Complications In Cardiac Surgery Patients Research Articles

Elevated Levels of Procalcitonin and Interleukin-6 are Linked with Postoperative Complications in Cardiac Surgery.

Cardiac surgery-associated acute kidney injury is a frequent and serious postoperative complication of cardiac surgery and is associated with an increased risk of morbidity, mortality, and length stay. In this study, we hypothesized that persistent elevation in inflammation in the first 48 h might be a powerful predictor of clinical outcome. Our aim was to elucidate the usefulness of interleukin-6 and procalcitonin postoperative levels in predicting mortality and renal complications in cardiac surgery patients. A total of 122 cardiac surgery patients were enrolled. Procalcitonin and interleukin-6 concentrations were measured on the second postoperative day, and their levels were evaluated versus a number of conditions and endpoints. Procalcitonin has a good predictive value for adverse renal outcome (p < 0.05). Interleukin-6 has a good predictive value for 30 days and overall mortality in cardiac surgery population (p < 0.05). We did not observe a significant difference in procalcitonin and interleukin-6 levels among patients with different types of surgery and different extracorporeal circulation time, but the levels of both the molecules increase significantly depending on number of transfusions received by patients (p < 0.01). We speculated that procalcitonin and interleukin-6 could be two effective biomarkers. There is a possibility of having a combined inflammatory multi-biomarker panel, with procalcitonin for predicting renal outcome and interleukin-6 for predicting mortality.

A Structured Transfer of Care Process Reduces Perioperative Complications in Cardiac Surgery Patients

A Structured Transfer of Care Process Reduces Perioperative Complications in Cardiac Surgery Patients

Postoperative pulmonary complications in cardiac surgery patients: a prospective cohort, single-centre study

Postoperative pulmonary complications in cardiac surgery patients: a prospective cohort, single-centre study

Discrepancy Between Superior Vena Cava Oxygen Saturation and Mixed Venous Oxygen Saturation Can Predict Postoperative Complications in Cardiac Surgery Patients

To determine if increases in discrepancy between ScvO2 and SvO2 (ScvO2 - SvO2 = ΔSO2) during surgery in cardiac surgery patients can predict postoperative complications. Prospective, observational study. University hospital. One hundred two patients undergoing cardiac surgery were enrolled. None. Central venous oxygen saturation (ScvO2) and mixed venous oxygen saturation (SvO2) values during surgery automatically were collected. The average value of ΔSO2 for every minute was calculated. The area under the receiver operating characteristic curve for prolonged postoperative ICU stay (≥3 days) was 0.745 for ΔSO2, which was significantly different from those of ScvO2 and SvO2 (p<0.05) (ScvO2; 0.584, SvO2; 0.598). The optimal threshold value of ΔSO2 to predict prolonged ICU stay (≥3 days) was 12% (sensitivity: 72.0%, specificity: 76.9%). Postoperative ICU duration, ventilation time, and hospital stay were significantly longer in Group D patients (intraoperative maximum ΔSO2 ≥12%) than those in Group N patients (intraoperative maximum ΔSO2<12%). As for postoperative complications, the number of patients with postoperative use of intra-aortic balloon pumping, delirium, respiratory failure requiring tracheotomy, and severe complications was significantly higher in Group D patients. Multivariate logistic regression models were used to evaluate the independent effects of perioperative variables on the risk of developing prolonged ventilation (>24 hours) and prolonged ICU stay (≥3 days). A discrepancy in intraoperative ΔSO2 was an independent risk factor for prolonged postoperative ventilation and ICU stay. The discrepancy between ScvO2 and SvO2 during cardiac surgery is an independent risk factor of postoperative complications such as prolonged ICU stay and ventilation time.

Медикаментозная профилактика гипоксии мозга у больных перед аортокоронарным шунтированием

Изучалась роль субъективных и объективных симптомов, когнитивные нарушения у больных в пред- и послеоперационном периоде. Полученные данные позволяли прогнозировать риски осложнений в послеоперационном периоде у кардиохирургических больных. Перед оперативным вмешательством на сердце необходимо тщательное предоперационное изучение состояния неврологических функций и церебральной гемодинамики для оценки степени риска периоперационных неврологических осложнений с применением методов медикаментозной профилактики.

EComment. Haemodynamic goal-directed therapy in cardiac surgery

Giglio et al. [1] are to be commended for trying to answer an important question that frequently arises in clinical practice: what are the effects of applying perioperative goal-directed therapy on postoperative complications in patients undergoing cardiac or vascular surgery? The authors concluded from this meta-analysis that perioperative goal-directed therapy prevents postoperative complications in cardiac surgery patients, but produces no benefit in vascular surgery. I entirely agree with their opinion and would like to add a brief comment related to the implementation of this strategy in cardiac surgery. Goal-directed therapy is a term used to describe the guidance of intravenous fluid and vasopressors with or without inotropic drugs by using cardiac output or related parameters to optimize the circulatory status in the immediate cardiac surgery patients. This concept was first propagated by Shoemaker et al. in 1988 [2], who found a significant reduction in mortality and hospital stay in high-risk surgical patients by avoiding a tissue oxygen debt perioperatively. The anaesthetic management consisted of early fluid loading with or without dobutamine to increase cardiac output to supranormal values. Conventional haemodynamic monitoring in cardiac surgery includes variables such as heart rate, mean arterial pressure, central venous pressure and urine output. Advanced monitoring is essential in goal- directed therapy. It comprises central venous oxygen saturation with one of the following technologies: pulmonary artery catheterization, oesophageal Doppler flowmetry, single trans-pulmonary thermodilution [3]. All these monitoring technologies can measure or calculate the cardiac output or the stoke volume and other advanced parameters with some degree of invasiveness. A previously written algorithm is usually implemented by hospital staff to early detect low cardiac output and to apply the protocol [4]. This meta-analysis demonstrates that applying goal-directed therapy by using advanced monitoring technologies reduces postoperative complications in elective cardiac surgery patients albeit without improvement in mortality. This is not in line with the 2011 ACCF/AHA guideline for coronary artery bypass graft (CABG) surgery, which recommends the placement of a pulmonary artery catheter before induction of anaesthesia only in patients with acute haemodynamic instability or cardiogenic shock. However, it is considered to be reasonable in clinically stable patients undergoing CABG after consideration of baseline patient risk, the planned surgical procedure, and the practice setting [5]. Continuing investigations into this area are warranted to better clarify the link between haemodynamic optimization and improved outcome in patients undergoing elective cardiac surgery. Conflict of interest: none declared

Haemodynamic goal-directed therapy in cardiac and vascular surgery. A systematic review and meta-analysis

In cardiovascular surgery, reduced organ perfusion and oxygen delivery contribute to increased postoperative morbidity and prolonged intensive care unit stay. Goal-directed therapy (GDT), a perioperative haemodynamic strategy aiming to increase cardiac output, is helpful in preventing postoperative complications, but studies in the context of cardiovascular surgery have produced conflicting results. The purpose of the present meta-analysis is to determine the effects of perioperative haemodynamic goal-directed therapy on mortality and morbidity in cardiac and vascular surgery. MEDLINE, EMBASE, The Cochrane Library and the DARE databases were searched until July 2011. Randomized controlled trials reporting on adult cardiac or vascular surgical patients managed with perioperative GDT or according to routine haemodynamic practice were included. Primary outcome measures were mortality and morbidity. Data synthesis was obtained by using odds ratio (OR) with 95% confidence interval (CI) by a random effects model. An OR <1 favoured GDT. Statistical heterogeneity was assessed by Q and I(2) statistics. Eleven articles (five cardiac surgery and six vascular procedures), enrolling a total sample of 1179 patients, were included in the analysis. As compared with routine haemodynamic practice, perioperative GDT did not reduce mortality in either cardiac or vascular surgery (pooled OR 0.87; 95% CI 0.37-2.02; statistical power 64%). GDT significantly reduced the number of cardiac patients with complications (OR 0.34; 95% CI 0.18-0.63; P = 0.0006), but no effect was observed in vascular patients (OR, 0.84; 95% CI 0.45-1.56; P = 0.58). Perioperative GDT prevents postoperative complications in cardiac surgery patients, while it has no effect in vascular surgery. The different characteristics and comorbidities of the population enrolled could explain these conflicting results. More trials conforming to the characteristics of low-risk-of-bias studies and enrolling a larger and well-defined population of patients are needed to better clarify the effect of GDT in the specific setting of cardiovascular surgery.

Summary of the consensus document: “Clinical practice guide for the management of low cardiac output syndrome in the postoperative period of heart surgery”

Low cardiac output syndrome (LCOS) is a potential complication in cardiac surgery patients and is associated with increased morbidity and mortality. This guide provides recommendations for the management of these patients, immediately after surgery and following admission to the Intensive Care Unit (ICU). The recommendations are grouped into different sections, addressing from the most basic concepts such as definition of the disorder to the different sections of basic and advanced monitoring, and culminating with the complex management of this syndrome. We propose an algorithm for initial management, as well as two others for ventricular failure (predominantly left or right). Most of the recommendations are based on expert consensus, due to the lack of randomized trials of adequate design and sample size in patients of this kind. The quality of evidence and strength of the recommendations were based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The guide is presented as a list of recommendations (with the level of evidence for each recommendation) for each question on the selected topic. For each question, justification of the recommendations is then provided.

Resumen del documento de consenso «Guías de práctica clínica para el manejo del síndrome de bajo gasto cardiaco en el postoperatorio de cirugía cardiaca»

Low cardiac output syndrome is a potential complication in cardiac surgery patients and is associated with increased morbidity and mortality. This guide provides recommendations for the management of these patients, immediately after surgery and following admission to the ICU. The recommendations are grouped into different sections, addressing from the most basic concepts such as definition of the disorder to the different sections of basic and advanced monitoring, and culminating with the complex management of this syndrome. We propose an algorithm for initial management, as well as two others for ventricular failure (predominantly left or right). Most of the recommendations are based on expert consensus, due to the lack of randomized trials of adequate design and sample size in patients of this kind. The quality of evidence and strength of the recommendations were based on the GRADE methodology. The guide is presented as a list of recommendations (with the level of evidence for each recommendation) for each question on the selected topic. For each question, justification of the recommendations is then provided.

Guías de práctica clínica para el manejo del síndrome de bajo gasto cardíaco en el postoperatorio de cirugía cardíaca

The low cardiac output syndrome is a potential complication in cardiac surgery patients and associated with increased morbidity and mortality. This guide is to provide recommendations for the management of these patients, immediately after surgery, admitted to the ICU. The recommendations are grouped into different sections, trying to answer from the most basic concepts such as the definition to the different sections of basic and advanced monitoring and ending with the complex management of this syndrome. We propose an algorithm for initial management, as well as two other for ventricular failure (predominantly left or right). Most of the recommendations are based on expert consensus because of the lack of randomized trials of adequate design and sample size in this group of patients. The quality of evidence and strength of the recommendations were made following the GRADE methodology. The guide is presented as a list of recommendations (and level of evidence for each recommendation) for each question on the selected topic. Then for each question, we proceed to the justification of the recommendations.

Ventilator-associated pneumonia is an important risk factor for mortality after major cardiac surgery

PurposeVentilator-associated pneumonia (VAP) is the main infectious complication in cardiac surgery patients and is associated with an important increase in morbidity and mortality. The aim of our study was to analyze the impact of VAP on mortality excluding other comorbidities and to study its etiology and the risk factors for its development. Materials and MethodsThis prospective cohort study included 1610 postoperative cardiac surgery patients' status post cardiopulmonary bypass (CPB) between July 2004 and January 2008. The primary outcome measures were the development of VAP and in-hospital mortality. ResultsVentilator-associated pneumonia was observed in 124 patients (7.7%). Patients with VAP had a longer length of hospitalization (40.7 ± 35.1 vs 16.1 ± 30.1 days, P < .0001) and greater in-hospital mortality (49.2% [61/124] vs 2.0% [30/1486], P = .0001) in comparison with patients without VAP. After performing the Cox multivariant analysis adjustment, VAP was identified as the most important independent mortality risk factor (adjusted hazard ratio [HR], 8.53; 95% confidence interval, 4.21-17.30; P = .0001). Other independent risk factors of in-hospital mortality were chronic renal failure (HR, 2.56), diabetes mellitus (HR, 1.90), CPB time (HR, 1.51), respiratory failure (HR, 2.13), acute renal failure (HR, 2.39), and mediastinal bleeding of at least 1000 mL (HR, 1.81). ConclusionsThe development of VAP after CPB is the most important independent risk factor for in-hospital mortality. Identification of effective strategies for the prevention of VAP is needed.

Prophylactic corticosteroids for cardiopulmonary bypass in adults.

High-dose prophylactic corticosteroids are often administered during cardiac surgery. Their use, however, remains controversial, as no trials are available that have been sufficiently powered to draw conclusions on their effect on major clinical outcomes. The objective of this meta-analysis was to estimate the effect of prophylactic corticosteroids in cardiac surgery on mortality, cardiac and pulmonary complications. Major medical databases (CENTRAL, MEDLINE, EMBASE, CINAHL and Web of Science) were systematically searched for randomised studies assessing the effect of corticosteroids in adult cardiac surgery. Database were searched for the full period covered, up to December 2009. No language restrictions were applied. Randomised controlled trials comparing corticosteroid treatment to either placebo treatment or no treatment in adult cardiac surgery were selected. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more end-points. The processes of searching and selection for inclusion eligibility were performed independently by two authors. Also, quality assessment and data-extraction of selected studies were independently performed by two authors. The primary endpoints were mortality, cardiac and pulmonary complications. The main effect measure was the Peto odds ratio comparing corticosteroids to no treatment/placebo. Fifty-four randomised studies, mostly of limited quality, were included. Altogether, 3615 patients were included in these studies. The pooled odds ratio for mortality was 1.12 (95% CI 0.65 to 1.92), showing no mortality reduction in patients treated with corticosteroids. The odds ratios for myocardial and pulmonary complications were 0.95, (95% CI 0.57 to 1.60) and 0.83 (95% CI 0.49 to 1.40), respectively. The use of a random effects model did not substantially influence study results. Analyses of secondary endpoints showed a reduction of atrial fibrillation and an increase in gastrointestinal bleeding in the corticosteroids group. This meta-analysis showed no beneficial effect of corticosteroid use on mortality, cardiac and pulmonary complications in cardiac surgery patients.

Predicting Hospital Mortality and Analysis of Long-Term Survival After Major Noncardiac Complications in Cardiac Surgery Patients

Predicting Hospital Mortality and Analysis of Long-Term Survival After Major Noncardiac Complications in Cardiac Surgery Patients

Predicting Hospital Mortality and Analysis of Long-Term Survival After Major Noncardiac Complications in Cardiac Surgery Patients

Predicting Hospital Mortality and Analysis of Long-Term Survival After Major Noncardiac Complications in Cardiac Surgery Patients

Predicting Hospital Mortality and Analysis of Long-Term Survival After Major Noncardiac Complications in Cardiac Surgery Patients

This study was designed to investigate the incidence of and early and midterm outcomes after major complications in cardiac surgery patients. We determined independent predictors of operative mortality to create a model for prediction of outcome. A particular focus was the fate of patients after the occurrence of these complications. Prospectively collected data of 6,641 patients (mean age, 64 ± 14 years; n = 2,499 female [38%]) undergoing cardiac surgery between January 1998 and December 2006 were retrospectively analyzed. Outcome measures were six index complications: respiratory failure, sepsis, dialysis-dependent renal failure, mediastinitis, gastrointestinal complication, and stroke; and their impact on operative mortality, hospital length of stay, and midterm survival using multivariate regression models. The discriminatory power was evaluated by calculating the area under the receiver operating characteristic curves (C statistic). A total of 1,354 complications were observed in 826 (12.4%) patients: respiratory failure (n = 634; 9.5%), sepsis (n = 202; 3%), stroke (n = 163; 2.5%), dialysis-dependent renal failure (n = 145; 2.2%), mediastinitis (n = 111; 1.7%), and gastrointestinal complication (n = 99; 1.5%). Overall operative mortality was 20% and correlated with the number of complications (single, 12.0%; n = 58 of 485; double, 25.5%; n = 52 of 204; ≥ 3, 40.1%; n = 55 of 137). Ten preoperative and five postoperative predictors of operative mortality were identified and included in the logistic model, which accurately predicted outcome (C statistic, 0.866). One-year survival was less than 50% in patients with three or more complications and a length of stay greater than 60 days. With a worsening in the risk profile of patients undergoing cardiac surgery, an increasing number of patients develop major complications leading to increased length of stay and mortality, which is correlated to the number and severity of these complications. Our predictive model based on preoperative and postoperative variables allowed us to determine with accuracy the operative mortality in critically ill patients after cardiac surgery. One-year survival after multiple complications and prolonged length of stay remains marginal.

Size of Left Cardiac Chambers Correlates with Cerebral Microembolic Load in Open Heart Operations

Background. Microemboli are a widely recognized etiological factor of cerebral complications in cardiac surgery patients. The present study was aimed to determine if size of left cardiac chambers relates to cerebral microembolic load in open heart operations. Methods. Thirty patients participated in the study. Echocardiography was performed in 2-3 days before surgery. A transcranial Doppler system was used for registering intraoperative microemboli. Results. Preoperative left atrium and left ventricular end-systolic and end-diastolic sizes significantly correlated with intraoperative microembolic load (rs = 0.48, 0.57 and 0.53, Ps < .01, resp.). The associations between left ventricular diameters and number of cerebral microemboli remained significant when cardiopulmonary bypass time was included as a covariate into the analysis. Conclusions. The present results demonstrate that increased size of left heart chambers is an influential risk factor for elevated cerebral microembolic load during open heart operations. Mini-invasive surgery and carbon dioxide insufflation into wound cavity may be considered as neuroprotective approaches in patients with high risk of cerebral microembolism.

Fatores pré-operatórios associados à injúria renal aguda após cirurgia cardíaca: estudo prospectivo

To evaluate the clinical characteristics and co-morbidities associated with development of Acute kidney injury (AKI) after cardiac surgery in patients of a predominantly tertiary care university hospital. One hundred and fifty cardiac surgery patients were prospectively studied at the Botucatu School of Medicine University Hospital - UNESP, using a protocol which started 48h before and finished 48h after surgery. AKI was defined as a 30% increase in baseline serum creatinine. Were expressed as mean +/- standard deviation or median, with a significance level of 5%. Results: There was a slight male predominance (57%); mean age of the studied population was 56+/-14 years. Sixty-five per cent of patients underwent myocardial revascularization. AKI was diagnosed in 34% of cases. Multivariate analysis showed that age over 60 years and peripheral vascular disease were significantly associated with AKI development. AKI was a common complication in cardiac surgery patients at this hospital. AKI was associated with age over 60 years and presence of peripheral vascular disease.

Radical scavenging for renal protection in cardiac surgery

Renal function impairment is a common complication in cardiac surgery patients. As cardiopulmonary bypass and cardioplegic arrest are associated with formation of free radicals, which have been shown to impair various organs including the kidneys, radical scavenging may protect renal function in patients subjected to cardiac surgery on cardiopulmonary bypass.

Postoperative complications in cardiac surgery patients with preoperative dialysis-dependent chronic renal failure

Postoperative complications in cardiac surgery patients with preoperative dialysis-dependent chronic renal failure

Renal protection by radical-scavenging in cardiac surgery patients

Objective: Perioperative renal dysfunction is a common complication in cardiac surgery patients and may be due to free radical formation induced by cardiopulmonary bypass (CPB) and cardioplegic arrest. Because anti-oxidants have been shown to attenuate free radical-induced renal dysfunction in medical patients, we hypothesized that the anti-oxidant N-acetylcysteine (NAC) protects renal function in patients subjected to cardiac surgery on CPB.