Perioperative Complications of Cardiac Surgery and Postoperative Care

Perioperative Risk Factors for Post-operative Pneumonia after Type A Acute Aortic Dissection Surgery

OBJECTIVE

Type A acute aortic dissection (TAAAD) is a dangerous and complicated condition with a high death rate before hospital treatment. Patients who are fortunate to receive prompt surgical treatment still face high in-hospital mortality. A series of post-operative complications further affects the prognosis. Post-operative pneumonia (POP) also leads to great morbidity and mortality. This study aimed to identify the prevalence as well as the risk factors for POP in TAAAD patients and offer references for clinical decisions to further improve the prognosis of patients who survived the surgical procedure.

METHODS

The study enrolled 89 TAAAD patients who underwent surgical treatment in Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei province, China from December 2020 to July 2021 and analyzed the perioperative data and outcomes of these patients. Logistic regression analyses were used to identify the risk factors for POP.

RESULTS

In the study, 31.5% of patients developed POP. Patients with POP had higher proportions of severe oxygenation damage, pneumothorax, reintubation, tracheotomy, renal replacement therapy, arrhythmia, gastrointestinal bleeding, and longer duration of mechanical ventilation, fever, ICU stay, and length of stay (all with P<0.05). The in-hospital mortality was 2.3%. Smoking, preoperative white blood cells, and intraoperative transfusion were the independent risk factors for POP in TAAAD.

CONCLUSION

Patients who underwent TAAAD surgery suffered poorer outcomes when they developed POP. Furthermore, patients with risk factors should be treated with caution.

The value of bioactive adrenomedullin and dipeptidyl peptidase 3 to predict short-term unfavourable outcomes after cardiac surgery: A prospective cohort study

BACKGROUND

Adrenomedullin (ADM) is a key regulator of endothelial barrier function and vascular tone. Dipeptidyl peptidase 3 (DPP3) is a protease involved in the degradation of several cardiovascular mediators. Increased levels of bioactive ADM (bio-ADM) and circulating DPP3 (cDPP3) were found to predict short-term outcome in cardiogenic shock patients.

OBJECTIVES

To investigate the unknown temporal profiles of bio-ADM and cDPP3 and their association with short-term outcome following cardiac surgery.

DESIGN

Prospective observational study of 203 adult cardiac surgery patients admitted to the intensive care unit (ICU) postoperatively. Plasma bio-ADM and cDPP3 levels were measured at ICU admission (day 1) and on days 2 and 3.

MAIN OUTCOME MEASURES

Biomarker prediction of prolonged vasopressor dependency (>3 days), acute kidney injury (AKI) and prolonged ICU length of stay (ICU-LOS) (>3 days).

RESULTS

bio-ADM and cDPP3 levels displayed distinct temporal profiles following cardiac surgery. cDPP3 levels were highest on day 1 and strongly correlated with surgical complexity and duration but subsequently normalised on day 2 in most patients. In contrast, bio-ADM levels on day 1 were within the normal range but subsequently increased. Day 2 bio-ADM levels were strongly associated with study outcomes: the area under the receiver-operating curves (AUROC) were 0.82 (95% CI, 0.72 to 0.92) for prolonged vasopressor dependency, 0.87 (0.81 to 0.92) for AKI and 0.82 (0.75 to 0.90) for prolonged ICU-LOS (all P < 0.0001). cDPP3 levels on day 2 also predicted these outcomes, albeit to a lesser extent, with AUROCs of 0.73 (95% CI, 0.64 to 0.81) for prolonged vasopressor dependency, 0.69 (0.61 to 0.77) for AKI and 0.70 (0.62 to 0.79) for prolonged ICU-LOS (all P < 0.0001).

CONCLUSION

Following cardiac surgery, increased bio-ADM levels are strongly associated with unfavourable short-term outcomes, whereas cDPP3 levels are mainly related to surgery complexity and duration. On the basis of these findings, ADM-modulating therapies may have beneficial effects in cardiac surgery patients whereas DPP3-targeted therapies should be reserved for patient categories with higher baseline disease severity.

Development and Validation of a Diagnostic Model to Predict the Risk of Ischemic Liver Injury After Stanford A Aortic Dissection Surgery

Objective: To define the risk factors of ischemic liver injury (ILI) following Stanford A aortic dissection surgery and to propose a diagnostic model for individual risk prediction. Methods: We reviewed the clinical parameters of ILI patients who underwent cardiac surgery from Beijing Anzhen Hospital, Capital Medical University between January 1, 2015 and October 30, 2020. The data was analyzed by the use of univariable and multivariable logistic regression analysis. A risk prediction model was established and validated, which showed a favorable discriminating ability and might contribute to clinical decision-making for ILI after Stanford A aortic dissection (AAD) surgery. The discriminative ability and calibration of the diagnostic model to predict ILI were tested using C statistics, calibration plots, and clinical usefulness. Results: In total, 1,343 patients who underwent AAD surgery were included in the study. After univariable and multivariable logistic regression analysis, the following variables were incorporated in the prediction of ILI: pre-operative serum creatinine, pre-operative RBC count <3.31 T/L, aortic cross-clamp time >140 min, intraoperative lactic acid level, the transfusion of WRBC, atrial fibrillation within post-operative 24 h. The risk model was validated by internal sets. The model showed a robust discrimination, with an area under the receiver operating characteristic (ROC) curve of 0.718. The calibration plots for the probability of perioperative ischemic liver injury showed coherence between the predictive probability and the actual probability (Hosmer-Lemeshow test, P = 0.637). In the validation cohort, the nomogram still revealed good discrimination (C statistic = 0.727) and good calibration (Hosmer-Lemeshow test, P = 0.872). The 10-fold cross-validation of the nomogram showed that the average misdiagnosis rate was 9.95% and the lowest misdiagnosis rate was 9.81%. Conclusion: Our risk model can be used to predict the probability of ILI after AAD surgery and have the potential to assist clinicians in making treatment recommendations.

Can soluble urokinase plasminogen receptor predict outcomes after cardiac surgery?

OBJECTIVES

Soluble urokinase plasminogen activator receptor (suPAR) is a biomarker that has been implicated in several cardiac pathologies and has been shown to be elevated in critically ill populations. We measured plasma suPAR in a cohort of cardiac surgical patients to evaluate its ability to predict prolonged intensive care unit (ICU) and hospital length of stay and development of complications following surgery. We compared suPAR against EuroSCORE II and C-reactive protein (CRP).

METHODS

Ninety patients undergoing cardiac surgery were recruited with samples taken preoperatively and on postoperative days 1, 2 and 3. suPAR was measured using enzyme-linked immunosorbent assay. Area under the receiver operator curve (AUROC) was used to test predictive capability of suPAR. Comparison was made with EuroSCORE II and CRP.

RESULTS

suPAR increased over time (P < 0.001) with higher levels in patients requiring prolonged ICU and hospital stay, and prolonged ventilation (P < 0.05). suPAR was predictive for prolonged ICU and hospital stay, and prolonged ventilation at all time points (AUROC 0.66-0.74). Interestingly, this association was also observed preoperatively, with preoperative suPAR predicting prolonged ICU (AUROC 0.66), and hospital stay (AUROC 0.67) and prolonged ventilation (AUROC 0.74). The predictive value of preoperative suPAR compared favourably to EuroSCORE II and CRP.

CONCLUSIONS

suPAR increases following cardiac surgery and levels are higher in those who require prolonged ICU stay, prolonged hospital stay and prolonged ventilation. Preoperative suPAR compares favourably to EuroSCORE II and CRP in the prediction of these outcomes. suPAR could be a useful biomarker in predicting outcome following cardiac surgery, helping inform clinical decision-making.

CLINICAL REGISTRATION

West of Scotland Research Ethics Committee Reference: 12/WS/0179 (AM01).

The effect of opium addiction on short-term postoperative outcomes after coronary artery bypass graft surgery: A prospective observational cohort study

Introduction

Opium addiction has been recently suggested as a potential risk factor for the occurrence of perioperative complications in patients undergoing coronary artery bypass graft (CABG) surgery. The aim of this study was to evaluate whether opium addiction can potentially affect patients' short-term postoperative outcomes after CABG surgery.

Material and methods

In a prospective observational cohort study, all consecutive patients who were scheduled for first-time isolated elective on pump CABG surgery were screened during the study period for opium addiction. The study was carried out between September 2015 and November 2016 at Mazandaran Heart Center, Sari, Iran. A total number of 228 patients [110 opium addicted (OA) and 118 non-addicted (NA)] were screened and included. All patients were evaluate, in terms of short-term postoperative outcomes, until hospital discharge or death.

Results

In the OA patients, the mean amount of estimated postoperative bleeding was significantly more than NA patients (535 ± 304.75 ml vs. 463.56 ± 209.77; P = 0.04). Mean ventilation time were significantly longer in the OA patients than in the NA (9.9 days vs. 8.66 days, P = 0.02). The mean duration of postoperative hospital stay was two days longer in the OA (10.83 days vs. 8.34 days, P < 0.001). Also, the mean use of packed cell during surgery and incidence of postoperative atrial fibrillation were higher in the OA patients than NA (P = 0.005).

Conclusion

The results of our study provide strong evidence that the opium addiction should be considered as a risk factors for developing perioperative complications, including higher mean postoperative bleeding, need for intraoperative packed red blood cell transfusion, ventilation time and length of hospital stay, in patients undergoing CABG surgery.

Healthcare-Associated Infections in a Cardiac Surgery Service in Brazil

Objectives

The study aimed to determine the incidence of healthcare-associated infections (HAI) and their sites in a cardiac surgery service, as well as to determine if gender and age were risk factors for infection and to quantify mortality and increase in the hospital length of stay (LOS) due to HAI.

Methods

Medical records of patients who underwent cardiac surgery from January 2012 to January 2018 were retrospectively analyzed. Data on age, gender, mortality, occurrence of HAI during hospitalization, and LOS were collected. Continuous variables were analyzed using Student's t-test, while categorical variables were compared using Fisher's exact test or chi-square test.

Results

Among the 195 patients available, the HAI rate in our service was 22.6%, with female gender being a risk factor for infections (odds ratio [OR]=2.23; P=0.015). Age was also a significant risk factor for infections, with a difference in the mean age between the group with and without infection (P=0.02). The occurrence of an infectious process increased the LOS in 14 days (P<0.001) and resulted in higher mortality rates (P=0.112). A patient who has HAI was approximately 19 times more likely to remain hospitalized for more than nine days (P<0.001).

Conclusion

Age and gender were risk factors for the development of HAI and the occurrence of an infectious process during hospitalization significantly increases the LOS. These findings may guide future actions aimed at reducing the impact of HAI on the health system.

Checklist validation for care provided to patients in the immediate postoperative period of cardiac surgery

AIMS AND OBJECTIVES

We created and validated a checklist for nursing care of patients in the immediate postoperative period of cardiac surgery.

BACKGROUND

Cardiovascular diseases (CVD) account for about 30% of all deaths recorded in Brazil. There is an arsenal of clinical and surgical treatments for CVD, with a significant number of patients evolving to surgical treatment. Thus, health professionals working in the perioperative period of cardiovascular surgeries need to be updated, trained and qualified to provide adequate and safe care to patients.

DESIGN

We developed a checklist that defined essential parameters for quality care, to ensure greater agility and patient safety.

METHODS

This methodology validation study comprised two stages: checklist creation for care provided by nurses to patients in the IPO of cardiac surgery, and content validation using the Delphi method. Participants were selected through an advanced survey conducted on the Lattes Platform website of the National Council for Scientific and Technological Development. The STROBE checklist was used to guide the study.

RESULTS

Three rounds of analysis by specialists resulted in average CVIs of: 95.8% for objectivity, 97.9% for simplicity, 91.0% for clarity, 93.1% for relevance and 96.5% for variety, suggesting high agreement among specialists.

CONCLUSIONS

The checklist focused on nursing care of patients in the IPO of cardiac surgery and was validated with three topics, four categories, 16 items and 86 sub-items of care assignments to be applied in clinical practice.

RELEVANCE TO CLINICAL PRACTICE

This is a validated instrument that guides nurses' actions by admitting postoperative cardiac surgery patients to the ICU based on evidence, which provides more scientific and professional support to health teams' performance, with the objective of strengthening roles and establishing routines; thus presenting a powerful tool for planning nursing actions, providing quality care to patients, and facilitating communication between teams, thereby minimising risks.

Nitric oxide delivery during cardiopulmonary bypass reduces acute kidney injury: A randomized trial

OBJECTIVE

Acute kidney injury (AKI) is a serious complication of cardiac surgery with cardiopulmonary bypass (CPB). The aim of this study was to evaluate the effects of nitric oxide (NO) supplementation to the CPB circuit on the development of cardiac surgery-associated AKI.

METHODS

This prospective randomized controlled study included 96 patients with moderate risk of renal complications who underwent elective cardiac surgery with CPB. The study protocol was registered at ClinicalTrials.gov (identifier NCT03527381). Patients were randomly allocated to either NO supplementation to the CPB bypass circuit (NO treatment group; n = 48) or usual care (control group; n = 48). In the NO treatment group, 40-ppm NO was administered during the entire CPB period. The primary outcome was the incidence of AKI.

RESULTS

NO treatment was associated with a significant decrease in AKI incidence (10 cases [20.8%] vs 20 cases [41.6%] in the control group; relative risk, 0.5; 95% confidence interval, 0.26-0.95; P = .023) and a higher median urine output during CPB (2.6 mL/kg/h [interquartile range (IQR), 2.1-5.08 mL/kg/h] vs 1.7 mL/kg/h [IQR, 0.80-2.50 mL/kg/h]; P = .0002). The median urinary neutrophil gelatinase-associated lipocalin level at 4 hours after surgery was significantly lower in the NO treatment group (1.12 ng/mL [IQR, 0.75-5.8 ng/mL] vs 4.62 ng/mL [IQR, 2.02-34.55 ng/mL]; P = .005). In the NO treatment group, concentrations of NO metabolites were significantly increased at 5 minutes postclamping, at 5 minutes after declamping, and at the end of the operation. Concentrations of proinflammatory and anti-inflammatory mediators and free plasma hemoglobin did not differ significantly between the 2 groups.

CONCLUSIONS

NO administration in patients at moderate risk of renal complications undergoing elective cardiac surgery with CPB was associated with a lower incidence of AKI.

Evaluation of the delta of immature platelet fraction as a predictive biomarker of inflammatory response after cardiac surgery

AIMS

Cardiac surgery (CS) can induce an inflammatory response (IR) that is associated with poorer outcomes. Immature platelets are among the factors that may be associated with IR development. We aimed to evaluate whether immature platelet fraction (IPF) could be a predictive biomarker for IR and whether IPF could improve the prognosis assessment of IR for Acute Physiologic and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) following CS.

METHODS

Three-hundred and twenty-seven (327) patients who underwent CS were enrolled during the study period. IR was defined according to the need for vasopressor support (>48 hours). Perioperative variables and outcomes were registered in our database. IPF was measured immediately following CS and at 24 hours by Sysmex XN analyzer and the difference between both measurements (ΔIPF) was calculated. To assess the relationship between ΔIPF and IR, univariate and multivariate logistic regression were performed. To analyse the additive value of ΔIPF in APACHE II and SOFA scores in predicting IR, an area under the receiver operating characteristic (AUROC) curve was calculated.

RESULTS

Among 327 patients included, 60 patients (18.3%) developed IR. Multivariate analysis showed ΔIPF was significantly associated with IR (OR: 1.26; 95% CI: 1.01 to 1.56; p=0.038). The combination of ΔIPF with scores improved the AUROC for IR prediction: 0.629 vs 0.728 (p=0.010) for APACHE II and 0.676 vs 0.715 (p=0.106) for SOFA.

CONCLUSION

These findings suggested that ΔIPF may be a useful and low-cost biomarker for the early identification of patients at risk of IR development.

Determinants and Outcomes of Vasoplegia Following Left Ventricular Assist Device Implantation

BACKGROUND

Vasoplegia is associated with adverse outcomes following cardiac surgery; however, its impact following left ventricular assist device implantation is largely unexplored.

METHODS AND RESULTS

In 252 consecutive patients receiving a left ventricular assist device, vasoplegia was defined as the occurrence of normal cardiac function and index but with the need for intravenous vasopressors within 48 hours following surgery for >24 hours to maintain a mean arterial pressure >70 mm Hg. We further categorized vasoplegia as none; mild, requiring 1 vasopressor (vasopressin, norepinephrine, or high-dose epinephrine [>5 μg/min]); or moderate to severe, requiring ≥2 vasopressors. Predictors of vasoplegia severity were determined using a cumulative logit (ordinal logistic regression) model, and 1-year mortality was evaluated using competing-risks survival analysis. In total, 67 (26.6%) patients developed mild vasoplegia and 57 (22.6%) developed moderate to severe vasoplegia. The multivariable model for vasoplegia severity utilized preoperative Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile, central venous pressure, systolic blood pressure, and intraoperative cardiopulmonary bypass time, which yielded an area under the curve of 0.76. Although no significant differences were noted in stroke or pump thrombosis rates (P=0.87 and P=0.66, respectively), respiratory failure and major bleeding increased with vasoplegia severity (P<0.01). Those with moderate to severe vasoplegia had a significantly higher risk of mortality than those without vasoplegia (adjusted hazard ratio: 2.12; 95% confidence interval, 1.08-4.18; P=0.03).

CONCLUSIONS

Vasoplegia is predictive of unfavorable outcomes, including mortality. Risk factors for future research include preoperative INTERMACS profile, central venous pressure, systolic blood pressure, and intraoperative cardiopulmonary bypass time.

The impact of prehabilitation on post-surgical complications in patients undergoing non-urgent cardiovascular surgical intervention: Systematic review and meta-analysis

Introduction

Cardiac surgery is an aggressive procedure, inducing a great level of stress and disturbance to the homeostasis of the organism and underlying several postoperative complications. Surgical prehabilitation comprises pre-operative physical conditioning designed to improve the physiological and functional capacities of the individual, prepare the organism for surgical stress and reduce the risk of postoperative morbidity.

Aim

This systematic review and meta-analysis is aimed at evaluating the ability of prehabilitation to prevent post-surgical complications in cardiac patients.

Methods

We selected studies conducted among patients who were waiting for non-urgent cardiac surgical procedures, where a comparison between prehabilitation and standard treatment was made. A total of 3650 possible studies were researched, of which eight were selected for inclusion.

Results

A reduction in the number of complications in the groups submitted to prehabilitation (odds ratio = 0.41; 95% confidence interval (CI): 0.28–0.62; p < 0.001; I2 = 0%) was observed, as well as a significant increase in maximal inspiratory pressure (standard mean difference (SMD) = 0.66; 95% CI: 0.35–0.96; p < 0.001; I2 = 58%), a non-significant decrease in the length of stay (SMD = –0.56; 95% CI: −1.13, 0.01; p = 0.05; I2 = 93%), a non-significant increase in the distance walked by the intervention group in the six-minute walk test (SMD = 0.89; 95% CI −0.06, 1.84; p = 0.07) and a lack of effect on mechanical ventilation time (SMD = −0.03; 95% CI: −0.22, 0.16; p = 0.75; I2 = 0%).

Conclusion

Prehabilitation reduces the number of post-surgical complications and increases maximal inspiratory pressure; a reduction in the length of stay and an improvement of functional capacities are also probable.