Postoperative Complications In Cardiac Surgery Research Articles

Frequency of Acute Kidney Injury in Patients Treated With Normal Saline after Off-Pump Coronary Artery Bypass Grafting

Introduction: Acute kidney injury (AKI) is a common postoperative complication of cardiac surgery, which is associated with an increased risk of morbidity and mortality. This study investigated the frequency of postoperative AKI in low risk adult patients undergoing off-pump coronary artery bypass grafting (CABG).Materials & Methods: All consecutive adult patients of American Society of Anesthesiologists (ASA) class II and III, who were transferred to the post-operative cardiac surgery ICU after off-pump CABG and were low risk for AKI from October 2013 to September 2014 at Emam Reza Hospital, Mashhad, Iran were enrolled in this prospective cohort study at a teaching hospital. The patients were explored for AKI development, based on risk-injury-failure-loss- end stage kidney disease (RIFLE) and acute kidney injury network (AKIN) criteria, frequency of metabolic acidosis, hypernatremia, hyperchloremia, and length of stay in ICU.Results: According to the results of the present study, 479 patients with the mean age of 60.8±10.75 yrs were included. AKI occurred in 22 (4.4%) and23 (4.8%) patients, based on both the RIFLE and AKIN criteria, respectively with the highest rate of AKI, reported on the third and fourth post-operative days. Additionally, hyperchloremia and hypernatremia were observed in 71 (14.8%) and 76 (15.9%) patients, respectively. Only one case of mortality occurred during the study. Metabolic acidosis was reported in 112 (23.4%) patients with a high anion gap in 60 (12.5%) cases.Conclusion: The current study demonstrated that hypernatremia and metabolic acidosis but not AKI are frequently seen in patients receiving normal saline following off pump CABG with low risk for AKI.

Elevated Levels of Procalcitonin and Interleukin-6 are Linked with Postoperative Complications in Cardiac Surgery.

Cardiac surgery-associated acute kidney injury is a frequent and serious postoperative complication of cardiac surgery and is associated with an increased risk of morbidity, mortality, and length stay. In this study, we hypothesized that persistent elevation in inflammation in the first 48 h might be a powerful predictor of clinical outcome. Our aim was to elucidate the usefulness of interleukin-6 and procalcitonin postoperative levels in predicting mortality and renal complications in cardiac surgery patients. A total of 122 cardiac surgery patients were enrolled. Procalcitonin and interleukin-6 concentrations were measured on the second postoperative day, and their levels were evaluated versus a number of conditions and endpoints. Procalcitonin has a good predictive value for adverse renal outcome (p < 0.05). Interleukin-6 has a good predictive value for 30 days and overall mortality in cardiac surgery population (p < 0.05). We did not observe a significant difference in procalcitonin and interleukin-6 levels among patients with different types of surgery and different extracorporeal circulation time, but the levels of both the molecules increase significantly depending on number of transfusions received by patients (p < 0.01). We speculated that procalcitonin and interleukin-6 could be two effective biomarkers. There is a possibility of having a combined inflammatory multi-biomarker panel, with procalcitonin for predicting renal outcome and interleukin-6 for predicting mortality.

Postoperative atrial fibrillation is not pulmonary vein dependent: results from a randomized trial.

Although often short-lived and self-limiting, postoperative atrial fibrillation (POAF) is a well-recognized postoperative complication of cardiac surgery and is associated with a 2-fold increase in cardiovascular mortality and morbidity. Our aim was to determine whether intraoperative bilateral pulmonary vein radiofrequency ablation decreases the incidence of POAF in patients undergoing coronary artery bypass grafting (CABG). A total of 175 patients undergoing CABG was prospectively randomized to undergo adjuvant bilateral radiofrequency pulmonary vein ablation in addition to CABG (group A; n = 89) or CABG alone (group B; n = 86). Intraoperative pulmonary vein isolation was confirmed by the inability to pace the heart via the pulmonary veins after ablation. All patients received postoperative β-blocker. There was no difference in the incidence of POAF in the treatment group who underwent adjuvant pulmonary vein ablation (group A; 37.1%) compared with the control group who did not (group B; 36.1%) (P = .887). There were no differences in postoperative inotropic support, antiarrhythmic drug use, need for oral anticoagulation, and complication rates. The mean length of postoperative hospital stay was 8.2 ± 6.5 days in the ablation group and 6.7 ± 4.6 days in the control group (P < .001). Adjuvant pulmonary vein isolation does not decrease the incidence of POAF or its clinical impact but increases the mean length of stay in the hospital. The mechanism of POAF does not appear to depend on the pulmonary veins.

Postępowanie w okresie okołooperacyjnym u chorych z ryzykiem wystąpienia ostrego uszkodzenia nerek, poddawanych operacjom kardiochirurgicznym

Acute kidney injury is one of the most frequent and clinically important of all postoperative complications in cardiac surgery. It is estimated that almost half of subjects suffer from a deterioration of kidney function after a cardio-pulmonary by-pass. Renal insufficiency impacts upon the outcome in terms of an increase in postoperative morbidity and mortality, and a decrease in quality of life. Recently, a modified and unified classification of cardio-renal syndrome has been devised, which takes into account bilateral association between the heart and the kidneys. Because acute decompensation in heart function leads to acute kidney damage, therefore cardiac surgery-associated acute kidney injury may be recognised as a type 1 cardio-renal syndrome from a pathophysiological point of view. This paper aims to review the current data on the diagnosis of acute kidney injury and preventive strategies that can be implemented in cardiac surgery perioperative care.

Deep sternal wound infection after cardiac surgery

BackgroundDeep sternal wound infection (DSWI) is a serious postoperative complication of cardiac surgery. In this study we investigated the incidence of DSWI and effect of re-exploration for bleeding on DSWI mortality.MethodsWe reviewed 73,700 cases registered in the Japan Adult Cardiovascular Surgery Database (JACVSD) during the period from 2004 to 2009 and divided them into five groups: 26,597 of isolated coronary artery bypass graft (CABG) cases, 23,136 valvular surgery cases, 17,441 thoracic aortic surgery cases, 4,726 valvular surgery plus CABG cases, and 1,800 thoracic aortic surgery plus CABG cases. We calculated the overall incidence of postoperative DSWI, incidence of postoperative DSWI according to operative procedure, 30-day mortality and operative mortality of postoperative DSWI cases according to operative procedure, 30-day mortality and operative mortality of postoperative DSWI according to whether re-exploration for bleeding, and the intervals between the operation and deaths according to whether re-exploration for bleeding were investigated. Operative mortality is defined as in-hospital or 30-day mortality. Risk factors for DSWI were also examined.ResultsThe overall incidence of postoperative DSWI was 1.8%. The incidence of postoperative DSWI was 1.8% after isolated CABG, 1.3% after valve surgery, 2.8% after valve surgery plus CABG, 1.9% after thoracic aortic surgery, and 3.4% after thoracic aortic surgery plus CABG. The 30-day and operative mortality in patients with DSWI was higher after more complicated operative procedures. The incidence of re-exploration for bleeding in DSWI cases was 11.1%. The overall 30-day/operative mortality after DSWI with re-exploration for bleeding was 23.0%/48.0%, and it was significantly higher than in the absence of re-exploration for bleeding (8.1%/22.0%). The difference between the intervals between the operation and death according to whether re-exploration for bleeding had been performed was not significant. Age and cardiogenic shock were significant risk factors related to re-exploration for bleeding, and diabetes control was a significant risk factor related to DSWI for all surgical groups. Previous CABG was a significant risk factor related to both re-exploration for bleeding and DSWI for all surgical groups.ConclusionsThe incidence of DSWI after cardiac surgery according to the data entered in the JACVSD registry during the period from 2004 to 2009 was 1.8%, and more complicated procedures were followed by higher incidence and mortality. When re-exploration for bleeding was performed, mortality was significantly higher than when it was not performed. Prevention of DSWI and establishment of an effective appropriate treatment for DSWI may improve the outcome of cardiac surgery.

Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery

Atrial fibrillation is a common post-operative complication of cardiac surgery and is associated with an increased risk of post-operative stroke, increased length of intensive care unit and hospital stays, healthcare costs and mortality. Numerous trials have evaluated various pharmacological and non-pharmacological prophylactic interventions for their efficacy in preventing post-operative atrial fibrillation. We conducted an update to a 2004 Cochrane systematic review and meta-analysis of the literature to gain a better understanding of the effectiveness of these interventions. The primary objective was to assess the effects of pharmacological and non-pharmacological interventions for preventing post-operative atrial fibrillation or supraventricular tachycardia after cardiac surgery. Secondary objectives were to determine the effects on post-operative stroke or cerebrovascular accident, mortality, cardiovascular mortality, length of hospital stay and cost of treatment during the hospital stay. We searched the Cochrane Central Register of ControlLed Trials (CENTRAL) (Issue 8, 2011), MEDLINE (from 1946 to July 2011), EMBASE (from 1974 to July 2011) and CINAHL (from 1981 to July 2011). We selected randomized controlled trials (RCTs) that included adult patients undergoing cardiac surgery who were allocated to pharmacological or non-pharmacological interventions for the prevention of post-operative atrial fibrillation or supraventricular tachycardia, except digoxin, potassium (K(+)), or steroids. Two review authors independently abstracted study data and assessed trial quality. One hundred and eighteen studies with 138 treatment groups and 17,364 participants were included in this review. Fifty-seven of these studies were included in the original version of this review while 61 were added, including 27 on interventions that were not considered in the original version. Interventions included amiodarone, beta-blockers, sotalol, magnesium, atrial pacing and posterior pericardiotomy. Each of the studied interventions significantly reduced the rate of post-operative atrial fibrillation after cardiac surgery compared with a control. Beta-blockers (odds ratio (OR) 0.33; 95% confidence interval) CI 0.26 to 0.43; I(2) = 55%) and sotalol (OR 0.34; 95% CI 0.26 to 0.43; I(2) = 3%) appear to have similar efficacy while magnesium's efficacy (OR 0.55; 95% CI 0.41 to 0.73; I(2) = 51%) may be slightly less. Amiodarone (OR 0.43; 95% CI 0.34 to 0.54; I(2) = 63%), atrial pacing (OR 0.47; 95% CI 0.36 to 0.61; I(2) = 50%) and posterior pericardiotomy (OR 0.35; 95% CI 0.18 to 0.67; I(2) = 66%) were all found to be effective. Prophylactic intervention decreased the hospital length of stay by approximately two-thirds of a day and decreased the cost of hospital treatment by roughly $1250 US. Intervention was also found to reduce the odds of post-operative stroke, though this reduction did not reach statistical significance (OR 0.69; 95% CI 0.47 to 1.01; I(2) = 0%). No significant effect on all-cause or cardiovascular mortality was demonstrated. Prophylaxis to prevent atrial fibrillation after cardiac surgery with any of the studied pharmacological or non-pharmacological interventions may be favored because of its reduction in the rate of atrial fibrillation, decrease in the length of stay and cost of hospital treatment and a possible decrease in the rate of stroke. However, this review is limited by the quality of the available data and heterogeneity between the included studies. Selection of appropriate interventions may depend on the individual patient situation and should take into consideration adverse effects and the cost associated with each approach.

STREM-1 as a Prognostic Marker of Postoperative Complications in Cardiac Surgery

Cell-activating receptor TREM-1 (triggering receptor expressed on myeloid cells 1) regulates congenital immune response and contributes to systemic inflammatory response syndrome (SIRS) development. It is able to multiply cytokine production while stimulated together with the main receptors of the congenital immune system. The purpose of the paper is to study the potential use of soluble TREM-1 (sTREM-1) as a marker of intensive SIRS and a criterion for postoperative complications prediction following on-pump coronary artery bypass surgery (CABG). Results show that early postoperative sTREM-1 concentrations demonstrate their potential prognostic value regarding SIRS-associated complications.

Sternal osteomyelitis caused by Aspergillus fumigatus following cardiac surgery: Case and review

Postsurgical sternal wound infection is a serious post-operative complication of cardiac surgery. Aspergillus infection of the sternum is extremely rare. We describe a case of sternal infection due to Aspergillus in an immunocompetent patient following aortic valve replacement.

Constipation: A common postoperative complication of cardiac surgery

Constipation is a common problem for the cardiac patient in the postoperative period. It can have a profound negative impact on quality of life, which is frequently underestimated by health-care professionals. Active prevention of constipation remains in its infancy with few assessment tools developed. The nurse working in a cardiac environment needs a good understanding of the issues that can exacerbate the situation in the post-operative period. This article discusses common causes and management options available to optimise patient care and prevent serious problems developing.

Effect of Dietary Fish Oil on Atrial Fibrillation After Cardiac Surgery

An open-label study reported that ingestion of a fish oil concentrate decreased the incidence of atrial fibrillation (AF) after coronary artery bypass grafting (CABG) surgery. However, a general cardiac surgery population involves valve and CABG surgeries. We undertook a double-blinded randomized controlled trial to examine the effectiveness of fish oil supplementation on the incidence of postsurgical AF after CABG and valve procedures. The primary end point was incidence of AF in the first 6 days after surgery. Two hundred patients were randomized to receive fish oil (providing 4.6 g/day of long-chain ω-3 fatty acids) or a control oil starting 3 weeks before surgery; 194 subjects completed the study, with 47 of 97 subjects in the control group and 36 of 97 subjects in the fish oil group developing AF (odds ratio 0.63, 95% confidence interval [CI] 0.35 to 1.11). There was a nonstatistically significant delay in time to onset of AF in the fish oil group (hazard ratio 0.66, 95% CI 0.43 to 1.01). There was a significant decrease in mean length of stay in the intensive care unit in the fish oil group (ratio of means 0.71, 95% CI 0.56 to 0.90). In conclusion, in a mixed cardiac surgery population, supplementation with dietary fish oil did not result in a significant decrease in the incidence of postsurgical AF. However, there was a significant decrease in time spent in the intensive care unit.

N-acetylcysteine in Cardiac Surgery: Do the Benefits Outweigh the Risks? A Meta-Analytic Reappraisal

N-acetylcysteine (NAC) reduces proinflammatory cytokines, oxygen free-radical production, and ameliorates ischemia reperfusion injury; therefore, it may theoretically reduce postoperative complications in cardiac surgery. The aim of this study was to determine, through systematic review and meta-analysis of all relevant randomized trials, whether NAC reduces mortality, morbidity, or resource utilization in cardiac surgery. Meta-analysis. University hospitals. A total of 1,407 patients from 15 randomized studies were included in the analysis. None. All randomized trials searched up to May 2009 comparing the use of NAC versus placebo during cardiac surgery in any language and reporting at least 1 predefined outcome were included. The random effect model was used to calculate odds ratios (ORs, 95% confidence intervals [CIs]) and weighted mean differences (WMD, 95% CI) for dichotomous and continuous variables, respectively. During cardiac surgery, the use of NAC did not significantly decrease acute renal failure requiring renal replacement therapy (OR = 1.05; 95% CI, 0.52-2.11; p = 0.90), new atrial fibrillation (OR = 0.67; 95% CI, 0.37-1.22; p = 0.19), or mortality (OR = 0.81; 95% CI, 0.39-1.68; p = 0.57). There were no differences in the incidence of incremental increase in serum creatinine concentration greater than 25% above baseline (OR = 0.86; 95% CI, 0.66-1.12; p = 0.26), acute myocardial infarction (OR = 0.69; 95% CI, 0.29-1.61, p =0.39), stroke (OR = 0.78; 95% CI, 0.30-2.03; p = 0.61), red blood cell transfusion requirement (OR = 0.77; 95% CI, 0.45-1.31; p = 0.33), re-exploration (OR = 1.33; 95% CI, 0.70-2.26; p = 0.29), or postoperative drainage (WMD = 33 mL; 95% CI,-125 to 191 mL; p = 0.69) between NAC and placebo. Current evidence shows that the perioperative use of NAC has no proven benefit or risk on clinically important outcomes in patients undergoing cardiac surgery.

Elaboração de escore de risco para mediastinite pós-cirurgia de revascularização do miocárdio

The mediastinitis is a serious postoperative complication of cardiac surgery, with an incidence of 0.4 to 5% and mortality between 14 and 47%. Several models were proposed to assess risk of mediastinitis after cardiac surgery. However, most of these models do not evaluate the postoperative morbidity. This study aims to develop a score risk model to predict the risk of mediastinitis for patients undergoing coronary artery bypass grafting. The study sample included data from 2,809 adult patients undergoing coronary artery bypass grafting between January 1996 and December 2007 at Hospital São Lucas -PUCRS. Logistic regression was used to examine the relationship between risk factors and the development of mediastinitis. Data from 1,889 patients were used to develop the model and its performance was evaluated in the remaining data (n=920). The definitive model was created with the data analysis of 2,809 patients. The rate of mediastinitis was 3.3%, with mortality of 26.6%. In the multivariate analysis, five variables remained independent predictors of the outcome: chronic obstructive pulmonary disease, obesity, surgical reintervention, blood transfusion and stable angina class IV or unstable. The area under the ROC curve was 0.72 (95% CI, 0.67-0.78) and P = 0.61. The risk score was constructed for use in daily practice to calculate the rate of mediastinitis after coronary artery bypass grafting. The score includes routinely collected variables and is simple to use.

Effects of allogeneic leukocytes in blood transfusions during cardiac surgery on inflammatory mediators and postoperative complications*

To investigate whether the higher prevalence of postoperative complications in cardiac surgery after transfusion of leukocyte-containing red blood cells can be related to inflammatory mediators. Analysis of inflammatory markers interleukin-6, interleukin-10, interleukin-12, and procalcitonin in patients participating in a randomized trial comparing leukocyte-depleted with leukocyte-containing, buffy-coat-depleted red blood cells. Two university-affiliated hospitals in the Netherlands. A total of 346 patients undergoing cardiac valve surgery with a complete series of pre- and postoperative blood samples. There were no differences in the cytokines and procalcitonin concentrations between both study arms when the patients arrived in the intensive care unit. In subgroups, patients who received zero to three red blood cell transfusions showed similar cytokine concentrations in both study arms, whereas patients with > or = 4 red blood cell transfusions had significantly higher interleukin-6 concentrations in the leukocyte-containing, buffy-coat-depleted red blood cell group. Patients who developed postoperative infections and multiple organ dysfunction syndrome showed, respectively, increased concentrations of interleukin-6 and interleukin-12 in the leukocyte-containing, buffy-coat-depleted, red blood cell group. The interaction tests in these subgroups showed significantly different reaction patterns in the leukocyte-containing, buffy-coat-depleted red blood cell group compared with leukocyte-depleted red blood cell group for interleukin-6 and interleukin-12. Multivariate analysis showed a high interleukin-6 concentration with multiple organ dysfunction syndrome and both high interleukin-6 and interleukin-10 concentrations with hospital mortality. Allogeneic leukocyte-containing blood transfusions compared with leukocyte-depleted blood transfusions induce dose-dependent significantly higher concentrations of proinflammatory mediators in the immediate postoperative period after cardiac surgery. High concentrations of interleukin-6 are strong predictors for development of multiple organ dysfunction syndrome, whereas both interleukin-6 and interleukin-10 are associated with hospital mortality. These findings suggest that leukocyte-containing red blood cells interfere with the balance between postoperative proinflammatory response, which may further affect the development of complications after cardiac surgery.

Clinical Summaries

Clinical Summaries

Epidemiology of acute kidney injury after cardiac surgery: an update

This aim of this review is to highlight recent studies that have furthered our understanding of the epidemiology, risk factors, and prognosis of acute kidney injury (AKI) following cardiac surgery. AKI is an important postoperative complication of cardiac surgery and is an independent risk factor for perioperative mortality. A consensus definition of AKI, the risk, injury, failure, loss, end-stage kidney disease (RIFLE) criteria, has recently been evaluated in the cardiac surgery population. AKI is an independent risk factor for postoperative death and is associated with increased postoperative complications and overall resource utilization. Despite the high early mortality rate, patients with postoperative AKI who survive to hospital discharge have a reasonable long-term prognosis. The identification of risk factors for AKI has allowed the development of preoperative risk stratification strategies. Future studies are necessary to determine if preoperative risk stratification leads to improved outcomes by...

Atrial Fibrillation Following Cardiac Surgery: A Retrospective Cohort Series

Atrial fibrillation (AF) is a common postoperative complication of cardiac surgery, yet the prevention and treatment of postoperative AF remains controversial and varies among practitioners. The purpose of this study was to document the incidence and time of onset of postoperative AF in a cardiac surgical cohort, examine risk factors implicated in the occurrence of postoperative AF, and assess effectiveness of current treatment strategies implemented for postoperative AF. A retrospective health record review was conducted on 1078 adults following cardiac surgery. Data on demographic, preoperative, perioperative, and postoperative risk factors for postoperative AF, documented episodes of AF, and clinical outcomes were recorded. Overall incidence of postoperative AF was 39.6%: 57.6% after cardiac valve surgery, 69.3% after combined coronary artery bypass graft and valve surgery, and 33% after bypass graft surgery alone. The peak onset of postoperative AF occurred on the second postoperative day. Advancing age, history of AF, combined cardiac valve and coronary artery bypass graft surgery, and high Mg+2 levels on the third postoperative day were significant predictors of postoperative AF in this cohort. Length of hospitalization increased with the presence of postoperative AF. Findings corroborate that multiple factors play a role in the development of AF following cardiac surgery.

Early assessment of diaphragmatic dysfunction in children in the ITU: chest radiology and phrenic nerve stimulation

Diaphragmatic dysfunction is a common postoperative complication of cardiac surgery in children, with important effects on respiratory morbidity. Its early diagnosis, followed by prompt surgical intervention, has been shown to reduce morbidity. However, the commonest method of diagnosis, based on hemi-diaphragmatic elevation on the chest radiograph, may be less accurate than direct techniques for assessing phrenic nerve function. We have compared electrophysiological and radiological diagnoses of diaphragmatic abnormality in 100 children (aged 3 days to 17.5 yrs) undergoing cardiac surgery, looking at respiratory morbidity as assessed by the duration of ventilation, the time spent on the cardiac intensive care unit (CICU), and the requirement for reintubation. Despite showing good reproducibility, radiological diagnosis was neither sensitive nor specific in identifying patients with electrophysiological phrenic nerve damage. Analysis of the measures of outcome supported the electrophysiological technique. Patients with electrophysiological evidence of damage had a longer duration of ventilation, spent longer on the CICU, and had a greater incidence of reintubation than either radiologically abnormal or "normal" patients. Chest X-rays are not a good method for diagnosing phrenic nerve damage in the early postoperative period in children. If early diagnosis is needed, then direct assessment of phrenic nerve function, such as the measurement of phrenic latency, may be a better technique.

Usefulness of transoesophagealechocardiography (TEE) in fast decision making process of early postoperative complications in cardiac surgery (CS)

Usefulness of transoesophagealechocardiography (TEE) in fast decision making process of early postoperative complications in cardiac surgery (CS)

Postoperative pulmonary insufficiency in cardiac surgery and its treatment.

The most common postoperative complications in cardiac surgery are low cardiac output symdrome, renal shutdown and respiratory failure. Respiratory insufficiency is often unrecognized clinically and effective treatment is under­ taken at too late a stage. One of the authors 1l 2l previously investigated posto­ perative pulmonary function in experimental thoracotomy and cardiopulmonary bypass from the point of view of respiratory mechanics and reported that tidal volume and compliance decreased, and respiratory work, frictional resistance, frequency and minute volume increased in early postoperative period. Patho­ logic basis of these alteration was that mucus in the large air way was re­ sponsible for increased respiratory frictional resistance while mucus in the bronchioles and atelectasis were responsible for decreased compliance. In­ creased frictional resistance and decreased compliance produced more work to maintain pulmonary ventilation. Atelectasis may increase pulmonary shunt and lead to eventual hypoxia. In order to explain the cause of postoperative respiratory failure in cardiac surgery, respiratory mechanics, lung volume, pulmonary shunt, He-clearance delay and pulmonary surfactant were investigated on clinical patients. This study may contribute to the management of postoperative pulmonary insufficiency.