Postoperative Cardiac Surgery Patients Research Articles

Use of Bioimpedance Spectroscopy for Postoperative Fluid Management in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass

ObjectiveTo assess whether bioimpedance spectroscopy analysis (BIA) can be used as a potential tool to guide postoperative fluid management in patients who undergo cardiac surgery. DesignAn observational study. SettingA single, tertiary hospital. ParticipantsPatients who underwent cardiac surgery with cardiopulmonary bypass between June to November 2023 who were able to undergo BIA measurements. InterventionsNone. Measurements and Main ResultsCorrelations between BIA measurements of extracellular fluid (ECF) and total body water (TBW) volumes and daily changes in weight and 24-hour net intake and output (I/O) of fluids were assessed. Correlations between pre-discharge ECF volume as a percentage of TBW volume (ECF%TBW) and pre-discharge Pro-BNP (Pro-BNP) levels and readmissions were analyzed. Changes in daily ECF volume significantly correlated with daily weight changes (p<0.01) and 24-hr I/O (p<0.01). TBW volume significantly correlated with daily weight changes (p<0.01) and with 24-hr I/O (p=0.04). Daily weight changes did not correlate with 24-hr I/O (p=0.06). The patients with pre-discharge ECF%TBW(%) greater than or equal to 51 had significantly higher pre-discharge Pro-BNP than those with ECF%TBW(%) less than 51 (p<0.01). Patients who had heart failure revisits or admissions after discharge had a higher pre-discharge ECF%TBW(%) on index admission compared to patients that did not have heart failure readmissions (p=0.01). ConclusionsUtilization of BIA measurements in postoperative cardiac surgery patients may be a valuable tool to quantitatively determine fluid status to help guide fluid management in this patient population. Further studies validating the use of BIA for postoperative care in this population are warranted.

Factors related to loss of appetite in postoperative cardiac surgery patients: A systematic review

Background Postoperative cardiac surgery patients often experience appetite loss. Although nutritional status is known to be associated with time of recovery, functional status, and length of stay, less is known about factors related to patient’s loss of appetite after cardiac surgery. This review aimed to identify and understand factors related to loss of appetite in postoperative cardiac surgery patients, systematic review with narrative summary design was applied. Data sources including CINAHL, SCOPUS, PubMed, ProQuest, ScienceDirect, ThaiLIS, ThaiJo, and E-Thesis were searched without restriction on publication year through August 2020. Methods We conducted the review following the Joanna Briggs Institute methodology, using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist to categorize methodological quality and the PRISMA flow diagram to record the studies’ factors. Results Six studies reported one or more of 16 factors related to loss of appetite: older age, sex (female), illiteracy, history of chronic disease, not knowing someone in health field, pain score ≥ 7, pain medications containing codeine, constipation, depression, heart-lung machine ≥ 120 minutes, preoperative serum creatinine levels ≥ 179 µmol/L, emergency surgery, perfusion pressure ≤ 40 mmHg, low cardiac output syndrome, mechanical ventilation ≥ 96 hours, and a New York Heart Association class III and IV. Conclusion The small number of publications restrict our conclusions. Future research should focus on multiple factors related to appetite loss in postoperative cardiac surgery patients. Additional research will provide a foundation for evidence-based interventions to reduce appetite loss and improve patient nutritional status after cardiac surgery. Nurses and other health professionals should assess postoperative cardiac surgery patients for the presence of the 16 significant factors. To promote patients’ nutritional status, there should be evidence-based practice guidelines on the management of postoperative symptoms such as pain management, treatment of constipation, and reduction of emotional stress and depression.

Effectiveness of Adaptive Support Ventilation in Facilitating Weaning from Mechanical Ventilation in Postoperative Patients

This meta-analysis aims to evaluate the effectiveness of adaptive support ventilation (ASV) in facilitating postoperative weaning from mechanical ventilation in cardiac surgery patients. A systematic review and meta-analysis to assess ASV in weaning postoperative cardiac surgery patients. Outcomes included early extubation, reintubation rates, time to extubation, and lengths of intensive care units and hospital stays. We searched electronic databases from inception to March 2023 and included randomized controlled trials that compared ASV with conventional ventilation methods in this population. Postoperative cardiac surgery patients. A random effects model was used for meta-analysis, and trial sequential analysis (TSA) was conducted to assess result robustness. The meta-analysis included 11 randomized controlled trials with a total of 1027 randomized patients. ASV was associated with a shorter time to extubation compared to conventional ventilation (random effects, mean difference -68.30 hours; 95% confidence interval, -115.50 to -21.09) with TSA providing a conclusive finding. While ASV indicated improved early extubation rates, no significant differences were found in reintubation rates or lengths of intensive care unit and hospital stays, with these TSA results being inclusive. ASV appears to facilitate a shorter time to extubation in postoperative cardiac surgery patients compared to conventional ventilation, suggesting benefits in accelerating the weaning process and reducing mechanical ventilation duration.

Prediction of ventilator weaning failure in postoperative cardiac surgery patients using vasoactive-ventilation-renal score and nomogram analysis.

This study evaluated the predictive value of the vasoactive-ventilation-renal (VVR) score in identifying the risk of weaning failure after cardiac surgery and developing a nomogram model to help physicians improve the success rate of weaning from mechanical ventilation in adult patients undergoing postoperative cardiac surgery. Clinical data were retrospectively collected from adult patients who underwent extracorporeal circulation cardiac surgery at the First Affiliated Hospital of Nanjing Medical University between August 2022 and April 2023 and who were subsequently transferred to the Intensive Care Unit (ICU) and treated with vasoactive drugs. Patients were divided into successful and unsuccessful weaning groups based on first-attempt weaning success. Variable selection was regularized using univariate logistic regression and Least absolute shrinkage and selection operator (LASSO) regularization. Multivariate logistic regression was performed to identify predictors and a nomogram was created to predict the risk of weaning failure. A total of 519 patients were included in the study. After selecting multiple stepwise variables, the VVR score before weaning, the modified Sequential Organ Failure Assessment (mSOFA) score on weaning day, and mechanical ventilation duration before weaning were determined as predictive indicators of weaning failure in adult patients after cardiac surgery. The optimal cut-off values for these indicators were 18.46 points, 4.33 points, and 20.50 h, respectively. The predictive model constructed using these three factors demonstrated good predictive performance. The VVR score before weaning accurately predicts the probability of weaning failure in adult patients after cardiac surgery. The weaning risk-predictive nomogram model, established based on the VVR score, mSOFA score, and mechanical ventilation duration before weaning, demonstrated robust predictive ability.

Relationship between Static Lung Compliance and Extubation Failure in Postoperative Cardiac Surgery Patients.

Static lung compliance, which is seriously affected during surgery, can lead to respiratory failure and extubation failure, which is little explored in the decision to extubate after cardiac surgery. To evaluate static lung compliance in the postoperative period of cardiac surgery and relate its possible reduction to cases of extubation failure in patients submitted to the fast-track method of extubation. Patients undergoing cardiac surgery using cardiopulmonary bypass (CPB) at a state university hospital admitted to the ICU under sedation and residual block were included. Their static lung compliance was assessed on the mechanical ventilator using software that uses least squares fitting (LSF) for measurement. Within 48 hours of extubation, the patients were observed for the need for reintubation due to respiratory failure. The level of significance adopted for the statistical tests was 5%, i.e., p<0.05. 77 patients (75.49%) achieved successful extubation and 25 (24.51%) failed extubation. Patients who failed extubation had lower static lung compliance compared to those who succeeded (p<0.001). We identified the cut-off point for compliance through analysis of the Receiver Operating Characteristic Curve (ROC), with the cut-off point being compliance <41ml/cmH2O associated with a higher probability of extubation failure (p<0.001). In the multiple regression analysis, the influence of lung compliance (divided by the ROC curve cut-off point) was found to be 9.1 times greater for patients with compliance <41ml/cmH2O (p< 0.003). Static lung compliance <41ml/cmH2O is a factor that compromises the success of extubation in the postoperative period of cardiac surgery.

Tracheostomy is associated with decreased vasoactive-inotropic score in postoperative cardiac surgery patients on prolonged mechanical ventilation

ObjectiveWe sought to quantify the influence that tracheostomy placement has on the hemodynamic stability of postoperative cardiac surgery patients with persistent ventilatory requirements. MethodsA retrospective, single-center, and observational analysis of postoperative cardiac surgery patients with prolonged mechanical ventilation who underwent tracheostomy placement from 2018 to 2022 was conducted. Patients were excluded if receiving mechanical circulatory support or if they had an unrelated significant complication 3 days surrounding tracheostomy placement. Vasoactive and inotropic requirements were quantified using the Vasoactive-Inotrope Score. ResultsSixty-one patients were identified, of whom 58 met inclusion criteria. The median vasoactive-inotrope score over the 3 days before tracheostomy compared with 3 days after decreased from 3.35 days (interquartile range, 0-8.79) to 0 days (interquartile range, 0-7.79 days) (P = .027). Graphic representation of this trend demonstrates a clear inflection point at the time of tracheostomy. Also, after tracheostomy placement, fewer patients were on vasoactive/inotropic infusions (67.2% [n = 39] pre vs 24.1% [n = 14] post; P < .001) and sedative infusions (62.1% [n = 36] pre vs 27.6% [n = 16] post; P < .001). The percent of patients on active mechanical ventilation did not differ. ConclusionsThe median vasoactive-inotrope score in cardiac surgery patients with prolonged mechanical ventilation was significantly reduced after tracheostomy placement. There was also a significant reduction in the number of patients on vasoactive/inotropic and sedative infusions 3 days after tracheostomy. These data suggest that tracheostomy has a positive effect on the hemodynamic stability of patients after cardiac surgery and should be considered to facilitate postoperative recovery.

Program Evaluation of Parent Engagement Activities With Postoperative Cardiac Surgery Patients in the Pediatric Cardiac Intensive Care Unit

Objective: The pediatric cardiac intensive care unit, a department dedicated to caring for cardiac patients, conducted a program evaluation to identify registered nurse (RN) and family perceptions of barriers and facilitators to parent engagement during postoperative care after surgery. Methods: A quasi-experimental presurgical/postsurgical design examined RN data using the Questionnaire of Factors That Influence Family Engagement and parent perception of engagement data via a survey. Results: Nearly half (44.6%) of RNs responded; most were younger (30–49 years old, 44.8%), female (91.4%), and White (94.8%) and held a bachelor's degree (72.4%). Those with more experience (&gt;15 vs. &lt;5 years) had a higher parent engagement score ( p = .021). RNs indicated that workflow (τb = .579, p = .000), unit environment (τb = .572, p = .000), nurse attitude (τb = .520, p = .000), and patient acuity (τb = .519, p = .000) correlated with overall family engagement score. The nine parents (100%) invited responded; most were mothers ( n = 7, 77.8%) and married ( n = 6, 66.7%), and 56% (n = 50) indicated this was not the child's first hospitalization. Parent overall safety score improved (presurgery/postsurgery, Z = −2.000, p = .046). RN barriers for family engagement included lack of written policy. For parents, a facilitator for engagement was safety. Both groups identified collaboration, communication, and shared decision making as a facilitator. Discussion: Results contribute to planning and implementing quality improvement initiatives. Understanding and developing a partnership between parents and RNs, nurturing mutual respect, and enhancing shared decision making improves parent engagement in care and, ultimately, a child's physical and psychological health.

Safety and Outcomes of Outpatient Pleural Drainage in Symptomatic Postoperative Cardiac Surgery Patients.

Symptomatic pleural effusions and anticoagulant/antiplatelet medication use in postoperative cardiac surgery are common. Guidelines and recommendations are currently mixed regarding medication management related to invasive procedure performance. We aimed to describe the outcomes of postoperative cardiac surgery patients referred for outpatient, symptomatic pleural effusion management. A retrospective study of post-cardiac surgery patients undergoing outpatient thoracentesis from 2016 to 2021 was performed. Demographics, operative details, pleural disease characteristics, outcomes, and complications were collected. Odds ratios with confidence intervals were estimated and adjusted by multivariate logistic regression to investigate the association with multiple thoracenteses. A total of 110 patients underwent 332 thoracenteses. The median age was 68 years and most common operation was coronary artery bypass. Anticoagulation or antiplatelet use was identified in 97%. Thirteen complications were identified, with all major complications (n=3) related to bleeding. The amount of fluid present at the time of initial thoracentesis (>1500 milliliters) was associated with increased odds ratio of subsequent multiple thoracentesis (Unadjusted odds ratio, 6.75 (CI - 1.43 to 31.9). No other variables had a significant association with the need for multiple procedures. Within a postoperative cardiac surgery population presenting with symptomatic pleural disease, we observed that thoracentesis performed on antiplatelet and/or anticoagulant medication is relatively safe. We also identified that many patients can be managed as outpatients and that most pleural effusions remain self-limited. The presence of larger amounts of pleural fluid at initial thoracentesis may be associated with increased odds for additional drainage.

Assessment of Health-Related Quality of Life and Medication Adherence in Post-Operative Cardiac Surgery Patients in a Tertiary Care Hospital

Assessment of Health-Related Quality of Life and Medication Adherence in Post-Operative Cardiac Surgery Patients in a Tertiary Care Hospital

Intensive Care Unit Hyperglycemia After Cardiac Surgery: Risk Factors and Clinical Outcomes

Patients with hyperglycemia after cardiac surgery face increased morbidity and mortality due to postoperative complications. The main purpose of this study was to evaluate the incidence of postoperative hyperglycemia, the hyperglycemia risk factors, and its association with clinical outcomes in patients admitted to the cardiac surgery intensive care unit after cardiac surgery. Prospective, observational study. Single-center hospital. Two hundred ten consecutive postoperative cardiac surgery patients admitted to the cardiac surgery intensive care unit. Patients' blood glucose levels were evaluated immediately after cardiac surgery and every 3 hours daily for 7 days or earlier upon discharge. Intravenous insulin was administered as per the institution's protocol. Perioperative predisposing risk factors for hyperglycemia and clinical outcomes were assessed. Postoperative hyperglycemia, defined as glucose level ≥180 mg/dL, occurred in 30% of cardiac surgery patients. Diabetes mellitus (odds ratio [OR] 6.73; 95% CI [3.2-14.3]; p < 0.001), white blood cell count (OR 1.28; 95% CI [1.1-1.4]; p < 0.001), and EuroSCORE II (OR 1.20; 95% CI [1.1-1.4]; p=0.004) emerged as independent prognostic factors for hyperglycemia. Moreover, patients with glucose ≥180 mg/dL had higher rates of acute kidney injury (34.9% v 18.9%, p=0.013), longer duration of mechanical ventilation (959 v 720 min, p=0.019), and sedation (711 v 574 min, p=0.034), and higher levels of intensive care unit (ICU)-acquired weakness (14% v 5.5%, p=0.027) and rate of multiorgan failure (6.3% v 0.7%, p=0.02) compared with patients with glucose levels <180 mg/dL. In the intensive care unit, hyperglycemia occurs frequently in patients immediately after cardiac surgery. Diabetes, high EuroSCORE II, and preoperative leukocytosis are independent risk factors for postoperative hyperglycemia. Hyperglycemia is associated with worse clinical outcomes, including a higher rate of acute kidney injury and ICU-acquired weakness, greater duration of mechanical ventilation, and a higher rate of multiorgan failure.

Improving cognitive function after cardiac surgery: home-based computerised cognitive training (FACCT study)

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Barts Charity Nurse / Allied Healthcare Professional Clinical Research Fellowship (MRC0229, Improving cognitive health after cardiac surgery) Background Postoperative cognitive dysfunction (POCD) occurs in up to 50% of patients after cardiac surgery. Despite extensive research, the underlying causes and pathophysiology are poorly understood. Further, definitive treatments for POCD are lacking. The focus of this doctoral work was to identify predictors of POCD, examine the effectiveness of existing cognitive interventions on improving cognitive function, and use the findings of both of these systematic reviews to design and develop a cognitive training programme in postoperative cardiac surgery patients. Objectives The aim of this study was to evaluate the feasibility and acceptability of a home-based computerised cognitive training programme in postoperative cardiac surgery patients. Methods This is a single-arm, non-blinded, feasibility and acceptability study involving adult (&amp;gt;18 years of age) patients admitted for first time elective cardiac surgery. Participants were required to complete an 8-week cognitive training programme (40 sessions [20 minutes/day, 5 days/week]), commencing one week postoperatively, and administered using their own computers or tablets. The Montreal Cognitive Assessment (MoCA), a brief test of global cognition, was administered preoperatively and after the training programme. Feasibility outcomes included recruitment and retention rates and adherence to the programme. Acceptability was assessed by the Theoretical Framework of Acceptability Questionnaire (TFA-Q) which was administered post-programme. Results In total, 95 patients were screened, 51 (53.7%) were eligible and approached, and 31 (60.8%) consented to participate. Of these, 29 participants enrolled in the cognitive training programme, 7 (24.1%) were female, 20 (69.0%) were white British, and the mean baseline MoCA was 26.9 (out of 30). Data collection is complete, final analysis will be complete for presentation prior to ACNAP 2023. Interim results suggest that home-based computerised cognitive training (CCT) is feasible in terms of recruitment rate (60.8%, exceeding the target of 50%) and acceptable (with 94.1% of those who completed the TFA-Q identifying CCT as acceptable). Other feasibility indicators measured include retention (58.6%) and adherence (31.0%). Conclusions A trial examining home-based computerised cognitive training appears feasible and acceptable to patients, although strategies to improve retention and adherence will need to be strengthened. If found to be beneficial, such a programme could offer an inexpensive and safe method of improving postoperative cognitive function.

Agreement between cardiac output estimation with a wireless, wearable pulse decomposition analysis device and continuous thermodilution in post cardiac surgery intensive care unit patients.

Pulse Decomposition Analysis (PDA) uses integration of the systolic area of a distally transmitted aortic pulse as well as arterial stiffness estimates to compute cardiac output. We sought to assess agreement of cardiac output (CO) estimation between continuous pulmonary artery catheter (PAC) guided thermodilution (CO-CCO) and a wireless, wearable noninvasive device, (Vitalstream, Caretaker Medical, Charlottesville, VA), that utilizes the Pulse Decomposition Analysis (CO-PDA) method in postoperative cardiac surgery patients in the intensive care unit. CO-CCO measurements were compared with post processed CO-PDA measurements in prospectively enrolled adult cardiac surgical intensive care unit patients. Uncalibrated CO-PDA values were compared for accuracy with CO-CCO via a Bland-Altman analysis considering repeated measurements and a concordance analysis with a 10% exclusion zone. 259.7h of monitoring data from 41 patients matching 15,583 data points were analyzed. Mean CO-CCO was 5.55L/min, while mean values for the CO-PDA were 5.73L/min (mean of differences +- SD 0.79 ± 1.11L/min; limits of agreement - 1.43 to 3.01L/min), with a percentage error of 37.5%. CO-CCO correlation with CO-PDA was moderate (0.54) and concordance was 0.83. Compared with the CO-CCO Swan-Ganz, cardiac output measurements obtained using the CO-PDA were not interchangeable when using a 30% threshold. These preliminary results were within the 45% limits for minimally invasive devices, and pending further robust trials, the CO-PDA offers a noninvasive, wireless solution to complement and extend hemodynamic monitoring within and outside the ICU.

Hemodynamic assessment in children after cardiac surgery: A pilot study on the value of infrared thermography.

Low cardiac output syndrome in the postoperative period after cardiac surgery leads to an increase in tissue oxygen extraction, assessed by the oxygen extraction ratio. Measurement of the oxygen extraction ratio requires blood gases to be taken. However, the temperature of the skin and various parts of the body is a direct result of blood flow distribution and can be monitored using infrared thermography. Thus, we conducted a prospective clinical study to evaluate the correlation between the thermal gradient obtained by infrared thermography and the oxygen extraction ratio in children at risk for low cardiac output after cardiac surgery. Children aged 0 to 18 years, having undergone cardiac surgery with cardio-pulmonary bypass in a pediatric intensive care unit were included in the study. One to 4 thermal photos were taken per patient using the FLIR One Pro thermal imaging camera. The thermal gradient between the central temperature of the inner canthus of the eye and the peripheral temperature was compared to the concomitant oxygen extraction ratio calculated from blood gases. 41 patients were included with a median age of 6 months (IQR 3-48) with median Risk Adjustment for Congenital Heart Surgery-1 score was 2 (IQR 2-3). Eighty nine thermal photos were analyzed. The median thermal gradient was 2.5 °C (IQR 1,01-4.04). The median oxygen extraction ratio was 35% (IQR 26-42). Nine patients had an oxygen extraction ratio ≥ 50%. A significant but weak correlation was found between the thermal gradient and the oxygen extraction ratio (Spearman's test p = 0.25, p = 0.016). Thermal gradient was not correlated with any other clinical or biologic markers of low cardiac output. Only young age was an independent factor associated with an increase in the thermal gradient. In this pilot study, which included mainly children without severe cardiac output decrease, a significant but weak correlation between thermal gradient by infrared thermography and oxygen extraction ratio after pediatric cardiac surgery was observed. Infrared thermography is a promising non-invasive technology that could be included in multimodal monitoring of postoperative cardiac surgery patients. However, a clinical trial including more severe children is needed.

186: IMPLEMENTATION OF A CRITERIA-BASED ALGORITHM FOR ALBUMIN UTILIZATION FOLLOWING CARDIAC SURGERY

Introduction: Although there is ample evidence supporting goal-directed fluid therapy during the perioperative period in cardiac surgical patients, there is inconsistent data on the fluid of choice. Existing literature has shown conflicting results between crystalloids vs. colloids (specifically albumin), creating ambiguity regarding albumin’s safety, efficacy, and place in therapy. The goal of this study was to develop and implement a criteria-based algorithm for albumin utilization following cardiac surgery and analyze its ability to standardize quality of care, enhance appropriateness of albumin utilization, and optimize documentation. Methods: The implemented process strategy incorporated a multi-phase approach: (1) criteria-based albumin algorithm implementation; (2) provider education; and (3) enhancements to the electronic medical record software to facilitate accurate documentation. All adult cardiac surgery patients who received postoperative albumin during the following periods were included: provider-driven prescribing (retrospective control, 4 months) versus criteria-based prescribing per algorithm (prospective study cohort, 4 months). The primary objective of the study was to evaluate the impact of this intervention on albumin utilization/appropriateness and quality of care (ICU length of stay, ventilator days, vasopressor use, and Hi-Flow/BIPAP post-extubation, dialysis requirement, and blood product transfusion/FFP). Secondary endpoints included the accuracy of albumin utilization documentation following enhancements to the electronic medical record software. Results: Following implementation, per-patient albumin vial requirements (5.27 vs. 4.03, p=0.67) and appropriateness of albumin utilization was maintained between groups (98% versus 95%, p=0.13). All quality of care metrics were similar between the groups. The accuracy of albumin utilization documentation demonstrated a statistically significant increase of 8% (89% vs 97% p=0.0003) following criteria-based algorithm implementation. Safety outcomes of mortality and incidence of adverse events were similar between cohorts. Conclusions: Development and implementation of a criteria-based algorithm to drive albumin utilization in postoperative cardiac surgery patients is safe and feasible.

144: COMPARISON OF FIXED VERSUS WEIGHT-BASED PROTHROMBIN COMPLEX CONCENTRATE DOSING IN CARDIAC SURGERY

Introduction: Excessive bleeding after cardiac surgery is a major complication associated with increased morbidity and mortality. Intraoperative use of plasma-derived coagulation factors, such as four-factor prothrombin complex concentrate (4F-PCC), have been introduced into clinical practice to attenuate adverse effects attributable to postoperative hemorrhage. Although recent literature reports positive outcomes with the use of lower, fixed doses of 4F-PCC for emergent anticoagulation reversal, there is a paucity of literature evaluating fixed dosing in the cardiac surgery setting. The purpose of this study is to compare the rates of moderate- or higher severity postoperative bleeding associated with use of a fixed-dose versus weight-based 4F-PCC dosing strategy in cardiac surgery patients. Methods: A retrospective cohort study was performed of adult patients who received either weight-based (25 IU/kg) or fixed-dose (1500 IU) 4F-PCC during a cardiac surgical procedure over a 2-year period. Bleeding outcomes were determined by postoperative blood product transfusion requirements, chest tube output volume, and the need for surgical reexploration due to bleeding complications. Results: Of the 122 patients included, 58 received weight-based 4F-PCC whereas 62 were managed with a fixed-dose strategy. Rates of moderate- or higher severity bleeding were similar between weight-based and fixed dosing groups (56.9% vs. 46.8%, respectively; χ2 = 3.8467, p = .278) despite the use of significantly lower total 4F-PCC doses in the fixed-dose 4F-PCC cohort (25.5 U/kg vs. 21.6 U/kg; z = -2.11, p = .04). Postoperative deep vein thrombosis occurred more frequently in the weight-based dosing group as compared to the fixed-dose cohort (8.6% vs. 0%; p = .02). Conclusions: Compared to a weight-based dosing strategy, intraoperative administration of fixed-dose 4F-PCC was associated with similar postsurgical bleeding outcomes and lower rates of deep vein thrombosis in postoperative cardiac surgery patients. Larger, prospective studies are needed to validate these findings and further evaluate the impact of fixed-dose 4F-PCC on patient-centered outcomes in the postoperative cardiac surgery population.

Abstract 11737: Transhepatic Echocardiographic Approach Compared to the Subcostal Approach for Evaluation of the Inferior Vena Cava in Postoperative Patients With Cardiac Surgery

Introduction: In postoperative cardiac surgery patients due to the presence of mediastinal tubes, evaluation of the IVC is complicated with the subcostal view, so the transhepatic view could be an option for its evaluation in these patients. Methods: We obtained a validation group of non-surgical patients and later in a group of postoperative cardiac surgery patients with mediastinal tubes. Measurements of the IVC diameter in both views was obtained. Agreement between measurements diameters, the time it took to obtain the images, the degree of pain and the quality of the echocardiographic image were compared. The agreement of the variables was determined by the Pearson test. Results: A total of 43 patients were obtained from the validation group and 49 patients from the group of postsurgical patients. In the validation group, no significant difference was found in the maximum diameter in subcostal vs. transhepatic (15.6 (± 6.1) vs 16.0 (± 6.2); p = 0.9, r = 0.93), neither in the minimum diameter (11.2 (± 6.8) vs 11.5 (± 6.8); p = 0.7, r = 0.94), nor at the time of execution of the images (15 (11-23) vs 10 (7 -21); p = 0.09, r = 0.17, neither in pain. The transhepatic view had a good image quality (98 % vs 85 %; p = 0.007). In the group of postsurgical patients, no significant difference was found in the maximum diameter in subcostal vs. transhepatic (18.3 (± 5.2) vs. 18.1 (± 4.8); p = 0.8, r = 0.90), neither in the minimum diameter (14.5 (± 5.4) vs 14.3 (± 7.2); p = 0.9, r = 0.93), the time to acquire the image was superior to the subcostal view (57s (40-83) vs 18s (12-32); p = &lt; 0.0001, r = 0.43); the subcostal view had an analogous visual scale of major pain (8 vs 0; p = &lt; 0.0001), transhepatic view had a better good image quality (96 % vs 40 %; p = &lt; 0.0001). Conclusions: In cardiac postoperative patients, it is possible to use the transhepatic view because it has an excellent agreement with the values of the subcostal window, with less time to obtain the images and with better image quality.

Outcomes After Prolonged ICU Stays in Postoperative Cardiac Surgery Patients.

Prolonged postoperative intensive care unit (ICU) stays are common after cardiac surgery and are associated with poor outcomes. There are few studies evaluating how risk factors associated with mortality may change during prolonged ICU stays or how mortality may vary with length of stay. We evaluated operative and long-term mortality in post-cardiac surgery patients after prolonged ICU stays at 7, 14, 21, and 28 days and factors associated with mortality. We included University of Michigan Medical Center cardiac surgery patients with ≥ 7 postoperative days in the ICU. We determined factors associated with hospital mortality at 7, 14, 21, and 28 days of ICU stay using logistic regression, and among hospital survivors, we determined the factors associated with long-term mortality using Cox regression. Of 8309 ICU admissions from cardiac surgery, 1174 (14%) had ICU stays > 7 days. Operative mortality was 11%, 18%, 22%, and 35% for the 7-, 14-, 21-, and 28-day groups, respectively. Mechanical ventilation on the day of assessment was associated with increased odds ratios of operative mortality in all models. Of the 1049 (89%) hospital survivors, 420 (40%) died by late follow-up. Median (IQR) Cox model survival was 10.7 (0.7) years. Longer ICU stays, postoperative pneumonia, and elevated discharge blood urea nitrogen were associated with increased hazard of dying; whereas higher discharge platelet count and cardiac transplant were protective. Both operative and late mortality increased as the duration of a ICU stay increased after cardiac surgery.

Agreement between cardiac output estimation by multi-beat analysis of arterial blood pressure waveforms and continuous thermodilution in post cardiac surgery intensive care unit patients

We sought to assess agreement of cardiac output estimation between continuous pulmonary artery catheter (PAC) guided thermodilution (CO-CTD) and a novel pulse wave analysis (PWA) method that performs an analysis of multiple beats of the arterial blood pressure waveform (CO-MBA) in post-operative cardiac surgery patients. PAC obtained CO-CTD measurements were compared with CO-MBA measurements from the Argos monitor (Retia Medical; Valhalla, NY, USA), in prospectively enrolled adult cardiac surgical intensive care unit patients. Agreement was assessed via Bland-Altman analysis. Subgroup analysis was performed on data segments identified as arrhythmia, or with low CO (less than 5 L/min). 927 hours of monitoring data from 79 patients was analyzed, of which 26 had arrhythmia. Mean CO-CTD was 5.29 ± 1.14 L/min (bias ± precision), whereas mean CO-MBA was 5.36 ± 1.33 L/min, (4.95 ± 0.80 L/min and 5.04 ± 1.07 L/min in the arrhythmia subgroup). Mean of differences was 0.04 ± 1.04 L/min with an error of 38.2%. In the arrhythmia subgroup, mean of differences was 0.14 ± 0.90 L/min with an error of 35.4%. In the low CO subgroup, mean of differences was 0.26 ± 0.89 L/min with an error of 40.4%. In adult patients after cardiac surgery, including those with low cardiac output and arrhythmia CO-MBA is not interchangeable with the continuous thermodilution method via a PAC, when using a 30% error threshold.

CARDIAC SURGERY VIRTUAL FOLLOW-UP FOR PATIENTS AT HIGH-RISK FOR HOSPITAL READMISSION: DEVELOPMENT OF AN ENHANCED REMOTE TELEMONITORING CARE PLATFORM

CARDIAC SURGERY VIRTUAL FOLLOW-UP FOR PATIENTS AT HIGH-RISK FOR HOSPITAL READMISSION: DEVELOPMENT OF AN ENHANCED REMOTE TELEMONITORING CARE PLATFORM

Development and Preliminary Psychometric Testing of the Drake Atrial Electrogram Assessment Survey: DAEGAS.

Critical care nurses who care for postoperative cardiac surgery patients need such specialty knowledge as atrial electrograms (AEGs). An inadequate audit trail exists for psychometric performance of instruments to measure knowledge of AEGs. The aim of this study was to revise a previously tested instrument and assess evidence for content validity (content validity index), internal consistency (Cronbach α), and stability (correlation coefficient, r) reliability against the a priori criterion of 0.80. The multiple-choice response, self-administered, paper-and-pencil instrument was revised to 20 items and named the Drake Atrial Electrogram Assessment Survey (DAEGAS). A panel of 6 AEG experts reviewed the DAEGAS for content validity evidence. The instrument was further revised to 19 items (13 knowledge and 6 AEG interpretation) and tested with 76 critical care nurses from the greater Houston metropolitan area. The content validity index was 0.93. Cronbach α was .51, and test-retest r was 0.74. Cronbach α increased to .60 and r was 0.73 with removal of 3 items: 2 items with a negative item-total correlation and 1 item that was transitioned to a sample question. Content validity evidence exceeded the a priori criterion. Internal consistency and stability reliability estimates did not meet the criterion, albeit the latter met the criterion recommended by psychometricians for a new instrument. Recommendations include further development of the DAEGAS to improve internal consistency estimates and testing for evidence of other forms of validity. Reliable and valid assessment of critical care nurse knowledge of AEGs will require improved psychometric performance of the DAEGAS.