Postoperative Cardiothoracic Surgery Patients Research Articles

Predictive Value of Ultrasonic Diaphragm Thickening Fraction on Successful Weaning in Postoperative Cardiothoracic Surgery Patients with Chronic Obstructive Pulmonary Disease (COPD)

Abstract Background The diaphragm is the most important muscle of respiration and is largely responsible for the change in the intra thoracic pressure. In mechanically ventilated patients, the diaphragm can develop atrophy and weakness leading to prolonged duration of mechanical ventilation. Many studies reported a high prevalence of diaphragm dysfunction during weaning, and it was found to be associated with poorer clinical outcomes. Objective To assess the predictive value of diaphragm thickening fraction (DTF) by bedside ultrasound on successful weaning in postoperative cardiothoracic surgery patients with COPD. Subjects and Methods This prospective study was conducted on 40 subjects at cardiothoracic ICU unit at Elmaadi Military hospital during the period from (September,2021) to (July,2022) after approval of the research Ethical committee at faculty of medicine, Ain shams university. Results Regarding the relation between the two studied groups and diaphragmatic thickness, the thickness was decreased in the failed group than the successful group during inspiration, expiration and thickness fraction %, with significant difference between two groups as p-Value was <0.05. There was an increase in the duration of ICU stay & mechanical ventilation in the failed group compared to the successful group, with significant difference between two groups as p-Value was <0.05. Regarding the correlation between ICU stay & mechanical ventilation and diaphragmatic thickness, there were negative correlation between ICU stay & MV duration and all parameters of the diaphragmatic thickness, with significant difference as p-Value was <0.05. Conclusion Weaning success in mechanically ventilated postoperative cardiothoracic surgery patients with COPD can be predicted by ultrasonography-based evaluation of diaphragm function by analyzing diaphragmatic thickness fraction. It is a practical, feasible, non-invasive technique that may be used at the bedside to rule out diaphragmatic dysfunction.

The global inhomogeneity index assessed by electrical impedance tomography overestimates PEEP requirement in patients with ARDS: an observational study

BackgroundElectrical impedance tomography (EIT) visualises alveolar overdistension and alveolar collapse and enables optimisation of ventilator settings by using the best balance between alveolar overdistension and collapse (ODCL). Besides, the global inhomogeneity index (GI), measured by EIT, may also be of added value in determining PEEP. Optimal PEEP is often determined based on the best dynamic compliance without EIT at the bedside. This study aimed to assess the effect of a PEEP trial on ODCL, GI and dynamic compliance in patients with and without ARDS. Secondly, PEEP levels from “optimal PEEP” approaches by ODCL, GI and dynamic compliance are compared.MethodsIn 2015–2016, we included patients with ARDS using postoperative cardiothoracic surgery patients as a reference group. A PEEP trial was performed with four consecutive incremental followed by four decremental PEEP steps of 2 cmH2O. Primary outcomes at each step were GI, ODCL and best dynamic compliance. In addition, the agreement between ODCL, GI, and dynamic compliance was determined for the individual patient.ResultsTwenty-eight ARDS and 17 postoperative cardiothoracic surgery patients were included. The mean optimal PEEP, according to best compliance, was 10.3 (±2.9) cmH2O in ARDS compared to 9.8 (±2.5) cmH2O in cardiothoracic surgery patients. Optimal PEEP according to ODCL was 10.9 (±2.5) in ARDS and 9.6 (±1.6) in cardiothoracic surgery patients. Optimal PEEP according to GI was 17.1 (±3.9) in ARDS compared to 14.2 (±3.4) in cardiothoracic surgery patients.ConclusionsCurrently, no golden standard to titrate PEEP is available. We showed that when using the GI, PEEP requirements are higher compared to ODCL and best dynamic compliance during a PEEP trial in patients with and without ARDS.

Nasal High Flow Versus Conventional Oxygen Therapy for Postoperative Cardiothoracic Surgery Patients.

Reintubation and complications in postoperative cardiothoracic patients remain high despite medical advancements. A 2-year retrospective, observational study was conducted in postextubated cardiothoracic patients to assess the effectiveness of the current standard-conventional oxygen therapy (COT) compared with a nasal high flow (NHF) therapy. The objective of this study was to understand whether NHF therapy would reduce the need for reintubation and improve clinical outcomes after surgery. All consecutive postoperative patients who had same-day elective cardiothoracic surgery in a tertiary hospital were included. The 2013 data were from patients' charts who received COT, and the 2014 data were from patients' charts after the implementation of NHF therapy post extubation as a standard of care. A total of 400 patient charts were analyzed: 221 and 179 patients in the COT and NHF, respectively. No significant difference was seen in the frequency of reintubation (P = .48). Despite both cohorts having the same length of stay (P = .10), patients treated with NHF required less time on supplemental oxygen (P = .001). Day 1 postoperative chest x-ray results did not show any significant differences between groups, whereas day 2 x-rays showed worsening results in the COT cohort (P < .001). Furthermore, the incidence of ventilator-associated pneumonia (VAP) post extubation was significantly higher in the COT cohort, with zero VAP episodes reported in the NHF cohort (P = .02). Although this study was not able to demonstrate the reduction in reintubation between groups, the use of NHF compared with COT seems to reduce the time spent on oxygen therapy and decrease the rate of VAP. Further evidence including randomized controlled trials is required to determine the impact of NHF on reintubation and complications in postoperative cardiothoracic surgery.

Improving Nutrition Practices for Critically Ill Postoperative Heart Transplant and Ventricular Assist Device Implant Patients

Purpose Patients undergoing orthotropic heart transplantation (OHT) and left ventricular assist device (LVAD) implantation may be challenging to feed postoperatively in the setting of cardiac dysfunction requiring high-dose vasoactive support. Variability in enteral nutrition (EN) practices in this setting is associated with onset of malnutrition and severe gastrointestinal (GI) complications such as bowel ischemia. Currently, there is limited guidance for nutrition in postoperative cardiothoracic surgery patients with significant hemodynamic compromise. To address the need for optimizing nutrition in this patient population, we created High Risk Enteral Nutrition Guidelines (HRENG) to provide postoperative nutritional guidance regarding EN route, timing, formula, feeding rate/progression, monitoring, and energy targets for EN and TPN in hemodynamically unstable OHT and LVAD patients. Methods HRENG were utilized in critically ill postoperative OHT and VAD implant patients that met at least two of the following criteria: cardiogenic shock, ECMO cannulation, low cardiac output on high dose vasopressor support, open chest, intubation >48 hours and signs of end organ dysfunction. Retrospective chart review was conducted on eligible OHT and LVAD patients for the 15 months prior to and following the implementation of HRENG at our institution. Data was collected regarding adherence to the guidelines and incidence of bowel ischemia. Results There were 26 eligible patients who underwent OHT and LVAD prior to initiating HRENG. Analysis of these revealed inconsistent postoperative feeding practices and 5 cases (19.2%) of bowel ischemia. After implementing HRENG, 28 patients OHT (n=11) and LVAD (n=17) met inclusion criteria. The mean age was 57.1 years, 38% ischemic, 38% women. 3/17 of LVAD patients had HM3; 14/17 had HVAD. Adherence to HRENG was achieved in 25/28 (89.2%) of patients. Of the 25 patients with adherence to HRENG, there were no cases (0%) of bowel ischemia. Of the 3 patients with nonadherence to these guidelines, 2 (66.67%) developed bowel ischemia. Conclusion Implementation of postoperative nutrition guidelines targeted for hemodynamically unstable OHT and VAD implantation patients may align feeding practices and reduce the incidence of ischemic GI complications.

Thoracostomy Tube Removal: Implementation of a Multidisciplinary Procedural Pain Management Guideline

ObjectiveThoracostomy tubes are placed following cardiothoracic surgery for the repair or palliation of congenital heart defects. The aim of this project was to develop and implement a clinical practice guideline for the provision of optimal analgesia during removal of thoracostomy tubes in pediatric postoperative cardiothoracic surgery patients. MethodsMethods used include a nonexperimental design utilizing chart audits to determine baseline documentation as well as procedure note evaluation to determine both baseline documentation and compliance with the new guideline. A convenience sample of unit-based nurses completed a knowledge test and a post-implementation survey. ResultsThere was a significant increase in nursing knowledge related to the clinical practice guideline education and implementation. Documentation compliance was observed. Nursing satisfaction and feasibility of the new guideline was demonstrated. DiscussionThis project was successful in increasing nursing knowledge of available resources for optimal procedural pain management in pediatric patients requiring thoracostomy tube removal on one in-patient acute care unit.

36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15-18 March 2016.

36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15-18 March 2016.

Patient-Centered Tools for Medication Information Search.

Recent research focused on online health information seeking highlights a heavy reliance on general-purpose search engines. However, current general-purpose search interfaces do not necessarily provide adequate support for non-experts in identifying suitable sources of health information. Popular search engines have recently introduced search tools in their user interfaces for a range of topics. In this work, we explore how such tools can support non-expert, patient-centered health information search. Scoping the current work to medication-related search, we report on findings from a formative study focused on the design of patient-centered, medication-information search tools. Our study included qualitative interviews with patients, family members, and domain experts, as well as observations of their use of Remedy, a technology probe embodying a set of search tools. Post-operative cardiothoracic surgery patients and their visiting family members used the tools to find information about their hospital medications and were interviewed before and after their use. Domain experts conducted similar search tasks and provided qualitative feedback on their preferences and recommendations for designing these tools. Findings from our study suggest the importance of four valuation principles underlying our tools: credibility, readability, consumer perspective, and topical relevance.

Fenoldopam Mesylate in Early Acute Tubular Necrosis: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

Acute tubular necrosis (ATN) occurs commonly in critically ill patients and is associated with increased morbidity and mortality. Fenoldopam is a dopamine receptor alpha1-specific agonist that increases renal blood flow in patients with kidney failure. We hypothesized that administration of low-dose fenoldopam during early ATN would decrease the need for dialysis therapy and/or incidence of death at 21 days. We conducted a prospective, randomized, double-blind, placebo-controlled, clinical trial in 155 patients with early ATN. Patients were considered eligible for enrollment if serum creatinine level increased to 50% greater than admission levels within 24 hours and mean arterial pressure was greater than 70 mm Hg. Patients were randomly assigned to the administration of placebo or fenoldopam for 72 hours. Overall, 22 of 80 patients (27.5%) in the fenoldopam group reached the primary end point compared with 29 of 75 patients (38.7%) in the placebo group (P = 0.235). This 11% absolute reduction in the primary end point was not statistically significant (P = 0.23). Similarly, there was no difference in the incidence of dialysis therapy between patients randomly assigned to fenoldopam (13 of 80 patients; 16.25%) versus the placebo group (19 of 75 patients; 25.3%; P = 0.163). Moreover, there was no statistically significant difference in 21-day mortality rates between the 2 groups (fenoldopam, 13.8% versus placebo, 25.3%; P = 0.068). In secondary analyses, fenoldopam tended to reduce the primary end point in patients without diabetes and postoperative cardiothoracic surgery patients with early ATN (fenoldopam patients without diabetes, 14 of 54 patients [25.9%] versus placebo patients without diabetes, 23 of 52 patients [44.2%]; P = 0.048) and postoperative cardiothoracic patients (6 of 34 patients [17.6%] versus 14 of 36 patients [38.8%]; P = 0.049). Conversely, fenoldopam did not improve the primary end point in patients with diabetes or those with acute renal failure from other causes. A larger multicenter trial using separate randomizations for patients with and without diabetes will be needed to determine the efficacy of fenoldopam mesylate in specific subpopulations with ATN. Fenoldopam does not reduce the incidence of death or dialysis therapy in intensive care unit patients with early ATN.

Comparison of continuous with intermittent bolus thermodilution cardiac output measurements

Few complete studies have been published to validate the agreement between continuous cardiac output and intermittent thermodilution cardiac output. To analyze the agreement between cardiac output measurements by the continuous thermodilution method and the intermittent bolus thermodilution method, using a continuous cardiac output catheter in postoperative cardiothoracic surgery patients. A convenience sample of 14 adult cardiothoracic surgical patients with thermodilution pulmonary artery catheters placed preoperatively was used. A total of 214 comparison measurements of cardiac output by both the continuous and intermittent thermodilution methods were taken on patient admission to the critical care unit, every 4 hours, and with any change greater than 10% from baseline readings. The intraclass correlation between continuous cardiac output and intermittent cardiac output was .89. The limits of agreement were -1.34 to 1.18 L/min, indicating that in 95% of readings the difference between continuous cardiac output and intermittent cardiac output were within this range. The continuous cardiac output monitoring method shows clinically acceptable agreement with the intermittent cardiac output method.

Esmolol: Safety and Efficacy in Postoperative Cardiothoracic Patients with Supraventricular Tachyarrhythmias

Esmolol, an intravenous, ultrashort-acting beta-blocker, was studied for its ability to safely control supraventricular arrhythmias up to 24 hours in 15 postoperative cardiothoracic surgery patients with atrial fibrillation or flutter and rapid ventricular response. Esmolol obtained an initial therapeutic response in nine (60 percent) patients. Mean heart rate for the 15 patients was reduced from 139 +/- 12 beats/min before therapy to 106 +/- 21 beats/min during esmolol infusion (p less than 0.01). The mean time to a therapeutic response after initiation of therapy, using a multistep titration regimen (500 micrograms/kg/min loading infusions over one minute, prior to incremental titration steps from 50 to 300 micrograms/kg/min over 4 to 14 minutes), was 22 +/- 9 minutes, and therapy was continued for 17 +/- 9 hours in responders. Esmolol significantly lowered blood pressure in the group studied and resulted in mild supine or orthostatic hypotension in ten (67 percent) patients. Side effects, including hypotension (10/15 patients), gastrointestinal disturbances (2/15), and weakness or somnolence (6/15), were transient and were not associated with serious clinical sequelae. We conclude that esmolol is effective for rate control in a majority of postoperative cardiothoracic surgery patients with atrial fibrillation or flutter. Side effects, although mild, occur relatively frequently, limiting prolonged infusions and warranting close surveillance of patients.

Clinical Evaluation of Three Techniques for Administering Low-Dose Heparin

The purpose of this study was to investigate the effect of three techniques for administering subcutaneous low-dose heparin on the formation of bruises at the injection site in adult postoperative cardiothoracic surgery patients. Forty-three subjects comprised the sample. All received subcutaneous injections of heparin, 5,000 units every 12 hours postsurgery. Three subcutaneous injection techniques, identified to study the variables of needle manipulation and tracking of the medication, were administered randomly to each subject. Forty-eight hours after the third injection, the sites were observed and bruises, if present, were measured. Data were analyzed by means of the Friedman test, and a 0.569 level of significance was obtained. It was concluded that, for this sample, none of the three techniques appeared clearly superior in yielding smaller or fewer bruises.