Perioperative predictors of extubation failure and the effect on clinical outcome after cardiac surgery

Association between serum albumin levels at admission and clinical outcomes in pediatric intensive care units: a multi-center study

BACKGROUND

Albumin, a vital component in regulating human blood oncotic pressure, plays an important role in the prediction of prognosis in pediatric patients.Previous research identified significant differences in serum albumin levels of healthy and critically ill children.

METHODS

The present study aims to investigate the correlation between albumin levels measured during pediatric intensive care unit(PICU) admission and clinical outcomes. In 2022, a comprehensive analysis of the records was conducted retrospectively in four tertiary hospital PICUs in different cities in the south-east region of Turkey. We then conducted a ROC analysis to predict mortality based on hypoalbuminemia.A cut-off value was determined, and the patients were divided into two groups: hypoalbuminemic and normoalbuminemic.Based on this cut-off level, we evaluated the association between admission serum albumin levels and mortality, length of stay, laboratories, need for mechanical ventilation, and extracorporeal treatments.

RESULTS

A total of 1329 patients admitted to the PICUs between January 1, 2022 and January 1, 2023 were included. The mortality rate amounted to 16.2%.The mean albumin level was 4.03 ± 0.69 g/dl in the surviving and 3.35 ± 0.90 g/dl in the non-surviving group(p < 0.001).The average length of stay in the PICU amounted to 8.98 ± 17.07, while the mean length of hospital stay was 11.23 ± 18.81days.Patients with hypoalbuminemia had significantly longer stays in the PICU and hospital as compared to those with normal albumin levels(p = 0.025 and p < 0.001,respectively).We found robust evidence that albumin levels are a strong predictor of mortality, with a predictive rate of 84.5%(OR:0.322, 95% CI:0.263-0.395, p < 0.001).The cut-off value was 3.785(AUC:0.731, Sensitivity:68.3%, Specificity:67%). A negative correlation was identified between albumin levels and lactate, C- reactive protein (CRP), and Blood urea nitrogen (BUN) levels across all patients. Conversely, a positive correlation was observed between neutrophil, lymphocyte, platelet, hemoglobin, sodium, and glucose levels. However, in patients with a cut-off point of 3.785 for albumin levels, a negative correlation was observed between albumin and lactate, CRP, and creatine levels. Conversely, a positive correlation was found between bicarbonate, platelet, hemoglobin, and glucose levels. Based on these findings, we conclude that hypoalbuminemia is associated with a higher rate of inotrope therapy and mechanical ventilation support. Furthermore, the rates of plasmapheresis, continuous renal replacement therapy, and extracorporeal membrane oxygenation initiation were markedly reduced in patients with elevated albumin levels (p < 0.001).

CONCLUSION

The serum albumin, which is an excellent and cost-effective biomarker that can be readily and economically evaluated in any center worldwide, as evidenced by the findings of our study, is a highly efficacious indicator of admission albumin levels for the prediction of mortality and outcomes in PICUs. Furthermore, it predicts the selection of appropriate treatment and mechanical supports. It is straightforward to utilise, as it does not necessitate the use of scoring systems or tests that require lengthy and intricate analyses, and it is readily available.

Prediction and prognosis of reintubation after surgery for Stanford type A aortic dissection

Background

Reintubation is a serious adverse respiratory event after Stanford type A aortic dissection surgery (AADS), however, published studies focused on reintubation after AADS are very limited worldwide. The objectives of the current study were to establish an early risk prediction model for reintubation after AADS and to clarify its relationship with short-term and long-term prognosis.

Methods

Patients undergoing AADS between 2016–2019 in a single institution were identified and divided into two groups based on whether reintubation was performed. Independent predictors were identified by univariable and multivariable analysis and a clinical prediction model was then established. Internal validation was performed using bootstrap method with 1,000 replications. The relationship between reintubation and clinical outcomes was determined by univariable and propensity score matching analysis.

Results

Reintubation were performed in 72 of the 492 included patients (14.6%). Three preoperative and one intraoperative predictors for reintubation were identified by multivariable analysis, including older age, smoking history, renal insufficiency and transfusion of intraoperative red blood cells. The model established using the above four predictors showed moderate discrimination (AUC = 0.753, 95% CI, [0.695–0.811]), good calibration (Hosmer-Lemeshow χ² value = 3.282, P = 0.915) and clinical utility. Risk stratification was performed and three risk intervals were identified. Reintubation was closely associated with poorer in-hospital outcomes, however, no statistically significant association between reintubation and long-term outcomes has been observed in patients who were discharged successfully after surgery.

Conclusions

The requirement of reintubation after AADS is prevalent, closely related to adverse in-hospital outcomes, but there is no statistically significant association between reintubation and long-term outcomes. Predictors were identified and a risk model predicting reintubation was established, which may have clinical utility in early individualized risk assessment and targeted intervention.

Accuracy evaluation of mainstream and sidestream end-tidal carbon dioxide monitoring during noninvasive ventilation: a randomized crossover trial (MASCAT-NIV trial)

Background

The end-tidal partial pressure of carbon dioxide (P_ETCO₂) can be used to estimate the arterial partial pressure of carbon dioxide (PaCO₂) in patients who undergo mechanical ventilation via endotracheal intubation. However, no reliable method for measuring P_ETCO₂ during noninvasive ventilation (NIV) has been established. The purpose of this study was to evaluate the correlation and agreement between PaCO₂ and P_ETCO₂ measured by these two methods and to compare them in patients who underwent NIV after extubation.

Methods

This study was a randomized, open-label, crossover trial in a mixed intensive care unit. We included patients who were planned for NIV after extubation and for whom the difference between P_ETCO₂ and PaCO₂ was ≤ 5 mmHg. We compared mainstream capnography using an inner cup via face mask (the novel method) with sidestream capnography (the previous method) during NIV. The relationships between PaCO₂ and P_ETCO₂ were evaluated by computing the Pearson correlation coefficient, and the agreement between PaCO₂ and P_ETCO₂ was estimated using the Bland–Altman method.

Results

From April 2020 to October 2021, 60 patients were included to the study. PaCO₂ and P_ETCO₂ were well correlated in both methods (the novel methods: r = 0.92, P < 0.001; the previous method: r = 0.79, P < 0.001). Mean bias between PaCO₂ and P_ETCO₂ measured using the novel method was 2.70 (95% confidence interval [CI], 2.15–3.26) mmHg with 95% limits of agreement (LoA) ranging from − 1.61 to 7.02 mmHg, similar to the result of measurement during SBT (mean bias, 2.51; 95% CI, 2.00–3.02; 95% LoA, − 1.45 to 6.47 mmHg). In contrast, measurement using the previous method demonstrated a larger difference (mean bias, 6.22; 95% CI, 5.22–7.23; 95% LoA, − 1.54 to 13.99 mmHg).

Conclusion

The current study demonstrated that the novel P_ETCO₂ measurement was superior to the previous method for PaCO₂ prediction. During NIV, the novel method may collect as sufficient exhalation sample as during intubation. Continuous P_ETCO₂ measurement combined with peripheral oxygen saturation monitoring is expected to be useful for early recognition of respiratory failure among high-risk patients after extubation.

Trial registration UMIN-CTR UMIN000039459. Registered February 11, 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-022-00603-w.

A Predictive Scoring Model for Postoperative Tracheostomy in Patients Who Underwent Cardiac Surgery

Background

A subset of patients require a tracheostomy as respiratory support in a severe state after cardiac surgery. There are limited data to assess the predictors for requiring postoperative tracheostomy (POT) in cardiac surgical patients.

Methods

The records of adult patients who underwent cardiac surgery from 2016 to 2019 at our institution were reviewed. Univariable analysis was used to assess the possible risk factors for POT. Then multivariable logistic regression analysis was performed to identify independent predictors. A predictive scoring model was established with predictor assigned scores derived from each regression coefficient divided by the smallest one. The area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test were used to evaluate the discrimination and calibration of the risk score, respectively.

Results

A total of 5,323 cardiac surgical patients were included, with 128 (2.4%) patients treated with tracheostomy after cardiac surgery. Patients with POT had a higher frequency of readmission to the intensive care unit (ICU), longer stay, and higher mortality (p &lt; 0.001). Mixed valve surgery and coronary artery bypass grafting (CABG), aortic surgery, renal insufficiency, diabetes mellitus, chronic obstructive pulmonary disease (COPD), pulmonary edema, age &gt;60 years, and emergent surgery were independent predictors. A 9-point risk score was generated based on the multivariable model, showing good discrimination [the concordance index (c-index): 0.837] and was well-calibrated.

Conclusions

We established and verified a predictive scoring model for POT in patients who underwent cardiac surgery. The scoring model was conducive to risk stratification and may provide meaningful information for clinical decision-making.

Incidence and Causes of Reintubation Other Than Reopening of the Chest in Post-Cardiac Surgical Patients in a Tertiary Care Hospital

Objective

To determine the incidence of endotracheal reintubation, excluding surgical reopening, in post-cardiac surgical patients in a tertiary care hospital.

Material and methods

A retrospective descriptive analysis of 408 patients who underwent different cardiac surgeries during this period. Post-operative extubation was performed when patients fulfilled the preset criteria for extubation, which include consciousness (awake and aware), stable vital signs, acceptable arterial blood gases, acceptable respiratory mechanics, a maximum inspiratory force greater than 20-25 cm H₂O, chest tube drainage less than 100 ml per hour, normal temperature and electrolytes. The total number of patients who were reintubated within 72 hours of extubation was noted. The criteria for reintubation included altered conscious level with Glasgow Coma Score (GCS) of less than 8, respiratory failure, unstable hemodynamics, and arrhythmias such as ventricular tachycardia (VT) and fibrillation. All of the information was collected retrospectively on a specifically prepared form. Data was entered and evaluated in Statistical Package for the Social Sciences.

The research was piloted in the Cardiac Intensive Care Unit (CICU) of Northwest General Hospital and Research Center, Hayatabad, Peshawar from December 2018 to March 2020.

Results

Out of 408 patients who had cardiac surgeries, only nine (2.2%) were reintubated after initial extubation. The average time for which patients remained on the ventilator was 8 ± 2 hours. The reasons for reintubation were recorded. Among those reintubated, eight patients (88.88%) had undergone coronary artery bypass grafting (CABG) whereas one patient (11.11%) had undergone mitral valve replacement (MVR). In three (33.33%) patients, stroke (hemiplegia in two and global brain ischemia in one) with low GCS was the primary cause of reintubation. Arrhythmias - which included VT, ventricular fibrillation (VF), and supraventricular tachyarrhythmias (SVT) - were responsible for three (33.33%) cases of reintubation. Respiratory failure - with a partial pressure of oxygen in arterial blood less than 60 mmHg, along with tachypnea - was responsible for reintubation in two (22.22%) patients. In one (11.11%) patient who had MVR, cardiac arrest was the underlying reason; the cause of arrest could not be retrieved from the retrospective data. Notably, as a common variable, five (62.5%) out of the eight reintubated CABG patients had a poor left ventricular function. 

Conclusion

Causes of reintubation were primarily cardiac (arrhythmias) and neurological, followed by respiratory causes in our center. Patients with poor left ventricular function and diffuse coronary artery disease appear to have a higher incidence of reintubation which can lead to extended CICU and hospital stay, elevated mortality, and higher costs.

Machine learning for the prediction of successful extubation among patients with mechanical ventilation in the intensive care unit: A retrospective observational study

BACKGROUND

Ventilator weaning protocols are commonly implemented for patients receiving mechanical ventilation. However, the rate of extubation failure remains high despite the protocols. This study investigated the usefulness and accuracy of ventilator weaning through machine learning to predict successful extubation.

METHODS

We retrospectively evaluated the data of patients who underwent intubation for respiratory failure and received mechanical ventilation in the intensive care unit (ICU). Data on 57 factors including patient demographics, vital signs, laboratory data, and data from ventilator were extracted. Extubation failure was defined as re-intubation within 72 hours of extubation. For supervised learning, the data were labeled requirement of intubation or not. We used three learning algorithms (Random Forest, XGBoost, and LightGBM) to predict successful extubation. We also analyzed important features and evaluated the area under curve (AUC) and prediction metrics.

RESULTS

Overall, 13 of the 117 included patients required re-intubation. LightGBM had the highest AUC (0.950), followed by XGBoost (0.946) and Random Forest (0.930). The accuracy, precision, and recall performance were 0.897, 0.910, and 0.909, for Random Forest; 0.910, 0.912, and 0.931 for XGBoost; and 0.927, 0.915, and 0.960 for LightGBM, respectively. The most important feature was the duration of mechanical ventilation followed by the fraction of inspired oxygen, positive end-expiratory pressure, maximum and mean airway pressures, and Glasgow Coma Scale.

CONCLUSIONS

Machine learning could predict successful extubation among patients on mechanical ventilation in the ICU. LightGBM has the highest overall performance. The duration of mechanical ventilation was the most important feature in all models.

Early extubation in current valve surgery requiring long cardiopulmonary bypass: Benefits and predictive value of preoperative spirometry

BACKGROUND

Early extubation (EEx) after cardiac surgery has been essentially studied in patients with short cardiopulmonary bypass (CPB). Whether preoperative spirometry can predict EEx remains controversial.

OBJECTIVES

To investigate whether EEx can be a goal and predicted by preoperative spirometry in valve surgery requiring long CPB.

METHODS

Nonemergent consecutive 210 patients who underwent valve surgery from January 2014 to August 2019 were investigated retrospectively.

RESULTS

EEx (<8 h) was achieved in 93 (44.3%) patients without increasing adverse events. Patients with EEx had shorter ICU and hospital stays than those without EEx. Multivariate analysis showed that higher estimated glomerular filtration rate and mitral valve repair were significant protective factors for EEx. Conversely, moderate and severe chronic obstructive pulmonary disease defined by spirometry, longer operation, CPB, and aortic cross-clamp time were significant risk factors.

CONCLUSIONS

EEx should be the goal in current valve surgery. Preoperative spirometry is a significant predictor.

Nighttime Extubation Does Not Increase Risk of Reintubation, Length of Stay, or Mortality: Experience of a Large, Urban, Teaching Hospital

BACKGROUND

In the intensive care unit (ICU), extubation failure has been associated with greater resource utilization and worsened clinical outcomes. Most recently, nighttime extubation (NTE) has been reported as a risk factor for increased ICU and hospital mortality. We hypothesized that, in a large, urban, university-affiliated hospital with multidisciplinary assessment for extubation, rigorously protocolized extubation algorithms, and expert airway managers available at all times of day for assessment of high-risk extubations, NTE would not confer additional risk of adverse clinical outcomes.

METHODS

This was a retrospective cohort study of mechanically ventilated adults at a single university-affiliated hospital. NTE was defined as occurring between 7:00 PM and 6:59 AM the following day. All data were extracted from the institution's electronic medical record. Multivariable regression analyses were used to assess associations between NTE and reintubation, ICU and hospital length of stay (LOS), and mortality with adjustments for demographic and clinical covariates defined a priori. Palliative, unplanned, and routine postoperative extubations were excluded in sensitivity analyses.

RESULTS

Of 2241 patients, 204 of 2241 (9.1%) underwent NTE. The rates of reintubation (NTE 6.9% versus daytime extubation [DTE] 12.4%; adjusted odds ratio [95% confidence interval {CI}], 0.78 [0.43-1.41]; P = .41) and in-hospital mortality (NTE 3.4% versus DTE 5.9%; adjusted odds ratio [95% CI], 0.72 [0.28-1.84]; P = .49) were not found to differ. NTE, compared to DTE, was associated with shorter duration of mechanical ventilation (median [interquartile range], 1 [0-1] days vs 2 [1-4] days; adjusted ratio of geometric means [RGMs] [95% CI], 0.64 [0.54-0.70]; P < .001), ICU (2 [1-5] days vs 4 [2-10] days; adjusted RGMs [95% CI], 0.65 [0.57-0.75]; P < .001), and hospital LOS (6 [3-18] days vs 13 [6-25] days; adjusted RGMs [95% CI], 0.64 [0.56-0.74]; P < .001). These results were unchanged in sensitivity analyses.

CONCLUSIONS

Patients who underwent NTE were not at increased risk of reintubation or in-hospital mortality. In addition, NTE was associated with a shortened duration of mechanical ventilation and hospital LOS. In health care systems with similar critical care delivery models, NTE may coincide with reduced resource utilization in appropriately selected patients.

Evaluation of two intensive care models in relation to successful extubation after cardiac surgery

OBJECTIVE

To compare outcomes between intensivist-directed and cardiac surgeon-directed care delivery models.

DESIGN

This retrospective, historical-control study was performed in a cohort of adult cardiac surgical patients at Zhongshan Hospital (Fudan University, China). During the first phase (March to August 2015), cardiac surgeons were in charge of postoperative care while intensivists were in charge during the second phase (September 2015-June 2016). Both phases were compared regarding successful extubation rate, intensive care unit (ICU) length of stay (LOS), and in-hospital mortality.

SETTING

Tertiary Zhongshan Hospital (Fudan University, China).

PATIENTS

Consecutive adult patients admitted to the cardiac surgical ICU (CSICU) after heart surgery.

INTERVENTIONS

Phase I patients treated by cardiac surgeons, and phase II patients treated by intensivists.

MAIN VARIABLES OF INTEREST

Successful extubation, ICU LOS and in-hospital mortality.

RESULTS

A total of 1792 (phase I) and 3007 patients (phase II) were enrolled. Most variables did not differ significantly between the two phases. However, patients in phase II had a higher successful extubation rate (99.17% vs. 98.55%; p=0.043) and a shorter median duration of mechanical ventilation (MV) (18 vs. 19h; p<0.001). In relation to patients with MV duration >48h, those in phase II had a comparatively higher successful extubation rate (p=0.033), shorter ICU LOS (p=0.038) and a significant decrease in in-hospital mortality (p=0.039).

CONCLUSIONS

The intensivist-directed care model showed improved rates of successful extubation and shorter MV durations after cardiac surgery.

Myocardial Protection by Glucose-Insulin-Potassium in Moderate- to High-Risk Patients Undergoing Elective On-Pump Cardiac Surgery: A Randomized Controlled Trial

BACKGROUND

Low cardiac output syndrome is a main cause of death after cardiac surgery. We sought to assess the impact of glucose-insulin-potassium (GIK) to enhance myocardial protection in moderate- to high-risk patients undergoing on-pump heart surgery.

METHODS

A randomized controlled trial was performed in adult patients (Bernstein-Parsonnet score >7) scheduled for elective aortic valve replacement and/or coronary artery bypass surgery. Patients were randomized to GIK (20 IU of insulin, 10 mEq of potassium chloride in 50 mL of glucose 40%) or saline infusion given over 60 minutes on anesthetic induction. The primary end point was postcardiotomy ventricular dysfunction (PCVD), defined as new/worsening left ventricular dysfunction requiring inotropic support (≥120 minutes). Secondary end points were the intraoperative changes in left ventricular function as assessed by transoesophageal echocardiography, postoperative troponin levels, cardiovascular and respiratory complications, and intensive care unit and hospital length of stay.

RESULTS

From 224 randomized patients, 222 were analyzed (112 and 110 in the placebo and GIK groups, respectively). GIK pretreatment was associated with a reduced occurrence of PCVD (risk ratio [RR], 0.41; 95% confidence interval [CI], 0.25-0.66). In GIK-treated patients, the left systolic ventricular function was better preserved after weaning from bypass, plasma troponin levels were lower on the first postoperative day (2.9 ng·mL(-) [interquartile range {IQR}, 1.5-6.6] vs 4.3 ng·mL(-) [IQR, 2.4-8.2]), and cardiovascular (RR, 0.69; 95% CI, 0.50-0.89) and respiratory complications (RR, 0.5; 95% CI, 0.38-0.74) were reduced, along with a shorter length of stay in intensive care unit (3 days [IQR, 2-4] vs 3.5 days [IQR, 2-7]) and in hospital (14 days [IQR, 11-18.5] vs 16 days [IQR, 12.5-23.5]), compared with placebo-treated patients.

CONCLUSIONS

GIK pretreatment was shown to attenuate PCVD and to improve clinical outcome in moderate- to high-risk patients undergoing on-pump cardiac surgery.

Association Between Pulmonary Hypertension and Transcatheter Aortic Valve Replacement: Analysis of a Nationwide Inpatient Sample Database

INTRODUCTION

This study was done to review the association of pulmonary hypertension (PH) with Transcatheter Aortic Valve Replacement (TAVR) procedures done in the US for years 2010 to 2012.

METHODS

We used Nationwide Inpatient Sample (NIS) data to extract data for patients who were hospitalized with a primary/secondary diagnosis of TAVR as specified by International Classification of Disease (ICD-9) codes 35.05 and 35.06. PH was identified with ICD-9 codes 416.0 and 416.8. Logistic regression models were used to analyze the association between PH and clinical outcomes of TAVR.

RESULTS

A total of 8,824 weighted discharges were identified with a primary/secondary diagnosis of TAVR, of which 1,976 (22.4%) also had PH. Mean age of patients undergoing TAVR with and without PH was 81.4 and 81.1 years, respectively. More females had a diagnosis of PH with TAVR when compared to males, (56.9% vs. 43.1). When controlling for demographics, diabetes and hypertension; the association between PH and TAVR was statistically significant (p<.0001). Estimated odds of TAVR with PH was 5.46 (95% CI: 4.63, 6.41) times greater than for TAVR without PH. Similarly, the estimated odds for a length of stay greater than 1 week for TAVR with PH was 1.43 (95% CI: 1.12, 1.82; p=.0034) times greater than odds for TAVR without PH. PH was not statistically significant for in-hospital mortality in patients receiving TAVR (p=0.7067).

CONCLUSION

This study suggests that underlying PH does not influence the immediate mortality of patients underlying TAVR. Further studies are needed to delve into the bearing of PH on TAVR.

Left ventricular-arterial coupling is associated with prolonged mechanical ventilation in severe post-cardiac surgery patients: an observational study

Background

Weaning post-cardiac surgery patients from mechanical ventilation (MV) poses a big challenge to these patients. Optimized left ventricular-arterial coupling (VAC) may be crucial for reducing the MV duration of these patients. However, there is no research exploring the relationship between VAC and the duration of MV. We performed this study to investigate the relationship between left ventricular-arterial coupling (VAC) and prolonged mechanical ventilation (MV) in severe post-cardiac surgery patients.

Methods

This was a single-center retrospective study of 56 severe post-cardiac surgery patients from January 2015 to December 2017 at the Department of Critical Care Medicine of Peking Union Medical College Hospital. Patients were divided into two groups according to the duration of MV (PMV group: prolonged mechanical ventilation group, MV > 6 days; Non-PMV group: non-prolonged mechanical ventilation group, MV ≤ 6 days). Hemodynamics and tissue perfusion data were collected or calculated at admission (T0) and 48 h after admission (T1) to the ICU.

Results

In terms of hemodynamic and tissue perfusion data, there were no differences between the two groups at admission (T0). Compared with the non-prolonged MV group after 48 h in the ICU (T1), the prolonged MV group had significantly higher values for heart rate (108 ± 13 vs 97 ± 12, P = 0.018), lactate (2.42 ± 1.24 vs.1.46 ± 0.58, P < 0.001), and Ea/Ees (5.93 ± 1.81 vs. 4.05 ± 1.20, P < 0.001). Increased Ea/Ees (odds ratio, 7.305; 95% CI, 1.181–45.168; P = 0.032) and lactate at T1 (odds ratio, 17.796; 95% CI, 1.377–229.988; P = 0.027) were independently associated with prolonged MV. There was a significant relationship between Ea/Ees_T1 and the duration of MV (r = 0.512, P < 0.01). The area under the receiver operating characteristic (AUC) of the left VAC for predicting prolonged MV was 0.801, and the cutoff value for Ea/Ees was 5.12, with 65.0% sensitivity and 90.0% specificity.

Conclusions

Left ventricular-arterial coupling was associated with prolonged mechanical ventilation in severe post-cardiac surgery patients. The assessment and optimization of left VAC might be helpful in reducing duration of MV in these patients.

Association between age-related factors and extubation failure in elderly patients

BACKGROUND

Elderly patients are being increasingly admitted to the intensive care unit (ICU) for mechanical ventilation. Previous studies demonstrated that 20% to 35% of elderly patients were reintubated within 48 to 72 hours after extubation. Given the age-related physiologic changes and multiple comorbidities in elderly patients, the current conventional parameters for predicting extubation outcomes may not be applicable to this population. This study was performed to identify the association between age-related parameters and extubation failure in elderly patients.

METHODS

Intubated elderly patients (age of ≥60 years) admitted to the medical ICU of a university-based hospital from October 2014 to July 2015 were included. Failed extubation was defined as reintubation within 48 hours after the first extubation. The associations of extubation failure with demographic data, vital signs, cognition and anxiety, and ventilator parameters at the time of intubation and extubation were analyzed.

RESULTS

In total, 127 intubated elderly patients were recruited. Extubation failure occurred in 15 patients (11.8%). Patients with failed extubation had a lower body temperature (37.0°C vs. 37.3°C, P < 0.05) but a higher Facial Anxiety Scale (FAS) score than those with successful extubation (3 vs. 2, P < 0.05). Patients with extubation failure had significantly higher levels of blood urea nitrogen (BUN) (39.88 vs. 58.47 g/dL), serum sodium (137.66 vs. 141.47 mmol/L), and serum calcium (9.52 vs. 10.0 g/dL) but a wider anion gap (12.23 vs. 9.97), but no significant differences in respiratory parameters were found between the two groups. Multiple logistic regression revealed no independent factors associated with successful extubation.

CONCLUSION

This study revealed no strong predictive factors. However, several physiological parameters (lower body temperature and higher FAS scores) and metabolic parameters (BUN, sodium, calcium, and anion gap) were significantly associated with the rate of extubation failure.

Impact of pulmonary hypertension on in-hospital outcome after surgical or transcatheter aortic valve replacement

AIMS

We aimed to analyse the impact of pulmonary hypertension (PH) on the in-hospital outcome of either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR).

METHODS AND RESULTS

Data from all 107,057 patients undergoing isolated SAVR or TAVR in Germany between 2007 and 2014 were provided by the German Federal Bureau of Statistics. About 18% of patients with aortic valve stenosis suffered from PH. Patients with PH had more comorbidities with consequently increased EuroSCORE (TAVR without PH: 12.3%; with PH: 24%). The presence of PH led to an increase of in-hospital strokes, bleedings, acute kidney injuries, and pacemaker implantations in both treatment groups (TAVR and SAVR), but the PH-associated increase of complications and mortality was less pronounced among patients receiving TAVR (mortality after TAVR without PH: 5.4%; with PH: 7.2%). After baseline risk adjustment, the TAVR procedure was associated with a reduced risk of in-hospital stroke (OR 0.81, p=0.011), bleeding (OR 0.22, p<0.001), and mortality (OR 0.70, p=0.005) among PH patients, and in comparison to surgical treatment.

CONCLUSIONS

PH is a risk factor for worse outcome of SAVR and TAVR. This fact is less pronounced among TAVR patients. Our data suggest a shift towards the transcatheter approach in patients suffering from PH.

Predictors of extubation failure after open-chest cardiac surgery based on routinely collected data. The importance of a shared interprofessional clinical assessment

BACKGROUND

Extubation failure (ExtF) is associated with prolonged hospital length of stay and mortality in adult cardiac surgery patients postoperatively. In this population, ExtF-related variables such as the arterial partial pressure of oxygen to fraction of inspired oxygen ratio (PaO₂/FiO₂), rapid shallow breathing index, cough strength, endotracheal secretions and neurological function have been sparsely researched.

AIM

To identify variables that are predictive of ExtF and related outcomes.

METHOD

Prospective observational longitudinal study. Consecutively presenting patients ( n=205) undergoing open-heart cardiac surgery and admitted to the Cardiosurgical Intensive Care Unit (CICU) were recruited. The clinical data were collected at CICU admission and immediately prior to extubation. ExtF was defined as the need to restart invasive or non-invasive mechanical ventilation while the patient was in the CICU.

RESULTS

The ExtF incidence was 13%. ExtF related significantly to hospital mortality, CICU length of stay and total hospital length of stay. The risk of ExtF decreased significantly, by 93% in patients with good neurological function and by 83% in those with a Rapid Shallow Breathing Index of ≥57 breaths/min per litre. Conversely, ExtF risk increased 27 times when the PaO₂/FiO₂ was <150 and 11 times when it was ≥450. Also, a reassuring PaO₂/FiO₂ value may hide critical pulmonary or extra-pulmonary conditions independent from alveolar function.

CONCLUSION

The decision to extubate patients should be taken after thoroughly discussing and combining the data derived from nursing and medical clinical assessments. Extubation should be delayed until the patient achieves safe respiratory, oxygenation and haemodynamic conditions, and good neurocognitive function.

Reintubation of patients submitted to cardiac surgery: a retrospective analysis

OBJECTIVES

To analyze patients after cardiac surgery that needed endotracheal reintubation and identify factors associated with death and its relation with the severity scores.

METHODS

Retrospective analysis of information of 1,640 patients in the postoperative period of cardiac surgery between 2007 and 2015.

RESULTS

The reintubation rate was 7.26%. Of those who were reintubated, 36 (30.3%) underwent coronary artery bypass surgery, 27 (22.7%) underwent valve replacement, 25 (21.0%) underwent correction of an aneurysm, and 8 (6.7%) underwent a heart transplant. Among those with comorbidities, 54 (51.9%) were hypertensive, 22 (21.2%) were diabetic, and 10 (9.6%) had lung diseases. Among those who had complications, 61 (52.6%) had pneumonia, 50 (42.4%) developed renal failure, and 49 (51.0%) had a moderate form of the transient disturbance of gas exchange. Noninvasive ventilation was performed in 53 (44.5%) patients. The death rate was 40.3%, and mortality was higher in the group that did not receive noninvasive ventilation before reintubation (53.5%). Within the reintubated patients who died, the SOFA and APACHE II values were 7.9 ± 3.0 and 16.9 ± 4.5, respectively. Most of the reintubated patients (47.5%) belonged to the high-risk group, EuroSCORE (> 6 points).

CONCLUSION

The reintubation rate was high, and it was related to worse SOFA, APACHE II and EuroSCORE scores. Mortality was higher in the group that did not receive noninvasive ventilation before reintubation.

Factors affecting reintubations after cardiac and thoracic surgeries in cardiac intensive care unit of a tertiary care hospital

Background

Reintubation and readmission after cardiothoracic surgeries are not uncommon, and its reasons are multifactorial. The study goal was to identify the factors that contribute reintubation after cardiac and thoracic surgery in tertiary care hospital and to compare the outcome with international benchmark.

Methodology

A prospective, observational study was planned in Cardiac Intensive Care Unit (CICU). The study included all those patients who required readmission in CICU due to endotracheal intubation following cardiac and thoracic surgeries. The study was conducted from January to December 2016. The primary focus was to identify the reasons for reintubation within 72 h of extubation after CICU discharge and its association with outcome.

Results

Out of 750 patients who shifted out from CICU following successful extubation, only 32 were readmitted and among them in 25 patients (3.33%) were reintubated and their reasons reintubation were noted. Patients underwent a coronary artery bypass grafting (CABG) with valve replacement had a higher incidence of reintubation 3/39 (7.69%) when compared with CABG 13/517 (2.51%) and 4/135 (2.96%) valve procedure alone. Single cause of endotracheal reintubation was observed in 7 patients (28%), in which 5 patients (20%) had respiratory and 2 patients had (8%) cardiac reason while 18 patients (72%) were observed with multisystem involvement, in which 7 patients (28%) had both respiratory and cardiovascular causes, and 2 (8%) had both respiratory and neurological causes. More than 70% cause of endotracheal reintubation was both respiratory and cardiovascular. The CICU stay after reintubations was 12.88 ± 16.88 days and the hospital stay prolonged to 23.84 ± 21.61 days.

Conclusion

Reasons of reintubation were mainly respiratory and cardiac. The rate of reintubations is high when multisystem involvement is there. CICU, hospital stay, and mortality are increases after reintubation.

Emergencies and outcome in invasive out-of-hospital ventilation: An observational study over a 1-year period

OBJECTIVES

The number of ventilated patients is further increasing which leads to an increasing number of patients with weaning failure. In Germany, the treatment of patients with invasive out-of-hospital becomes more and more common. The aim of the study was to observe the outcome, the frequency and character of emergencies of patients with invasive out-of-hospital ventilation.

METHODS

We conducted a prospective study over 1 year. Fifty-nine invasively ventilated patients living either at home or at nursing homes specialized in ventilator medicine were included.

RESULTS

Forty-one (71%) of the patients were living in a nursing home. Chronic obstructive pulmonary disease (COPD) was the most common underlying disease (52.5%). Duration of daily ventilation did not change over the 1-year period. 52.8% of the months went without a documented emergency. The most common emergencies were oxygen desaturation (29.6%), increase of secretion (12.2%) and dyspnea (8.7%). We found no difference in the frequency of emergencies between patients cared for in their own home compared with residential care. Ten patients died during the observation period. Fewer emergencies (P = .02, CI 0.03-0.85) was the only parameter associated with a reduced mortality. Frequency of emergencies as well as survival showed no difference regarding the way patients were cared for.

CONCLUSIONS

In patients with invasive home mechanical ventilation survival for more than 1 year seems to be common. Only the rate of emergencies affected survival.

The effect of reintubation on ventilator-associated pneumonia and mortality among mechanically ventilated patients with intubation: A systematic review and meta-analysis

OBJECTIVES

This meta-analysis summarized the risks that reintubation impose on ventilator-associated pneumonia (VAP) and mortality.

BACKGROUND

Extubation failure increases the probability of poor clinical outcomes pertaining to mechanical ventilation.

METHODS

Literature published during a 15-year period was retrieved from PubMed, Web of Knowledge databases, the Embase (Excerpa Medica database), and the Cochrane Library. Data involving reintubation, VAP, and mortality were extracted for a meta-analysis.

RESULTS

Forty-one studies involving 29,923 patients were enrolled for the analysis. The summary odds ratio (OR) between VAP and reintubation was 7.57 (95% confidence interval [CI] = 3.63-15.81). The merged ORs for mortality in hospital and intensive care unit were 3.33 (95% CI = 2.02-5.49) and 7.50 (95% CI = 4.60-12.21), respectively.

CONCLUSIONS

Reintubation can represent a threat to survival and increase the risk of VAP. The risk of mortality after reintubation differs between planned and unplanned extubation. Extubation failure is associated with a higher risk of VAP in the cardiac surgery population than in the general population.

Cumulative Probability and Time to Reintubation in U.S. ICUs

OBJECTIVE

Reintubation after liberation from mechanical ventilation is viewed as an adverse event in ICUs. We sought to describe the frequency of reintubations across U.S. ICUs and to propose a standard, appropriate time cutoff for reporting of reintubation events.

DESIGN AND SETTING

We conducted a cohort study using data from the Project IMPACT database of 185 diverse ICUs in the United States.

PATIENTS

We included patients who received mechanical ventilation and excluded patients who received a tracheostomy, had a do-not-resuscitate order placed, or died prior to first extubation.

MEASUREMENTS AND MAIN RESULTS

We assessed the percentage of patients extubated who were reintubated; the cumulative probability of reintubation, with death and do-not-resuscitate orders after extubation modeled as competing risks, and time to reintubation. Among 98,367 patients who received mechanical ventilation without death or tracheostomy prior to extubation, 9,907 (10.1%) were reintubated, with a cumulative probability of 10.0%. Median time to reintubation was 15 hours (interquartile range, 2-45 hr). Of patients who required reintubation in the ICU, 90% did so within the first 96 hours after initial extubation; this was consistent across various patient subtypes (89.3% for electives surgical patients up to 94.8% for trauma patients) and ICU subtypes (88.6% for cardiothoracic ICUs to 93.5% for medical ICUs).

CONCLUSIONS

The reintubation rate for ICU patients liberated from mechanical ventilation in U.S. ICUs is approximately 10%. We propose a time cutoff of 96 hours for reintubation definitions and benchmarking efforts, as it captures 90% of ICU reintubation events. Reintubation rates can be reported as simple percentages, without regard for deaths or changes in goals of care that might occur.

Factors Associated with Reintubation in an Intensive Care Unit: A Prospective Observational Study

Background and Aims:

The objective of the study was to determine the incidence of failed extubations in our Intensive Care Unit (ICU) and identify associated clinical factors.

Materials and Methods:

A prospective observational study of mechanically ventilated patients who underwent extubation attempts in our (predominantly surgical) ICU was undertaken from July 2012 to August 2013. The primary endpoint was the need for nonelective reintubation within 72 h of extubation. Clinical data of the reintubated patients were compared with those who were successfully extubated to identify factors associated with reintubation.

Results:

Five hundred and eight extubation attempts were documented, 38 (7.5%) of which were unsuccessful. On multivariate analysis, the following clinical factors were found to be associated with an increased risk of failed extubation: unplanned extubations (adjusted odds ratio [OR] 5.8), the use of noninvasive ventilation (NIV) postextubation (adjusted OR 3.2), and sepsis (adjusted OR 2.9). Patient demographic factors, other premorbid and comorbid medical conditions, and differences of laboratory parameters did not appear to significantly influence reintubation rates in our study.

Conclusions:

Our study has demonstrated a relatively low reintubation rate, likely due to inclusion of elective admissions/intubations in our patient population. Unplanned extubations, the use of NIV postextubation, and sepsis were associated with increased reintubation risk, reinforcing the need for increased vigilance in this subgroup of patients after extubation.

Combined Mitral and Tricuspid Valve Surgery Performed via a Right Minithoracotomy Approach

OBJECTIVE

Combined mitral and tricuspid valve surgery is associated with an increased perioperative morbidity and mortality. We evaluated the outcomes of a less invasive right minithoracotomy approach in patients undergoing primary or reoperative double-valve surgery.

METHODS

We retrospectively evaluated 132 consecutive patients with mitral and tricuspid valve disease who underwent double-valve surgery via a right minithoracotomy at our institution between January 2009 and April 2014.

RESULTS

The cohort included 81 female (61%) and 51 male (39%) patients, with a mean ± SD age of 67 ± 13 years. The mean ± SD preoperative left ventricular ejection fraction, mitral regurgitation grade, and creatinine were 53% ± 12%, 3.8 ± 0.6, and 1.26 ± 1.17, respectively. The patients underwent primary (88%) or reoperative (12%) mitral and tricuspid valve surgery, which consisted of 88 mitral repairs (67%), 44 mitral replacements (33%), 131 tricuspid repairs (99%), and 1 tricuspid replacement (1%). Postoperatively, there were 6 cases of acute kidney injury (5%), 6 reoperations for bleeding (5%), 4 cerebrovascular accidents (3%), and 12 cases of atrial fibrillation (9%). The median intensive care unit length of stay and total hospital lengths of stay were 61 hours (interquartile range, 43-112 hours) and 8 days (interquartile range, 6-13 days), respectively. The in-hospital mortality was 4%. Actuarial survival at 1 and 5 years was 93% and 88%, respectively.

CONCLUSIONS

In patients undergoing primary or reoperative mitral and tricuspid valve surgery, a right minithoracotomy approach is associated with a low perioperative morbidity and good midterm survival.

Fast-Track Cardiac Anesthesia: Choice of Anesthetic Agents and Techniques

Fast-track cardiac anesthesia (FTCA) incorporates early tracheal extubation, decreased length of intensive care unit (ICU) and hospital stay, and (ideally) should avoid or reduce complications to safely achieve cost-savings. A growing body of evidence from randomized trials has identified many anesthetic interventions that can improve outcome after cardiac surgery. These include new short-acting hypnotic, opioid, and neuromuscular blocking drugs. An effective FTCA program requires the appropriate selection of suitable patients, a lowdose opioid anesthetic technique, early tracheal extubation, a short stay in the ICU, and coordinated perioperative care. It is also dependent on the avoidance of postoperative complications such as excessive bleeding, myocardial ischemia, low cardiac output state, arrhythmias, sepsis, and renal failure. These complications will have a much greater adverse effect on hospital length of stay and healthcare costs. A number of clinical trials have identified interventions that can reduce some of these complications. The adoption of effective treatments into clinical practice should improve the effectiveness of FTCA.

Continuous Positive Airway Pressure Versus Oxygen Therapy in the Cardiac Surgical Ward: A Randomized Trial

BACKGROUND

Noninvasive ventilation (NIV) is a common technique to manage patients with acute respiratory failure in the intensive care unit. However, use of NIV in general wards is less well described. The authors' aim was to demonstrate efficacy of NIV, applied in a cardiac surgery ward, in improving oxygenation in patients who developed hypoxemic acute respiratory failure after being discharged from the intensive care unit.

DESIGN

Randomized, open-label trial.

SETTING

University hospital.

PARTICIPANTS

Sixty-four patients with hypoxemia (PaO₂/F_IO₂ ratio between 100 and 250) admitted to the main ward after cardiac surgery.

INTERVENTIONS

Patients were randomized to receive standard treatment (oxygen, early mobilization, a program of breathing exercises and diuretics) or continuous positive airway pressure in addition to standard treatment. Continuous positive airway pressure was administered 3 times a day for 2 consecutive days. Every cycle lasted 1 to 3 hours. All patients completed their 1-year follow-up. Data were analyzed according to the intention-to-treat principle.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was the number of patients with PaO₂/F_IO₂<200 48 hours after randomization. Continuous positive airway pressure use was associated with a statistically significant reduction in the number of patients with PaO₂/F_IO₂<200 (4/33 [12%] v 14/31 [45%], p = 0.003). One patient in the control group died at the 30-day follow-up.

CONCLUSIONS

Among patients with acute respiratory failure following cardiac surgery, administration of continuous positive airway pressure in the main ward was associated with improved respiratory outcome. This was the first study that was performed in the main ward of post-surgical patients with acute respiratory failure.

Evaluation of the influence of pulmonary hypertension in ultra-fast-track anesthesia technique in adult patients undergoing cardiac surgery

Objective

To evaluate the influence of pulmonary hypertension in the ultra-fast-track anesthesia technique in adult cardiac surgery.

Methods

A retrospective study. They were included 40 patients divided into two groups: GI (without pulmonary hypertension) and GII (with pulmonary hypertension). Based on data obtained by transthoracic echocardiography. We considered as the absence of pulmonary hypertension: a pulmonary artery systolic pressure (sPAP) <36 mmHg, with tricuspid regurgitation velocity <2.8 m/s and no additional echocardiographic signs of PH, and PH as presence: a sPAP >40 mmHg associated with additional echocardiographic signs of PH. It was established as influence of pulmonary hypertension: the impossibility of extubation in the operating room, the increase in the time interval for extubation and reintubation the first 24 hours postoperatively. Univariate and multivariate analyzes were performed when necessary. Considered significant a P value <0.05.

Results

The GI was composed of 21 patients and GII for 19. All patients (100%) were extubated in the operating room in a medium time interval of 17.58±8.06 min with a median of 18 min in GII and 17 min in GI. PH did not increase the time interval for extubation (P=0.397). It required reintubation of 2 patients in GII (5% of the total), without statistically significant as compared to GI (P=0.488).

Conclusion

In this study, pulmonary hypertension did not influence on ultra-fast-track anesthesia in adult cardiac surgery.

Intensive Care Unit Stay of More than 14 Days after Cardiac Surgery is Associated with Non-cardiac Organ Failure

Some studies have shown an association between a prolonged intensive care unit (ICU) stay and risk factors such as mediastinal re-exploration, advanced age, low ejection fraction, lung disease and organ failure. The aim of this retrospective study was first to evaluate peri-operative risk factors ( n = 2683) and secondly to evaluate long-term survival ( n = 2563) in cardiac surgery patients with an ICU stay > 14 days. Long-term survival was assessed in an observational 3-year follow-up study. An ICU stay of > 14 days was associated independently with respiratory failure and dialysis-dependent acute renal failure, and with a significantly lower survival rate. Since an ICU stay is associated with a higher hospital and long-term mortality, measures should be taken throughout the entire hospital stay to identify and reduce the risk of organ failure.

Risk of reintubation in neurosurgical patients

BACKGROUND

Reintubation among neurosurgical patients is poorly characterized. The aim of this study was to delineate the rate of reintubation among neurosurgical patients. In addition, we seek to characterize the patient demographic features, comorbidities, and surgical characteristics that may be associated with reintubation among neurosurgical patients.

METHODS

This is a retrospective cohort study conducted in the setting of hospitals participating in the American College of Surgeons' National Surgical Quality Improvement Program between 2005 and 2010. All adult patients undergoing neurosurgery under general anesthesia were included. Exclusion criteria were preoperative mechanical ventilation or pneumonia prior to surgery. Reintubation was defined as placement of an endotracheal tube or mechanical ventilation within 48 h after surgery.

RESULTS

Among 17,483 eligible patients, 74 (0.42 %; 95 % CI 0.33-0.52 %) required reintubation within 48 h of surgery. In multiple logistic regression, the following were associated with increased risk of reintubation: age >65 years (OR 2.1; 95 % CI 1.3-3.4), preoperative renal failure (OR 2.9; 95 % CI 1.0-8.5), quadriplegia (OR 8.2; 95 % CI 3.3-20.3), COPD (OR 2.1; 95 % CI 1.0-4.3), operative time >3 h (OR 2.9; 95 % CI 1.8-4.8), and higher ASA class (OR per point, 2.1; 95 % CI 1.4-3.1). Spinal surgery was found to be protective relative to cranial neurosurgery or endarterectomy (OR 0.3; 95 % CI 0.2-0.5).

CONCLUSIONS

Reintubation after neurosurgery is associated with older patients with a greater number of comorbidities. In particular, renal, pulmonary, and severe neurologic comorbidities; longer operative duration; and cranial, rather than spinal, pathology were associated with increased risk for reintubation. These findings may be helpful in triage decisions regarding postoperative intensity of care and monitoring.

Modified rapid shallow breathing index adjusted with anthropometric parameters increases predictive power for extubation failure compared with the unmodified index in postcardiac surgery patients

OBJECTIVE

The aim of this study was to determine the best predictors of successful extubation after cardiac surgery, by modifying the rapid shallow breathing index (RSBI) based on patients' anthropometric parameters.

DESIGN

Single-center prospective observational study.

SETTING

Two general intensive care units at a single research institute.

PARTICIPANTS

Patients who had undergone uncomplicated cardiac surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The following parameters were investigated in conjunction with modification of the RSBI: Actual body weight (ABW), predicted body weight, ideal body weight, body mass index (BMI), and body surface area. Using the first set of patient data, RSBI threshold and modified RSBI for extubation failure were determined (threshold value; RSBI: 77 breaths/min (bpm)/L, RSBI adjusted with ABW: 5.0 bpm×kg/mL, RSBI adjusted with BMI: 2.0 bpm×BMI/mL). These threshold values for RSBI and RSBI adjusted with ABW or BMI were validated using the second set of patient data. Sensitivity values for RSBI, RSBI modified with ABW, and RSBI modified with BMI were 91%, 100%, and 100%, respectively. The corresponding specificity values were 89%, 92%, and 93%, and the corresponding receiver operator characteristic values were 0.951, 0.977, and 0.980, respectively.

CONCLUSIONS

Modified RSBI adjusted based on ABW or BMI has greater predictive power than conventional RSBI.

Frontal planar QRS/T angle can be a prognostic factor in the early postoperative period of patients undergoing coronary bypass surgery

BACKGROUND

Wide QRS/T angle reflects the ventricular repolarization heterogeneity and has been found in association with cardiac morbidity and mortality in various study populations. However, literature data about the availability of QRS/T angle in patients undergoing cardiac surgery has not yet been available.

METHODS

A total of 157 patients who underwent isolated coronary artery bypass surgery were included in this study. A preoperative 12-lead ECG was obtained one day before surgical procedure. The absolute difference between the frontal QRS wave axes and T-wave axes was defined as frontal planar QRS/T angle. Afterwards, patients were divided into two groups according to their frontal planar QRS/T angle (the cut-off value as 90°).

RESULTS

Group 1 consisted of 109 patients with frontal planar QRS/T angle of <90, and the remaining 48 patients with frontal planar QRS/T angle 90 were placed into group 2. Mean EuroSCORE was much higher in group 2. There were significant differences for positive inotropic agent usage (27.5% for group 1 versus 58.3% for group 2, P < .001) and the prevalence of postoperative atrial fibrillation (11.9% for group 1 versus 31.2% for group 2, P = .004) between the two groups. In multivariate logistic regression analysis, used to determine the independent predictors of positive inotropic usage in the early postoperative period, only frontal planar QRS/T angle (OR: 0.989, 95% CI: 0.981-0.997, P = .008) and EuroSCORE (OR: 0.792, 95% CI: 0.646-0.971, P = .025) were found to be statistically significant.

CONCLUSION

We found that frontal planar QRS/T angle might be an important preoperative parameter in predicting the need for inotropic drugs in the early postoperative period following coronary artery bypass surgery.

Role of the Clinical Nurse Specialist in Improving Patient Outcomes After Cardiac Surgery

Health care reform continues to focus on improving patient outcomes while reducing costs. Clinical nurse specialists (CNSs) should facilitate this process to ensure that best practice standards are used and patient safety is enhanced. One example of ensuring best practices and patient safety is early extubation after open heart surgery, which is a critical component of fast track protocols that reduces may reduce the development of pulmonary complications in the postoperative period while decreasing overall length of stay in the hospital. This project was an interdisciplinary endeavor, led by the CNS and nurse manager, which combined early extubation protocols with enhanced rounding initiatives to help decrease overall length of ventilation time as well as reduce pulmonary complications in patients in the cardiac surgery intensive care unit. The project resulted in a significant decrease in length of stay and a decrease in pulmonary complications in the postoperative period.

Variation in tracheal reintubations among patients undergoing cardiac surgery across Washington state hospitals

OBJECTIVES

The objectives of this study were to examine the variation in reintubations across Washington state hospitals that perform cardiac surgery, and explore hospital and patient characteristics associated with variation in reintubation.

DESIGN

Retrospective cohort study.

SETTING

All nonfederal hospitals performing cardiac surgery in Washington state.

PARTICIPANTS

A total of 15,103 patients undergoing coronary artery bypass grafting or valvular surgery between January 1, 2008 and September 30, 2011.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patient and hospital characteristics were compared between hospitals that had a reintubation frequency ≥5% or<5%. Multivariate logistic regression was used to compare the odds of reintubation across the hospitals. The authors tested for heterogeneity of odds of reintubation across hospitals by performing a likelihood ratio test on the hospital factor. After adjusting for patient-level characteristics and procedure type, significant heterogeneity in reintubations across hospitals was present (p = 0.005). This exploratory analyses suggested that hospitals with lower reintubations were more likely to have more acute care days and teaching intensive care units (ICU).

CONCLUSIONS

After accounting for patient and procedure characteristics, significant heterogeneity in the relative odds of requiring reintubation was present across 16 nonfederal hospitals performing cardiac surgery in Washington state. The findings suggested that greater hospital volume and ICU teaching status were associated with fewer reintubations.

Glasgow Coma Scale for outcome prediction after cardiac surgery: is it applicable?

OBJECTIVES

The Glasgow Coma Scale (GCS) is used commonly for assessing patients' neurologic condition and outcome in intensive care units (ICUs); however, its reliability in cardiac surgical patients has been questioned. It has been claimed that active sedation is the cause of its unsuitability for these patients. This study aimed to compare the accuracy of GCS in cardiac surgical patients with and without active sedation to find out if the inapplicability of GCS in surgical patients is related to active sedation.

DESIGN

This was an observational cohort study.

SETTING

The study was conducted in a cardiac surgical intensive care unit between January 1, 2007 and December 31, 2009.

PARTICIPANTS

All consecutive adult cardiac surgical patients were included in this study.

INTERVENTIONS

All types of cardiac surgical procedures performed during the study period were included without any exceptions. The study population was divided into 2 groups: sedated and non-sedated.

MEASUREMENTS AND MAIN RESULTS

GCS was calculated daily for the first 7 postoperative days. The authors developed a new 4-point neurologic descriptor (ND): (1) neurologically free, (2) ICU psychosis, (3) actively sedated, and (4) documented focal neurologic deficits. The accuracy of both scales (GCS and ND) at predicting ICU mortality was compared by replacing the GCS in the Sequential Organ Failure Assessment (SOFA) score with the new ND, producing a modified SOFA. GCS was not an accurate outcome predictor in non-sedated or sedated patients. The ND was superior to GCS. Correspondingly, the modified SOFA showed a significantly higher accuracy of ICU-mortality prediction than the original SOFA.

CONCLUSIONS

Regardless of active sedation, GCS is not accurate at outcome prediction for cardiac surgical patients. The suggested ND is a simple and more accurate risk stratification variable in cardiac surgical ICUs.

Hypoalbuminemia in critically sick children

CONTEXT

There is a paucity of data evaluating serum albumin levels and outcome of critically ill-children admitted to intensive care unit (ICU).

AIMS

The aim was to study frequency of hypoalbuminemia and examine association between hypoalbuminemia and outcome in critically ill-children.

SETTINGS AND DESIGN

Retrospective review of medical records of 435 patients admitted to 12 bedded pediatric ICU (PICU).

MATERIALS AND METHODS

Patients with hypoalbuminemia on admission or any time during PICU stay were compared with normoalbuminemic patients for demographic and clinical profile. Effect of albumin infusion was also examined. Odds ratio and 95% confidence interval were calculated using SPSS 16.

RESULTS

Hypoalbuminemia was present on admission in 21% (92 of 435) patients that increased to 34% at the end of 1(st) week and to 37% (164 of 435) during rest of the stay in PICU. Hypoalbuminemic patients had higher Pediatric Risk of Mortality scores (12.9 vs. 7.5, P < 0.001) and prolonged PICU stay (13.8 vs. 6.7 days, P < 0.001); higher likelihood of respiratory failure requiring mechanical ventilaton (84.8% vs. 28.8%, P < 0.001), prolonged ventilatory support, progression to multiorgan dysfunction syndrome (87.8% vs. 16.2%) and risk of mortality (25.6% vs. 17.7%). Though, the survivors among recipients of albumin infusion had significantly higher increase in serum albumin level (0.76 g/dL, standard deviation [SD] 0.54) compared with nonsurvivors (0.46 g/dL, SD 0.44; P = 0.016), albumin infusion did not reduce the risk of mortality.

CONCLUSIONS

Hypoalbuminemia is a significant indicator of mortality and morbidity in critically sick children. More studies are needed to define role of albumin infusion in treatment of such patients.

Daytime Versus Nighttime Extubations

Purpose:

Despite studies regarding outcomes of day versus night medical care, consequences of nighttime extubations are unknown. It may be favorable to extubate patients off-hours, as soon as weaning parameters are met, since this could decrease complications and shorten length of stay (LOS). Conversely, nighttime extubation could be deleterious, as staffing varies during this time. We hypothesized that patients have similar reintubation rates, irrespective of extubation time.

Methods:

A retrospective cohort study performed at 2 hospitals within a tertiary academic medical center included all adult intensive care unit (ICU) patients extubated between July 01, 2009 and May 31, 2011. Those extubated due to withdrawal of support were excluded. The nighttime group included patients extubated between 7:00 pm and 6:59 am and the daytime group included patients extubated between 7:00 am and 6:59 pm.

Results:

Of 2240 extubated patients, 1555 were extubated during the day and 685 were extubated at night. Of these, 119 (7.7%) and 26 (3.8%), respectively, were reintubated in 24 hours with likelihood of reintubation significantly lower for nighttime than daytime after multivariable adjustment (odds ratio [OR] = 0.5, 95% confidence interval [CI] 0.3-0.9, P = .01), with a similar trend for reintubation within 72 hours (OR = 0.7, 95% CI = 0.5-1.0, P = .07). There was a trend toward decreased mortality for patients extubated at night (OR = 0.6, 95% CI = 0.3-1.0, P = .06). There was also a significantly lower LOS for patients extubated at night ( P = .002). In a confirmatory frequency-matched analysis, there was no significant difference in reintubation proportion or mortality, but LOS was significantly less in those extubated at night.

Conclusions:

Intensive care unit extubations at night did not have higher likelihood of reintubation, LOS, or mortality compared to those during the day. Since patients should be extubated as soon as they meet parameters in order to potentially decrease complications of mechanical ventilation, these data provide no support for delaying extubation until daytime.

Comparison of Positive End-Expiratory Pressure of 8 versus 5 cm H2O on Outcome After Cardiac Operations

PURPOSE

Postoperative positive end-expiratory pressure (PEEP) selection in patients who are mechanically ventilated after cardiac operations often seems random. The aim of this investigation was to compare the 2 most common postoperative initial PEEP settings at our institution, 8 and 5 cm H2O, on postoperative initial tracheal intubation time (primary outcome); cardiovascular intensive care unit (CVICU); hospital length of stay (LOS); occurrence of pneumonia; and hospital mortality (secondary outcomes).

MATERIALS AND METHODS

The electronic medical records of patients who were mechanically ventilated after isolated coronary artery bypass grafting (CABG) or combined CABG and valve operations were reviewed. Propensity score matching was used to compare patients with an initial postoperative PEEP setting of 8 cm H2O (n = 4722 [25.9%]) with those who had PEEP of 5 cm H2O (n = 13 535 [74.1%]) on the primary and secondary outcomes listed earlier.

RESULTS

There was no difference in initial postoperative intubation time between the PEEP of 8 cm H2O and the PEEP of 5 cm H2O patient groups (mean 11.9 vs 12.0 hours [median 8.2 vs 8.8 hours], P = .89). The groups did not differ on the occurrence of pneumonia (0.43% vs 0.60%, P = .25) nor on hospital mortality (0.47% vs 0.43%, P = .76). Aspiration pneumonia occurrence approached a significant difference (0.06% vs 0.21%, P value = .052), as did CVICU LOS (mean: 47.9 vs 49.8 hours [median: 28.5 vs 28.4 hours], P = .057), but were not statistically different. There was a slight but likely clinically unimportant difference in hospital LOS (7.7 vs 7.4 days, PEEP = 8 vs 5, P < .001).

CONCLUSION

Patients being mechanically ventilated after cardiac operations with an initial postoperative PEEP setting of 8 versus 5 cm H2O differed significantly only on hospital LOS but the difference was likely clinically unimportant. Thus, use of 8 cm H2O PEEP in these patients without a clinical indication, although likely not harmful, does not seem beneficial.

Anemia and transfusion in critically ill pediatric patients: a review of etiology, management, and outcomes

This article describes the incidence and etiology of anemia in critically ill children. In addition, the article details the pathophysiology and clinical ramifications of anemia in this population. The use of transfused packed red blood cells as a therapy for anemia in critically ill patients is also discussed, including the indications for and complications associated with this practice as well as potential reasons for these complications. Finally, the article lists some therapeutic practices that may lessen the risks associated with transfusion, and briefly discusses the use of blood substitutes.

Anemia and blood transfusions in critically ill patients

Anemia is common in critically ill patients. As a consequence packed red blood cell (PRBC) transfusions are frequent in the critically ill. Over the past two decades a growing body of literature has emerged, linking PRBC transfusion to infections, immunosuppression, organ dysfunction, and a higher mortality rate. However, despite growing evidence that risk of PRBC transfusion outweighs its benefit, significant numbers of critically ill patients still receive PRBC transfusion during their intensive care unit (ICU) stay. In this paper, we summarize the current literature concerning the impact of anemia on outcomes in critically ill patients and the potential complications of PRBC transfusions.

Prenatally diagnosed coarctation: a more sinister disease?

Prenatal diagnosis of coarctation may improve survival, but little is known regarding its association with severity of left heart hypoplasia and surgical outcome. This study compared echocardiographic measurements of left heart structures, surgical strategies, and postoperative outcomes between neonates with a prenatal diagnosis of coarctation and those with a postnatal diagnosis. All the neonates who underwent coarctation repair during 2006-2010 were reviewed. The neonates with complex congenital heart disease or an unrestrictive ventricular septal defect requiring cardiopulmonary bypass (CPB) for closure were excluded from the study. Based on the time of diagnosis, the subjects were divided into the following three groups: group 1 (prenatal diagnosis), group 2 (diagnosis at 0-7 days), and group 3 (diagnosis at 8-28 days). The study population consisted of 46 neonates: 14 in group 1, 14 in group 2, and 18 in group 3. Compared with group 3, group 1 had a smaller left ventricular volume index, lower mitral and aortic valve diameter z-scores, and lower transverse arch z-scores. Compared with group 2, group 1 had smaller aortic valve z-scores but otherwise had similar measurements. At repair, 64 % of the neonates in group 1 required CPB versus 29 % in group 2 (p = 0.12) and 22 % in group 3 (p = 0.03). All the neonates underwent biventricular repair, with no surgical mortality. Group 1 had a hospital stay of 13.4 ± 10.8 versus 7.5 ± 4.2 days in group 2 (p = 0.06) and 7.3 ± 4.5 days in group 3 (p = 0.03). The neonates with prenatally diagnosed coarctation had smaller left heart structures than the neonates with coarctation diagnosed after the first week of age, were more likely to require extensive arch reconstruction under CPB, and had longer hospital stays.