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Song P, Holmes M, Mackensen GB. Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00031-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Abstract
OBJECTIVES Cost-effectiveness analyses are increasingly used to aid decisions about resource allocation in healthcare; this practice is slow to translate into critical care. We sought to identify and summarize original cost-effectiveness studies presenting cost per quality-adjusted life year, incremental cost-effectiveness ratios, or cost per life-year ratios for treatments used in ICUs. DESIGN We conducted a systematic search of the English-language literature for cost-effectiveness analyses published from 1993 to 2018 in critical care. Study quality was assessed using the Drummond checklist. SETTING Critical care units. PATIENTS OR SUBJECTS Critical care patients. INTERVENTIONS Identified studies with cost-effectiveness analyses. MEASUREMENTS AND MAIN RESULTS We identified 97 studies published through 2018 with 156 cost-effectiveness ratios. Reported incremental cost-effectiveness ratios ranged from -$119,635 (hypothetical cohort of patients requiring either intermittent or continuous renal replacement therapy) to $876,539 (data from an acute renal failure study in which continuous renal replacement therapy was the most expensive therapy). Many studies reported favorable cost-effectiveness profiles (i.e., below $50,000 per life year or quality-adjusted life year). However, several therapies have since been proven harmful. Over 2 decades, relatively few cost-effectiveness studies in critical care have been published (average 4.6 studies per year). There has been a more recent trend toward using hypothetical cohorts and modeling scenarios without proven clinical data (2014-2018: 19/33 [58%]). CONCLUSIONS Despite critical care being a significant healthcare cost burden there remains a paucity of studies in the literature evaluating its cost effectiveness.
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Parody-Rúa E, Rubio-Valera M, Guevara-Cuellar C, Gómez-Lumbreras A, Casajuana-Closas M, Carbonell-Duacastella C, Aznar-Lou I. Economic Evaluations Informed Exclusively by Real World Data: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E1171. [PMID: 32059593 PMCID: PMC7068655 DOI: 10.3390/ijerph17041171] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/03/2020] [Accepted: 02/08/2020] [Indexed: 12/28/2022]
Abstract
Economic evaluations using Real World Data (RWD) has been increasing in the very recent years, however, this source of information has several advantages and limitations. The aim of this review was to assess the quality of full economic evaluations (EE) developed using RWD. A systematic review was carried out through articles from the following databases: PubMed, Embase, Web of Science and Centre for Reviews and Dissemination. Included were studies that employed RWD for both costs and effectiveness. Methodological quality of the studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Of the 14,011 studies identified, 93 were included. Roughly half of the studies were carried out in a hospital setting. The most frequently assessed illnesses were neoplasms while the most evaluated interventions were pharmacological. The main source of costs and effects of RWD were information systems. The most frequent clinical outcome was survival. Some 47% of studies met at least 80% of CHEERS criteria. Studies were conducted with samples of 100-1000 patients or more, were randomized, and those that reported bias controls were those that fulfilled most CHEERS criteria. In conclusion, fewer than half the studies met 80% of the CHEERS checklist criteria.
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Affiliation(s)
- Elizabeth Parody-Rúa
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu–Institut de Recerca Sant Joan de Déu, 08830 Barcelona, Spain; (M.R.-V.); (C.C.-D.); (I.A.-L.)
- Primary Care Prevention and Health Promotion Network (redIAPP), 08007 Barcelona, Spain
| | - Maria Rubio-Valera
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu–Institut de Recerca Sant Joan de Déu, 08830 Barcelona, Spain; (M.R.-V.); (C.C.-D.); (I.A.-L.)
- CIBER of Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
| | | | - Ainhoa Gómez-Lumbreras
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAPJGol), 08007 Barcelona, Spain; (A.G.-L.); (M.C.-C.)
- Universitat Autònoma de Barcelona, 08193 Bellaterra (Cerdanyola del Vallès), Spain
- Health Science School, Universitat de Girona, 17071 Girona, Spain
| | - Marc Casajuana-Closas
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAPJGol), 08007 Barcelona, Spain; (A.G.-L.); (M.C.-C.)
- Universitat Autònoma de Barcelona, 08193 Bellaterra (Cerdanyola del Vallès), Spain
| | - Cristina Carbonell-Duacastella
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu–Institut de Recerca Sant Joan de Déu, 08830 Barcelona, Spain; (M.R.-V.); (C.C.-D.); (I.A.-L.)
- CIBER of Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
| | - Ignacio Aznar-Lou
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu–Institut de Recerca Sant Joan de Déu, 08830 Barcelona, Spain; (M.R.-V.); (C.C.-D.); (I.A.-L.)
- CIBER of Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
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Berkelmans GFN, Greving JP, van der Graaf Y, Visseren FLJ, Dorresteijn JAN. Would treatment decisions about secondary prevention of CVD based on estimated lifetime benefit rather than 10-year risk reduction be cost-effective? Diagn Progn Res 2020; 4:4. [PMID: 32318625 PMCID: PMC7161238 DOI: 10.1186/s41512-020-00072-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 03/13/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To test the hypothesis that treatment decisions (treatment with a PCSK9-mAb versus no treatment) are both more effective and more cost-effective when based on estimated lifetime benefit than when based on estimated risk reduction over 10 years. METHODS A microsimulation model was constructed for 10,000 patients with stable cardiovascular disease (CVD). Costs and quality-adjusted life years (QALYs) due to recurrent cardiovascular events and (non)vascular death were estimated for lifetime benefit-based compared to 10-year risk-based treatment, with PCSK9 inhibition as an illustration example. Lifetime benefit in months gained and 10-year absolute risk reduction were estimated using the SMART-REACH model, including an individualized treatment effect of PCSK9 inhibitors based on baseline low-density lipoprotein cholesterol. For the different numbers of patients treated (i.e. the 5%, 10%, and 20% of patients with the highest estimated benefit of both strategies), cost-effectiveness was assessed using the incremental cost-effectiveness ratio (ICER), indicating additional costs per QALY gain. RESULTS Lifetime benefit-based treatment of 5%, 10%, and 20% of patients with the highest estimated benefit resulted in an ICER of €36,440/QALY, €39,650/QALY, or €41,426/QALY. Ten-year risk-based treatment decisions of 5%, 10%, and 20% of patients with the highest estimated risk reduction resulted in an ICER of €48,187/QALY, €53,368/QALY, or €52,390/QALY. CONCLUSION Treatment decisions (treatment with a PCSK9-mAb versus no treatment) are both more effective and more cost-effective when based on estimated lifetime benefit than when based on estimated risk reduction over 10 years.
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Affiliation(s)
- Gijs F. N. Berkelmans
- grid.7692.a0000000090126352Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 Utrecht, GA The Netherlands
| | - Jacoba P. Greving
- grid.7692.a0000000090126352Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yolanda van der Graaf
- grid.7692.a0000000090126352Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank L. J. Visseren
- grid.7692.a0000000090126352Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 Utrecht, GA The Netherlands
| | - Jannick A. N. Dorresteijn
- grid.7692.a0000000090126352Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 Utrecht, GA The Netherlands
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Lima CA, Ritchrmoc MK, Leite WS, Silva DARG, Lima WA, Campos SL, de Andrade AD. Impact of fast-track management on adult cardiac surgery: clinical and hospital outcomes. Rev Bras Ter Intensiva 2019; 31:361-367. [PMID: 31618356 PMCID: PMC7005967 DOI: 10.5935/0103-507x.20190059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 05/13/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To compare the impact of two fast-track strategies regarding the extubation time and removal of invasive mechanical ventilation in adults after cardiac surgery on clinical and hospital outcomes. METHODS This was a retrospective cohort study with patients undergoing cardiac surgery. Patients were classified according to the extubation time as the Control Group (extubated 6 hours after admission to the intensive care unit, with a maximum mechanical ventilation time of 18 hours), Group 1 (extubated in the operating room after surgery) and Group 2 (extubated within 6 hours after admission to the intensive care unit). The primary outcomes analyzed were vital capacity on the first postoperative day, length of hospital stay, and length of stay in the intensive care unit. The secondary outcomes were reintubation, hospital-acquired pneumonia, sepsis, and death. RESULTS For the 223 patients evaluated, the vital capacity was lower in Groups 1 and 2 compared to the Control (p = 0.000 and p = 0.046, respectively). The length of stay in the intensive care unit was significantly lower in Groups 1 and 2 compared to the Control (p = 0.009 and p = 0.000, respectively), whereas the length of hospital stay was lower in Group 1 compared to the Control (p = 0.014). There was an association between extubation in the operating room (Group 1) with reintubation (p = 0.025) and postoperative complications (p = 0.038). CONCLUSION Patients undergoing fast-track management with extubation within 6 hours had shorter stays in the intensive care unit without increasing postoperative complications and death. Patients extubated in the operating room had a shorter hospital stay and a shorter stay in the intensive care unit but showed an increase in the frequency of reintubation and postoperative complications.
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Affiliation(s)
| | | | | | | | | | | | - Armele Dornelas de Andrade
- Universidade Federal do Rio Grande do Norte - Natal (RN), Brasil
- Universidade Federal de Pernambuco - Recife (PE), Brasil
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van Schoonhoven AV, Gout-Zwart JJ, de Vries MJS, van Asselt ADI, Dvortsin E, Vemer P, van Boven JFM, Postma MJ. Costs of clinical events in type 2 diabetes mellitus patients in the Netherlands: A systematic review. PLoS One 2019; 14:e0221856. [PMID: 31490989 PMCID: PMC6730996 DOI: 10.1371/journal.pone.0221856] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 08/18/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) is an established risk factor for cardiovascular and nephropathic events. In the Netherlands, prevalence of T2DM is expected to be as high as 8% by 2025. This will result in significant clinical and economic impact, highlighting the need for well-informed reimbursement decisions for new treatments. However, availability and consistent use of costing methodologies is limited. OBJECTIVE We aimed to systematically review recent costing data for T2DM-related cardiovascular and nephropathic events in the Netherlands. METHODS A systematic literature review in PubMed and Embase was conducted to identify available Dutch cost data for T2DM-related events, published in the last decade. Information extracted included costs, source, study population, and costing perspective. Finally, papers were evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). RESULTS Out of initially 570 papers, 36 agreed with the inclusion criteria. From these studies, 150 cost estimates for T2DM-related clinical events were identified. In total, 29 cost estimates were reported for myocardial infarction (range: €196-€27,038), 61 for stroke (€495-€54,678), fifteen for heart failure (€325-€16,561), 24 for renal failure (€2,438-€91,503), and seventeen for revascularisation (€3,000-€37,071). Only four estimates for transient ischaemic attack were available, ranging from €587 to €2,470. Adherence to CHEERS was generally high. CONCLUSIONS The most expensive clinical events were related to renal failure, while TIA was the least expensive event. Generally, there was substantial variation in reported cost estimates for T2DM-related events. Costing of clinical events should be improved and preferably standardised, as accurate and consistent results in economic models are desired.
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Affiliation(s)
- Alexander V. van Schoonhoven
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Judith J. Gout-Zwart
- Asc Academics, Groningen, the Netherlands
- Department of Nephrology, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, the Netherlands
| | - Marijke J. S. de Vries
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Antoinette D. I. van Asselt
- Department of Epidemiology, University Medical Centre Groningen, Groningen, the Netherlands
- Department of Health Sciences, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, the Netherlands
| | | | - Pepijn Vemer
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, the Netherlands
- Department of Epidemiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Job F. M. van Boven
- Department of General Practice & Elderly Care, University of Groningen, University Medical Center Groningen (UMCG), Groningen, the Netherlands
- Department of Clinical Pharmacy & Pharmacology, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, the Netherlands
| | - Maarten J. Postma
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, the Netherlands
- Department of Health Sciences, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, the Netherlands
- Department of Economics, Econometrics & Finance, University of Groningen, Faculty of Economics & Business, Groningen, The Netherlands
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Muller Moran HR, Maguire D, Maguire D, Kowalski S, Jacobsohn E, Mackenzie S, Grocott H, Arora RC. Association of earlier extubation and postoperative delirium after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2019; 159:182-190.e7. [PMID: 31076177 DOI: 10.1016/j.jtcvs.2019.03.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/09/2019] [Accepted: 03/13/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Earlier extubation after cardiac surgery is reported to have benefits on length of stay and complication rates, but the influence on postoperative delirium remains unclear. We sought to determine the effect of earlier extubation on delirium after coronary artery bypass grafting. METHODS A single-center retrospective review of consecutive isolated coronary artery bypass grafting patients from January 1, 2010, to December 31, 2015, was conducted. Baseline demographic characteristics, preoperative comorbidities, intraoperative data, and postoperative data were collected. A multivariable logistic regression was performed with analysis limited to extubation within the first 24 hours postoperatively. RESULTS We identified 2561 eligible patients. Delirium occurred in 13.9% (n = 357). Duration of postoperative mechanical ventilation was associated with higher delirium rates following adjustment, particularly after 12 to 24 hours (hourly odds ratio, 1.12; 95% confidence interval, 1.05-1.19; P < .001). No association was observed during the time period from 0 to 12 hours (hourly odds ratio, 1.02; 95% confidence interval, 0.99-1.06; P = .218). Major adverse events were associated with duration of ventilation after 0 to 12 hours (hourly odds ratio, 1.08; 95% confidence interval, 1.03-1.14; P < .002) but not after 12 to 24 hours (hourly odds ratio, 1.04; 95% CI, 0.96-1.14; P = .316). The overall rate of reintubation was 2.9% (n = 73). CONCLUSIONS Our findings suggest that delirium rates increase with lengthier postoperative ventilation times. This study provides the basis for consideration of the appropriate selection of earlier extubation to minimize delirium in patients undergoing cardiac surgery.
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Affiliation(s)
- Hellmuth R Muller Moran
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Duncan Maguire
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada; Department of Anesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Doug Maguire
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada; Department of Anesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stephen Kowalski
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada; Department of Anesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric Jacobsohn
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada; Department of Anesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Scott Mackenzie
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada; Department of Anesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Hilary Grocott
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada; Department of Anesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada.
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Flynn BC, He J, Richey M, Wirtz K, Daon E. Early Extubation Without Increased Adverse Events in High-Risk Cardiac Surgical Patients. Ann Thorac Surg 2019; 107:453-459. [DOI: 10.1016/j.athoracsur.2018.09.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/27/2018] [Accepted: 09/14/2018] [Indexed: 11/25/2022]
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The influence of prolonged intensive care stay on quality of life, recovery, and clinical outcomes following cardiac surgery: A prospective cohort study. J Thorac Cardiovasc Surg 2018; 156:1906-1915.e3. [DOI: 10.1016/j.jtcvs.2018.05.076] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 05/05/2018] [Accepted: 05/07/2018] [Indexed: 11/22/2022]
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Chan JL, Miller JG, Murphy M, Greenberg A, Iraola M, Horvath KA. A Multidisciplinary Protocol-Driven Approach to Improve Extubation Times After Cardiac Surgery. Ann Thorac Surg 2018. [DOI: 10.1016/j.athoracsur.2018.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Tunç M, Şahutoğlu C, Karaca N, Kocabaş S, Aşkar FZ. Risk Factors for Prolonged Intensive Care Unit Stay After Open Heart Surgery in Adults. Turk J Anaesthesiol Reanim 2018; 46:283-291. [PMID: 30140535 DOI: 10.5152/tjar.2018.92244] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 11/26/2017] [Indexed: 11/22/2022] Open
Abstract
Objective Prolonged intensive care unit (ICU) stay prevents the use of ICU equipment by other patients and increases hospital cost. This retrospective study aimed to investigate the risk factors for prolonged ICU stay in patients undergoing open heart surgery. Methods The medical records of 513 patients who underwent coronary artery bypass grafting and valvular heart surgery were retrospectively evaluated. Patients were divided into two groups based on their ICU stay: groups I (<48 h) and II (≥48 h). The effect of patient variables on the ICU stay duration was investigated using logistic regression analysis. Results The mean age of the patients was 61.5±10 years, and 69% were males. The ICU stay of ≥48 h was observed in 20.1% of the patients. Diabetes mellitus and low ejection fraction (pre-operative variables); long aortic cross clamp, cardiopulmonary bypass time and intra-aortic balloon pump requirement (intra-operative variables); arrhythmia, myocardial infarction, renal dysfunction and need for haemodialysis, use of ≥2 inotropic agents, infection, sepsis and respiratory complication (post-operative variables) were found to prolong the ICU stay. In multivariate logistic regression analysis, intra-aortic balloon pump requirement, use of ≥2 inotropic agents, post-operative myocardial infarction and need for haemodialysis were found to be independent risk factors for prolonged ICU stay (p<0.05). Early mortality was 0.97% (5 patients). Conclusion Intra-aortic balloon pump requirement, use of ≥2 inotropic agents, post-operative myocardial infarction and need for post-operative haemodialysis are independent risk factors for patients undergoing open heart surgery. Selection of methods for protecting the myocardium and renal functions during the intra-operative period would reduce the duration of ICU stay.
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Affiliation(s)
- Muzaffer Tunç
- Department of Anaesthesiology and Reanimation, Ege University School of Medicine, İzmir, Turkey
| | - Cengiz Şahutoğlu
- Department of Anaesthesiology and Reanimation, Ege University School of Medicine, İzmir, Turkey
| | - Nursen Karaca
- Department of Anaesthesiology and Reanimation, Ege University School of Medicine, İzmir, Turkey
| | - Seden Kocabaş
- Department of Anaesthesiology and Reanimation, Ege University School of Medicine, İzmir, Turkey
| | - Fatma Zekiye Aşkar
- Department of Anaesthesiology and Reanimation, Ege University School of Medicine, İzmir, Turkey
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Kolarczyk LM, Arora H, Manning MW, Zvara DA, Isaak RS. Defining Value-Based Care in Cardiac and Vascular Anesthesiology: The Past, Present, and Future of Perioperative Cardiovascular Care. J Cardiothorac Vasc Anesth 2018; 32:512-521. [DOI: 10.1053/j.jvca.2017.09.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Indexed: 12/22/2022]
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Stam-Slob MC, van der Graaf Y, de Boer A, Greving JP, Visseren FL. Cost-effectiveness of PCSK9 inhibition in addition to standard lipid-lowering therapy in patients at high risk for vascular disease. Int J Cardiol 2018; 253:148-154. [DOI: 10.1016/j.ijcard.2017.10.080] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 10/04/2017] [Accepted: 10/19/2017] [Indexed: 12/28/2022]
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Kebapcı A, Kanan N. Effects of nurse-led clinical pathway in coronary artery bypass graft surgery: A quasi-experimental study. J Clin Nurs 2018; 27:980-988. [PMID: 28881078 DOI: 10.1111/jocn.14069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2017] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To develop and evaluate the effects of a nurse-led clinical pathway for patients undergoing coronary artery bypass graft surgery. BACKGROUND A clinical pathway is a multidisciplinary care plan, based on evidence and guidelines to provide consistent, quality care to patients and improve outcomes. DESIGN Prospective, quasi-experimental design. METHODS Patients hospitalised for coronary artery bypass graft between April 2014-November 2015 in a hospital in Turkey were studied. First 42 usual care patients were enrolled to determine outcomes and plan for the development of the clinical pathway followed by 40 patients in the newly developed clinical pathway. The primary outcome was length of stay and secondary outcomes related to recovery from surgery (e.g., time to extubation, first feeding). RESULTS The mean age for the clinical pathway group was 60 and for usual care was 63 years. Most were male (CP = 78%, UC = 69%). There were significant differences between groups for the primary outcome. Length of stay in the intensive care unit was 38.9 hr for CP and 50.7 hr for usual care patients p < .01. Total hospital time was 144.4 hr for clinical pathway and 162.2 hr for usual care, p < .05. For secondary measures, the following times were less for the clinical pathway group than for the usual care: time to extubation and nasogastric tube removal (5.7 vs. 8.6 hr, p < .01), first oral feeding (4.7 vs. 10.9 hr, p < .001), first mobilisation (8.4 vs. 22.9 hr, p < .001) and first bowel movement (69.8 vs. 85.9 hr, p < .01). There were no statistically significant differences in the 3-month readmission rates and complication rates between the groups, except the renal complication rates were higher in the usual care (n = 16, 38%) than in the clinical pathway (n = 7, 17.5%) (p < .05). CONCLUSION The nurse-led clinical pathway was effective in improving length of stay in both the ICU and hospital as well as the secondary outcomes. RELEVANCE TO CLINICAL PRACTICE This study contributes to previous studies supporting clinical pathway use can improve the length of stay and quality of care in patients undergoing coronary artery bypass graft surgery.
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Affiliation(s)
- Ayda Kebapcı
- School of Nursing, Koç University, Istanbul, Turkey
| | - Nevin Kanan
- Florence Nightingale School of Nursing, Istanbul University, Istanbul, Turkey
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Ultrafast Track Robotic-Assisted Minimally Invasive Coronary Artery Surgical Revascularization. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017; 12:346-350. [DOI: 10.1097/imi.0000000000000401] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective Contemporary anesthetic techniques have enabled shorter sedation and early extubation in off-pump and minimally invasive coronary artery bypass (CABG) surgery. Robotic-assisted CABG represents the optimal surgical approach for ultrafast track anesthesia, with patients able to bypass the cardiac surgical intensive care unit with recovery in the postanesthesia care unit (PACU) and inpatient ward. Methods In-hospital postoperative outcomes from ninety patients who underwent either elective or urgent robotically-assisted CABG at our institution were reviewed. These patients were carefully selected by a multidisciplinary team to undergo fast-track anesthesia: extubation in the operating room, 4-hour recovery in the postanesthesia care unit and transfer to the inpatient ward. Intrathecal, paravertebral local, and patient-controlled anesthesia techniques were used to facilitate transition to oral analgesics. Results Average patient age was 61 ± 9 years. Sixty-six patients (73%) were male. Seventy cases were elective, and 20 patients required urgent revascularization. All patients underwent intraoperative angiography after graft construction, which revealed Fitzgibbon class A grafts. There were no in-hospital mortalities. One patient required re-exploration for bleeding, through the same minimally invasive incision, did not require conversion to sternotomy for bleeding, and was transferred to the intensive care unit postexploration for bleeding for standard postoperative care. Postoperative complications were limited to one superficial wound infection. The mean hospital length of stay was 3.5 ± 1.17 days. Conclusions In patients undergoing robotic-assisted CABG, ultrafasttrack cardiac surgery with immediate postprocedure extubation and transfer to the inpatient ward has been demonstrated to be safe with no increase in perioperative morbidity or mortality. It requires a dedicated heart team with a carefully selected group of patients. Avoiding cardiac surgical intensive care unit expedites recovery, with possible avoidance of infection and early discharge from hospital.
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Tarola CL, Al-Amodi HA, Balasubramanian S, Fox SA, Harle CC, Iglesias I, Sridhar K, Teefy PJ, Chu MW, Kiaii BB. Ultrafast Track Robotic-Assisted Minimally Invasive Coronary Artery Surgical Revascularization. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017. [DOI: 10.1177/155698451701200506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | - Stephanie A. Fox
- Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | - Christopher C. Harle
- Department of Anesthesia and Perioperative Medicine, Western University, London, Ontario, Canada
| | - Ivan Iglesias
- Department of Anesthesia and Perioperative Medicine, Western University, London, Ontario, Canada
| | - Kumar Sridhar
- Department of Cardiology, Western University, London, Ontario, Canada
| | - Patrick J. Teefy
- Department of Cardiology, Western University, London, Ontario, Canada
| | - Michael W.A. Chu
- Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | - Bob B. Kiaii
- Division of Cardiac Surgery, Western University, London, Ontario, Canada
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Diab M, Bilkhu R, Soppa G, McGale N, Hirani SP, Newman SP, Jahangiri M. Quality of Life in Relation to Length of Intensive Care Unit Stay After Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:1080-1090. [DOI: 10.1053/j.jvca.2016.06.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Indexed: 12/24/2022]
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Stam-Slob MC, van der Graaf Y, Greving JP, Dorresteijn JAN, Visseren FLJ. Cost-Effectiveness of Intensifying Lipid-Lowering Therapy With Statins Based on Individual Absolute Benefit in Coronary Artery Disease Patients. J Am Heart Assoc 2017; 6:e004648. [PMID: 28214794 PMCID: PMC5523762 DOI: 10.1161/jaha.116.004648] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 12/20/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND A validated prediction model estimates the absolute benefit of intensive versus standard lipid-lowering therapy (LLT) with statins on next major cardiovascular events for individual patients with coronary artery disease. We aimed to assess whether targeting intensive LLT therapy to coronary artery disease patients with the highest predicted absolute benefit is cost-effective compared to treating all with standard or all with intensive LLT. METHODS AND RESULTS A lifetime Markov model was constructed for coronary artery disease patients (n=10 000) with mean age 61 years. Number of major cardiovascular events, (non) vascular death, costs, and quality-adjusted life years (QALYs) were estimated for the following strategies: (1) standard LLT for all (reference strategy); (2) intensive LLT for those with 5-year absolute major cardiovascular events risk reduction (ARR) ≥3%, ≥2.3%, or ≥1.5% (corresponding to ≥20%, ≥15%, or ≥10% 5-year major cardiovascular events risk); and (3) intensive LLT for all. With intensive LLT for those with ≥3% 5-year ARR (13% of patients), 380 QALYs were gained for €2423/QALY. Using a threshold of ≥2.3% ARR (26% of patients), 630 QALYs were gained for €5653/QALY. Using a threshold of ≥1.5% ARR (56% of patients), 1020 QALYs were gained for €10 960/QALY. By treating all intensively, 1410 QALYs were gained (0.14 QALY per patient) for €17 223/QALY. With benefit-based treatment, 0.16 to 0.17 QALY was gained per treated patient. CONCLUSIONS Intensive LLT with statins for all coronary artery disease patients results in the highest overall QALY gain against acceptable costs. However, the number of QALYs gained with intensive LLT by statins in individual patients can be increased with selective benefit-based treatment. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00327691 and NCT00159835.
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Affiliation(s)
- Manon C Stam-Slob
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yolanda van der Graaf
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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Wong WT, Gomersall CD. Adaptive support ventilation of cardiac surgical patients: A component of a complex intervention. J Crit Care 2016; 37:251. [PMID: 27765410 DOI: 10.1016/j.jcrc.2016.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 06/28/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Wai Tat Wong
- Department of Anaesthesia & Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Charles D Gomersall
- Department of Anaesthesia & Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong.
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Chang B, Lorenzo J, Macario A. Examining Health Care Costs: Opportunities to Provide Value in the Intensive Care Unit. Anesthesiol Clin 2016; 33:753-70. [PMID: 26610628 DOI: 10.1016/j.anclin.2015.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
As health care costs threaten the economic stability of American society, increasing pressures to focus on value-based health care have led to the development of protocols for fast-track cardiac surgery and for delirium management. Critical care services can be led by anesthesiologists with the goal of improving ICU outcomes and at the same time decreasing the rising cost of ICU medicine.
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Affiliation(s)
- Beverly Chang
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H3580, Stanford, CA 94305-5640, USA.
| | - Javier Lorenzo
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H3580, Stanford, CA 94305-5640, USA
| | - Alex Macario
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H3580, Stanford, CA 94305-5640, USA; Department of Health Research and Policy, Stanford University School of Medicine, 300 Pasteur Drive, H3580, Stanford, CA 94305-5640, USA
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Abstract
BACKGROUND Fast-track cardiac care is a complex intervention involving several components of care during cardiac anaesthesia and in the postoperative period, with the ultimate aim of early extubation after surgery, to reduce length of stay in the intensive care unit and in the hospital. Safe and effective fast-track cardiac care may reduce hospital costs. This is an update of a Cochrane review first published in 2003, updated in 2012 and updated now in 2016. OBJECTIVES To determine the safety and effectiveness of fast-track cardiac care compared with conventional (not fast-track) care in adult patients undergoing cardiac surgery. Fast-track cardiac care intervention includes administration of low-dose opioid-based general anaesthesia or use of a time-directed extubation protocol, or both. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (January 2012 to May 2015), Embase (January 2012 to May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL; January 2012 to May 2015) and the Institute for Scientific Information (ISI) Web of Science (January 2012 to May 2015), along with reference lists of articles, to identify additional trials. We applied no language restrictions. SELECTION CRITERIA We included all randomized controlled trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement) that compared fast-track cardiac care and conventional (not fast-track) care groups. We focused on the following fast-track interventions, which were designed for early extubation after surgery: administration of low-dose opioid-based general anaesthesia during cardiac surgery and use of a time-directed extubation protocol after surgery. The primary outcome was risk of mortality. Secondary outcomes included postoperative complications, reintubation within 24 hours of surgery, time to extubation, length of stay in the intensive care unit and in the hospital, quality of life after surgery and hospital costs. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted study data. We contacted study authors for additional information. We calculated a Peto odds ratio (OR) for risk of mortality and used a random-effects model to report risk ratio (RR), mean difference (MD) and 95% confidence intervals (95% CIs) for all secondary outcomes. MAIN RESULTS We included 28 trials (4438 participants) in the updated review. We considered most participants to be at low to moderate risk of death after surgery. We assessed two studies as having low risk of bias and 11 studies high risk of bias. Investigators reported no differences in risk of mortality within the first year after surgery between low-dose versus high-dose opioid-based general anaesthesia groups (OR 0.53, 95% CI 0.25 to 1.12; eight trials, 1994 participants, low level of evidence) and between a time-directed extubation protocol versus usual care (OR 0.80, 95% CI 0.45 to 1.45; 10 trials, 1802 participants, low level of evidence).Researchers noted no significant differences between low-dose and high-dose opioid-based anaesthesia groups in the following postoperative complications: myocardial infarction (RR 0.98, 95% CI 0.48 to 1.99; eight trials, 1683 participants, low level of evidence), stroke (RR 1.17, 95% CI 0.36 to 3.78; five trials, 562 participants, low level of evidence) and tracheal reintubation (RR 1.77, 95% CI 0.38 to 8.27; five trials, 594 participants, low level of evidence).Comparisons with usual care revealed no significant differences in the risk of postoperative complications associated with a time-directed extubation protocol: myocardial infarction (RR 0.59, 95% CI 0.27 to 1.31; eight trials, 1378 participants, low level of evidence), stroke (RR 0.85, 95% CI 0.33 to 2.16; 11 trials, 1646 participants, low level of evidence) and tracheal reintubation (RR 1.34, 95% CI 0.74 to 2.41; 12 trials, 1261 participants, low level of evidence).Although levels of heterogeneity were high, low-dose opioid anaesthesia was associated with reduced time to extubation (reduction of 4.3 to 10.5 hours, 14 trials, 2486 participants, low level of evidence) and length of stay in the intensive care unit (reduction of 0.4 to 7.0 hours, 12 trials, 1394 participants, low level of evidence). Use of a time-directed extubation protocol was associated with reduced time to extubation (reduction of 3.7 to 8.8 hours, 16 trials, 2024 participants, low level of evidence) and length of stay in the intensive care unit (reduction of 3.9 to 10.5 hours, 13 trials, 1888 participants, low level of evidence). However, these two fast-track care interventions were not associated with reduced total length of stay in the hospital (low level of evidence). AUTHORS' CONCLUSIONS Low-dose opioid-based general anaesthesia and time-directed extubation protocols for fast-track interventions have risks of mortality and major postoperative complications similar to those of conventional (not fast-track) care, and therefore appear to be safe for use in patients considered to be at low to moderate risk. These fast-track interventions reduced time to extubation and shortened length of stay in the intensive care unit but did not reduce length of stay in the hospital.
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Affiliation(s)
- Wai‐Tat Wong
- The Chinese University of Hong KongDepartment of Anaesthesia and Intensive CarePrince of Wales HospitalShatinNew TerritoriesHong Kong
| | - Veronica KW Lai
- The Chinese University of Hong KongDepartment of Anaesthesia and Intensive CarePrince of Wales HospitalShatinNew TerritoriesHong Kong
| | - Yee Eot Chee
- Queen Mary HospitalDepartment of AnaesthesiologyPokfulamHong Kong
| | - Anna Lee
- The Chinese University of Hong KongDepartment of Anaesthesia and Intensive CarePrince of Wales HospitalShatinNew TerritoriesHong Kong
- The Chinese University of Hong KongHong Kong Branch of The Chinese Cochrane Centre, The Jockey Club School of Public Health and Primary Care, Faculty of MedicineShatinNew TerritoriesHong Kong
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Tam MKP, Wong WT, Gomersall CD, Tian Q, Ng SK, Leung CCH, Underwood MJ. A randomized controlled trial of 2 protocols for weaning cardiac surgical patients receiving adaptive support ventilation. J Crit Care 2016; 33:163-8. [PMID: 27006266 DOI: 10.1016/j.jcrc.2016.01.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 12/23/2015] [Accepted: 01/15/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE This study aims to compare the effectiveness of weaning with adaptive support ventilation (ASV) incorporating progressively reduced or constant target minute ventilation in the protocol in postoperative care after cardiac surgery. MATERIAL AND METHODS A randomized controlled unblinded study of 52 patients after elective coronary artery bypass surgery was carried out to determine whether a protocol incorporating a decremental target minute ventilation (DTMV) results in more rapid weaning of patients ventilated in ASV mode compared to a protocol incorporating a constant target minute ventilation. RESULTS Median duration of mechanical ventilation (145 vs 309 minutes; P = .001) and intubation (225 vs 423 minutes; P = .005) were significantly shorter in the DTMV group. There was no difference in adverse effects (42% vs 46%) or mortality (0% vs 0%) between the 2 groups. CONCLUSIONS Use of a DTMV protocol for postoperative ventilation of cardiac surgical patients in ASV mode results in a shorter duration of ventilation and intubation without evidence of increased risk of adverse effects.
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Affiliation(s)
- M K P Tam
- Department of Anaesthesia & Intensive Care, Prince of Wales Hospital, Shatin, Hong Kong
| | - W T Wong
- Department of Anaesthesia & Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - C D Gomersall
- Department of Anaesthesia & Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong.
| | - Q Tian
- Department of Anaesthesia & Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - S K Ng
- Department of Anaesthesia & Intensive Care, Prince of Wales Hospital, Shatin, Hong Kong
| | - C C H Leung
- Department of Anaesthesia & Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - M J Underwood
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
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A Randomized Controlled Trial of Adaptive Support Ventilation Mode to Wean Patients after Fast-track Cardiac Valvular Surgery. Anesthesiology 2015; 122:832-40. [DOI: 10.1097/aln.0000000000000589] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background:
Adaptive support ventilation can speed weaning after coronary artery surgery compared with protocolized weaning using other modes. There are no data to support this mode of weaning after cardiac valvular surgery. Furthermore, control group weaning times have been long, suggesting that the results may reflect control group protocols that delay weaning rather than a real advantage of adaptive support ventilation.
Methods:
Randomized (computer-generated sequence and sealed opaque envelopes), parallel-arm, unblinded trial of adaptive support ventilation versus physician-directed weaning after adult fast-track cardiac valvular surgery. The primary outcome was duration of mechanical ventilation. Patients aged 18 to 80 yr without significant renal, liver, or lung disease or severe impairment of left ventricular function undergoing uncomplicated elective valve surgery were eligible. Care was standardized, except postoperative ventilation. In the adaptive support ventilation group, target minute ventilation and inspired oxygen concentration were adjusted according to blood gases. A spontaneous breathing trial was carried out when the total inspiratory pressure of 15 cm H2O or less with positive end-expiratory pressure of 5 cm H2O. In the control group, the duty physician made all ventilatory decisions.
Results:
Median duration of ventilation was statistically significantly shorter (P = 0.013) in the adaptive support ventilation group (205 [141 to 295] min, n = 30) than that in controls (342 [214 to 491] min, n = 31). Manual ventilator changes and alarms were less common in the adaptive support ventilation group, and arterial blood gas estimations were more common.
Conclusion:
Adaptive support ventilation reduces ventilation time by more than 2 h in patients who have undergone fast-track cardiac valvular surgery while reducing the number of manual ventilator changes and alarms.
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Abstract
BACKGROUND Fast-track cardiac care is a complex intervention involving several components of care during cardiac anaesthesia and in the postoperative period, all with the ultimate aim of early extubation after surgery, to reduce the length of stay in the intensive care unit and in the hospital. Safe and effective fast-track cardiac care may reduce hospital costs. This is an update of a Cochrane review published in 2003. OBJECTIVES To update the evidence on the safety and effectiveness of fast-track cardiac care compared to conventional (not fast-track) care in adult patients undergoing cardiac surgery. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 3), MEDLINE (January 1966 to April 2012), EMBASE (January 1980 to April 2012), CINAHL (January 1982 to April 2012), and ISI Web of Science (January 2003 to April 2012). We searched reference lists of articles and contacted experts in the field. SELECTION CRITERIA All randomized controlled trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement) that compared fast-track cardiac care and conventional (not fast-track) care groups were included. We focused on the following fast-track interventions that were designed for early extubation after surgery, administration of low-dose opioid based general anaesthesia during cardiac surgery and the use of a time-directed extubation protocol after surgery. The primary outcome was the risk of mortality. Secondary outcomes included postoperative complications, reintubation within 24 hours of surgery, time to extubation, length of stay in the intensive care unit and in the hospital, quality of life after surgery and hospital costs. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted the data. Study authors were contacted for additional information. We used a random-effects model and reported relative risk (RR), mean difference (MD) and 95% confidence intervals (95% CI). MAIN RESULTS Twenty-five trials involving 4118 patients were included in the review. There were two studies with a low risk of bias and nine studies with a high risk of bias. There were no differences in the risk of mortality within the first year after surgery between low-dose versus high-dose opioid based general anaesthesia groups (RR 0.58, 95% CI 0.28 to 1.18) and between early extubation protocol versus usual care groups (RR 0.84, 95% CI 0.40 to 1.75).There were no significant differences between low-dose versus high-dose opioid based anaesthesia groups for postoperative complications: myocardial infarction (RR 0.98, 95% CI 0.48 to 1.99), reintubation (RR 1.77, 95% CI 0.38 to 8.27), acute renal failure (RR 1.19, 95% CI 0.33 to 4.33), major bleeding (RR 0.48, 95% CI 0.16 to 1.44), and stroke (RR 1.17, 95% CI 0.36 to 3.78). Compared to the usual care, there were no significant differences in the risk of postoperative complications associated with early extubation: myocardial infarction (RR 0.94, 95% CI 0.55 to 1.60), reintubation (RR 1.91, 95% CI 0.90 to 4.07), acute renal failure (RR 0.77, 95% CI 0.19 to 3.10), major bleeding (RR 0.80, 95% CI 0.45 to 1.44), stroke (RR 0.87, 95% CI 0.31 to 2.46), major sepsis (RR 1.25, 95% CI 0.08 to 19.75) and wound infection (RR 0.67, 95% CI 0.25 to 1.83).Although there were high levels of heterogeneity, both low-dose opioid anaesthesia and the use of time-directed extubation protocols were associated with reductions in the time to extubation (3.0 to 10.5 hours) and in the length of stay in the intensive care unit (0.4 to 8.7 hours). However, these fast-track care interventions were not associated with reductions in the total length of stay in hospital. One high quality cost-effectiveness analysis included in a randomized controlled trial showed that early extubation was likely to be cost-effective. AUTHORS' CONCLUSIONS The use of low-dose opioid based general anaesthesia and time-directed protocols for fast-track interventions have similar risks of mortality and major postoperative complications to conventional (not fast-track) care, and therefore appear to be safe in patients considered to be at low to moderate risk. These fast-track interventions reduced the time to extubation and shortened the length of stay in the intensive care unit, but did not reduce the length of stay in the hospital.
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Affiliation(s)
- Fang Zhu
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
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Chenitz KB, Lane-Fall MB. Decreased urine output and acute kidney injury in the postanesthesia care unit. Anesthesiol Clin 2012; 30:513-26. [PMID: 22989592 DOI: 10.1016/j.anclin.2012.07.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Decreased urine output and acute kidney injury (also known as acute renal failure) are among the most important complications that may develop in the postanesthetic period. In this article, the authors present definitions of decreased urine output, oliguria, and acute kidney injury. They review the epidemiology, pathophysiology, and prevention of postoperative acute kidney injury. Finally, the article offers approaches to diagnosis and management of the postsurgical patient with decreased urine output or acute kidney injury.
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Affiliation(s)
- Kara Beth Chenitz
- Renal, Electrolyte and Hypertension Division, Department of Internal Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 1 Founders Building, Philadelphia, PA 19104, USA
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123-210. [PMID: 22070836 DOI: 10.1016/j.jacc.2011.08.009] [Citation(s) in RCA: 582] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:e652-735. [PMID: 22064599 DOI: 10.1161/cir.0b013e31823c074e] [Citation(s) in RCA: 390] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Soonawala D, Middelburg RA, Egger M, Vandenbroucke JP, Dekkers OM. Efficacy of experimental treatments compared with standard treatments in non-inferiority trials: a meta-analysis of randomized controlled trials. Int J Epidemiol 2010; 39:1567-81. [DOI: 10.1093/ije/dyq136] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Hawkes C, Foxcroft DR, Yerrell P. Clinical guideline for nurse-led early extubation after coronary artery bypass: an evaluation. J Adv Nurs 2010; 66:2038-49. [PMID: 20626495 DOI: 10.1111/j.1365-2648.2010.05337.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
AIM This paper is a report of an investigation of the development, implementation and outcomes of a clinical guideline for nurse-led early extubation of adult coronary artery bypass graft patients. BACKGROUND Healthcare knowledge translation and utilization is an emerging but under-developed research area. The complex context for guideline development and use is methodologically challenging for robust and rigorous evaluation. This study contributes one such evaluation. METHODS This was a mixed methods evaluation, with a dominant quantitative study with a secondary qualitative study in a single UK cardiac surgery centre. An interrupted time series study (N = 567 elective coronary artery bypass graft patients) with concurrent within person controls was used to measure the impact of the guideline on the primary outcome: time to extubation. Semi-structured interviews with 11 clinical staff, informed by applied practitioner ethnography, explored the process of guideline development and implementation. The data were collected between January 2001 and January 2003. RESULTS There was no change in the interrupted time series study primary outcome as a consequence of the guideline implementation. The qualitative study identified three themes: context, process and tensions highlighting that the guideline did not require clinicians to change their practice, although it may have helped maintain practice through its educative role. CONCLUSION Further investigation and development of appropriate methods to capture the dynamism in healthcare contexts and its impact on guideline implementation seems warranted. Multi-site mixed methods investigations and programmes of research exploring knowledge translation and utilization initiatives, such as guideline implementation, are needed.
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Affiliation(s)
- Claire Hawkes
- Centre for Health-Related Research, School of Healthcare Sciences, Bangor University, UK.
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Health-related quality of life after fast-track treatment results from a randomized controlled clinical equivalence trial. Qual Life Res 2010; 19:631-42. [PMID: 20340049 PMCID: PMC2874031 DOI: 10.1007/s11136-010-9625-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2010] [Indexed: 11/03/2022]
Abstract
PURPOSE This randomized clinical equivalence trial was designed to evaluate health-related quality of life (HRQoL) after fast-track treatment for low-risk coronary artery bypass (CABG) patients. METHODS Four hundred and ten CABG patients were randomly assigned to undergo either short-stay intensive care treatment (SSIC, 8 h of intensive care stay) or control treatment (care as usual, overnight intensive care stay). HRQoL was measured at baseline and 1 month, and one year after surgery using the multidimensional index of life quality (MILQ), the EQ-5D, the Beck Depression Inventory and the State-Trait Anxiety Inventory. RESULTS At one month after surgery, no statistically significant difference in overall HRQoL was found (MILQ-score P-value=.508, overall MILQ-index P-value=.543, EQ-5D VAS P-value=.593). The scores on the MILQ-domains, physical, and social functioning were significantly higher at one month postoperatively in the SSIC group compared to the control group (P-value=.049; 95%CI: 0.01-2.50 and P-value=.014, 95% CI: 0.24-2.06, respectively). However, these differences were no longer observed at long-term follow-up. CONCLUSIONS According to our definition of clinical equivalence, the HRQoL of SSIC patients is similar to patients receiving care as usual. Since safety and the financial benefits of this intervention were demonstrated in a previously reported analysis, SSIC can be considered as an adequate fast-track intensive care treatment option for low-risk CABG patients.
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Lin YK, Chen CP, Tsai WC, Chiao YC, Lin BYJ. Cost-effectiveness of clinical pathway in coronary artery bypass surgery. J Med Syst 2009; 35:203-13. [PMID: 20703569 DOI: 10.1007/s10916-009-9357-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2009] [Accepted: 07/27/2009] [Indexed: 10/20/2022]
Abstract
Few studies have been devoted to the exploration of the effect of clinical pathways on coronary artery diseases treated with coronary artery bypass (CAB) surgery. This study was aimed to investigate the cost and effectiveness of the clinical pathway on CAB surgery in a medical center. With a retrospective dataset in 2003-2007, 212 CAB surgery patients were included. Data of the costs and postoperative complication occurrence and length of stays were the focus and patient demographics, surgical risk indicator EuroSCORE, surgical conditions were collected. It revealed that there was differentiation across specified cost items in beating heart CAB surgery patients, but not for heart arrest CAB surgery patients with and without clinical pathways enrolled. In addition, there was no difference in postoperative complication occurrence in CAB surgery patients enrolled into clinical pathways. However, robotic beating heart CAB surgery patients enrolled clinical pathways were shown to have less postoperative ordinary ward stay than those not enrolled clinical pathways. CAB surgery patients' age and surgical risks were related to their postoperative lengths of stay to some extent.
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Affiliation(s)
- Yung-Kai Lin
- Division of Cardiovascular Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
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Kranke P, Redel A, Schuster F, Muellenbach R, Eberhart LH. Pharmacological interventions and concepts of fast-track perioperative medical care for enhanced recovery programs. Expert Opin Pharmacother 2008; 9:1541-64. [DOI: 10.1517/14656566.9.9.1541] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Management of the Patient after Cardiac Surgery. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50039-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Postoperative lung injury is a common, although decreasing, complication of cardiac surgery. This article discusses various means to prevent and minimize postoperative lung injury. These include lung-protective strategies, pharmacologic strategies, and mechanical ventilation.
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Affiliation(s)
- Jayashree K Raikhelkar
- Department of Anesthesiology, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1010, New York, NY 10029-6574, USA.
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