The impact of previous COVID-19 pneumonia on postoperative outcomes and complications in coronary artery bypass grafting

Background

This study aimed to provide nuanced insights in managing patients with a history of coronavirus disease 2019 (COVID-19) pneumonia undergoing coronary artery bypass grafting.

Methods

This retrospective cohort study involved 168 patients (131 males, 37 females; mean age: 61.2±9.7 years; range, 51 to 72 years) undergoing isolated coronary artery bypass grafting surgery between December 2021 and December 2023. The study examined factors such as age, sex, comorbidities, blood test results, vaccination status, operative parameters, and postoperative complications. Patients' health records were reviewed to confirm the presence of previous COVID-19 pneumonia and vaccination status. Patients were divided into two groups based on their history of COVID-19 pneumonia: Group 1 included 140 who had not been diagnosed with COVID-19 pneumonia, and Group 2 included 28 patients who had a documented history of COVID-19 pneumonia. Postoperative pulmonary complications, including atelectasis, pleural effusion, acute respiratory distress syndrome, and pneumonia, were noted.

Results

Patients with a history of COVID-19 pneumonia (Group 2, n=28) demonstrated significantly higher seropositivity for COVID-19 (89.3% vs. 29.3%, p=0.001) compared to those without a history (Group 1, n=140). Although pulmonary complications were higher in Group 2 (17.9% vs. 3.6%, p=0.013), postoperative mortality rates did not differ significantly between the groups. Pleural effusion was markedly higher in Group 2 (14.3% vs. 2.1%, p=0.015). Vaccination did not significantly affect perioperative and postoperative outcomes, except for a minor difference in postoperative drainage volume.

Conclusion

This study highlights the impact of prior COVID-19 pneumonia on postoperative outcomes in coronary artery bypass grafting patients. Although there was a rise in pulmonary complications, the mortality rates stayed similar among individuals with and without a prior history of COVID-19 pneumonia. Vaccination did not significantly influence outcomes, emphasizing the need for further research with larger cohorts to validate and expand upon these findings.

Pain management after cardiac surgery via median sternotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations

BACKGROUND

Pain after cardiac surgery via median sternotomy can be difficult to treat, and if inadequately managed can lead to respiratory complications, prolonged hospital stays and chronic pain.

OBJECTIVES

To evaluate available literature and develop recommendations for optimal pain management after cardiac surgery via median sternotomy.

DESIGN

A systematic review using PROcedure-SPECific Pain Management (PROSPECT) methodology.

ELIGIBILITY CRITERIA

Randomised controlled trials and systematic reviews published in the English language until November 2020 assessing postoperative pain after cardiac surgery via median sternotomy using analgesic, anaesthetic or surgical interventions.

DATA SOURCES

PubMed, Embase and Cochrane Databases.

RESULTS

Of 319 eligible studies, 209 randomised controlled trials and three systematic reviews were included in the final analysis. Pre-operative, intra-operative and postoperative interventions that reduced postoperative pain included paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), intravenous magnesium, intravenous dexmedetomidine and parasternal block/infiltration.

CONCLUSIONS

The analgesic regimen for cardiac surgery via sternotomy should include paracetamol and NSAIDs, unless contraindicated, administered intra-operatively and continued postoperatively. Intra-operative magnesium and dexmedetomidine infusions may be considered as adjuncts particularly when basic analgesics are not administered. It is not clear if combining dexmedetomidine and magnesium would provide superior pain relief compared with either drug alone. Parasternal block/surgical site infiltration is also recommended. However, no basic analgesics were used in the studies assessing these interventions. Opioids should be reserved for rescue analgesia. Other interventions, including cyclo-oxygenase-2 specific inhibitors, are not recommended because there was insufficient, inconsistent or no evidence to support their use and/or due to safety concerns.

Development of the Modern Cardiothoracic Intensive Care Unit and Current Management

The modern cardiothoracic intensive care unit (CTICU) developed as a result of advances in critical care, cardiology, and cardiac surgery. Patients undergoing cardiac surgery today are sicker, frailer, and have more complex cardiac and noncardiac morbidities. CTICU providers need to understand postoperative implications of different surgical procedures, complications that can occur in CTICU patients, resuscitation protocols for cardiac arrest, and diagnostic and therapeutic interventions such as transesophageal echocardiography and mechanical circulatory support. Optimum CTICU care requires a multidisciplinary team with collaboration between cardiac surgeons and critical care physicians with training and experience in the care of CTICU patients.

Effect of mechanical ventilation during cardiopulmonary bypass on end-expiratory lung volume in the perioperative period of cardiac surgery: an observational study

BACKGROUND

Many studies explored the impact of ventilation during cardiopulmonary bypass (CPB) period with conflicting results. Functional residual capacity or End Expiratory Lung Volume (EELV) may be disturbed after cardiac surgery but the specific effects of CPB have not been studied. Our objective was to compare the effect of two ventilation strategies during CPB on EELV.

METHODS

Observational single center study in a tertiary teaching hospital. Adult patients undergoing on-pump cardiac surgery by sternotomy were included. Maintenance of ventilation during CPB was left to the discretion of the medical team, with division between "ventilated" and "non-ventilated" groups afterwards. Iterative intra and postoperative measurements of EELV were carried out by nitrogen washin-washout technique. Main endpoint was EELV at the end of surgery. Secondary endpoints were EELV one hour after ICU admission, PaO₂/FiO₂ ratio, driving pressure, duration of mechanical ventilation and post-operative pulmonary complications.

RESULTS

Forty consecutive patients were included, 20 in each group. EELV was not significantly different between the ventilated versus non-ventilated groups at the end of surgery (1796 ± 586 mL vs. 1844 ± 524 mL, p = 1) and one hour after ICU admission (2095 ± 562 vs. 2045 ± 476 mL, p = 1). No significant difference between the two groups was observed on PaO₂/FiO₂ ratio (end of surgery: 339 ± 149 vs. 304 ± 131, p = 0.8; one hour after ICU: 324 ± 115 vs. 329 ± 124, p = 1), driving pressure (end of surgery: 7 ± 1 vs. 8 ± 1 cmH₂O, p = 0.3; one hour after ICU: 9 ± 3 vs. 9 ± 3 cmH₂O), duration of mechanical ventilation (5.5 ± 4.8 vs 8.2 ± 10.0 h, p = 0.5), need postoperative respiratory support (2 vs. 1, p = 1), occurrence of pneumopathy (2 vs. 0, p = 0.5) and radiographic atelectasis (7 vs. 8, p = 1).

CONCLUSION

No significant difference was observed in EELV after cardiac surgery between not ventilated and ventilated patients during CPB.

Inspiratory and end-expiratory effects of lung recruitment in the prone position on dorsal lung aeration - new physiological insights in a secondary analysis of a randomised controlled study in post-cardiac surgery patients

Background

Cardiac surgery produces dorso-basal atelectasis and ventilation/perfusion mismatch, associated with infection and prolonged intensive care. A postoperative lung volume recruitment manoeuvre to decrease the degree of atelectasis is routine. In patients with severe respiratory failure, prone positioning and recruitment manoeuvres may increase survival, oxygenation, or both. We compared the effects of lung recruitment in prone vs supine positions on dorsal inspiratory and end-expiratory lung aeration.

Methods

In a prospective RCT, 30 post-cardiac surgery patients were randomly allocated to recruitment manoeuvres in the prone (n=15) or supine position (n=15). The primary endpoints were late dorsal inspiratory volume (arbitrary units [a.u.]) and left/right dorsal end-expiratory lung volume change (a.u.), prone vs supine after extubation, measured using electrical impedance tomography. Secondary outcomes included left/right dorsal inspiratory volumes (a.u.) and left/right dorsal end-expiratory lung volume change (a.u.) after prone recruitment and extubation.

Results

The last part of dorsal end-inspiratory volume after extubation was higher after prone (49.1 a.u.; 95% confidence interval [CI], 37.4-60.6) vs supine recruitment (24.2 a.u.; 95% CI, 18.4-29.6; P=0.024). Improvement in left dorsal end-expiratory lung volume after extubation was higher after prone (382 a.u.; 95% CI, 261-502) vs supine recruitment (-71 a.u., 95% CI, -140 to -2; n=15; P<0.001). After prone recruitment, left vs right predominant end-expiratory dorsal lung volume change disappeared after extubation. However, both left and right end-expiratory volumes were higher in the prone group, after extubation.

Conclusions

Recruitment in the prone position improves dorsal inspiratory and end-expiratory lung volumes after cardiac surgery.

Clinical trial registration

NCT03009331.

Is continuous Erector Spinae Plane Block (ESPB) better than continuous Serratus Anterior Plane Block (SAPB) for mitral valve surgery via mini-thoracotomy? Results from a prospective observational study

Aims

Chest wall blocks are effective alternatives for postoperative pain control in mitral valve surgery in right mini-thoracotomy (mini-MVS). We compared the efficacy of Serratus Anterior plane block (SAPB) and Erector Spinae plane block (ESPB) on postoperative pain relief after mini-MVS.

Settings and Design

It is a prospective, observational study.

Material and Methods

A total of 85 consecutive patients undergoing continuous SAPB and continuous ESPB for mini-MVS from March 2019 to October 2020 were included. The primary outcome was the assessment of postoperative pain evaluated as absolute value of NRS at 12, 24 and 48 h. Secondary outcomes were assessment of salvage analgesia (both opioids and NSAIDs), incidence of mild adverse effects (i.e. nausea, vomiting, and incorrect catheter placement) and timing of postoperative course (ICU and hospital length of stay, duration of mechanical ventilation, ventilator-free days).

Results

The median NRS was 0.00 (0.00-3.00) at 12 h and 0.00 (0.00-2.00) at 24 and 48 h. No significant differences were observed between groups. Postoperative morphine consumption in the first 24 h was similar in both groups (P = 0.76), whereas between 24 and 48 h was significantly less in the ESPB group compared with SAPB group, P = 0.013. NSAIDs median consumption and Metoclopramide consumption were significantly lower in the ESPB group compared to SAPB group (P = 0.002 and P = 0.048, respectively).

Conclusions

ESPB, even more than SAPB, appears to be a feasible and effective strategy for the management of postoperative pain, allowing good quality analgesia with low consumption of opioids, NSAIDs and antiemetic drugs.

Comparative Evaluation of the Incidence of Postoperative Pulmonary Complications After Minimally Invasive Valve Surgery vs. Full Sternotomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Propensity Score-Matched Studies

Background: Postoperative pulmonary complications remain a leading cause of increased morbidity, mortality, longer hospital stays, and increased costs after cardiac surgery; therefore, our study aims to analyze whether minimally invasive valve surgery (MIVS) for both aortic and mitral valves can improve pulmonary function and reduce the incidence of postoperative pulmonary complications when compared with the full median sternotomy (FS) approach. Methods: A comprehensive systematic literature research was performed for studies comparing MIVS and FS up to February 2021. Randomized controlled trials (RCTs) and propensity score-matching (PSM) studies comparing early respiratory function and pulmonary complications after MIVS and FS were extracted and analyzed. Secondary outcomes included intra- and postoperative outcomes. Results: A total of 10,194 patients from 30 studies (6 RCTs and 24 PSM studies) were analyzed. Early mortality differed significantly between the groups (MIVS 1.2 vs. FS 1.9%; p = 0.005). Compared with FS, MIVS significantly lowered the incidence of postoperative pulmonary complications (odds ratio 0.79, 95% confidence interval [0.67, 0.93]; p = 0.004) and improved early postoperative respiratory function status (mean difference -24.83 [-29.90, -19.76]; p < 0.00001). Blood transfusion amount was significantly lower after MIVS (p < 0.02), whereas cardiopulmonary bypass time and aortic cross-clamp time were significantly longer after MIVS (p < 0.00001). Conclusions: Our study showed that minimally invasive valve surgery decreases the incidence of postoperative pulmonary complications and improves postoperative respiratory function status.

A nomogram to predict postoperative pulmonary complications after cardiothoracic surgery

OBJECTIVE

The objective was to develop a novel scoring system that would be predictive of postoperative pulmonary complications in critically ill patients after cardiac and major vascular surgery.

METHODS

A total of 17,433 postoperative patients after coronary artery bypass graft, valve, or thoracic aorta repair surgery admitted to the cardiovascular intensive care units at Cleveland Clinic Main Campus from 2009 to 2015. The primary outcome was the composite of postoperative pulmonary complications, including pneumonia, prolonged postoperative mechanical ventilation (>48 hours), or reintubation occurring during the hospital stay. Elastic net logistic regression was used on the training subset to build a prediction model that included perioperative predictors. Five-fold cross-validation was used to select an appropriate subset of the predictors. The predictive efficacy was assessed with calibration and discrimination statistics. Post hoc, of 13,353 adult patients, we tested the clinical usefulness of our risk prediction model on 12,956 patients who underwent surgery from 2015 to 2019.

RESULTS

Postoperative pulmonary complications were observed in 1669 patients (9.6%). A prediction model that included baseline and demographic risk factors along with perioperative predictors had a C-statistic of 0.87 (95% confidence interval, 0.86-0.88), with a corrected Brier score of 0.06. Our prediction model maintains satisfactory discrimination (C-statistics of 0.87) and calibration (Brier score of 0.07) abilities when evaluated on an independent dataset of 12,843 recent adult patients who underwent cardiovascular surgery.

CONCLUSIONS

A novel prediction nomogram accurately predicted postoperative pulmonary complications after major cardiac and vascular surgery. Intensivists may use these predictors to allow for proactive and preventative interventions in this patient population.

Contrasting effects of three breathing techniques on pulmonary function, functional capacity and daily life functional tasks in patients following valve replacement surgery- A pilot randomized clinical trial

Background

Valve replacement surgeries affect the physiological mechanisms of patients leading to various postoperative pulmonary complications. Lung expansion therapy consisting of numerous techniques is routinely used for the prevention and treatment of these complications.

Objectives

Our study aimed to compare the effects of diaphragmatic breathing (DB), flow (FS) and volume-oriented incentive spirometer (VS) in patients following valve replacement surgery.

Methods

29 patients posted valve replacement surgeries were randomly assigned to VS, FS and DB groups. Patients underwent preoperative training and seven-day rehabilitation post-surgery. Pulmonary function tests were performed before surgery and for seven days afterward. On the seventh postoperative day, patients performed a six-minute walk test and completed a functional difficulties questionnaire (FDQ).

Results

Pulmonary function test values reduced in all three groups postoperatively when compared to the preoperative values but improved by the seventh postoperative day (p < 0.05). On comparing the seventh postoperative day values to the preoperative values, the VS group had no significant difference (p = 1.00) (Forced Vital Capacity- % change: DB-37.76, VS-1.59, FS-27.98), indicating that the value had nearly returned to the baseline. As compared to the DB and FS groups, FVC showed a greater improvement in the VS group (p = 0.01 and p = 0.06 respectively). No significant differences were observed between groups for distance walked (p > 0.05), however, FDQ scores demonstrated positive changes in favor of VS when contrasted with FS or DB (p < 0.05).

Conclusion

Diaphragmatic breathing, flow or volume-oriented spirometer could improve pulmonary function in the postoperative period. The volume-oriented spirometer, however, was found to be the most beneficial among the three techniques in improving patients’ pulmonary function and daily life functional tasks. Further research is warranted to confirm these findings.

•

The present pilot randomized clinical trial is the first of a kind that exhibits the effects of three breathing exercises in patients following valve replacement cardiac surgery.

•

The study demonstrates the individual and contrasting effects of volume spirometry, volume spirometry and deep breathing exercise between preoperative day until postoperative day 7 in terms of pulmonary function and function activities.

Safety of Ultrasound-Guided Serratus Anterior and Erector Spinae Fascial Plane Blocks: A Retrospective Analysis in Patients Undergoing Cardiac Surgery While Receiving Anticoagulant and Antiplatelet Drugs

OBJECTIVES

Chest wall blocks are an effective strategy for postoperative pain control in minimally invasive cardiac surgery, but, in the absence of clinical trials evaluating their safety in the presence of anticoagulant and antiplatelet drugs, it still is recommended to follow the same guidelines developed for the neuraxial procedures and for peripheral blocks.

DESIGN

Retrospective observational study.

SETTING

AOU Città della Salute e della Scienza di Torino, University of Turin, Italy.

PARTICIPANTS

Between March 28, 2019 and October 19, 2020, 70 patients who underwent mitral valve surgery via right minithoracotomy were enrolled: 35 treated with continuous erector spinae plane block (ESPB) and 35 with continuous serratus anterior plane block (SAPB).

INTERVENTIONS

The primary objective was the evaluation of the number of blocks performed or catheters removed while coagulation was abnormal or antithrombotic and anticoagulant therapies were in progress.

MEASUREMENTS AND MAIN RESULTS

Eleven patients (15.7%) received fascial plane block with international normalized ratio (INR) > 1.40, four patients (5.71%) with a platelet count <80 × 10³, and one patient received ESPB block during dual-antiplatelet therapy. In 16 patients (22.9%), the catheter was removed with an INR > 1.40, in five patients (7.1%) with a platelet count <80 × 10³, and in 53 patients (75.71%) despite low-molecular-weight heparin at therapeutic dose. The median antagonist dose of vitamin K at the time of catheter removal was 2.5 mg (range 2.5-3.44 mg) in both groups. No major adverse effects directly attributable to the blocks were observed.

CONCLUSIONS

The authors did not find any problems related to the use of continuous ESPB and SAPB, although they were performed in the presence of anticoagulation and in a context with a high risk of bleeding such as cardiac surgery.

High Flow Oxygen Therapy at Two Initial Flow Settings versus Conventional Oxygen Therapy in Cardiac Surgery Patients with Postextubation Hypoxemia: A Single-Center, Unblinded, Randomized, Controlled Trial

In cardiac surgery patients with pre-extubation PaO₂/inspired oxygen fraction (FiO₂) < 200 mmHg, the possible benefits and optimal level of high-flow nasal cannula (HFNC) support are still unclear; therefore, we compared HFNC support with an initial gas flow of 60 or 40 L/min and conventional oxygen therapy. Ninety nine patients were randomly allocated (respective ratio: 1:1:1) to I = intervention group 1 (HFNC initial flow = 60 L/min, FiO₂ = 0.6), intervention group 2 (HFNC initial flow = 40 L/min, FiO₂ = 0.6), or control group (Venturi mask, FiO₂ = 0.6). The primary outcome was occurrence of treatment failure. The baseline characteristics were similar. The hazard for treatment failure was lower in intervention group 1 vs. control (hazard ratio (HR): 0.11, 95% CI: 0.03–0.34) and intervention group 2 vs. control (HR: 0.30, 95% CI: 0.12–0.77). During follow-up, the probability of peripheral oxygen saturation (SpO₂) > 92% and respiratory rate within 12–20 breaths/min was 2.4–3.9 times higher in intervention group 1 vs. the other 2 groups. There was no difference in PaO₂/FiO₂, patient comfort, intensive care unit or hospital stay, or clinical course complications or adverse events. In hypoxemic cardiac surgery patients, postextubation HFNC with an initial gas flow of 60 or 40 L/min resulted in less frequent treatment failure vs. conventional therapy. The results in terms of SpO₂/respiratory rate targets favored an initial HFNC flow of 60 L/min.

Mitral valve surgery: current status and future prospects of the minimally invasive approach

Introduction: During the past five years the approach to procedural planning, operative techniques and perfusion strategies for minimally invasive mitral valve surgery (MIMVS) has evolved. With the goal to provide a maximum of patient safety the procedure has been modified according to individual patient characteristics and is largely based on preoperative imaging.Areas covered: In this review article we describe the important factors in image based therapy planning and simulation, different access strategies, the operative key-steps, a rationale use of devices, and highlight a few future developments in the field of MIMVS. Published studies were identified through pearl growing, citation chasing, a search of PubMed using the systematic review methods filter, and the authors' topic knowledge.Expert opinion: With the help of expert teams including surgeons specialized in mitral repair, anesthesiologists and perfusionists a broad spectrum of mitral valve pathologies and related pathologies can be treated with excellent functional outcomes. Avoiding procedure related complications is the key for success for any MIMVS program.

Lung recruitment in the prone position after cardiac surgery: a randomised controlled study

BACKGROUND

Atelectasis after cardiac surgery is common and promotes ventilation/perfusion mismatch, infection, and delayed discharge from critical care. Recruitment manoeuvres are often performed to reduce atelectasis. In severe respiratory failure, recruitment manoeuvres in the prone position may increase oxygenation, survival, or both. We compared the effects of recruitment manoeuvres in the prone vs supine position on lung aeration and oxygenation in cardiac surgical patients.

METHODS

Subjects were randomised to recruitment manoeuvres (40 cm H₂O peak inspiratory pressure and 20 cm H₂O PEEP for 30 s) in either the prone or supine position after uncomplicated cardiac surgery. The co-primary endpoints were lung aeration (end-expiratory lung volume measured by electrical impedance tomography (arbitrary units [a.u.]) and lung oxygenation (ratio of arterial oxygen partial pressure to fractional inspired oxygen [Pao₂/FiO₂ ratio]). Secondary outcomes included postoperative oxygen requirement and adverse events.

RESULTS

Thirty subjects (27% female; age, 48-81 yr) were recruited. Dorsal lung tidal volume was higher after prone recruitment manoeuvres (363 a.u.; 95% confidence intervals [CI], 283-443; n=15) after extubation, compared with supine recruitment manoeuvres (212 a.u.; 95% CI, 170-254; n=15; P<0.001). Prone recruitment manoeuvres increased dorsal end-expiratory lung volume by 724 a.u. (95% CI, 456-992) after extubation, compared with 163 a.u. decrease (95% CI, 73-252) after supine recruitment manoeuvres (P<0.001). The Pao₂/FiO₂ ratio after extubation was higher after prone recruitment manoeuvres (46.6; 95% CI, 40.7-53.0) compared with supine recruitment manoeuvres (39.3; 95% CI, 34.8-43.8; P=0.04). Oxygen therapy after extubation was shorter after prone (33 h [13]) vs supine recruitment manoeuvres (52 h [22]; P=0.01). No adverse events occurred.

CONCLUSIONS

Recruitment manoeuvres in the prone position after cardiac surgery improve lung aeration and oxygenation.

CLINICAL TRIAL REGISTRATION

NCT03009331.

Pulmonary Complications of Cardiac Surgery

Cardiothoracic surgery posits an arrangement of large, significant hemodynamic, and physiologic alterations upon the human body, which predisposes a patient to develop pathology. The care of these patients in the postoperative realm requires an astute physician with deep understanding of the cardiopulmonary system, who is able to address subtle developing problems promptly, before the patient suffers further sequelae. In this review, we describe the presentation and management of an assortment of important complications which occur in the pulmonary system. In addition, we aim to shed better light upon how the physiology of a patient responds to the condition of cardiothoracic surgery.

Positive expiratory pressure in postoperative cardiac patients in intensive care: A randomized controlled trial

OBJECTIVE

To evaluate effectiveness of positive expiratory pressure blow-bottle device compared to expiratory positive airway pressure and conventional physiotherapy on pulmonary function in postoperative cardiac surgery patients in intensive care unit.

DESIGN

A randomized controlled trial.

SETTINGS

Tertiary care.

SUBJECTS

48 patients (16 in each group; aged 64.5 ± 9.1 years, 38 male) submitted to cardiac surgery.

INTERVENTIONS

Patients were randomized into conventional physiotherapy (G1), positive expiratory pressure blow-bottle device (G2) or expiratory positive airway pressure, both associated with conventional physiotherapy (G3). G2 and G3 performed three sets of 10 repetitions in each session for each technique.

MAIN MEASURES

Pulmonary function (primary); respiratory muscle strength, radiological changes, pulmonary complications, length of intensive care unit and hospital stay (secondary) assessed preoperatively and on the 3rd postoperative day.

RESULTS

Pulmonary function (except for forced expiratory volume in one second/ forced vital capacity % predicted) and respiratory muscle strength showed significant reduction from the preoperative to the 3rd postoperative in all groups (P < 0.001), with no difference between groups (P > 0.05). Regarding radiological changes, length of intensive care unit stay and length of hospital stay, there was no significant difference between groups (P > 0.05).

CONCLUSION

Both positive expiratory pressure techniques associated with conventional physiotherapy were similar, but there was no difference regarding the use of positive expiratory pressure compared to conventional physiotherapy.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03639974.https://clinicaltrials.gov/ct2/show/NCT03639974.

Predictors and outcomes of postoperative respiratory failure after cardiac surgery

BACKGROUND

Postoperative respiratory failure after cardiac surgery (CS-PRF) is a devastating complication and its incidence and predictors vary depending on how it is defined and the patient population.

AIMS

This study was conducted to determine the incidence, predictors and outcomes of CS-PRF defined as prolonged mechanical ventilation >48 hours and reintubation.

METHODS

This is a retrospective chart review of 1257 patients who underwent cardiac surgery between June 2011 and December 2018. The research questions were addressed through bivariate inferential, descriptive and binary logistic regression.

RESULTS

The overall incidence of CS-PRF was 15.9% and significant regression predictors included diabetes mellitus (OR = 1.77, P = .001), preoperative renal replacement therapy (OR = 2.07, P = .033), need for intraoperative transfusion (OR = 2.35, P = .000), combined coronary bypass/valvular surgery (OR = 2.61, P = .001) and intra-aortic balloon pump (OR = 3.60, P = .000). CS-PRF patients had increased postoperative blood transfusions (69.5% vs 27.9%, P = .000), reoperation for bleeding (9.0 vs 0.4%, P = .000), pleural effusion (13.5% vs 4.1%, P = .000), pneumonia (33.5% vs 1.6%, P = .000), acute kidney injury (70.9% vs 39.9%, P = .000), atrial fibrillation (42.5% vs 26.3%, P = .000), coma/encephalopathy (21.5% vs 3.3%, P = .000) and cerebrovascular accident (6.0% vs 1.3%, P = .000). They also had longer intensive care (262.1 vs 97.4 hours, P = .000) and hospital lengths of stay (17 vs 8 days, P = .000), and increased in-hospital mortality (17.5% vs 0.4%, P = .000). Survivors of CS-PRF were less likely to be discharged home (38.0% vs 84.4%, P = .000).

CONCLUSIONS

Knowledge of predictors for CS-PRF may help identify patients who are at risk for this complication and who may benefit from preventive measures to promote early extubation and to avert reintubation.

Postoperative pain treatment with erector spinae plane block and pectoralis nerve blocks in patients undergoing mitral/tricuspid valve repair - a randomized controlled trial

BACKGROUND

Effective postoperative pain control remains a challenge for patients undergoing cardiac surgery. Novel regional blocks may improve pain management for such patients and can shorten their length of stay in the hospital. To compare postoperative pain intensity in patients undergoing cardiac surgery with either erector spinae plane (ESP) block or combined ESP and pectoralis nerve (PECS) blocks.

METHODS

This was a prospective, randomized, controlled, double-blinded study done in a tertiary hospital. Thirty patients undergoing mitral/tricuspid valve repair via mini-thoracotomy were included. Patients were randomly allocated to one of two groups: ESP or PECS + ESP group (1:1 randomization). Patients in both groups received a single-shot, ultrasound-guided ESP block. Participants in PECS + ESP group received additional PECS blocks. Each patient had to be extubated within 2 h from the end of the surgery. Pain was treated via a patient-controlled analgesia (PCA) pump. The primary outcome was the total oxycodone consumption via PCA during the first postoperative day. The secondary outcomes included pain intensity measured on the visual analog scale (VAS), patient satisfaction, Prince Henry Hospital Pain Score (PHHPS), and spirometry.

RESULTS

Patients in the PECS + ESP group used significantly less oxycodone than those in the ESP group: median 12 [interquartile range (IQR): 6-16] mg vs. 20 [IQR: 18-29] mg (p = 0.0004). Moreover, pain intensity was significantly lower in the PECS + ESP group at each of the five measurements during the first postoperative day. Patients in the PECS + ESP group were more satisfied with pain management. No difference was noticed between both groups in PHHPS and spirometry.

CONCLUSIONS

The addition of PECS blocks to ESP reduced consumption of oxycodone via PCA, reduced pain intensity on the VAS, and increased patient satisfaction with pain management in patients undergoing mitral/tricuspid valve repair via mini-thoracotomy.

TRIAL REGISTRATION

The study was registered on the 19th July 2018 (first posted) on the ClinicalTrials.gov identifier: NCT03592485.

The Effects of Escalation of Respiratory Support and Prolonged Invasive Ventilation on Outcomes of Cardiac Surgical Patients: A Retrospective Cohort Study

Objectives

The aim of this study was to determine the effects of escalation of respiratory support and prolonged postoperative invasive ventilation on patient-centered outcomes, and identify perioperative factors associated with these 2 respiratory complications.

Design

A retrospective cohort analysis of cardiac surgical patients admitted to the cardiothoracic intensive care unit (ICU) between August 2015 and January 2018. Escalation of respiratory support was defined as “unplanned continuous positive airway pressure,” “non-invasive ventilation,” or “reintubation” after surgery; prolonged invasive ventilation was defined as “invasive ventilation beyond the first 12 hours following surgery.” The primary endpoint was the composite of escalation of respiratory support and prolonged ventilation.

Setting

Tertiary cardiothoracic ICU.

Participants

A total of 2,098 patients were included and analyzed.

Interventions

None.

Measurements and Main Results

The composite of escalation of support or prolonged ventilation occurred in 509 patients (24.3%). Patients who met the composite had higher mortality (2.9% v 0.1%; p < 0.001) and longer median [interquartile range] length of ICU (2.1 [1.0-4.9] v 0.9 [0.8-1.0] days; p < 0.0001) and hospital (10.6 [8.0-16.0] v 7.2 [6.2-10.0] days; p < 0.0001) stay. Hypoxemia and anemia on admission to ICU were the only 2 factors independently associated with the need for escalation of respiratory support or prolonged invasive ventilation.

Conclusions

Escalation of respiratory support or prolonged invasive ventilation is frequently seen in cardiac surgery patients and is highly associated with increased mortality and morbidity. Hypoxemia and anemia on admission to the ICU are potentially modifiable factors associated with escalation of respiratory support or prolonged invasive ventilation.

High-Flow Therapy by Nasal Cannulae Versus High-Flow Face Mask in Severe Hypoxemia After Cardiac Surgery: A Single-Center Randomized Controlled Study-The HEART FLOW Study

OBJECTIVE

To determine whether high-flow oxygen therapy by nasal cannulae (HFNC) is more effective than a high-flow face mask (HFFM) in severe hypoxemia.

DESIGN

Randomized, single-center, open-labeled, controlled trial.

SETTING

University Hospital of Nantes, France.

PARTICIPANTS

Cardiac surgery patients presenting oxygen saturation <96% with Venturi mask 50%.

INTERVENTION

Oxygenation by HFNC (45 L/min, F_IO₂ 100%) or Hudson RCI non-rebreather face mask with a reservoir bag (15 L/min).

MEASUREMENTS AND MAIN RESULTS

The co-primary outcomes were the PaO₂/F_IO₂ ratio at 1 and 24 hours. In the intent-to-treat analysis (90 patients), the mean (standard deviation) PaO₂/F_IO₂ ratios were: after 1 hour, 113.4 (50.2) in HFFM versus 137.8 (57.0) in HFNC (mean difference 24.4, CI 97.5% [2.9-45.9], p = 0.03), and after 24 hours, 106.9 (62.6) in HFFM versus 129.9 (54.0) in HFNC (mean difference 23.0, CI 97.5% [1.5-44.6], p = 0.04). After adjustment on baseline PaO₂/F_IO_2, this difference persisted at 24 hours (p = 0.04). For secondary outcomes, the PaO₂/F_IO₂ ratio after 6 hours was 108.7 (47.9) in HFFM versus 136.0 (45.2) in HFNC (p = 0.01), without difference after 48 hours (p = 0.95). Refractory hypoxemia requiring noninvasive ventilation occurred in 13 (28%) patients in HFNC versus 24 (56%) patients in HFFM (p = 0.007). The HFNC improved satisfaction (p = 0.0002) and reduced mucus dryness (p = 0.003) compared with HFFM.

CONCLUSION

In patients with severe hypoxemia after cardiac surgery, PaO₂/F_IO₂ at 1 and 24 hours were higher and the use of noninvasive ventilation was reduced in HFNC compared with HFFM.

Survival and Risk Factors Among Dialytic Acute Kidney Injury Patients After Cardiovascular Surgery

OBJECTIVE

Acute kidney injury (AKI) is a frequent postoperative complication after cardiovascular surgery. It has been described as a predictor of decreased survival rates, but how dialysis decreases survival when initiated on the postoperative period has yet to be determined. To analyze the survival of patients who presented postoperative AKI requiring dialysis up to 30 days after cardiovascular surgery and its risk factors is the aim of this study.

METHODS

Of the 5,189 cardiovascular surgeries performed in a 4-year period, 157 patients developed AKI requiring dialysis in the postoperative period. The Kaplan-Meier survival curve and log-rank test were used in the statistical analysis to compare the curves of categorical variables. P-value< 0.05 was considered significant.

RESULTS

Patient average survival was 546 days and mortality was 70.7%. The need for dialysis on the postoperative period decreased late survival. Risk factors for decreased survival included age (P<0.001) and postoperative complications (P<0.0003).

CONCLUSION

The average survival was approximately one year among dialytic patients. Age and postoperative complications were risk factors that determined decreased survival.

The association between hope, marital status, depression and persistent pain in men and women following cardiac surgery

Background

Cardiac surgery is a major life event, and outcomes after surgery are associated with men’s and women’s ability to self-manage and cope with their cardiac condition in everyday life. Hope is suggested to impact cardiac health by having a positive effect on how adults cope with and adapt to illness and recommended lifestyle changes.

Methods

We did a secondary analysis of 416 individuals (23% women) undergoing elective coronary artery bypass graft and/or valve surgery between March 2012 and September 2013 enrolled in randomized controlled trial. Hope was assessed using The Herth Hope Index (HHI) at three, six and 12 months following cardiac surgery. Linear mixed model analyses were performed to explore associations after cardiac surgery between hope, marital status, depression, persistent pain, and surgical procedure.

Results

For the total sample, no statistically significant difference between global hope scores from 3 to 12 months was observed (ranging from 38.3 ± 5.1 at 3 months to 38.7 ± 5.1 at 12 months), and no differences between men and women were observed at any time points. However, 3 out of 12 individual items on the HHI were associated with significantly lower scores in women: #1) I have a positive outlook toward life, #3) I feel all alone, and #6) I feel scared about my future. Over the study period, diminished hope was associated with older age, lower education, depression prior to surgery, and persistent pain at all measurement points. Isolated valve surgery was positively associated with hope. While neither sex nor marital status, as main effects, demonstrated significant associations with hope, women who were divorced/widowed/single were significantly more likely to have lower hope scores over the study period.

Conclusion

Addressing pain and depression, and promoting hope, particularly for women living alone may be important targets for interventions to improve outcomes following cardiac surgery.

Trial registration

Clinical Trials gov Identifier: NCT01976403. Date of registration: November 28, 2011.

Incidence and Outcomes of Acute Kidney Injury After Orthotopic Cardiac Transplant: A Population-Based Cohort

OBJECTIVES

Acute kidney injury is a frequent complication after orthotopic cardiac transplant. We aimed to describe the risk factors for acute kidney injury after cardiac transplant according to Kidney Disease: Improving Global Outcomes criteria.

MATERIALS AND METHODS

We retrospectively studied a population-based cohort of cardiac transplant recipients (aged > 12 y) at Başkent University between February 2003 and January 2015. Of 94 patients, 64 were evaluated and included in the study. The main outcome was acute kidney injury, defined and classified according to Kidney Disease: Improving Global Outcomes criteria, during 7 postoperative days. Other outcomes included risk factors, use of renal replacement therapy, postoperative complications, mortality, and kidney recovery.

RESULTS

Mean age at transplant was 34.14 ± 16.30 years, and 45 patients (70.32%) were men. Acute kidney injury developed in 34 (53.12%) of 64 cardiac transplant recipients, with severity classified as stage 1 in 10 (15.62%), stage 2 in 14 (21.87%), and stage 3 in 10 (15.62%). Renal replacement therapy was given to 25 patients (39.06%). Patients with acute kidney injury were significantly older (40.41 ± 15.85 y vs 27.03 ± 13.91 y; P = .001), had larger body surface area (1.78 ± 0.28 m2 vs 1.61 ± 0.31 m2; P = .033), and more frequently had a history of hypertension (P = .011) and smoking (P = .007) than did patients without acute kidney injury. They also had lower intraoperative urine output (453.380 ± 266.85 mL) than did patients who did not develop acute kidney injury (632.33 ± 430.94 mL (P = .01).

CONCLUSIONS

According to the Kidney Disease: Improving Global Outcomes criteria, acute kidney injury occurs in more than 50% of heart transplant patients postoperatively. Older age, larger body surface area, and history of hypertension and smoking are associated with acute kidney dysfunction following orthotopic heart transplant.

Shock Management for Cardio-surgical Intensive Care Unit Patient: The Silver Days

Shock in cardio-surgical intensive care unit (ICU) patients requires prompt identification of the underlying condition and timely therapeutic interventions. Management during the first 6 hours, also referred to as "the golden hours", is of paramount importance to reverse the shock state and improve the patient's outcome. The authors have previously described a state-of-the-art diagnostic work-up and discussed how to optimise preload, vascular tone, contractility, heart rate and oxygen delivery during this phase. Ideally, shock can be reversed during this initial period. However, some patients might have developed multiple organ dysfunction, which persists beyond the first 6 hours despite the early haemodynamic treatment goals having been accomplished. This period, also referred to as "the silver days", is the focus of this review. The authors discuss how to reduce vasopressor load and how to minimise adrenergic stress by using alternative inotropes, extracorporeal life-support and short acting beta-blockers. The review incorporates data on fluid weaning, safe ventilation, daily interruption of sedation, delirium management and early rehabilitation. It includes practical recommendations in areas where the evidence is scarce or controversial. Although the focus is on cardio-surgery ICU patients, most of the considerations apply to critical ill patients in general.