) identify PGx variants that may inform treatment regimens and may warrant prescribing adjustments. Descriptive, single cohort cross-sectional design. Adult (≥18 years) CV patients with an anticipated postoperative ICU stay were enrolled from a large Midwestern tertiary academic medical center. Eligible patients provided informed consent at the time of their CV clinic appointment; PGx testing was then ordered. Pharmacogenomic testing consisted of the Focused Pharmacogenomics panel which included 10 genes and 55 medications. Of the 272 patients screened, 100 (68% male) patients completed PGx testing (mean age 66.2 ± 9.6 years, mean Acute Physiology, Age and Chronic Health Evaluation III score 76.1 ± standard deviation). Pharmacogenomic results were available in the medical record within a median of 52.4 hours (interquartile range: 33.4-80.3). Pharmacogenomic testing results identified 5 CYP2C19 poor metabolizers, 26 CYP2C19 rapid metabolizers, 5 CYP2C19 ultrarapid metabolizers, 6 CYP2D6 poor metabolizers, 5 CYP2D6 poor to intermediate metabolizers, and 2 CYP2D6 rapid metabolizers identified. Overall, 98% of patients had actionable or potentially actionable PGx results, including 82% for warfarin, 65% for propafenone, 65% for tramadol, 46% for oxycodone, 45% for metoprolol, 33% for clopidogrel, 32% for proton pump inhibitors, 25% for statins, and 12% for haloperidol. A significant portion of patients had identified genetic variants that may warrant changes in medication management during and after CV-ICU stay. It remains to be seen if PGx testing leads to improvements in ICU patient outcomes.

Cardiopulmonary Bypass Duration and the Incidence of Pressure Injuries in Patients Undergoing Cardiovascular Surgery: A Retrospective Cohort Study.

The purpose of our study was to investigate the association between cardiopulmonary bypass (CPB) duration and the incidence of pressure injuries (PIs) in patients undergoing cardiovascular surgery. Retrospective chart review. Two hundred and eighty-eight patients who underwent cardiovascular surgery with CPB from January 2016 through December 2016 in a 2000-bed general hospital, which integrates medical service, education, and research and in which 300 to 350 cardiovascular surgical procedures with CPB are performed each year. We retrospectively collected data from patients' medical records. Univariate analysis and multivariate logistic regression analysis were performed to identify the independent risk factors for the development of PI. In addition, a simple linear regression model was conducted to assess the relationship between CPB duration and PI development. Of the 288 patients, 56 developed 80 PIs, with an incidence of 19.4% (95% confidence interval, 14.9%-24.3%). Multivariate logistic regression analysis showed that CPB duration, use of vasoactive drugs, and diabetes mellitus were independent risk factors for the development of PIs in patients receiving cardiovascular surgery. Median CPB duration was significantly longer in the group with PIs compared with the group without PIs (144 [range 48-415] minutes compared with 102.5 [range 16-678] minutes, P = .000). This result was consistent in the subgroup analysis of pediatric and adult patients. Pressure injuries also increased proportionally with CPB duration, from 12.2% at 60 minutes or shorter to 45.5% at more than 300 minutes (P = .002, R = 0.936). The CPB duration, use of vasoactive drugs, and presence of diabetes mellitus are independent risk factors for the development of PIs in patients undergoing cardiovascular surgery with CPB. Our findings indicated that PI incidence increased incrementally with the duration of CPB. We recommend implementing measures to prevent PIs in cardiovascular surgical patients, especially those undergoing prolonged CPB, receiving vasoactive drugs, and diagnosed with diabetes.

A Nomogram for Predicting Long Length of Stay in The Intensive Care Unit in Patients Undergoing CABG: Results From the Multicenter E-CABG Registry

Many papers evaluated predictive factors for prolonged intensive care unit (ICU) stay after cardiac surgery, but efforts in translating those models in practical clinical tools is lacking. The aim of this study was to build a new nomogram score and test its calibration and discrimination power for predicting a long length of stay in the ICU among patients undergoing coronary artery bypass graft surgery (CABG). Retrospective analysis of an international registry. Multicentric. Based on the european multicenter study on coronary artery bypass grafting (E-CABG) registry (NCT02319083), a total of 7,352 consecutive patients who underwent isolated CABG were analyzed. A "long length of stay" in the ICU was considered when equal to or more than 3 days. Predictive factors were analyzed through a multivariate logistic regression model that was used for the nomogram. Long length of ICU stay was observed in 2,665 patients (36.2%). Ten independent variables were included in the final regression model: the SYNTAX score class critical preoperative state, left ventricular ejection fraction class, angina at rest, poor mobility, recent potent antiplatelet use, estimated glomerular filtration rate class, body mass index, sex, and age. Based on this 10-risk factors logistic regression model, a nomogram has been designed. The authors defined a nomogram model that can provide an individual prediction of long length of ICU stay in cardiovascular surgical patients undergoing CABG. This type of model would allow an early recognition of high-risk patients who might receive different preoperative and postoperative treatments to improve outcomes.

Chinese Society of Anesthesiology Expert Consensus on Anesthetic Management of Cardiac Surgical Patients With Suspected or Confirmed Coronavirus Disease 2019

The outbreak of a new coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) in China in December 2019 has brought serious challenges to disease prevention and public health. Patients with severe coronavirus disease 2019 (COVID-19) who undergo cardiovascular surgery necessitate extremely high demands from anesthesia personnel, and face high risks of mortality and morbidity. Based on the current understanding of COVID-19 and the clinical characteristics of cardiovascular surgical patients, the authors provide anesthesia management guidelines for cardiovascular surgery along with the prevention and control of COVID-19.

Down Syndrome Reduces the Sedative Effect of Midazolam in Pediatric Cardiovascular Surgical Patients

Down syndrome (DS) is frequently comorbid with congenital heart disease and has recently been shown to reduce the sedative effect of benzodiazepine (BDZ)-class anesthesia but this effect in a clinical setting has not been studied. Therefore, this study compared midazolam sedation after heart surgery in DS and normal children. We retrospectively reviewed patient records in our pediatric intensive care unit (PICU) of pediatric cardiovascular operations between March 2015 and March 2018. We selected five days of continuous post-operative data just after termination of muscle relaxants. Midazolam sedation was estimated by Bayesian inference for generalized linear mixed models. We enrolled 104 patients (average age 26 weeks) of which 16 (15%) had DS. DS patients had a high probability of receiving a higher midazolam dosage and dexmedetomidine dosage over the study period (probability = 0.99, probability = 0.97) while depth of sedation was not different in DS patients (probability = 0.35). Multi regression modeling included severity scores and demographic data showed DS decreases midazolam sedation compared with controls (posterior OR = 1.32, 95% CrI = 1.01–1.75). In conclusion, midazolam dosages should be carefully adjusted as DS significantly decreases midazolam sedative effect in pediatric heart surgery patients.

Preoperative elevated E/e\u2019 (\u2265\u200915) with preserved ejection fraction is associated with the development of postoperative heart failure in intermediate-risk non-cardiac surgical patients

PurposeLeft ventricular diastolic dysfunction is an independent risk factor for adverse cardiovascular morbidities and mortalities in cardiovascular and high-risk surgical patients. However, there were only a few investigations among intermediate-risk surgical patients. This study aimed to investigate postoperative heart failure (HF) in intermediate-risk surgical patients who had preoperative diastolic dysfunction with preserved ejection fraction (EF).MethodsConsecutive patients underwent intermediate-risk surgery between January 2016 and December 2018 were retrospectively evaluated. Patients with preserved EF were divided into three groups using one of the parameters of diastolic function: the ratio of early diastolic filling velocity to the peak diastolic velocity of mitral medial annulus (E/e’) ≥ 15, E/e’ between 8 and 15, and E/e’ < 8. Postoperative HF was defined as clinical symptoms and radiological evidence and low SpO2 less than 93%. The primary outcome was the incidence of postoperative HF and its relation to preoperative E/e’. Chi-squared test, unpaired t test with Welch’s correction, and multivariate logistic regression were used for analysis.ResultsIn total, 965 patients were included in the final analysis. Postoperative HF developed in 36/965 (3.7%) patients with preserved EF. The incidence of postoperative HF was stratified according to the E/e’, and the rates of HF occurrence in patients with E/e’ < 8, 8–15, and ≥ 15 were 1.8%, 2.7%, and 15%, respectively (P < 0.01).ConclusionPreoperative elevated E/e’ (≥ 15) was associated with the development of postoperative HF in intermediate-risk surgical patients with preserved EF.

Association of Wearable Activity Monitors With Post-Operative Activity Level Among Cardiovascular Surgical Patients

Association of Wearable Activity Monitors With Post-Operative Activity Level Among Cardiovascular Surgical Patients

Three-factor prothrombin complex concentrates for refractory bleeding after cardiovascular surgery within an algorithmic approach to haemostasis.

Prothrombin complex concentrates (PCC) are increasingly administered off-label in the United States to treat bleeding in cardiovascular surgical patients and carry the potential risk for acquired thromboembolic side-effects after surgery. Therefore, we hypothesized that the use of low-dose 3-factor (3F) PCC (20-30IU/kg), as part of a transfusion algorithm, reduces bleeding without increasing postoperative thrombotic/thromboembolic complications. After IRB approval, we retrospectively analysed 114 consecutive, complex cardiovascular surgical patients (age>18years), between February 2014 and June 2015, that received low-dose 3F-PCC (Profilnine® ), of which seven patients met established exclusion criteria. PCC was dosed according to an institutional perioperative algorithm. Allogeneic transfusions were recorded before and after PCC administration (n=107). The incidence of postoperative thromboembolic events was determined within 30days of surgery, and Factor II levels were measured in a subset of patients (n=20) as a quality control measure to avoid excessive PCC dosing. Total allogeneic blood product transfusion reached a mean of 12·4±9·9 units before PCC and 5·0±6·3 units after PCC administration (P<0·001). The mean PCC dose was 15·8±7·1IU/kg. Four patients (3·8%) each experienced an ischaemic stroke on postoperative day 1, 2, 4 and 27. Seven patients (6·5%) had acquired venous thromboembolic disease within 10 days of surgery. Median factor II level after transfusion algorithm adherence and PCC administration was 87%. 3F-PCC use for refractory bleeding after cardiovascular surgery resulted in reduced transfusion of allogeneic blood and blood products. Adherence to this algorithmic approach was associated with an acceptable incidence of postoperative thrombotic/thromboembolic complications.

Cardiopulmonary Bypass Time Predicts Early Postoperative Enterobacteriaceae Bloodstream Infection

A bloodstream infection in patients undergoing cardiovascular operations is crucial because it can result in significantly worse outcomes. However, microbiological patterns have rarely been investigated in these patients. We retrospectively reviewed the data of 1,041 adult patients who underwent cardiovascular operations using cardiopulmonary bypass from January 2013 to December 2017 at the National Cheng Kung University Hospital, Tainan, Taiwan. The microbiological pattern and associated variables were analyzed in patients with early postoperative primary bloodstream infection. Primary bloodstream infection developed in 28 patients (2.7%) within 7 days after cardiovascular operations using cardiopulmonary bypass. In patients with early primary bloodstream infection, 36 microorganisms were isolated, and a gram-negative bacillus was identified to be the predominant pathogen (28 of 36 [77.8%]). The most common microorganisms comprised the Enterobacter (n= 8) and Acinetobacter (n= 7) species, and 16 of the 28 gram-negative bacilli belonged to the Enterobacteriaceae family. Compared with those without postoperative bloodstream infection, patients with Enterobacteriaceae family-related early postoperative bloodstream infections had a significantly longer cardiopulmonary bypass time and also worse early and late survival rates. Most patients with early primary bloodstream infection after cardiovascular operations using cardiopulmonary bypass were infected with gram-negative bacilli, and the Enterobacteriaceae family was the most common microorganism observed. Endogenous bacterial translocation after prolonged cardiopulmonary bypass is a possible mechanism of Enterobacteriaceae family-related early primary bloodstream infection in these patients. Prophylactic use of an antibiotic regimen with broader gram-negative bacteria coverage in cardiovascular surgical patients with prolonged cardiopulmonary bypass should be considered.

MRSA colonization and infection rates among cardiovascular thoracic surgical patients

Background: Infection due to Staphylococcus aureus is a common complication of cardiovascular and thoracic surgery (CVTS). Infections due to methicillin-resistant S aureus (MRSA), results in even greater morbidity and mortality than infections from methicillin-sensitive S aureus (MSSA) strains. To prevent such consequences, implementation of MRSA screening to identify MRSA carriers, followed by decolonization protocol is becoming a norm for cardiothoracic centres. Methods & Materials: We retrospectively studied the clinical and microbiological data of all cardiovascular thoracic surgical (CVTS) patients who were admitted for their procedure at Faculty of Medicine, University Teknologi MARA, Malaysia. The study period was five years, starting from November 2012 to October 2017. Inclusion criteria for the cases were screened for MRSA colonization upon admission, underwent appropriate decolonization procedure following detection of MRSA and remained with cardiothoracic follow-up post-surgery, for at least a month after the surgical procedure. Decolonization protocol practised by our infection control unit was the application of mupirocin ointment for nasal colonization and chlorhexidine bath for axilla and groin colonization. Results: Three hundred and fifty-eight CVTS patients were admitted for procedures during the five-year study. We identified six MRSA carriers, pre-operatively colonized at either their nose, groin or axilla. This gives an overall MRSA carrier rate of 1.7%. The majority of them, which were four patients or 67% of MRSA carriers, were colonized at their nasal sites. One patient was colonized at groin and the other one at axilla. All carriers had single-site colonization, none with multiple-sites colonization. They all successfully underwent decolonizing procedure as per protocol. Consecutively, none of the carriers developed surgical site infection (SSI) due to MRSA within a month following surgery, giving an MRSA infection rate of 0%. Conclusion: Our centre's MRSA carrier rate of less than 2% among the CVTS patients is generally lower than that reported from other similar cohorts of patients from various institutions. This, coupled with an effective decolonization protocol, appeared to have contributed to the absence of SSI due to MRSA in these patients for the past five years. The application of this ‘MRSA search and destroy’ strategy contributes not only to life-saving, but also financial saving in the long run.