Requirement For Inotropic Support Research Articles

Relationship between gender and in-hospital morbidity and mortality after coronary artery bypass grafting surgery in an Iranian population.

Background:Many previous studies have investigated the influence of gender on coronary artery bypass grafting surgery (CABG) outcomes. Despite the great volume of reports on this issue, it is still not clear whether it is the gender of the patient or pre-existing comorbid conditions that is the best predictor for the different outcomes seen between men and women. Multiple studies have shown that women are at higher risk of postoperative complications than men, particularly in the perioperative period.Objectives:The goal of this study was to determine whether sex differences exist in preoperative variables between men and women, and to evaluate the effect of gender on short-term mortality and morbidity after CABG in an Iranian population.Patients and Methods:Data were collected prospectively from 690 consecutive patients (495 men and 195 women) who underwent isolated CABG. Preoperative, intraoperative, and postoperative variables, major complications and death were compared between the male and female patients until hospital discharge using multivariate analysis.Results:Women were older (P = 0.020), had more diabetes (P = 0.0001), more obesity (P = 0.010), a higher New York Heart Association functional class (P = 0.030), and there was less use of arterial grafts (P = 0.016). Men had more tobacco smokers (P = 0.0001) and lower preoperative ejection fractions (EF) (P = 0.030). After surgery, women had a higher incidence of respiratory complications (P = 0.003), higher creatine kinase (CK) – MB levels (P = 0.0001), and higher inotropic support requirements (P = 0.030). They also had a higher incidence of decreased postoperative EF versus preoperative values (P = 0.020). The length of ICU stay, incidence of return to ICU and postoperative death, were similar between men and women. Nevertheless, after adjusting for age and diabetes, female gender was still independently associated with higher morbidity in patients over 50 years of age.Conclusions:Women had more risk factors, comorbidities, and postoperative complications. Women older than 50 years of age were at a higher risk of postoperative complications than men. This difference decreased with younger age. In-hospital mortality rates were not influenced by sex, as there was no difference found between the two groups (2.5% women vs. 2.2% men; P > 0.05).

Xenon offers stable haemodynamics independent of induced hypothermia after hypoxia–ischaemia in newborn pigs

To assess the effect of 18hour (h) 50% xenon (Xe) inhalation at normothermia (NT, 38.5°C) or hypothermia (HT, 33.5°C) on mean arterial blood pressure (MABP), inotropic support and heart rate (HR) following an induced perinatal global hypoxic-ischaemic insult (HI) in newborn pigs. Newborn pigs ventilated under inhalational anaesthesia, following a 45min HI (inhaled oxygen fraction reduced until amplitude integrated electroencephalogram was less than 7μV), were randomised to three Xe (n=45) (50% Xe 18h with NT, HT 12h or HT 24h) or three non-Xe groups (n=53) (0% Xe with NT, HT 12h or HT 24h) under otherwise identical conditions. We measured MABP and HR every minute. Hypotension (MABP <40mmHg) was treated sequentially with 2×10mL/kg saline, dopamine, norepinephrine and hydrocortisone if required. Xe maintained higher MABP during HT (5.1mmHg, 95% CI 2.34, 7.89), rewarming (10.1mmHg, 95% CI 6.26, 13.95) and after cessation (4.1mmHg, 95% CI 0.37, 7.84) independent of HT, inotropic support and acidosis. Xe reduced the duration of inotropic support by 12.6h (95% CI 5.5, 19.73). Inotropic support decreased the HR reduction induced by HT from 9 to 5bpm/°C during cooling and from 10-7 to 4-3bpm/°C during rewarming. There was no interaction between Xe, HT, inotropic support and acidosis. Xe during HT cleared lactate faster; 3h post-HI median (IQR) values of (Xe HT) 2.8mmol/L (0.9, 3.1) vs. (HT) 5.9mmol/L (2.5, 7.9), p=0.0004. Xe maintained stable blood pressure, thereby reducing the inotropic support requirements during and after administration independently of induced HT-current neonatal encephalopathy treatment. Xe may offer haemodynamic benefits in clinical neuroprotection studies.

Seven-day antibiotic courses have similar efficacy to prolonged courses in severe community-acquired pneumonia—a propensity-adjusted analysis

There are no studies to guide the optimal duration of therapy in severe community-acquired pneumonia (CAP). The aim of this study was to determine whether 7 days of antibiotic treatment is equivalent to longer-course therapy in severe CAP. In this prospective observational study, we included patients with severe CAP (CURB65 score 3–5) admitted to the hospital with signs and symptoms consistent with pneumonia. A propensity score, derived through multiple logistic regression, was used to match patients into two groups: treated for 7 days vs. treated for >7 days. Patients who died, were admitted to the intensive-care unit, developed complicated pneumonia, failed to reach clinical stability or had positive cultures for microorganisms requiring prolonged treatment within the first 7 days were excluded. Patients outside the mutual range of the propensity score were also excluded. The primary outcome of this study was 30-day mortality. Secondary outcomes were subsequent requirement for mechanical ventilation and/or inotropic support and the development of complicated pneumonia or re-admission within 30 days. Four hundred and twelve patients were suitable for derivation of the propensity score. After matching on propensity score, 164 patients treated for 7 days were compared with 164 treated for >7 days; they were well matched in terms of age, gender, comorbidities, and physiological parameters. The results showed no significant differences in the primary and the secondary outcomes between the two groups. This study therefore suggests that, in the majority of severe CAP patients who have clinically responded, antibiotics can be safely discontinued at 7 days.

What are the differences in outcomes between right-sided active infective endocarditis with and without left-sided infection?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with isolated right-sided infective endocarditis (RSE) is the outcome of surgical management the same as in patients with or without left-sided involvement? Altogether, 419 papers were found using the reported search, six of which represented the best evidence to answer the clinical question. Two studies point towards better outcomes with isolated RSE. In one paper, mortality was significantly lower in isolated RSE patients (P = 0.0093) for the duration of the follow-up time (median 488 patient-years). Two studies reported early mortality (<30 days) for RSE patients at 3.6 and 3.8%, respectively. Combined right- and left-sided endocarditis (RLSE) patients were found to have a poorer pre-operative clinical presentation than isolated RSE patients with a greater requirement for inotropic support (P < 0.006) and the likelihood of an emergency operation (P < 0.001). They had a poorer intra-operative course with a higher incidence of cardiac abscess formation (P < 0.001). One study suggested that there is no significant difference in in-hospital and long-term mortality between intravenous drug abuse (IVDA) patients and non-IVDA patients. Left-heart involvement in the IVDA group was 61.5%. This was in-line with the published literature, demonstrating a rise in RLSE in IVDA compared with non-IVDA patients. Three articles looking at isolated left-sided endocarditis (LSE) gave mortality rates in the surgical group to be 27.1, 27.8 and 38%, respectively. In one study, the LSE mortality was not different for native vs. prosthetic valve infection (OR 0.65, 95% CI 0.23-1.87). After propensity matching and adjusting for hazards, the complication rate in the LSE group was higher and this translated to a higher mortality rate. We conclude from the literature that outcomes are more favourable with lower early and late mortality for isolated RSE patients over pure LSE or combined RLSE.

Myocardial Protection in Heart Surgery

One of the unmet clinical needs in heart surgery is the prevention of myocardial stunning and necrosis that occurs as a result of ischemia-reperfusion. Myocardial stunning, a frequent consequence after heart surgery, is characterized by a requirement for postoperative inotropic support despite a technically satisfactory heart operation. In high-risk patients with marginal cardiac reserve, stunning is a major cause of prolonged critical care and may be associated with as much as a 5-fold increase in mortality. In contrast, the frequency of myocardial necrosis (myocardial infarction [MI]) after cardiac surgery is less appreciated and its consequences are much more subtle. The consequences may not be apparent for months to years. While we now have a much better understanding of the molecular mechanisms underlying myocardial stunning and MI, we still have no effective way to prevent these complications, nor a consistently effective means to engage the well-studied endogenous mechanisms of cardioprotection. The failure to develop clinically effective interventions is multifactorial and can be attributed to reliance on findings obtained from subcellular and cellular studies, to drawing conclusions from preclinical large animal studies that have been conducted in a disease-free state, and to accepting less than robust surrogate markers of injury in phase II clinical trials. These factors also explain the disappointing failure to identify effective adjuvant therapy in the setting of percutaneous coronary revascularization for acute MI (AMI) and reperfusion injury. These issues have contributed to the disappointing outcomes of large and costly phase III trials, resulting in a lack of enthusiasm on the part of the pharmaceutical industry to engage in further drug development for this indication. The purpose of this review is to (1) define the scope of the clinical problem; (2) summarize the outcomes of selected phases II and III clinical trials; and (3) identify the gap that needs to be closed in order to address the unmet clinical need.

Xenon offers stable haemodynamics after global hypoxic-ischaemia in newborn pigs

BackgroundPerinatal hypoxic ischaemic encephalopathy (HIE) causes cardiac dysfunction/hypotension. Xenon (Xe) anaesthesia offers short term stable haemodynamics in human adults/mature animals with cardiovascular risk. We studied long term haemodynamics during 50%...

Impact of inhaled corticosteroid use on outcome in COPD patients admitted with pneumonia

The aim of this study was to investigate whether inhaled corticosteroid (ICS) use affects outcome in patients with chronic obstructive pulmonary disease (COPD) admitted with community-acquired pneumonia (CAP). This was a prospective, observational study of patients with spirometry-confirmed COPD presenting with a primary diagnosis of CAP in Lothian, UK. Outcome measures were compared between ICS users and non-ICS users. Of 490 patients included in the study, 76.7% were classified as ICS users. ICS users had higher Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage compared with non-ICS users (mean ± sd 3.2 ± 0.8 versus 2.6 ± 0.9; p<0.0001). There were no significant differences in pneumonia severity (mean ± sd Pneumonia Severity Index (PSI) 4.2 ± 0.8 versus 4.3 ± 0.8 (p = 0.3); mean ± sd CURB-65 score 2.1 ± 1.3 versus 2.3 ± 1.3 (p = 0.07)) or markers of systemic inflammation (median C-reactive protein 148 (interquartile range 58-268) mg·L(-1) versus 183 (IQR 85-302) mg·L(-1); p = 0.08) between ICS users and non-ICS users. On multivariable analysis, after adjustment for COPD severity and PSI, ICS use was not independently associated with 30-day mortality (OR 1.71, 95% CI 0.75-3.90; p = 0.2), 6-month mortality (OR 1.62, 95% CI 0.82-3.16; p = 0.2), requirement for mechanical ventilation and/or inotropic support (OR 0.73, 95% CI 0.33-1.62; p = 0.4) or development of complicated pneumonia (OR 0.71, 95% CI 0.25-1.99; p = 0.5). Prior ICS use had no impact on outcome in patients with COPD admitted with CAP.

Early and delayed stroke after coronary surgery — an analysis of risk factors and the impact on short- and long-term survival

Stroke is a serious complication to cardiac surgery, and is generally considered as a uniform disease regardless of its temporal relationship to surgery. Our hypothesis suggests that stroke, in association with surgery, reflects other characteristics than stroke occurring with a free interval. This issue was here explored for risk factors and survival effects. Data were collected from 7839 procedures of isolated coronary artery bypass grafting (CABG), 297 off-pump CABG, and 986 combined CABG and valve procedures. Records of patients with any signs of neurological complications were reviewed to extract 149 subjects with stroke at extubation (early, 1.6%) versus 99 patients having a free interval (delayed, 1.1%). Survival data were complete, with a median follow-up time of 9.3 years (maximum 16.3 years). Independent risk factors were analyzed by logistic regression and survival by Cox regression. Risk factors for early stroke were advanced age, high preoperative creatinine level, extent of aortic atherosclerosis, and long cardiopulmonary bypass time (all P<0.001). Factors associated with delayed stroke were female gender (P<0.001), unstable angina (P=0.003), previous cerebrovascular disease (P=0.009), inotropic support requirement (P<0.001), and postoperative atrial fibrillation (P<0.001). Stroke explained mortality not only in the early postoperative period (P<0.001), but also at long-term follow-up (P<0.001). Early and delayed stroke were associated with mortality hazard ratios (HRs) of 1.44 and 1.85 (P=0.008, P<0.001), respectively. However, for patients surviving their first postoperative year, early stroke did not influence long-term mortality (HR 1.07, P=0.695). This was in contrast to delayed stroke (HR 1.71, P=0.001). Early and delayed stroke differed in their related risk factors. The influence of stroke on short-term mortality was obvious and devastating. Mortality in association with early stroke mainly presented itself in the acute period, whereas for delayed stroke survival continued to be impaired also in the long-term perspective. Our report emphasizes that early and delayed stroke should be considered as two separate entities.

Mini-cardiopulmonary bypass impact on blood conservation strategy in coronary artery bypass grafting

Cardiopulmonary bypass (CPB) using a closed circuit system with minimal priming volume can be a solution to ameliorate adverse effects of CPB. We hypothesize that the use of mini-bypass in routine coronary artery bypass grafting (CABG) reduces homologous blood product use and postoperative bleeding. The study is designed to determine the differences in blood loss and transfusion requirements associated with a minimized CPB circuit vs. a standard bypass circuit. From February 2009 to August 2009, 80 patients were prospectively randomized to undergo elective CABG. Group A included 40 patients who had the minimized bypass circuit (Medtronic Resting Heart Circuit). Group B had an equal number of patients who had the standard CPB circuit (Stockert III, SEC.BM). Laboratory parameters for hemoglobin, hematocrit and platelet count were measured at baseline after initiation of CPB and after bypass. Blood usage was controlled by study-specific protocol (transfusion for hemoglobin <8 g/dl). Records were kept for blood products. The chest and mediastinal drainage was monitored for the first 24 postoperative hours. Ventilation time, inotropic use and intensive care unit (ICU) stay was compared in both groups. There were no statistical differences in terms of patients' demographics. Statistically significant differences were seen in transfused red blood cells volume (1.47±1.13 units in group A vs. 2.05±1.19 in group B, P<0.05), fresh frozen plasma (2.5±1.62 unit vs. 3.55±2.58 units, P<0.001), platelets (1.95±2.95 units vs. 3.23±2.85), and postoperative drainage in 24 hours (531.62±220.12 ml vs. 729±294.9 ml, P<0.05). The hematocrit was 33±5% in group A, and 27±1% in group B. There was statistical differences seen in the mean hemoglobin level which was 10.19±0.65 g/dl in group A, and 9.4±0.68 g/dl in group B. There was statistical difference in the duration of ventilation, length of ICU stay. The requirement of inotropic support was lower in group A. The adoption of mini-bypass significantly reduces morbidity including donor blood usage and postoperative bleeding in routine CABG patients.

Glucose–insulin–potassium therapy in adult patients undergoing cardiac surgery: a meta-analysis

Glucose-insulin-potassium (GIK) has long been used as adjuvant treatment for patients with serious cardiovascular disease. Although many studies have reported their results based on GIK therapy in the setting of heart surgery, the outcomes remain controversial and inconclusive. The aim of this meta-analysis of randomized controlled trials (RCTs) was to determine the clinical effects of GIK in adult cardiac surgery patients. Electronic databases and manual bibliographical searches were conducted. A meta-analysis of all RCTs comparing GIK with control in heart surgery was performed. Data for all-causes mortality (within 2 months after surgery), perioperative myocardial infarction, postoperative inotropic support, atrial fibrillation, cardiac index, durations of intensive unit care stay and total hospital stay were extracted, and we summarized the combined results of the data of the RCTs as relative risk (RR), with 95% confidence intervals (CIs). A total of 33 RCTs including 2113 patients were assessed in this study. GIK infusion was associated with significantly fewer perioperative myocardial infarctions (RR = 0.63, 95% CI 0.42-0.95), less inotropic support requirement (RR = 0.66, 95% CI 0.45-0.96), better postoperative cardiac index (weighted mean difference (WMD) = 0.43, 95% CI 0.31-0.55), and reduced length of stay in the intensive care unit (WMD = -7.96, 95% CI -13.36 to -2.55). Further analysis showed that diabetic patients were benefited from GIK with glycemic control, but not GIK infusion without glucose control. GIK significantly reduced myocardial injury and improved hemodynamic performance in patients undergoing cardiac surgery. Glycemic control with GIK might be required for cardiac surgery patients with diabetes.

Steroids and statins: an old and a new anti-inflammatory strategy compared

This study compared the anti-inflammatory effects of methylprednisolone (MP) and atorvastatin and analysed their influences on clinical variables in patients undergoing coronary revascularization. Ninety patients with compromised left ventricular ejection fraction (≤30%) undergoing elective coronary surgery were equally randomized to one of three groups: statin group, treatment with atorvastatin (20 mg/day) 3 weeks before surgery; methylprednisolone group, a single shot of methylpredniosolone (10mg/kg); and control group. Postoperative IL-6 was higher in the control group when compared to the methylprednisolone and statin groups (p<0.01). IL-6 was higher in the statin-treated patients (p<0.05 versus methylprednisolone). Administration of methylprednisolone as well as statin treatment increased postoperative cardiac index, left ventricular stroke work index, decreased postoperative atrial fibrilation rate and reduced ICU stay (p<0.05 versus control). The number of patients requiring inotropic support was lower in the methylprednisolone group when compared with the other two groups (p<0.01). Tracheal intubation time was reduced in patients who received methylprednisolone (p<0.01 versus control). Preoperative administration of either methylprednisolone or atorvastatin reduced pro-inflammatory cytokine release, improved haemodynamics, decreased postoperative atrial fibrilation rate and reduced ICU stay in patients with significantly impaired cardiac function undergoing coronary revascularization. Treatment with methylprednisolone was associated with less inotropic support requirements and reduced mechanical ventilation time.

Incidence and Prognostic Implications of Acute Kidney Injury on Admission in Patients With Community-Acquired Pneumonia

A consensus definition of acute kidney injury (AKI)-the risk, injury, failure, loss, and end-stage kidney disease (RIFLE) classification-predicts mortality in general hospital and ICU populations. We aimed to assess its value on admission in patients with community-acquired pneumonia (CAP). A prospective observational study with CAP was carried out. We classified each patient according to his or her maximum RIFLE class using admission creatinine (risk, ≥ 1.5 × baseline creatinine; injury, ≥ 2 × baseline; failure, ≥ 3 × baseline; no-AKI, < 1.5 × baseline). Outcomes were 30-day mortality, requirement for mechanical ventilation and inotropic support (MV/IS), and requirement for renal replacement therapy (RRT). A total of 1,241 patients were included (no-AKI, 1,018; risk, 130; injury, 63; failure, 30). On multivariate analysis, factors predicting development of AKI include severity of pneumonia (adjusted odds ratio [AOR], 1.74; 95% CI, 1.46-2.08; P < .0001), elevated C-reactive protein (AOR, 1.04; 95% CI, 1.03-1.06; P < .0001), and prior use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin-II-receptor blockers (AIIBs) (AOR, 1.77; 95% CI, 1.19-2.58; P = .005). Adjusting for severity of pneumonia, RIFLE criteria independently predicted 30-day mortality (AOR, 1.48; 95% CI, 1.15-1.91; P = .002), requirement for MV/IS (AOR, 2.22; 95% CI, 1.74-2.83; P < .0001), and RRT (AOR, 3.20; 95% CI, 2.01-5.11; P < .0001). Prior use of ACEIs or AIIBs was not associated with adverse outcome in either the entire cohort or patients without AKI. The RIFLE classification is a simple tool to assess and classify AKI on admission and independently predicts 30-day mortality and the need for MV/IS and RRT in patients with CAP.

Prediction of cardiogenic shock using plasma B-type natriuretic peptide and the N-terminal fragment of its pro-hormone concentrations in ST elevation myocardial infarction: An analysis from the ASSENT-4 Percutaneous Coronary Intervention Trial

Cardiogenic shock is a major cause of death in ST elevation myocardial infarction. We investigated whether determination of plasma [corrected] B-type natriuretic peptide and the N-terminal fragment of its pro-hormone in the acute phase of ST elevation myocardial infarction could identify patients prone to development of cardiogenic shock. Retrospective analysis of a multicenter, randomized open-label trial (ASSENT-4 PCI; ClinicalTrials.gov Identifier: NCT00168792). Plasma B-type natriuretic peptide and the N-terminal fragment of its pro-hormone were determined in available stored samples of 1016 ST elevation myocardial infarction patients without signs of cardiogenic shock at randomization to primary percutaneous coronary intervention or to full-dose tenecteplase before percutaneous coronary intervention. The end point of the present analysis was in-hospital cardiogenic shock. None. In total, 57 (5.6%) patients had cardiogenic shock during index hospitalization. In-hospital cardiogenic shock increased precipitously with higher baseline concentrations of plasma B-type natriuretic peptide and the N-terminal fragment of its pro-hormone (B-type natriuretic peptide and the N-terminal fragment of its pro-hormone < or =67 pg/mL: 1.9%; 68-1482 pg/mL: 5.9%; >1482 pg/mL: 14.9%; p < .001). Higher plasma [corrected] B-type natriuretic peptide and the N-terminal fragment of its pro-hormone concentrations were predictors of in-hospital shock, especially among those patients with relatively low clinical risk (no requirement of inotropic support before angiography, systolic blood pressure >100 mm Hg, heart rate <100 bpm, Global Utilization of Streptikonase and Tissue-Plasminogen Activator for Occluded Coronary Arteries score of <122). In multivariate Cox regression analysis, higher plasma B-type natriuretic peptide and the N-terminal fragment of its pro-hormone concentrations remained significant predictors of shock, in addition to age, systolic blood pressure, heart rate, and randomization to facilitated percutaneous coronary intervention and Killip classification. Furthermore, plasma B-type natriuretic peptide and the N-terminal fragment of its pro-hormone significantly predicted in-hospital shock independently of the validated Global Utilization of Streptikonase and Tissue-Plasminogen Activator for Occluded Coronary Arteries score (p = .014). Plasma B-type natriuretic peptide and the N-terminal fragment of its pro-hormone concentrations measured early in the acute phase of ST elevation myocardial infarction are useful in predicting the development of in-hospital cardiogenic shock.

Outcome of patients with severe abdominal sepsis in intensive care - experience at Charlotte Maxeke Johannesburg Academic Hospital

Despite advances in diagnosis, surgery, antimicrobial therapy and intensive care support, the mortality rate associated with intra-abdominal sepsis remains unacceptably high. The aim of the present study was to identify prognostic factors in 54 consecutive cases with abdominal sepsis admitted to the intensive care unit (ICU) over a two-year period, from January 2001 to December 2002. This was a retrospective record review of cases with abdominal sepsis admitted to the ICU. Of 54 patients that were studied, only 14 survived. The mortality rate was 74.1%. Non-survivors had signifcantly longer ICU stay, had more relook laparotomies, more blood transfusions and a signifcantly higher APACHE II score on admission to the ICU. Other results revealed that non-survivors required signifcantly more inotropic support and corticosteroids, had a lower paO2/FiO2 ratio and had more total parenteral nutrition days. None of the patients who survived required dialysis. The number of relook laparotomies were higher in the non-survivors and the maximum number of relook laparotomies were four in the survivors and 13 in the non-survivors. The non-survivors were also more likely to have an open abdomen. We conclude that patients with abdominal sepsis have an extremely high mortality and utilise an enormous amount of limited intensive care resources. The length of ICU stay, APACHE II score on admission, number of relook laparotomies, whether the abdomen was left open or not, and requirement for inotropic support, dialysis, total parenteral nutrition and blood transfusions were predictive of adverse outcomes in these patients.

Study of erythromycin and metoclopramide in treatment of feeding intolerance of critically ill patients in intensive care unit

To compare the effect of erythromycin and metoclopramide on feeding intolerance of critically ill patients in intensive care unit (ICU). One hundred and fifty-two critically ill patients in ICU who needed early enteral nutrition exceeding 7 days between January 2007 and January 2009 were included in the study. The patients were randomly divided into three groups: erythromycin group (200 mg intravenous drip, once every 12 hours), metoclopramide group (10 mg intravenous injection, once every 8 hours), and combination therapy group. The whole experiment was carried out for 7 days. Residual gastric volume was aspirated and measured every day at 03:00, 09:00, 15:00 and 21:00. The daily mean gastric residual volume was compared. At the same time, the daily effectiveness of erythromycin and metoclopramide on the success of feeding was also compared. The factors associated with a poor response to prokinetic therapy were looked for. The daily gastric residual volume in the combination therapy group was smallest, the maximum was (40+/-8) ml; the maximum of gastric residual volume in erythromycin group was (42+/-7) ml; the maximum of gastric residual volume in metoclopramide group was (59+/-8) ml (P<0.05 or P<0.01). The successful rate of feeding was highest in the combination therapy group, and it was as high as 97.4%, the erythromycin group ranked the second (90.0%), and that of the metoclopramide group was lowest (89.5%, P<0.05 or P<0.01). Factors that were associated with a poor response to prokinetic therapy was high pretreatment 24-hour gastric residual volume (r=-0.584, P=0.000), high blood sugar level (r=-0.345, P=0.029), a high acute physiology and chronic health evaluation II (APACHEII) score (r=-0.437, P=0.005), and requirement for inotropic drug support (r=-0.389, P=0.041). Low dose of erythromycin could improve the successful rate of feeding in critically ill patients in ICU. The combined administration of erythromycin and metoclopramide was more effective. Its side effect was minimal.

Factors Predicting the Outcome of the Blood and Marrow Transplant Patients Admitted to Intensive Care Unit.

Abstract 3340Poster Board III-228 Aim:To identify factors predicting outcome of patients admitted to intensive care (ICU) following allogeneic haematopoietic stem cell transplantation (allo-HSCT). Methods:Retrospective audit of all allo-HSCT patients requiring ICU admission. Results:Between 2000 and 2009, 392 patients underwent allo-HSCT. Of these, 106 (27%) had 129 ICU admissions. The median age was 47 (range 16-65) with myeloablative transplant in 89 and reduced intensity in 40 patients. Respiratory failure was the main reason for admission (54.6%) followed by sepsis (41.5%).During the period of ICU admission, 29.2% demonstrated improvement in organ failures, 39.2% remained stable and 28.4% deteriorated. Sixty-seven patients (51.9%) were discharged from ICU but only 48 (37%) were subsequently discharged from the hospital (ICU). Univariate analysis identified ICU admission within 30 days post HSCT, number of organ failures at admission, progression of organ failure during ICU admission, APACHE II score at admission, steroid refractory GVHD, and requirement for inotropic support or dialysis as significant predictors for survival in ICU. Patients requiring intubation and mechanical ventilation had a poorer outcome than the group who did not (84.4% Vs 20.0%, p=0.001). Those who required only non-invasive ventilation generally had a good outcome with 84.4% surviving til ICU discharge. While bacterial infection prior to ICU admission did not alter the outcome (p=0.221), the onset of a new infection in ICU was associated with a poor outcome (p=0.0001). Logistic regression analysis identified steroid refractory GvHD (P=0.027; 95% CI of 1.17-14.8), APACHE II score > 30 (p=0.003; 95% CI 1.5-10.5), admission <30 days post HSCT (p = 0.015; 95% CI 0.12-0.8), requirement of invasive ventilatory support (p = 0.005, 95% CI 2.58 – 223.83) and dialysis (p = 0.011; 95%CI 1.401 – 13.20) as significant factors for a poor outcome. Conclusion:More than 50% of patients admitted to ICU following allogeneic HSCT survive. A high APACHE II score, steroid refractory GVHD, admission into ICU within 30 days of HSCT, multiorgan failure, progression of organ failure during ICU stay, and the need for ventilation or dialysis, carries a dismal prognosis. Identification of risk factors associated with a poor outcome will assist in clinical management and may ultimately improve the outcome of patients requiring ICU admission following allogeneic HSCT. Disclosures:No relevant conflicts of interest to declare.

Clinico‐pathologic findings in end‐stage pediatric heart transplant grafts

The pathologic patterns existing in end-stage pediatric heart transplant grafts may help explain the symptoms and changes seen by echocardiography and angiography in these children. Retrospective chart review and pathologic study of explanted heart grafts was performed on 12 patients that had undergone 14 heart re-transplantations. Clinical status, echocardiographic and catheterization data at the time of transplantation were correlated to the pathologic findings. At re-OHT, eight were inpatients with heart failure symptoms and/or inotropic support requirements. Echocardiograms were abnormal in all prior to re-OHT with significant diastolic dysfunction, but LVEF >40% in all but one. There was significant epicardial fibrosis in all grafts, and all had severe CAV of epicardial arteries. However, intramyocardial coronary disease was mild in nine (64%) grafts. Moderate or severe interstitial fibrosis occurred in only three grafts, and in a perivascular distribution in eight. End-stage pediatric heart allografts have severe epicardial CAV and epicardial fibrosis, with relative sparing of the myocardium. Epicardial disease with sparing of the myocardium may explain the restrictive hemodynamics and relatively preserved systolic function present in these grafts at the time of re-OHT.

Effect of Adenosine Monophosphate Deaminase-1 C34T Allele on the Requirement for Donor Inotropic Support and on the Incidence of Early Graft Dysfunction After Cardiac Transplantation

The C34T T allele of the adenosine monophosphate deaminase-1 (AMPD1) gene has been associated with improved outcome in patients with cardiac dysfunction. We hypothesized that possession of this allele by donor hearts plays a role in the outcome of cardiac transplantation; 262 cardiac donors and 190 of their recipients were studied. AMPD1 C34T genotype was determined using 5' exonuclease chemistry. Requirement for inotropic agents before organ donation, 1-year post-transplantation survival, cause of death, and factors known to affect survival after transplantation were also studied. Multiple regression models for factors affecting survival were constructed. A significant yearly increase in frequency of the T allele in donors was noted (0.06 to 0.18 from 1994 to 1999). Donors with the CT or TT genotype required less inotropic support than those with the CC genotype (mean number of inotropes per donor with CT or TT genotype 0.27 compared with 0.47 per donor with CC genotype, n = 206, p = 0.03). Recipients of T-allele-carrying organs showed worse 1-year survival after transplantation (59% vs 79%, p <0.001). Excess deaths in these patients was due to early graft dysfunction (odds ratio for early graft dysfunction 6.6, 95% confidence interval 2 to 21.6, p = 0.0001). Multivariate analysis showed donor AMPD1 genotype, recipient age, and pretransplantation anemia to independently affect 1-year post-transplantation survival (adjusted hazard ratios 3.7, 1.06, and 2.6, respectively). In conclusion, possession of the AMPD1 T allele is associated with decreased inotropic requirements before heart donation. The incidence of early graft dysfunction, however, was significantly higher in recipients who received AMPD1 T-allele-possessing organs resulting in worse 1-year survival.

Levosimendan pre-treatment improves outcomes in patients undergoing coronary artery bypass graft surgery

The calcium sensitizer levosimendan has anti-ischaemic effects mediated via the opening of sarcolemmal and mitochondrial ATP-sensitive potassium channels. These properties suggest potential application in clinical situations where cardioprotection would be beneficial, such as cardiac surgery. We thus decided to investigate whether pharmacological pre-treatment with levosimendan reduces intensive care unit (ICU) length of stay in patients undergoing elective myocardial revascularization under cardiopulmonary bypass. One hundred and six patients undergoing elective coronary artery bypass grafting were randomly assigned in a double-blind manner to receive levosimendan or placebo. Levosimendan (24 microg kg(-1)) or placebo was administered as a slow i.v. bolus over a 10 min period before the initiation of bypass. Tracheal intubation time and the length of ICU stay were significantly reduced in the levosimendan group (P<0.01). The number of patients needing inotropic support for >12 h was significantly higher in the control group (18.0% vs 3.8%; P=0.021). Compared with control patients, levosimendan-treated patients had lower postoperative troponin I concentrations (P<0.0001) and a higher cardiac power index (P<0.0001). Pre-treatment with levosimendan in patients undergoing surgical myocardial revascularization resulted in less myocardial injury, a reduction in tracheal intubation time, less requirement for inotropic support, and a shorter length of ICU stay.

Are current smokers paradoxically protected against atrial fibrillation after cardiac surgery?

The hyperadrenergic condition following surgical stress and inotropic drugs have been identified as leading causes for postoperative atrial fibrillation (AF). Smokers are characterized by higher catecholamine levels and tolerance. We tested the hypothesis that smoking patients are less prone to develop postoperative AF. A total of 3,245 coronary artery bypass and valvular procedures were reviewed. Predictors of AF and interaction between variables were explored by multivariable logistic regression. AF-predictive scores were created and validated for goodness of fit, and receiver operating characteristic curves were created. Postoperative AF occurred in 26% of patients. Smokers accounted for 15% of the study population and demonstrated a reduced incidence of postoperative AF compared with nonsmoking individuals (20% vs. 27%, p < .001). Multivariate analysis revealed a significant interaction between smoking status and inotropic support requirement. The AF-protective effect of smoking was confounded by inotropic drugs. However, when we excluded from analysis the patients with inotropic support, smoking conferred a 46% risk reduction of AF (odds ratio [OR] = 0.54, 95% CI = 0.34-0.87, p = .011). In addition, age, valvular surgery, and hypertension were independently associated with AF. Postoperative AF increased the length of hospitalization, without affecting hospital mortality. AF was associated with an increased 1-year mortality (p = .002). Current smokers are less prone to develop AF after cardiac surgery. Our data support the hypothesis that hyperadrenergic state and catecholamines are key mechanisms in the pathophysiology of postoperative AF.