Fluid overload after coronary artery bypass graft in patients on maintenance hemodialysis is associated with prolonged time on mechanical ventilation

The Overall Prevalence and Main Determinants of Prolonged Mechanical Ventilation in Patients Undergoing Coronary Artery Bypass Grafting: A Systematic Review

Background

Although respiratory support is necessary to maintain hemodynamic stability in patients undergoing major surgeries, prolonging the time of mechanical ventilation is considered a major complication following these procedures. The identification of potential factors related to this phenomenon should be identified. In the present systematic review, we first assess the pooled prevalence of prolonged mechanical ventilation (PMV) in patients undergoing coronary artery bypass grafting (CABG) surgery and also determine the main predictors for PMV by deeply reviewing the literature.

Materials and Methods

The manuscript databases including Medline, Web of Knowledge, Google Scholar, Scopus, and Cochrane were deeply searched by the two blinded investigators for all eligible studies based on the relevant keywords. Based on the titles and abstracts, 88 records were initially included and of those, 15 articles were eligible for the final analysis.

Results

The pooled prevalence of PMV in the studies that defined PMV as ventilation >24 h was 6.5% (95% confidence interval [CI]: 4.1%-10.2%) and in the studies, PMV as ventilation >48 h was 2.8% (95% CI: 1.7%-4.7%). Demographics (gender and advanced age), obesity, underlying comorbidities (hypertension, chronic kidney disease, cerebrovascular accident, high New York Heart Association class, history of chronic obstructive pulmonary disease, and history of acute coronary syndrome), emergency surgery, intraoperative characteristics (needing intra-aortic balloon pump, increased peak airway pressure, using cardiopulmonary bypass, the type of dose of anesthetics, cross-clamp time, increased units of blood transfusion, occurring cardiac ischemic events within an operation, fluid imbalance, and some anastomoses), and some postoperative outcome such as lowering O2 saturation, sequential organ failure assessment score, inotrope use, pleural effusion, delirium, and prolonged intensive care unit stay were found to be the main determinants for PMV.

Conclusion

Depending on the definition of PMV, the prevalence of PMV varied from 1.7% to 10.2%. Various factors before, during, and after surgery are the predictors of PMV in these patients, which can be used to design new scoring systems to predict it.

Coronary Artery Bypass Grafting in Dialysis-Dependent Patients - Key Peri-Operative Considerations

Cardiovascular disease represents the leading cause of mortality in dialysis-dependent (DD) patients, with the great majority of these patients afflicted by severe coronary artery disease. As rates of end-stage renal disease increase worldwide, DD patients represent a growing proportion of the coronary artery bypass grafting (CABG) cohort. Yet, these patients are complex, with crucial changes in their haemodynamic and physiologic profiles that complicate revascularisation surgery. First, this comprehensive literature review explores the outcomes and prognostic factors for DD patients undergoing CABG. We then summarise the intricacies relating to important peri-operative decisions such as use of cardio-pulmonary bypass and choice of conduit.

Prolonged Mechanical Ventilation Following Coronary Artery Bypass Graft in Santiago De Cali, Colombia

Purpose

The purpose of this study was to describe factors associated with prolonged ventilatory support in subjects undergoing coronary artery bypass graft.

Patients and Methods

This was an analytical retrospective case-control study. Cases were defined as subjects requiring prolonged mechanical ventilation (>48 hours) following isolated coronary artery bypass graft. Subjects older than 18 years who had undergone surgery were included, while subjects with missing clinical record data, subjects in coma or subjects with prior cardiac surgery were excluded. Variables were measured at the three time points surrounding surgery.

Results

A total of 204 cases and 408 controls were included. The final logistic model showed an association between prolonged mechanical ventilation and the following presurgical variables: chronic obstructive pulmonary disease (OR 1.85; 95% CI: 1.06-3.23, p = 0.03) and chronic kidney disease (OR 1.90; 95% CI: -3.31; p = 0.02). The associated transurgical variable was the use of intra-aortic balloon pump (OR 3.63; 95% CI: 1.73-7.61, p = 0.00), and associated postsurgical variables were venous oxygen saturation <60% (OR 2.00; 95% CI: 1.18-3.40, p = 0.01), mediastinitis (OR 18.51; 95% CI: 4.06-84.40, p = 0.00), inotrope use (OR 2.82; 95% CI: 1.77-4.48, p = 0.00), pleural effusion requiring drainage (OR 3.57; 95% CI: 2.02-6.32, p = 0.00) and delirium (OR 3.45; 95% CI: 1.91-6.25, p = 0.00).

Conclusion

This study identifies factors associated with prolonged mechanical ventilation in subjects subject to coronary artery bypass graft over the presurgical, transurgical and postsurgical periods, identifying a new factor, delirium, for this type of population.