Post-cardiac Surgery Research Articles

David Procedure for Aortic Root Aneurysm in a Post-Mitral Valve Repair patient with Marfan’s Syndrome – a Case Report.

Marfan’s syndrome is a multisystem connective tissue disorder caused by mutation of FBN1 gene, frequently affects the human cardiac valves. These patients commonly die due to cardiovascular diseases. David procedure has been recognized as a durable treatment option in younger adults for aortic root replacement in aortic aneurysm. But performing a David re-implantation for aortic root replacement in a post cardiac (mitral valve repair/MVR) surgery patient is not an easy task. We hereby present a case of successful David re-implantation of aortic root in a young post MVR patient. (Bangladesh Heart Journal 2024; 39(2): 168-171

Efficacy of Sternum Guard vs. bone wax in post-cardiac surgery patients: a randomized controlled trial.

Median sternotomy offers the main access during cardiac surgery. However, a surgical site infection (SSI) of the sternum is a distressing complication following this procedure. The incidence of postoperative superficial and deep SSI in cardiac surgery varies from 1.3% to 12.8%. Bone wax, a nonabsorbable substance applied as a mechanical barrier following a median sternotomy, can increase the risk of postoperative sternal dehiscence. Sternum Guard (Vygon, Ecouen, France), a sternal protection device used to cover the sternum after a median sternotomy, offers mechanical protection to prevent lesions on the sternum. The aim of this study was to compare the effectiveness of Sternum Guard (Vygon) and bone wax in reducing SSI and facilitating hemostasis in post-cardiac surgery patients. This single-blinded, single center randomized controlled trial comprised 414 adult patients who underwent cardiac surgery. The postoperative outcomes assessed were SSI and the quantity of blood lost from the sternal edges in the Sternum Guard (Vygon; treatment) and bone wax (control) groups. The superficial SSI prevalence in the Sternum Guard group was lower than that in the bone wax group (2.9% vs. 8.2%, respectively; P=0.018). The incidence of deep SSI was also lower in the Sternum Guard group (1%) compared to the control group (2.9%) although this was not statistically significant (P=0.284). In terms of intraoperative sternal bleeding, Sternum Guard (Vygon) absorbed more than the sterile drapes used in the control group (84.97±115.99 vs. 81.18±14.62, respectively; P=0.012). Sternum Guard (Vygon) had a significantly lower incidence of postoperative infection and bleeding from the sternum compared to bone wax.

Depression predicts delayed return to daily activities in patients post-cardiac surgery: a prospective observational study

BackgroundDepression significantly impacts recovery and return to daily activities in cardiac surgery patients. Assessing and managing depressive symptoms before and after surgery are crucial for improving surgical outcomes and timely return to daily activities, including work. The objectives of this study were to examine differences in patients’ depression levels in relation to their return to daily activities in the early post-cardiac surgery period, and to assess predictors of delayed return to daily activities.MethodsThis single-centered study assessed return to independence, social participation, hobbies, and work in 100 cardiac surgical patients at 2 and 6 weeks post-surgery. Associations between depression levels and return to daily activities scores were evaluated.ResultsHigher Center for Epidemiologic Studies Depression Scale (CES-D) scores were significantly associated with delayed return to daily activities in all categories at both 2 and 6 weeks post-surgery. Specifically, higher depression score delayed return to independence and social participation at 2 weeks, and delayed return to independence, social participation, and return to work at 6 weeks.ConclusionElevated depression scores are significantly associated with delayed return to daily activities post-cardiac surgery, indicating the importance of evaluating depression in cardiac surgical patients in the postend stage-operative period.

Multimodal Analgesia Strategies for Cardiac Surgery: A Literature Review

In cardiac surgery, poststernotomy pain is a significant issue, peaking within 48 h and requiring proper analgesia for both acute relief and avoidance of chronicization. Opioids are commonly used for pain management postsurgery but pose risks such as adverse effects and dependency. Post-cardiac surgery pain can stem from various sources—somatic, visceral, and neuropathic—making opioid reliance a concern. Multimodal analgesia, which combines different medications and regional anesthesia techniques, is increasingly recommended to decrease opioid use and its related problems. Strategies include acetaminophen, gabapentinoids, NMDA antagonists, alpha-2 agonists, intravenous lidocaine, anti-inflammatory drugs, and regional anesthesia. These approaches can enhance pain control, reduce opioid reliance, and improve cardiac surgery outcomes. The ERAS® Cardiac Society strongly advocates for an opioid-sparing multimodal approach to improve patient recovery by reducing complications and increasing patient satisfaction. This review aims to consolidate current evidence to assist healthcare providers in customizing pain management for patients post-cardiac surgery, emphasizing reduced opioid use and optimizing the recovery process.

The geriatric nutritional risk index is related to adverse hospitalization outcomes in individuals undergoing cardiac surgery

Malnutrition is linked to adverse outcomes in post-cardiac surgery patients. This study investigates the correlation between the Geriatric Nutritional Risk Index (GNRI) and adverse hospital outcomes in patients following cardiac surgery. This retrospective study included elderly patients with heart disease who were admitted to the Department of Cardiology, Fujian Medical University Union Hospital from January 2020 to December 2022. Patients were divided into two groups based on the cut-off value (98 g/dL). Data from 407 patients were assessed, with 278 (68.3%) classified as having nutritional risk and 129 (31.7%) as having no nutritional risk. Notable distinctions were observed in body weight, BMI, and left ventricular ejection fraction (P < 0.05). Laboratory indicators indicated lower levels of serum albumin, lymphocytes, red blood cells, hemoglobin, admission blood glucose, and admission triglyceride in the nutritional risk group (P < 0.05). Neutrophils and serum creatinine were higher in the nutritional risk group (P < 0.05). Poor prognosis was prevalent in the nutrition risk group (64.7%), with higher incidences of adverse outcomes (P < 0.05). Univariate and multivariate studies showed that GNRI < 98 g/dL was an independent predictor of postoperative cardiac surgery. Nutritional risk was an important predictor of adverse hospital outcomes after the surgery.

Magnesium sulphate to prevent perioperative atrial fibrillation in cardiac surgery: a randomized clinical trial

BackgroundPostoperative atrial fibrillation (POAF) is a common and potentially serious complication post cardiac surgery. Hypomagnesaemia is common after cardiac surgery and recent evidence indicates that supplementation of magnesium may prevent POAF. We aim to investigate the effectiveness of continuous intravenous magnesium sulphate administration in the perioperative period to prevent POAF as compared to placebo.MethodsThe (POMPAE) trial is a phase 2, single-center, double-blinded randomized superiority clinical study. It aims to assess the impact of perioperative continuous intravenous magnesium administration on the occurrence of cardiac surgery-related POAF. A total of 530 patients will be included. Eligible patients will be randomized in 1:1 ratio to the intervention or placebo group with stratification based on the presence of valvular surgery. The objective of the infusion is to maintain ionized magnesium levels between 1.5 and 2.0 mmol/L.DiscussionThe primary outcome measure is the incidence of de novo POAF within the first 7 days following surgery, with censoring at hospital discharge. This trial may generate crucial evidence for the prevention of POAF and reduce clinical adverse events in patients following cardiac surgery.Trial registrationThe POMPAE trial was registered at ClinicalTrials.gov under the following identifier NTC05669417, https://clinicaltrials.gov/ct2/show/NCT05669417. Registered on December 30, 2022.Protocol versionVersion 3.3, dated 13–01-2023.

Assessing the predictive value of elevated postoperative syndecan-1 levels for progressive acute kidney injury and kidney replacement therapy necessity in adult cardiac surgery patients

BackgroundThe development of acute kidney injury (AKI) post-cardiac surgery significantly increases patient morbidity and healthcare costs. Prior researches have established Syndecan-1 (SDC-1) as a potential biomarker for endothelial injury and subsequent acute kidney injury development. This study assessed whether postoperative SDC-1 levels could further predict AKI requiring kidney replacement therapy (AKI-KRT) and AKI progression.MethodsIn this prospective study, 122 adult cardiac surgery patients, who underwent valve or coronary artery bypass grafting (CABG) or a combination thereof and developed AKI within 48 h post-operation from May to September 2021, were monitored for the progression to stage 2–3 AKI or the need for KRT. We analyzed the predictive value of postoperative serum SDC-1 levels in relation to multiple endpoints.ResultsIn the study population, 110 patients (90.2%) underwent cardiopulmonary bypass, of which thirty received CABG or combined surgery. Fifteen patients (12.3%) required KRT, and thirty-eight (31.1%) developed progressive AKI, underscoring the severe AKI incidence. Multivariate logistic regression indicated that elevated SDC-1 levels were independent risk factors for progressive AKI (OR = 1.006) and AKI-KRT (OR = 1.011). The AUROC for SDC-1 levels in predicting AKI-KRT and AKI progression was 0.892 and 0.73, respectively, outperforming the inflammatory cytokines. Linear regression revealed a positive correlation between SDC-1 levels and both hospital (β = 0.014, p = 0.022) and ICU stays (β = 0.013, p < 0.001).ConclusionElevated postoperative SDC-1 levels significantly predict AKI progression and AKI-KRT in patients following cardiac surgery. The study’s findings support incorporating SDC-1 level monitoring into post-surgical care to improve early detection and intervention for severe AKI.

Smartwatch for Identification of Atrioventricular Block in Post-cardiac Surgery: Going Beyond Atrial Fibrillation Detection

Smartwatch for Identification of Atrioventricular Block in Post-cardiac Surgery: Going Beyond Atrial Fibrillation Detection

Incidence of Acute Kidney Injury and Mortality Post Successful Cardiac Surgery in a Kashmiri Cohort: A Prospective Comparison of the RIFLE and KDIGO Criteria.

Background and objectives In critically ill patients, acute kidney injury (AKI) influences mortality and morbidity. Few studies have looked at mortality and the frequency of AKI following successful heart and thoracic operations. The current study investigates the association between AKI and mortality rates among patients undergoing post-cardiac surgery care within the Cardiology & Cardio Vascular Thoracic Surgery (CVTS) Intensive Care Unit (ICU). Methodology In this prospective research, 124 patients who underwent successful cardiovascular and thoracic procedures between June 2022 and June 2023 were admitted to the CVTS ICU. To determine mortality, we contrasted the two scoring methods, Kidney Disease-Improving Global Outcomes (KDIGO) and Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease (RIFLE). Results Based on the KDIGO criteria, AKI was identified in 37.90% (n = 47) of the patients, and it was identified in 15.32% (n = 19) of the patients utilizing RIFLE. Notably, patients diagnosed with AKI using either the RIFLE criteria or KDIGO criteria exhibited considerably higher mortality rates (p< 0.001). Receiver operating characteristic (ROC) analysis demonstrated the effectiveness of both scoring systems in identifying mortality (area under the ROC curve for RIFLE = 0.224 and KDIGO = 0.150). Conclusion Post-cardiac surgery, AKI escalates both mortality and morbidity rates. Despite KDIGO detecting more severe renal injury and mortality, both scoring systems exhibit comparable sensitivity and specificity in predicting death among patients undergoing various cardiovascular and thoracic procedures.

Early administration of ketorolac after cardiac surgery and postoperative complications: Analysis of the MIMIC-IV database.

Inflammation may contribute to postoperative cardiac complications and ketorolac, an anti-inflammatory agent inhibiting cyclooxygenase (COX), shows promise in enhancing cardiac graft patency by suppressing endothelial cell proliferation in animal studies. However, the safety of postoperative ketorolac use remains controversial. This study investigates the association between early ketorolac application and complications following cardiac surgery. Data from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database fueled this retrospective cohort study. The primary outcome is a composite of mortality, pulmonary insufficiency, severe acute kidney injury (AKI), hemorrhage or hematoma, infection, cardiogenic shock, and cerebrovascular infarction postcardiac surgery. Propensity score matching (PSM; 1:1 match, caliper 0.2), multivariate logistic regression, interaction stratification analysis, pairwise algorithmic, and overlap weight model analyses were employed. Following inclusion and exclusion criteria, 7143 patients who underwent valvular surgery or coronary artery bypass grafting (CABG) were included. PSM created a balanced cohort of 3270 individuals (1635 in the ketorolac group). The matched cohort exhibited an 8.1% overall rate of postoperative complications, with a lower composite outcome rate in patients receiving ketorolac within 48 h of surgery compared with those without (PSM, OR 0.70 [95% CI, 0.54-0.90]). Consistent associations were observed in total cohort analyses, sensitivity, and subgroup analyses. Early ketorolac use within 48 h post-CABG or valvular procedures in adults is independently associated with a lower incidence of composite postoperative adverse events. Prospective trials are warranted to assess causality.

Cardiac Surgical Unit-Advanced Life Support–certified centers are associated with improved failure to rescue after cardiac arrest: A propensity score–matched analysis

ObjectiveThe impact of Cardiac Surgical Unit-Advanced Life Support (CSU-ALS) training on failure to rescue after cardiac arrest (FTR-CA) is unknown. We hypothesized that institutional CSU-ALS certification would be associated with lower FTR-CA. MethodsPatients undergoing Society of Thoracic Surgeons index operations from 2020 to 2023 from a regional collaborative were analyzed. Each institution was surveyed regarding its status as a CSU-ALS–certified center. Patients stratified by CSU-ALS certification were 1:1 propensity score matched with subsequent multivariable model reviewing associations with FTR-CA. ResultsA total of 12,209 patients were included in the study period across 15 institutions. Eight centers reported CSU-ALS certification. After propensity score matching, 2 patient cohorts were formed (n = 3557). Patients at CSU-ALS centers had greater rates of intensive care unit readmission (3.9% vs 2.3%, P < .01) and total operating room time (340 minutes vs 323 minutes, P < .01). Hospital readmission was less likely in the CSU-ALS centers (9.0% vs 10.1%, P < .01). There was no difference in the rate of postoperative cardiac arrest (1.8% vs 2.2%, P = .24) or operative mortality (2.5% vs 2.9%, P = .30). After risk adjustment, CSU-ALS centers (odds ratio, 0.30; 95% confidence interval, 0.12-0.72, P < .01) and greater-volume centers (odds ratio, 0.15; confidence interval, 0.03-0.74, P = .02) had reduced odds of FTR-CA. ConclusionsCenters with CSU-ALS certification are associated with a lower risk-adjusted likelihood of FTR-CA. This highlights the importance of well-trained staff and treatment algorithms in the care of patients postcardiac surgery.

Cardiac Catheterization Post Congenital Cardiac Surgery: Analysis of Risk Factors for Mortality and Literature Review.

Background Diagnostic and interventional cardiac catheterization plays a significant role in the management of congenital heart defects with acceptable risks. Its role has also evolved in sick children but is associated with higher risks due to technical difficulties and co-morbidity factors. Some of the post-cardiac surgery children who show resistance to conventional management during the early postoperative period usually have residual defects or obstructions. Trans-catheter intervention (TCI) in such high-risk circumstances and relatively sick children is challenging, demands much expertise, and should be backed up by a competent multidisciplinary team. Some cases improve clinically, while others may require surgical or transcatheter re-intervention for a positive outcome. There is minimal data so far regarding the major complications after interventional cardiac catheterization during the immediate postoperative period after cardiac surgery.We analyzed multiple factors, including age, sex, weight, the initial diagnosis, and the time interval between surgery and TCI, to stratify the possible risks for mortality after TCI during the immediate postoperative period after cardiac surgery. Results Thirty-five patients fulfilled the inclusion criteria and underwent 43 interventional procedures. Five patients could not survive.Four had stent angioplasties on natural vasculature and one patient had in synthetic conduit. None of the mortality was related to the procedure.Multivariable risk factor analysis confirmed a moderate positive correlation coefficient (r) of 0.8017 between the variables. Still, it was not statistically significant if compared among subgroups or among the mortality and survival groups. Conclusion Interventional cardiac catheterization in sick children during the immediate postoperative period can be carried out without much-added risks in expert hands and under the supervision of a multi-disciplinary team.Though no conclusions could be drawn, our study adds to the limited existing data that could inspire others to perform such procedures on sick children. Moreover, the trend in our results indicated a large sample size could have identified a possible risk factor for mortality.

The Importance of Monitoring Blood Glucose Test in Patients Post-operative Coronary Artery Bypass Graft Surgery

Hyperglycemia is a risk factor for cardiac surgery-associated acute kidney injury in post-operative coronary artery bypass graft surgery patients. Glycemic control is important to prevent cardiac surgery-associated acute kidney injury. Postoperative glycemic control suggested 110-150 mg/dL. The aims of this study were to lower blood glucose levels and reduce the risk of occurrence or severity of cardiac surgery-associated acute kidney injury in post coronary artery bypass graft surgery patients. This study was conducted with a case study design involving 2 post operative coronary artery bypass graft patients who experienced hyperglycemia on the 1st to the 3rd day of treatment. Data collection was carried out from May 22 to May 23, 2023. The results of the case study showed that monitoring blood glucose in post-cardiac surgery patients is very important. Both patients experienced hyperglycemia in the early postoperative phase. With close monitoring and administration of insulin therapy according to the doctor's advice, the blood sugar levels of both patients were controlled. Monitoring urine output and evaluating serum creatinine levels showed that the first patient had cardiac surgery-associated acute kidney injury stage 1 on day 2 and showed improvement on day 3. The second patient did not develop cardiac surgery-associated acute kidney injury. The role of critical nurses in monitoring blood glucose levels and administering insulin doses is supported by related research. Strict monitoring and target ranges of blood glucose levels, in collaboration with the medical team are necessary to reduce the risk of cardiac surgery-associated acute kidney injury events.

Breast Milk and Necrotizing Enterocolitis in Congenital Heart Disease: A Case-Control Study.

Background: Necrotizing enterocolitis (NEC) is a complication that can affect infants with congenital heart disease (CHD). The objective of this study is to determine whether breast milk, which is associated with decreased incidence of NEC in preterm infants, is protective in infants with CHD. Methods: Retrospective case-control study of infants ≥ 33 weeks gestational age with CHD who underwent cardiac surgery during their admission to the Infant Cardiac Unit from 2008 to 2017. Cases were defined as infants with modified Bell's stage ≥ II NEC. Controls were matched by date of birth, gestational age, and pre- or postcardiac surgery feed initiation. Results: A total of 926 infants with gestational age ≥ 33 weeks and CHD were admitted; 18 cases of NEC were identified and compared with 84 controls. Breast milk intake was higher in controls, but this difference was not statistically significant. Single ventricle (SV) physiology was identified as an independent risk factor for NEC by multivariable analysis. Analysis of infants with SV physiology demonstrated that median age at time of surgery was 9 days (interquartile range [IQR], 7-12) in NEC cases and 5 days (IQR, 4-9) in controls (P = .02). Conclusions: While this study is inconclusive with regard to feeding composition and risk of NEC in infants with CHD, the trend toward greater intake of breast milk in the control group suggests that breast milk may be protective for these infants. Infants with SV physiology are at high risk for NEC. Earlier time to stage I palliation may be a modifiable risk factor for NEC.

A dimensional analysis of experienced intensive care unit nurses' clinical decision-making for bleeding after cardiac surgery.

Bleeding following cardiac surgery is common and serious, yet a gap persists in understanding how experienced intensive care nurses identify and respond to such complications. To describe the clinical decision-making of experienced intensive care unit nurses in addressing bleeding after cardiac surgery. This qualitative study adopted the Recognition-Primed Decision Model as its theoretical framework. Thirty-nine experienced nurses from four adult intensive care units participated in semi-structured interviews based on the critical decision method. The interviews explored their clinical judgements and decisions in bleeding situations, and data were analysed through dimensional analysis, an alternative to grounded theory. Participants maintained consistent vigilance towards post-cardiac surgery bleeding, recognizing it through a haemorrhagic dimension associated with blood loss and chest drainage and a hypovolemic dimension focusing on the repercussions of reduced blood volume. These dimensions organized their understanding of bleeding types (i.e., normal, medical, surgical, tamponade) and necessary actions. Their decision-making encompassed monitoring bleeding, identifying the cause, stopping the bleeding, stabilizing haemodynamic and supporting the patient and family. Participants also adapted their actions to specific circumstances, including local practices, professional autonomy, interprofessional dynamics and resource availability. Nurses' decision-making was shaped by their personal attributes, the patient's condition and contextual circumstances, underscoring their expertise and pivotal role in anticipating actions and adapting to diverse conditions. The concept of actionability emerged as the central dimension explaining their decision-making, defined as the capability to implement actions towards specific goals within the possibilities and constraints of a situation. This study underscores the need for continual updates to care protocols to align with current evidence and for quality improvement initiatives to close existing practice gaps. Exploring the concept of actionability further, developing adaptability-focused educational programmes, and understanding decision-making intricacies are crucial for informing nursing education and decision-support systems.

Nutritional Status and Post-Cardiac Surgery Outcomes: An Updated Review with Emphasis on Cognitive Function.

Background/Objectives: Nutritional status significantly influences cardiac surgery outcomes, with malnutrition contributing to poorer results and increased complications. This study addresses the critical gap in understanding by exploring the relationship between pre-operative nutritional status and post-operative cognitive dysfunction (POCD) in adult cardiac patients. Methods: A comprehensive search across key databases investigates the prevalence of malnutrition in pre-operative cardiac surgery patients, its effects, and its association with POCD. Factors exacerbating malnutrition, such as chronic illnesses and reduced functionality, are considered. The study also examines the incidence of POCD, its primary association with CABG procedures, and the impact of malnutrition on complications like inflammation, pulmonary and cardiac failure, and renal injury. Discussions: Findings reveal that 46.4% of pre-operative cardiac surgery patients experience malnutrition, linked to chronic illnesses and reduced functionality. Malnutrition significantly contributes to inflammation and complications, including POCD, with an incidence ranging from 15 to 50%. CABG procedures are particularly associated with POCD, and malnutrition prolongs intensive care stays while increasing vulnerability to surgical stress. Conclusions: The review underscores the crucial role of nutrition in recovery and advocates for a universally recognized nutrition assessment tool tailored to diverse cardiac surgery patients. Emphasizing pre-operative enhanced nutrition as a potential strategy to mitigate inflammation and improve cognitive function, the review highlights the need for integrating nutrition screening into clinical practice to optimize outcomes for high-risk cardiac surgery patients. However, to date, most data came from observational studies; hence, there is a need for future interventional studies to test the hypothesis that pre-operative enhanced nutrition can mitigate inflammation and improve cognitive function in this patient population.

Altered Microvascular Reactivity During a Skin Thermal Challenge Is Associated With Organ Dysfunction and Slow Recovery After Cardiac Surgery

ObjectivesTo assess microvascular reactivity during a skin thermal challenge early post-cardiac surgery and its association with outcome. DesignNon-invasive physiological study. SettingThirty-five-bed department of intensive care. ParticipantsPatients admitted to the ICU post-cardiac surgery. InterventionsThermal challenge. Measurements and Main ResultsForty-six patients were included; 14 needed vasoactive support or ventilatory support for at least 48 hours (slow recovery) and 32 had a more rapid recovery. Skin blood flow (SBF) was measured on the anterior proximal forearm using skin laser Doppler (SLD). A thermal challenge was performed by abruptly increasing local skin temperature from 37°C to 43°C while monitoring SBF. The ratio between the SBFs at 43°C and 37°C was calculated as a measure of microvascular reactivity. SBF at 37°C was not significantly different in patients with a slow recovery and those with a rapid recovery, but SBF after 9 min at 43°C was lower [48.5 (17.3-69.0) vs 85.1 (45.2-125.7), p<0.01], resulting in a lower SBF ratio [2.8 (1.5-4.7) vs 4.8 (3.7-7.8), p<0.01]. Patients with lower SBF ratios were more likely to have dysfunction of at least 1 organ (as assessed using the sequential organ dysfunction [SOFA] score) 48 hours post-cardiac surgery than those with higher ratios: 88% vs 40% vs 27% (p<0.01), respectively, for the lowest, middle, and highest tertiles of SBF ratio. In multivariable analysis, lower SBF ratio was an independent risk factor for slow recovery. ConclusionsEarly alterations in microvascular reactivity as evaluated by a skin thermal challenge are correlated with organ dysfunction. These observations may help in the development of new, simple, non-invasive monitoring systems in postoperative patients.

POStoperative INTELLiVENT-adaptive support VEntilation in cardiac surgery patients (POSITiVE) II—study protocol of a randomized clinical trial

BackgroundOne single-center randomized clinical trial showed that INTELLiVENT-adaptive support ventilation (ASV) is superior to conventional ventilation with respect to the quality of ventilation in post-cardiac surgery patients. Other studies showed that this automated ventilation mode reduces the number of manual interventions at the ventilator in various types of critically ill patients. In this multicenter study in patients post-cardiac surgery, we test the hypothesis that INTELLiVENT-ASV is superior to conventional ventilation with respect to the quality of ventilation.Methods“POStoperative INTELLiVENT-adaptive support VEntilation in cardiac surgery patients II (POSITiVE II)” is an international, multicenter, two-group randomized clinical superiority trial. In total, 328 cardiac surgery patients will be randomized. Investigators screen patients aged > 18 years of age, scheduled for elective cardiac surgery, and expected to receive postoperative ventilation in the ICU for longer than 2 h. Patients either receive automated ventilation by means of INTELLiVENT-ASV or ventilation that is not automated by means of a conventional ventilation mode. The primary endpoint is quality of ventilation, defined as the proportion of postoperative ventilation time characterized by exposure to predefined optimal, acceptable, and critical (injurious) ventilatory parameters in the first two postoperative hours. One major secondary endpoint is ICU team staff workload, captured by the ventilator software collecting manual settings on alarms. Patient-centered endpoints include duration of postoperative ventilation and length of stay in ICU.DiscussionPOSITiVE II is the first international, multicenter, randomized clinical trial designed to confirm that POStoperative INTELLiVENT-ASV is superior to non-automated conventional ventilation and secondary to determine if this closed-loop ventilation mode reduces ICU team staff workload. The results of POSITiVE II will support intensive care teams in their choices regarding the use of automated ventilation in postoperative care of uncomplicated cardiac surgery patients.Trial registrationClinicaltrials.gov NCT06178510. Registered on December 4, 2023.

Analysis of Risk Factors of Difficult Weaning from Mechanical Ventilation after Pediatric Cardiac Surgery: A Single Center Prospective Study

Abstract Background Weaning from mechanical ventilation (MV( and timing of extubation are crucial components in the postoperative management of cardiac surgery as altered respiratory mechanics and positive pressure ventilation may have significant influence on hemodynamics. Aim: To evaluate risk factors for failure of weaning from mechanical ventilation after pediatric cardiac surgery and to assess the frequency of phrenic nerve injury. Methodology This Cohort study included medical records of 101 children admitted consecutively to Pediatric post-cardiac surgery ICU in Academy of Cardiovascular surgery in Ain Shams university Hospitals between April, 2020 and April, 2021, who had undergone heart surgery. The patients were divided into two groups : - successefully weaned group. - Difficult to wean group. Diaphragmatic ultrasound was done for every difficult weaning patient to assess diaphragmatic paralysis. Result: Age (P &amp;lt; 0.001), Weight (P &amp;lt; 0.001), volum intake (P &amp;lt; 0.001), systolic blood pressure (P = 0.017), Diastolic blood pressure (P = 0.004), were significantly lower in patients who showed difficult weaning compared to patients with successful weaning. Furthermore operation time (P &amp;lt; 0.001), use of noradrenaline (P = 0.019), use of adrenaline ( P = 0.017), use of Milirinon ( P = 0.003), respiratory rate ( P = 0.003), inotropic support (P = 0.001), positive fluid balance (P &amp;lt; 0.001), heart failure, renal failure, Pulmonary complications, need of pace maker, sepsis ( P &amp;lt; 0.001), diaphragmatic paralysis ( P &amp;lt; 0.001), transposition of great arteries operations ( P = 0.009), were significantly higher in patients who showed difficult weaning compared to patients with successful weaning. While use of dobutamine, discharge with open chest, reoperation, transfusion &amp;gt; 50 ml / kg, urine output, reoperation bleeding and any operation other than atrial septal defect, transposition of great arteries all did not affect weaning difficulty. Conclusion younger age, operation time, as well as sepsis were the best predictors for difficulty of weaning.

Outcomes associated with postoperative cognitive dysfunction: a systematic review and meta-analysis.

Postoperative cognitive dysfunction (POCD) manifests as a subtle decline in cognition, potentially leading to unfavourable postoperative outcomes. We explored the impact of POCD on physical function, length of hospital stay (LOS), dementia and mortality outcomes. PubMed and Scopus were searched until May 2023. All studies of major surgical patients that assessed POCD and outcomes of interest were included. POCD effects were stratified by surgery type (cardiac and noncardiac) and time of POCD assessment (<30 and ≥30days postsurgery). Of 2316 studies, 20 met the inclusion criteria. POCD was not associated with functional decline postsurgery. Patients who experienced POCD postcardiac surgery had an increased relative risk (RR) of death of 2.04 [(95% CI: 1.18, 3.50); I2= 0.00%]. Sensitivity analyses showed associations with intermediate-term mortality among noncardiac surgical patients, with an RR of 1.84 [(95% CI: 1.26, 2.71); I2= 0.00%]. Patients who developed POCD <30days postcardiac and noncardiac surgeries experienced longer LOS than those who did not [mean difference (MD) = 1.37days (95% CI: 0.35, 2.39); I2= 92.38% and MD = 1.94days (95% CI: 0.48, 3.40); I2= 83.29%, respectively]. Postoperative delirium (POD) may contribute to the heterogeneity observed, but limited data were reported within the studies included. Patients undergoing cardiac and noncardiac surgeries who developed POCD <30days postsurgery had poorer outcomes and an increased risk of premature death. Early recognition of perioperative neurocognitive disorders in at-risk patients may enable early intervention. However, POD may confound our findings, with further studies necessary to disentangle the effects of POD from POCD on clinical outcomes.