Period Of Cardiac Surgery Research Articles

Immediate Extubation Versus Extubation Within Six Hours: Analysis of Clinical Outcomes in The Postoperative Period of Cardiac Surgery

The advances of the quality of anesthetics and of anesthetics techniques have facilitated the optimization of time for extubation in coronary heart disease graft. Aim: Comparison of clinical outcomes between patients extubated in the operating room and extubated patients within 6 hours after Intensive Care Unit (ICU) admission in patients undergoing cardiac surgery using extracorporeal circulation. Material and methods: A retrospective observational study of 194 patients submitted to cardiac surgery using extracorporeal circulation in one of the biggest tertiary hospitals in São Paulo. They were divided into two groups. In the first group, patient’s extubated in the operating room was composed of 95 patients. The second group of patients extubated within 6 hours of ICU admission from the intubated operating room, composed of 99 patients. We excluded 10 patients who were extubated after 6 hours of ICU admission. Results: Patients extubated in the operating room (median of 8 days, IQR 6 to 10) had shorter hospital stay time than patients extubated within 6 hours of ICU admission (median of 10 days, IQR 8 to 12.5), prevalence of similar delirium (2.0% x 2.1%), absence of pneumonia associated with mechanical ventilation (VAP) (0%), absence of non-caloric-protein readjustment (0%) and regarding safety, only one patient was reintubated for anesthetic recirculation in the group of extubated in the room and there was no difference in the rate of ICU readmission with the non-extubated group. Conclusion: In this sample of patients, we found that extubation in the room was safe. Patients extubated in the operating room immediately after cardiac surgery have a lower chance of evolving with prolonged hospitalization when compared to patients who are extubated within 6 hours of ICU admission.

The changes in the structure of cognitive functions and anxiety in cardiac surgery patients depending on the severity of carotid arteries

Highlights. The article revealed that severe (more than 50%) carotid artery (CA) stenosis was associated with significant slowdown of the information selection processes, and these patients were characterized by older age and tendency to an increase in trait anxiety compared to the patients without CA stenosis.It was found that the reduced attention and memory was a typical feature of the cognitive status in patients with severe CA stenosis in the early postoperative period of cardiac surgery in comparison with the patients without CA stenosis. At the same time the speed characteristics indicators of the information selection processes in these patients are positively related to state anxiety.Aim. The cardiac surgery patients were studied in order to analyze the postoperative changes in the efficiency of selection information and memory processes depending on the degree of carotid artery (CA) stenosis (including more than 50%) and the age and the role of the trait anxiety indicator assessed before surgery.Methods. The prospective study included 229 patients undergoing elected coronary artery bypass grafting (CABG) or CABG and carotid endarterectomy (CEE). Each study participant underwent clinical, instrumental and extended psychometric examination before cardiac surgery and at 7-10 days after surgery. The evaluation of the extracranial vessels state was carried out before surgery using color duplex scanning. Based on the results of assessing the extracranial vessels state, all patients were divided into three groups: no stenosis (n = 124), CA stenosis less than 50% (n = 69) and more than 50% (n = 36).Results. It was found out that the patients with CA stenoses more than 50% are characterized by a slower reaction under different conditions of visual stimuli selection and by an older age as compared with patients with no stenoses as well as patients with stenoses less than 50%. In the postoperative period of cardiac surgery in comparison with testing before surgery there was an improvement in the information selection stability (an increase in the number of processed symbols per 4 minute of the Bourdon's test (p<0.00006)) and short-term memory (p = 0.03) only in the group of patients without stenoses. The patients with stenoses of less than 50% had an increase the of the information selection stability but the short-term memory decrease (p<0.05) whereas the group with stenoses more than 50% had a decrease in both the stability of information selection and short-term memory (p<0,05). Additional factors of cognitive deficit in CA stenosis patients were trait anxiety associated with memory impairment and a history of stroke that related to a decrease in the effectiveness of a complex visual-motor reaction.Conclusion. The comprehensive analysis of the cognitive status of cardiac surgery patients with different severity of CA stenosis showed that an increase in the age and stenosis degree is the factor of the reaction time slowdown under different conditions of information selection. To differentiate groups of patients depending on the severity of stenosis in the postoperative period the testing short-term memory and stability of attention is informative. These indicators improve in the group without stenosis but decrease in the group with pronounced stenosis. The trait anxiety and the history of stroke were the additional factors of memory impairment due to CA stenosis.

Health evaluation of three types of baths in patients with severe heart diseases

Aim: To analyze the cost of three bed bath technologies in critically ill cardiac patients. Study design: Non-participant, prospective, observational, and cost assessment study. Data were collected between February and August 2017, at the cardiac intensive care (ICU) of a university hospital. The convenience sample corresponded to 18 patients in the immediate postoperative period of cardiac surgery. Data were collected within 72 h after cardiac surgery, with 24-hour washout between baths. Project was approved under the number: 1.823.316. Results: The mean time for bed bath was 39.00±15.00 min (traditional bath), 33.00±12.24 min (distilled water bath) and 25.28±7.35 min (disposable bath). The average final costs identified were R$ 45.47 (US$ 8.80), R$ 40.78 (US$ 7.89) and R$ 48.36 (US$ 9.36). Conclusion: The bath with the lowest total average cost was the distilled water bath. The cost category that most burdens the bed baths is human capital, which represents more than 2/3 of the procedures total cost. There are few studies exploring the costs associated to nursing procedures, and this analysis can contribute to discussions about materials purchase and support managers to make better decisions about nursing care.

Acute respiratory distress syndrome following coronary artery bypass grafting successfully treated with venovenous extracorporeal membrane oxygenation

Introduction. Acute respiratory distress syndrome (ARDS) is one of the most serious complications during the postoperative period in cardiac surgery. Venovenous extracorporeal membrane oxygenation (VV-ECMO) has proven to be a valuable therapy in ARDS when standard therapy is insufficient. Our aim is to present a case of severe ARDS which was succesfully treated by VV-ECMO. Case outline. A 54-year-old male patient was urgently admitted to our hospital due to anterior wall myocardal infarction. Urgent coronarography was performed, which found severe three-vessel coronary disease. Triple coronary artery bypass grafting (CABG) was performed. After surgery, due to prolonged respiratory insufficiency, the patient was diagnosed with ARDS and VV-ECMO was placed. Nine days later, normal values of gase exchange were achieved and the patient was succesfully weaned from VV-ECMO. Conclusion. We showed that when conventional therapy for ARDS is not effective, use of ECMO should be considered.

Nursing actions in the management of pain related to the use of a patient-controlled analgesia pump during the postoperative period of cardiac surgery

Nursing actions in the management of pain related to the use of a patient-controlled analgesia pump during the postoperative period of cardiac surgery

Nursing actions in the management of pain related to the use of a patient-controlled analgesia pump during the postoperative period of cardiac surgery

Nursing actions in the management of pain related to the use of a patient-controlled analgesia pump during the postoperative period of cardiac surgery

The effects of dual task training on the neurophysiological parameters in cardiac surgery patients: a pilot study

Abstract Background Preventive strategies for postoperative cognitive decline in cardiac patients are being actively developed. The dual task method has demonstrated beneficial potential for treating patients with cognitive impairment. Purpose To evaluate the effects of dual task training on the neurophysiological parameters in cardiac surgery patients. Methods 47 patients who underwent elected coronary artery bypass grafting (CABG) or CABG combined with carotid endarterectomy (CEE) were recruited in a prospective study. Patients who did not undergo any cognitive training were assigned to Group 1 (n=21), whereas those who underwent postoperative cognitive training I (postural training and an open-type task) (n=11) and II (visual-motor response and an open-type task) (n=15) were assigned to Group 2 and Group 3, respectively. Cognitive training was carried out daily, starting from the 4th day of the postoperative period. The average number of trainings was 5 for each training group. All patients underwent extensive neuropsychological testing and electroencephalographic (EEG) studies 3–5 days before and 8–11 days after surgery. Results All patients demonstrated an increase of the theta1 and beta1 EEG rhythms power, an increase in theta/alpha EEG index and a decrease in theta/beta activity index in the early postoperative period of cardiac surgery. Importantly, Group 3 patients undergoing cognitive training II showed an improvement in a larger number of indicators related to executive functions and attention than Group 2 patients undergoing training I. The last reported only improved short-term memory and attention. Conclusion All patients had similar ischemic brain damage. Those who underwent cognitive training reported improvements in neurodynamics, attention, and memory. The results of the study indicate the need to improve further the approaches to postoperative cognitive training using dual tasks with intensification of the load and individual support for patients undergoing cardiac surgery. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Russian Foundation for Basic Research

Fluid responsiveness in patients under mechanical ventilation and low tidal volume ventilation through the pulse pressure variation after tidal volume challenge in the post-operative cardiac surgery

Abstract Background It is known that in the immediate postoperative period of cardiac surgery, strict control of hemodynamic variables and blood volume is necessary, since there is an imbalance between oxygen supply and consumption. Thus, the present study seeks to validate methods previously used in different clinical situations to predict fluid responsiveness, in the current scenario of the immediate postoperative period of cardiac surgery. Purpose To evaluate the influence of “tidal volume challenge” from 6 ml / kg to 8 ml / kg of the predicted body weight (PBW) in conjunction with the end expiratory occlusion test (EEOT) in the variation of pulse pressure to predict fluid responsiveness in the immediate postoperative period of cardiac surgery. Methodology This prospective study included 30 patients after cardiac surgery. Hemodynamic and ventilatory parameters were initially recorded in mechanical ventilation at 6 ml/kg and after tidial volume challenge and with the EEOT at 8 ml/kg of predicted body weight (PBW). After recorded the intervention data, there was a return to ventilation at 6 ml/kg and a saline infusion of 500 ml was performed for 15 minutes. Fluid responsiveness was defined for patients who had an increase of 10% or more in velocity time integral (VTI) by echocardiogram after volume expansion compared to baseline value. Multivariate analysis was used to identify independent predictors of fluid response status. Sensitivity and specificity analyzes were performed to determine the predictive precision of each parameter. Results The main result of our study is that, when the tidal volume is increased from 6 to 8 ml/kg of PBW, the relative increase in pulse pressure variation (%ΔPPV6–8) predicts with excellent accuracy responsiveness to fluids with cut-off values of 18.3%, with sensitivity of 92.9% and specificity of 84% (P=0.019). Although changing PPV6, EEOT6 and EEOT8 are not reliable in predicting fluid responsiveness, they still require additional calculations. PPV8 also discriminates between responders and non-responders; however, with sensitivity (78.6%) and specificity (66.6%) when the value found in the PPV8 is up 8.5, but without statistical significance (figure). Conclusion The challenge of tidal volume and its influence on the ΔPP variation has excellent accuracy to predict fluid responsiveness in the immediate postoperative period of cardiac surgery. EEOT did not present good accuracy to predict fluid responsiveness in patients in the immediate postoperative period of cardiac surgery. Funding Acknowledgement Type of funding sources: None.

196-OR: Digital Insulin Therapy Protocol in the Postoperative Period of Coronary Artery Bypass Graft Surgery: A Prospective Randomized Study

Introduction: Adequate glycemic control with intravenous insulin therapy in the postoperative period of coronary artery bypass grafting (CABG) in an intensive care unit (ICU) reduces unfavorable clinical outcomes, such as mortality, acute kidney injury (AKI), arrhythmias and nosocomial infection. After discharge from ICU, even still hospitalized, adherence to consensus on inpatient insulin therapy is low, and about 50% of patients do not receive adequate subcutaneous insulin therapy in the ward, consequently in-hospital hyperglycemia (IH) is frequent. Medical apps are increasingly facilitating the medical routine. InsulinAPP is a digital protocol for inpatient glycemic management and already validated. A 16% reduction in blood glucose (BG) has been demonstrated in clinical patients with this protocol. Method: Prospective randomized trial was performed on diabetic patients in CABG postoperative period, after discharge from ICU. The groups were randomized according to the glycemic control protocol: InsulinAPP group (APP) or protocol defined by the assistant team (ST - standard group). The aim is to compare the groups regarding the composite outcome of AKI, nosocomial infection and atrial fibrillation. Results: A total of 41 patients were evaluated (15 in APP and 26 in ST). There was no difference between APP vs. ST group in age (65.1±9.8 vs. 65.1±9.8 years), female gender (40 vs. 46%), body mass index (28.5±4.9 vs. 27.3±5.1 Kg/m2) and estimated glomerular function (68.0±24.1 vs. 69.1±24.5 mL/min, respectively). APP had better BG than ST group (162±28.6 mg/dL vs. 183±34.4 mg/dL, respectively; p = 0.036). Besides, in APP there was a significant reduction of the composite outcome (27% vs. 77%, p=0.002), infection (20% vs. 61%, p<0.001) and AKI (13% vs. 50%, p=0.019). Conclusion: The InsulinAPP protocol was more effective in glycemic control and in reducing unfavorable outcomes in the postoperative period of cardiac surgery after discharge from the ICU. Disclosure A. B. Camara de souza: None. M. T. Toyoshima: None.

Effect of preoperative pneumococcal immunization on the incidence of respiratory infection in the postoperative period of cardiac surgery

Objective: To analyze whether the incidence of respiratory infections in the postoperative period of cardiac surgery is lower in patients immunized with the 13-valent pneumococcal conjugate vaccine. To study the main risk factors related to the development of infections in patients undergoing cardiac surgery. Methodology: 40 patients were included in the study, randomized 1: 1 to receive pneumococcal vaccine or placebo, 14 days before undergoing elective cardiac surgery. The incidence of infections in the 30 postoperative days was compared between groups. Results: There were 6 respiratory infections in the vaccine group and 2 in the placebo group (p=0.2024) and one death in the placebo group and none in the vaccine group (p=0.3173). Chronic obstructive pulmonary disease (p=0.003), diabetes mellitus (p=0.047) and peripheral arterial disease (p=0.0001) were listed as risk factors for the development of infections, which generated an increase in hospital stay (95% CI : 1.33- 7.13; p =0.0147) and ICU stay in the postoperative period (95% CI: 1.87- 33.45; p=0.0025). Conclusion: The application of pneumococcal vaccine 13v did not influence the development of postoperative pulmonary infections. Chronic obstructive pulmonary disease, diabetes mellitus and peripheral arterial disease were identified as risk factors for the development of infections, increasing the length of total hospital stay and time in the ICU.

Effectiveness and safety evaluation of a cough stimulation device in early postoperative respiratory rehabilitation in cardiac surgery patients

To evaluate the effectiveness and safety of cough stimulation using the mechanical in- and exsufflator in the early postoperative period in cardiac surgery patients. The study included 37 patients; mean age was 57±12.3 years. Inclusion criteria: age over 18 years; post-extubation spontaneous breathing; fully conscious and cooperative; adequate gas exchange with oxygen therapy; adequate pain control (2 points or less on 10-point visual analogue scale). Exclusion criteria: need for re-intubation and mechanical ventilation; noninvasive mask ventilation; high-flow oxygen therapy; acute cerebrovascular event; uncontrolled bleeding; heart failure (inotropic score over 10); shock; need of extracorporeal blood purification; neuromuscular disease; pneumothorax, hydro- or hemothorax. Cough stimulation was performed using the mechanical in- and exsufflator Comfort Cough Plus («Seoil Pacific Corporation», Republic of Korea). The device provides cough stimulation after high-frequency vibrations transmitted through a special vest and lung tissue recruiting by changing the airways pressure of the gas mixture, delivered through the anesthesia face mask. Cough stimulation device use was associated with an increase in the cough effectiveness; the number of patients with productive cough increased 8-fold, from 4 (10.8%) to 32 (86.4%), p=0.0000. The increase of blood oxygen saturation (SpO2) on room air from 92% to 96% (p=0.000001) and inspiratory capacity (IC) from 750 mL to 1200 mL (p=0.000002) was observed. The number of patients with IC of 1200-1500 mL increased 3-fold, and those with an IC over 1500 mL increased 2.6-fold. The proportion of patients with low oxygenation (SpO2 less than 92%) decreased 5-fold after the procedure (p=0.0011). Good tolerability and no side effects of the procedure were noted in all patients. Impaired sputum expectoration early after cardiac surgery is observed in most patients and may cause low oxygenation. The main effects of the cough stimulation device were improvement of sputum expectoration and an increase in oxygenation. An increase in blood oxygen saturation and inspiratory capacity after a single procedure with this device was demonstrated. It resulted in a significantly decreased proportion of patients with respiratory insufficiency. No adverse effects of the procedure were observed.

Acute kidney injury in cardiac surgery: definition, epidemiology, outcomes and socio-economic significance

Surgical intervention on an ‘open’ heart during cardio-pulmonary bypass is the method of choice for patients with valvular defects, complicated forms of coronary heart disease and combined pathology. The level of perioperative mortality in these interventions range from 2 % to 10 %. Acute kidney injury associated with cardiac surgery is a common and serious complication which dramatically worsens operative prognoses and results. According to several major studies, the incidence of acute renal injury in cardiac surgery is comparable with the incidence of myocardial infarction, with corresponding unsatisfactory outcomes.The introduction of the term ‘acute kidney injury’ into clinical practise, replacing the concept of acute renal failure, occurred relatively recently. This facilitated a universal definition for this condition, and unified the criteria for diagnosis and stratification of acute renal dysfunction severity. The article defines acute kidney injury using RIFLE, AKIN and KDIGO criteria. Acute kidney injury in cardiac surgery dramatically worsens short-term results and long-term outcomes, and thus increases the economic cost of treating patients. According to some reports, in industrialised countries, the health costs associated with acute kidney injury are estimated at $ 1 billion. Acute kidney injury is associated with approximately 300,000 deaths per annum, as well as approximately 300,000 new cases of chronic kidney disease. Cumulative expenses associated with acute renal injury in cardiac surgery are not directly limited to the hospitalisation period, but are often prolonged and/or deferred. These patients require additional financial expenses after discharge from hospital, which once again exemplifies this problem in cardiac surgery.Manifest acute kidney injury in the postoperative period of cardiac surgery leads to an increased number of extrarenal complications, reduced short-and long-term survival rates, increased economic costs in hospitals and prolonged treatment effects in the long-term. The introduction of a single definition of cardiac acute renal injury according to KDIGO criteria into clinical practise will identify patient groups with a high risk of developing this pathology. Similarly, it will also facilitate timely measures to prevent the development of complications in postoperative periods, which will reduce the risk of complications in cardiac patients.Received 10 July 2020. Revised 2 September 2020. Accepted 9 September 2020.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.Author contributionsConception and design: N.O. Kamenshchikov, Y.K. Podoksenov, M.L. DiakovaData collection and analysis: N.O. Kamenshchikov, A.M. Boyko, M.L. DiakovaDrafting the article: N.O. Kamenshchikov, M.L. Diakova, A.M. BoykoCritical revision of the article: M.L. Diakova, Y.K. PodoksenovFinal approval of the version to be published: N.O. Kamenshchikov, Y.K. Podoksenov, M.L. Diakova, A.M. Boyko, B.N. Kozlov

Efeitos da supressão da aspiração endotraqueal na incidência de complicações pulmonares no pós operatório de cirurgia cardíaca

INTRODUÇÃO: Aspiração traqueal é utilizada rotineiramente após cirurgia cardíaca para garantir adequada ventilação. OBJETIVO: Verificar se a ausência da aspiração traqueal antes da extubação em pacientes sem sinais de secreção brônquica influencia na incidência de complicações pulmonares, além de repercussões hemodinâmicas e ventilatórias do procedimento e custos. MÉTODOS: Pacientes foram avaliados entre agosto/2012 e julho/2014, divididos igualmente em Grupo ASP (aspiração traqueal prévia à extubação) e NASP (sem aspiração prévia). Foram incluídos indivíduos com: primeira cirurgia cardíaca, idade entre 18 e 75 anos, IMC ? 30 kg/m² e sem doença pulmonar prévia. Foram excluídos indivíduos com tempo de CEC > 120 minutos, necessidade de assistência circulatória mecânica, relação PaO2/FiO2 < 200, SpO2 < 92%, tempo de intubação > 12 horas, PAM < 60 mmHg e sinais de secreção pulmonar. Variáveis hemodinâmicas, ventilatórias, complicações pulmonares e custos hospitalares foram avaliados. RESULTADOS: Foram analisados 228 pacientes (ASP= 114 NASP= 114). FC, PAS, PAD e PAM elevaram-se após aspiração e pós extubação nos grupos, retornando aos valores basais no decorrer do tempo. Não houve diferença estatística na FR e SpO2. Complicações pulmonares representaram 7,8%, sem diferença entre os grupos. CONCLUSÃO: A supressão da aspiração traqueal nos pacientes em pós-operatório imediato de cirurgia cardíaca não influenciou na incidência de complicações pulmonares e evolução clínica pós-operatória. Durante aspiração, houve alterações hemodinâmicas e respiratórias, sem repercussões clínicas, porém estas mesmas alterações ocorreram no grupo NASP após extubação, em menor intensidade. Aspiração endotraqueal sem indicação mostrou-se custosa e com desperdício de tempo dos profissionais.

Efetividade oxi-hemodinâmica de três tipos de banho no leito de pacientes cardiopatas graves: crossover

Objetivo: identificar alterações hemodinâmicas e/ou oximétricas decorrentes de três técnicas de banho no leito em pacientes cardiopatas internados em uma Unidade de Terapia Intensiva Cirúrgica. Método: Ensaio clínico tipo crossover 3 X 3 no qual foram aplicadas três tecnologias de banho no leito, no mesmo indivíduo, em três momentos diferentes. As intervenções consideradas foram: banho tradicional a 42,5ºC com temperatura da água monitorada e constante; Banho com frasco-ampola de 1L de água destilada aquecido por 1 minuto no forno de micro-ondas em potência máxima sem controle da temperatura; Banho com lenços umedecidos aquecidos por 20 segundos no forno de micro-ondas em potência máxima. Amostra composta por 18 pacientes em pós-operatório de cirurgias cardíacas. Foram analisadas as variáveis frequência cardíaca, frequência respiratória, Pressão arterial (sistólica, diastólica e média), temperatura axilar e saturação de oxigênio por meio de oximetria de pulso. Para comparação das médias, foi utilizado o teste ANOVA Two-way de medidas repetidas com nível de significância pré-estabelecido de 5%. Resultados: Amostra predominantemente masculina, parda e não fumante, submetida majoritariamente à cirurgia de revascularização do miocárdio. Não houve nenhuma alteração significativa nas variáveis estudadas (p > 0,05), considerando os diversos tipos de banho nos diferentes momentos (antes, durante e após o procedimento). Conclusão: Os banhos no leito com água a 42,5°C, com frasco-ampola de água destilada aquecido e com lenços umedecidos, em pacientes pós-cirurgia cardíaca e internados em UTI, não acarretam nenhuma alteração significativa sobre as variáveis oxi-hemodinâmicas.

Neurological Complications after Coronary Artery Bypass Grafting for High-Risk Patients: Current State of the Problem

Neurological disorders are the most serious and debilitating complications of the postoperative period in cardiac surgery. The main clinical manifestations of cerebral dysfunction are as follows: stroke, decreased cognitive function, encephalopathy and depressive disorder.
 The aim. To perform a literature review of neurological complications after coronary artery bypass grafting (CABG) in high-risk patients.
 Results. The main neurological complications after CABG in high-risk patients were considered. The main pathophysiological mechanisms of development of cerebral circulation disorders in the form of macro- and microembolization, hypoperfusion secondary to hypotension and systemic inflammatory response have been determined. According to the literature, the incidence of stroke in the postoperative period is 1.5–6%, and it increases in the elderly. It’s important to perform carotid arteries ultrasound before CABG. According to the literature, carotid stenosis greater than 60% is found, depending on the age group, in 7–12% of patients. There is an ongoing debate around the world regarding the method and time of carotid atherosclerosis surgery (before revascularization, during or after CABG). Newman and co-authors have shown that in 5 years after myocardial revascularization, 41% of patients have a decrease in cognitive function, and it is lower than it was before surgery. Opponents of on-pump CABG have hypothesized the occurrence of Alzheimer’s disease after surgery with extracorporeal circulation, but authors from Mayo Clinic have investigated this question and refuted this theory; Canadian researchers have even proved the positive effect of revascularization on prevention of Alzheimer’s disease. The main strate­ gy for the prevention of cerebral complications is an individual approach for each high-risk patient.

Predicción de aparición de injuria renal aguda después de cirugía cardiovascular en la unidad de cuidados intensivos del Hospital Universitario San Ignacio

*Trabajo ganador del Premio al "Mejor Trabajo de Investigación Clínica" otorgado por el XXI Congreso Colombiano de Medicina Interna, Cali, 14 al 17 de octubre de 2010
 
 Objetivo: identificar pacientes de alto riesgo de presentar injuria renal aguda en el posoperatorio de cirugía cardiovascular en la unidad de cuidados intensivos del Hospital Universitario San Ignacio.
 
 Contexto y tipo de estudio: la población de referencia estuvo conformada por aquellos pacientes atendidos en el Hospital San Ignacio de la ciudad de Bogotá, institución de IV nivel de complejidad, con una población estudio conformada por aquellos pacientes que ingresaron a la unidad de cuidados intensivos en posoperatorio inmediato de cirugía cardiovascular.
 
 Material y métodos: estudio observacional descriptivo, retrospectivo, tipo serie de casos. La información fue recolectada por los investigadores a partir de la revisión de las historias clínicas, es decir, a partir de una fuente secundaria. Dicha recolección se realizó teniendo en cuenta un formulario diseñado para ese fin, el cual incluye datos generales y datos de las variables de la escala de predicción, registrando los datos generales de cada uno de los pacientes, incluyendo antecedentes personales y las variables de la escala de predicción.
 
 Durante la recolección de información se fue conformando la base de datos, la cual fue debidamente revisada y depurada, y posteriormente analizada utilizando el programa Epi Info 2000.
 
 Resultados: se analizaron 213 pacientes que ingresaron a la unidad de cuidado intensivo del Hospital Universitario San Ignacio en el posoperatorio inmediato de CVC. Entre los pacientes analizados la incidencia de IRA fue 3.3% (n=7) los cuales fueron sometidos a TRR. Estos pacientes tuvieron una creatinina posterior al procedimiento significativamente más alta (p=0.000). Entre los pacientes que requirieron TRR se encontró una proporción significativamente mayor de casos con una FEVI menor a 40% (71.4% vs 14.1%). Otra diferencia significativa fue el porcentaje de pacientes en quienes se utilizó el balón intraaórtico, el cual fue mucho mayor entre los pacientes que recibieron TRR (p=0.000). En cuanto a la relación entre la IRA y los procedimientos realizados a los pacientes se evidenció una mayor proporción de casos manejados con CEC dentro del grupo de pacientes que requirieron TRR; así mismo, la proporción de pacientes a quienes se les colocó balón intraaórtico fue significativamente mayor (p=0.000). Al aplicar la escala de riesgo en los pacientes analizados se evidenció que existían cuatro pacientes con alto riesgo de IRA cuyo puntaje fue mayor a cuatro. De estos pacientes solamente dos (50%) terminaron en TRR.
 
 Conclusiones: la aparición de lesión renal aguda en pacientes que son llevados a cirugía cardiovascular se ha demostrado como factor independiente de mortalidad en los pacientes en las unidades de cuidado intensivo. Los modelos predictivos para determinar la aparición de IRA en el posoperatorio de CVC han facilitado la toma de decisiones y la evaluación y estratificación del riesgo, abriendo la posibilidad de realizar intervenciones más tempranas y efectivas en pro de la recuperación, disminución de complicaciones y descenso de la morbimortalidad en estos pacientes

Effect of opioid-free anaesthesia on post-operative period in cardiac surgery: a retrospective matched case-control study

BackgroundNo study has been conducted to demonstrate the feasibility of an opioid-free anesthesia (OFA) protocol in cardiac surgery to improve patient care. The aim of the present study was to evaluate the effect of OFA on post-operative morphine consumption and the post-operative course.MethodsAfter retrospectively registering to clinicaltrial.gov (NCT03816592), we performed a retrospective matched cohort study (1:1) on cardiac surgery patients with cardiopulmonary bypass between 2018 and 2019. Patients were divided into two groups: OFA (lidocaine, dexamethasone and ketamine) or opioid anaesthesia (OA) (sufentanil). The main outcome was the total postoperative morphine consumption in the 48 h after surgery. Secondary outcomes were rescue analgesic use, a major adverse event composite endpoint, and ICU and hospital length of stay (LOS).ResultsOne hundred ten patients were matched (OFA: n = 55; OA: n = 55). On inclusion, demographic and surgical data for the OFA and OA groups were comparable. The total morphine consumption was higher in the OA group than in the OFA group (15 (6–34) vs 5 mg (2–18), p = 0.001). The pain score during the first 48 post-operative hours did not differ between the two groups. Creatinine values did not differ on the first post-operative day (80 (IQR: 66–115) vs 77 mmol/l (IQR: 69–95), p = 0.284). Incidence of the composite endpoint was lower in the OFA group (25 patients (43%) vs 38 patients (68%), p = 0.021). The time to extubation and the ICU stays were shorter in the OFA group (3 (1–5) vs 5 (3–6) hours, p = 0.001 and 2 (1–3) vs 3 (2–5) days, p = 0.037).ConclusionThe use of OFA was associated with lower morphine consumption. OFA might be associated with shorter intubation time and ICU stays. Further randomized studies are needed to confirm these results.Trial registrationThis study was retrospectively registered to ct2 (identifier: NCT03816592) on January 25, 2019.

Pilot study of viability in the use of cycle ergometer for upper limbs in the immediate postoperative period of cardiac surgery

INTRODUCTION: The use of a cycle ergometer for the upper limbs may contribute to maintain the functional capacity in patients after heart surgery (HS). OBJECTIVES: To investigate the cardiorespiratory responses of HS patients receiving or not vasoactive drugs (VADs) during the realizations of cycle ergometer for upper limbs, verifying the incidence of loss of radial arterial catheter or of steel wire fractures in the sternum. MATERIAL AND METHODS: A pilot study involving 26 patients divided in 2 groups. Group CO: no use of VADs (13 patients, age: 57±12 years, 09 male) and VAD group: (13 patients, age: 61±10 years, 07 male), submitted to HS, which on the first postoperative day (1stPO) performed the cycle ergometer for upper limbs. The parameters evaluated during the exercise were heart rate (HR), oxygen saturation (SpO2), dyspnea, fatigue of upper limbs and mean arterial pressure (MAP). The incidence of losses of the radial artery catheter and of steel wire fractures in the sternum was calculated. Statistical analysis adopted one-way or two-way analysis of variance, with post hoc from Newman Kauls or Scheffé, when necessary. The significance level was 0.05%. RESULTS: HR increased in both groups at the end of the exercise (p=0.00), with no difference between them (p=0.97); SpO2, dyspnea and MAP did not change from rest to the end of exercise (p=0.49; p=0.78 and p=0.25, respectively); The fatigue in the upper limbs increased in both groups (p=0.04), without difference between groups (p=0.79); There was no event of loss of radial artery catheter or steel wire fractures in the sternum. CONCLUSION: The adoption of the cycle ergometer for upper limbs was safe in the 1stPO of HS, even in the individuals using VADs. There was no relationship between the use of the upper limbs cycle ergometer and losses of arterial catheters or steel wire fractures in the sternum.

Factores de riesgo para ansiedad y depresión en el periodo preoperatorio de cirugía cardiaca

Objetivo: Evaluar los factores de riesgo de ansiedad y depresión en el período preoperatorio de la cirugía cardíaca.Método: Se trata de un estudio seccional, realizado entre enero y junio de 2017, en un hospital universitario de referencia en cardiología en el nordeste de Brasil. Se evaluaron 174 pacientes utilizando un cuestionario propio y la Escala Hospitalaria de Ansiedad y Depresión (HADS) y calculadas las Odds Ratios para evaluar el riesgo.Resultados: En la evaluación de la ansiedad, fueron factores de riesgo significativos: sexo femenino, años de estudio, ausencia de acompañante, experiencia previa de cirugía cardiaca y la cancelación de la cirugía durante el internamiento. En cuanto a la depresión, se revelaron factores de riesgo: sexo femenino y tiempo de internamiento mayor de 15 días.Conclusión: El enfermero tiene instrumentos disponibles para reconocer la ansiedad y la depresión, incluyendo los diagnósticos de enfermería y las escalas validadas, así como tiene un papel preponderante en la actuación en estos casos. Debe ser un desafío institucional dinamizar el servicio para evitar prolongaciones de la internación y cancelaciones de cirugía por cuestiones estructurales. Objective: To evaluate the risk factors of anxiety and depression in the preoperative period of cardiac surgery.Method: This is a sectional study, conducted between January and June 2017, in a university hospital of reference in cardiology in northeastern Brazil. A total of 174 patients were evaluated using their own questionnaire and the Hospital Anxiety and Depression Scale (HADS) and Odds Ratios were calculated to assess the risk.Results: In the assessment of anxiety, significant risk factors were: female gender, years of study, absence of companion, previous experience of cardiac surgery and cancellation of surgery during hospitalization. As for depression, risk factors were revealed: female sex and hospitalization time greater than 15 days.Conclusion: The nurse has instruments available to recognize anxiety and depression, including nursing diagnoses and validated scales, as well as having a preponderant role in these cases. It should be an institutional challenge to streamline the service in order to avoid prolongation of hospitalization and cancellations of surgery for structural reasons. Objetivo: avaliar os fatores de risco de ansiedade e depressão no período pré-operatório de cirurgia cardíaca. Método: Trata-se de um estudo seccional, realizado entre janeiro e junho de 2017, em um hospital universitário de referência em cardiologia no nordeste do Brasil. Foram avaliados 174 pacientes utilizando-se um questionário próprio e a Escala Hospitalar de Ansiedade e Depressão (HADS) e calculadas as Odds Ratios para avaliar o risco. Resultados: Na avaliação da ansiedade, foram fatores de risco significativos: sexo feminino, anos de estudo, ausência de acompanhante, experiência prévia de cirurgia cardíaca e o cancelamento da cirurgia durante o internamento. Quanto à depressão, revelaram-se fatores de risco: sexo feminino e tempo de internamento maior de 15 dias. Conclusão: O enfermeiro tem instrumentos disponíveis para reconhecer a ansiedade e a depressão, incluindo os diagnósticos de enfermagem e as escalas validadas, assim como tem papel preponderante na atuação nestes casos. Deve ser um desafio institucional dinamizar o serviço de forma a evitar prolongamentos do internamento e cancelamentos de cirurgia por questões estruturais.

Post esophagectomy diaphragmatic hernia: a case report of a rare cause of acute respiratory distress

BackgroundDiaphragmatic hernia is frequent among the elderly and is usually associated with mild chronic digestive and respiratory symptoms.Case presentationAn elderly post-esophagectomy male patient, in the early postoperative period of cardiac surgery, presented with acute respiratory distress. An emergent surgery was performed to reduce a giant diaphragmatic herniation.ConclusionsAn acute transhiatal herniation can cause serious respiratory impairment; surgical repair should be considered in select patients of cardiac surgery.