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Singh A, McAllister M, De León LE, Kücükak S, Rochefort MM, Mazzola E, Maldonado L, Hartigan PM, Jaklitsch MT, Swanson SJ, Bueno R, Deeb AL, Patil N. Liposomal bupivacaine intercostal block placed under direct vision reduces morphine use in thoracic surgery. J Thorac Dis 2024; 16:1161-1170. [PMID: 38505026 PMCID: PMC10944765 DOI: 10.21037/jtd-23-1405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/29/2023] [Indexed: 03/21/2024]
Abstract
Background Thoracic epidural analgesia (TEA) and liposomal bupivacaine (LB) are two methods used for postoperative pain control after thoracic surgery. Some studies have compared LB to standard bupivacaine. However, data comparing the outcomes of LB to TEA after minimally invasive lung resection is limited. Therefore, the objective of our study was to compare postoperative pain, opioid usage, and outcomes between patients who received TEA vs. LB. Methods We conducted a retrospective chart review of patients who underwent minimally invasive lung resections over an 8-month period. Intraoperatively, patients received either LB under direct vision or a TEA. Pain scores were obtained in the post-anesthesia care unit (PACU) and at 12, 24, and 48 hours postoperatively. Morphine milligram equivalents (MMEs) were calculated at 24 and 48 hours postoperatively. Postoperative outcomes were then compared between groups. Results In total, 391 patients underwent minimally invasive lung resection: 236 (60%) wedge resections, 51 (13%) segmentectomies, and 104 (27%) lobectomies. Of these, 326 (83%) received LB intraoperatively. Fewer patients in the LB group experienced postoperative complications (18% vs. 34%, P=0.004). LB patients also had lower median pain scores at 24 (P=0.03) and 48 hours (P=0.001) postoperatively. There was no difference in MMEs at 24 hours (P=0.49). However, at 48 hours, patients who received LB required less narcotics (P=0.02). Median hospital length of stay (LOS) was significantly shorter in patients who received LB (2 vs. 4 days, P<0.001). On multivariable analysis, increasing age, postoperative complications, and use of TEA were independently associated with a longer hospital LOS. Conclusions Compared to TEA, LB intercostal block placed under direct vision reduced morphine use 48 hours after thoracic surgery. It was also associated with fewer postoperative complications and shorter median hospital LOS. LB is a good alternative to TEA for pain management after minimally invasive lung resection.
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Affiliation(s)
- Anupama Singh
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Miles McAllister
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Luis E. De León
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Suden Kücükak
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Emanuele Mazzola
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Luisa Maldonado
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | | | | | - Scott J. Swanson
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Raphael Bueno
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Ashley L. Deeb
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Namrata Patil
- Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
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Yeom R, Gorgone M, Malinovic M, Panzica P, Maslow A, Augoustides JG, Marchant BE, Fernando RJ, Nampi RG, Pospishil L, Neuburger PJ. Surgical Aortic Valve Replacement in a Patient with Very Severe Chronic Obstructive Pulmonary Disease. J Cardiothorac Vasc Anesth 2023; 37:2335-2349. [PMID: 37657996 DOI: 10.1053/j.jvca.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 08/06/2023] [Indexed: 09/03/2023]
Affiliation(s)
- Richard Yeom
- Department of Anesthesiology, Westchester Medical Center, Valhalla, NY
| | - Michelle Gorgone
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Matea Malinovic
- Department of Anesthesiology, Westchester Medical Center, Valhalla, NY
| | - Peter Panzica
- Department of Anesthesiology, Westchester Medical Center, Valhalla, NY
| | - Andrew Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Bryan E Marchant
- Department of Anesthesiology, Cardiothoracic and Critical Care Sections, Wake Forest University School of Medicine, Winston Salem, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest University School of Medicine, Medical Center Boulevard, Winston Salem, NC.
| | - Robert G Nampi
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Liliya Pospishil
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Peter J Neuburger
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY
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3
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Morisawa T, Saitoh M, Otsuka S, Takamura G, Tahara M, Ochi Y, Takahashi Y, Iwata K, Oura K, Sakurada K, Takahashi T. Association between hospital-acquired functional decline and 2-year readmission or mortality after cardiac surgery in older patients: a multicenter, prospective cohort study. Aging Clin Exp Res 2023; 35:649-657. [PMID: 36629994 DOI: 10.1007/s40520-022-02335-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 12/20/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Hospital-acquired functional decline (HAFD) is a new predictor of poor prognosis in hospitalized older patients. AIMS We aimed to assess the impact of HAFD on the prognosis of older cardiac surgical patients 2 years after discharge. METHODS This multicenter prospective cohort study assessed 293 patients with cardiac disease aged ≥ 65 years who underwent cardiac surgery at 7 Japanese hospitals between June 2017 and June 2018. The primary endpoint was the composite outcome of cardiovascular-related readmission and all-cause mortality 2 years after discharge. HAFD was assessed using the total Short Physical Performance Battery at hospital discharge. RESULTS The primary outcome was observed in 17.3% of the 254 included patients, and HAFD was significantly associated with the primary outcome. Female sex (hazard ratio [HR], 2.451; 95% confidence interval [CI] 1.232-4.878; P = 0.011), hemoglobin level (HR, 0.839; 95% CI 0.705-0.997; P = 0.046), preoperative frailty (HR, 2.391; 95% CI 1.029-5.556; P = 0.043), and HAFD (HR, 2.589; 95% CI 1.122-5.976; P = 0.026) were independently associated with the primary outcome. The incidence rate of HAFD was 22%, with female sex (odds ratio [OR], 1.912; 95% CI 1.049-3.485; P = 0.034), chronic obstructive pulmonary disease (OR, 3.958; 95% CI 1.413-11.086; P = 0.009), and the time interval (days) between surgery and the start of ambulation (OR, 1.260, 95% CI 1.057-1.502; P = 0.010) identified as significant factors. DISCUSSION HAFD was found to be an independent prognostic determinant of the primary outcome 2 years after discharge. CONCLUSION HAFD prevention should be prioritized in the hospital care of older cardiac surgery patients.
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Affiliation(s)
- Tomoyuki Morisawa
- Faculty of Health Science, Juntendo University, Tokyo, Japan. .,Department of Physical Therapy, Juntendo University, 3-2-12 Hongo, Bunkyo-Ku, Ochanomizu Center Building 5F, Tokyo, 113-0033, Japan.
| | - Masakazu Saitoh
- Faculty of Health Science, Juntendo University, Tokyo, Japan
| | - Shota Otsuka
- Department of Rehabilitation, Nozomi Heart Clinic, Osaka, Japan
| | - Go Takamura
- Department of Rehabilitation, Tsuchiya General Hospital, Hiroshima, Japan
| | - Masayuki Tahara
- Department of Physical Therapy, Higashi Takarazuka Satoh Hospital, Hyogo, Japan
| | - Yusuke Ochi
- Department of Rehabilitation, Fukuyama Cardiovascular Hospital, Hiroshima, Japan
| | - Yo Takahashi
- Department of Rehabilitation, Yuuai Medical Center, Okinawa, Japan
| | - Kentaro Iwata
- Department of Rehabilitation, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Keisuke Oura
- Department of Rehabilitation, Nozomi Heart Clinic, Osaka, Japan
| | - Koji Sakurada
- Department of Rehabilitation, The Cardiovascular Institute, Tokyo, Japan
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4
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Dankert A, Dohrmann T, Löser B, Zapf A, Zöllner C, Petzoldt M. Pulmonary Function Tests for the Prediction of Postoperative Pulmonary Complications. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:99-106. [PMID: 34939921 PMCID: PMC9131183 DOI: 10.3238/arztebl.m2022.0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 08/12/2021] [Accepted: 11/29/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pulmonary function tests (PFTs) such as spirometry and blood gas analysis have been claimed to improve preoperative risk assessment. This systematic review summarizes the available scientific literature regarding the ability of PFTs to predict postoperative pulmonary complications (PPC) in non-thoracic surgery. METHODS We systematically searched MEDLINE, CINAHL, and the Cochrane Library for pertinent original research articles (PROSPERO CRD42020215502), framed by the PIT-criteria (PIT, participants, index test, target conditions), respecting the PRISMA-DTA recommendations (DTA, diagnostic test accuracy). RESULTS 46 original research studies were identified that used PFT-findings as index tests and PPC as target condition. QUADAS-2 quality assessment revealed a high risk of bias regarding patient selection, blinding, and outcome definitions. Qualitative synthesis of prospective studies revealed inconclusive study findings: 65% argue for and 35% against preoperative spirometry, and 43% argue for blood gas analysis. A (post-hoc) subgroup analysis in prospective studies with low-risk of selection bias identified a possible benefit in upper abdominal surgery (three studies with 959 participants argued for and one study with 60 participants against spirometry). CONCLUSION As the existing literature is inconclusive it is currently unknown if PFTs improve risk assessment before non-thoracic surgery. Spirometry should be considered in individuals with key indicators for chronic obstructive pulmonary disease (COPD) scheduling for upper abdominal surgery.
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Affiliation(s)
- André Dankert
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf
| | - Thorsten Dohrmann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf
| | - Benjamin Löser
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medicine Rostock
| | - Antonia Zapf
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf
| | - Christian Zöllner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf
| | - Martin Petzoldt
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf
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Hospital-Acquired Functional Decline and Clinical Outcomes in Older Cardiac Surgical Patients: A Multicenter Prospective Cohort Study. J Clin Med 2022; 11:jcm11030640. [PMID: 35160093 PMCID: PMC8836607 DOI: 10.3390/jcm11030640] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 02/04/2023] Open
Abstract
This study aimed to determine the effect of hospital-acquired functional decline (HAFD) on prognosis, 1-year post-hospital discharge, of older patients who had undergone cardiac surgery in seven Japanese hospitals between June 2017 and June 2018. This multicenter prospective cohort study involved 247 patients with cardiac disease aged ≥65 years. HAFD was defined as a decrease in the short physical performance battery at hospital discharge compared with before surgery. Primary outcomes included a composite outcome of frailty severity, total mortality, and cardiovascular readmission 1-year post-hospital discharge. Secondary outcomes were changes in the total score and sub-item scores in the Ki-hon Checklist (KCL), assessed pre- and 1-year postoperatively. Poor prognostic outcomes were observed in 33% of patients, and multivariate analysis identified HAFD (odds ratio [OR] 3.43, 95% confidence interval [CI] 1.75–6.72, p < 0.001) and low preoperative gait speed (OR 2.47, 95% CI 1.18–5.17, p = 0.016) as independent predictors of poor prognosis. Patients with HAFD had significantly worse total KCL scores and subscale scores for instrumental activities of daily living, mobility, oral function, and depression at 1-year post-hospital discharge. HAFD is a powerful predictor of prognosis in older patients who have undergone cardiac surgery.
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6
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Risom EC, Buggeskov KB, Petersen RH, Mortensen J, Ravn HB. Influence of reduced diffusing capacity and FEV 1 on outcome after cardiac surgery. Acta Anaesthesiol Scand 2021; 65:1221-1228. [PMID: 34089538 DOI: 10.1111/aas.13935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Impaired lung function is a well-known risk factor in cardiac surgery patients and reduced forced expiratory volume in 1 second (FEV1 ) is associated with increased mortality. However, there is limited knowledge regarding the influence of impaired diffusing capacity of the lungs for carbon monoxide (DLCO) in unselected cardiac surgery patients. The aim of this study was to investigate the association of impaired DLCO and/or reduced FEV1 on post-operative mortality and morbidity in cardiac surgery patients. METHODS In a prospective cohort study, 390 patients scheduled for elective cardiac surgery underwent preoperative lung function test including spirometry and DLCO measurements. We defined reduced FEV1 as FEV1 below lower limit of normal (LLN) and impaired DLCO as DLCO <60% of predicted. RESULTS Mortality within 1 year (90-570 days) was significantly higher in patients with impaired DLCO (12% vs 3%, P = .010) and with reduced FEV1 (9% vs 3%, P = .028). Mortality was higher in patients with impaired DLCO both in the presence and absence of FEV1 < LLN. In multivariate analysis, only impaired DLCO [OR: 3.3, 95% confidence interval (CI) 1.4-7.5; P = .005] and age (OR: 1.1 per year, 95% CI 1.0-1.2; P = .001) were independent predictors of the combined outcome of mortality and prolonged intensive care unit (ICU) stay. Impaired DLCO was also associated with post-operative respiratory complications. CONCLUSION In patients undergoing elective cardiac surgery, preoperative impaired FEV1 and DLCO were associated with increased mortality and morbidity. In multivariate analysis, only DLCO and age were independent predictors of a combined outcome of mortality and prolonged ICU stay.
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Affiliation(s)
- Emilie C. Risom
- Department of Cardiothoracic Anaesthesiology Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
| | - Katrine B. Buggeskov
- Department of Cardiothoracic Anaesthesiology Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
| | - René H. Petersen
- Department of Cardiothoracic Surgery Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
| | - Jann Mortensen
- Department of Clinical Physiology Nuclear Medicine & PET, Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
| | - Hanne B. Ravn
- Department of Cardiothoracic Anaesthesiology Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
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7
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Hess NR, Seese LM, Hickey GW, Keebler ME, Wang Y, Thoma F, Kilic A. The predictive value of preimplant pulmonary function testing in LVAD patients. J Card Surg 2020; 36:105-110. [PMID: 33124124 DOI: 10.1111/jocs.15180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 09/20/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The predictive value of preoperative pulmonary function testing (PFT) in left ventricular assist device (LVAD) patients remains unknown. This study evaluates the relationship between abnormal PFTs and postimplant outcomes in LVAD patients. METHODS LVAD implants from January 2004 to December 2018 at a single institution were included. Patients were stratified based on the presence of abnormal preoperative PFTs, and the primary outcome was respiratory adverse events (AE). Secondary outcomes included 1-year overall postimplant survival, and complications including bleeding, renal failure, thromboembolism, and device malfunction. RESULTS The total of 333 patients underwent LVAD implant, 46.5% (n = 155) with normal PFTs and 53.5% (n = 178) with abnormal PFTs. Patients with abnormal PFTs were noted to have higher rates of respiratory AEs (25.9% vs. 15.1%, p = .049). In multivariable analysis, the impact of PFTs was most significant when forced expiratory volume in 1 s/forced expiratory volume (FEV1/FVC) ratio was less than 0.5 (hazard ratio [HR] 16.32, 95% confidence interval [CI], 1.70-156.78). The rates of other AEs including bleeding, renal failure, right heart failure, and device malfunction were similar. One-year overall postimplant survival was comparable between the groups (56.8% vs. 68.8%, p = .3183), though patients in the lowest strata of FEV1 (<60% predicted) and FEV1/FVC (<0.5) had elevated risk-adjusted hazards for mortality (HR 2.63, 95% CI, 1.51-4.60 and HR 18.92, 95% CI, 2.10-170.40, respectively). CONCLUSIONS The presence of abnormal preoperative PFTs is not prohibitory for LVAD implantation although it can be used for risk stratification for respiratory AEs and mortality, particularly in patients with severely reduced metrics. The importance of careful patient selection should be underscored in this higher risk patient subset.
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Affiliation(s)
- Nicholas R Hess
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Laura M Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gavin W Hickey
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mary E Keebler
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd Thoma
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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8
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Alam M, Shehzad MI, Hussain S, Paras I, Kanwal M, Mushtaq A. Spirometry Assessment and Correlation With Postoperative Pulmonary Complications in Cardiac Surgery Patients. Cureus 2020; 12:e11105. [PMID: 33240701 PMCID: PMC7682508 DOI: 10.7759/cureus.11105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To observe spirometry and its correlation with postoperative pulmonary complications in cardiac surgery patients. Study design Prospective observational study Place and duration of the study Chaudhary Pervaiz Elahi Institute of Cardiology (CPEIC) Multan, from January 1, 2017, to June 30, 2020 Methodology Written informed consent was taken from 357 patients. Spirometry was performed in all the patients using the conventional method. Baseline data, including gender, age, body mass index (BMI), living area, smoking history, known lung illness, six-minute walk distance, predicted forced vital capacity (FVC) %, predicted forced expiratory volume in one second (FEV1) %, and type of the procedure such as aortic valve replacement (AVR), coronary artery bypass grafting (CABG), double-valve replacement (DVR), and mitral valve replacement (MVR) were documented for all the patients. Outcome data included postoperative ICU length of stay (LOS), respiratory failure, respiratory infection, atelectasis, and mortality. Results The most common procedure was CABG and MVR proceeded by n=254 (71.1%) and n=83 (23.2%) patients, respectively. Postoperative complications, such as respiratory failure, respiratory infection, and atelectasis, was noted in n=29 (8.1%), n=28 (7.8 %), and n=127 (35.6 %) patients, respectively, while n=5 (1.4%) patients died. Conclusion Deranged pulmonary function tests (PFTs) are associated with poor prognosis following elective cardiac surgery in terms of postoperative pulmonary complications such as pulmonary infection, respiratory failure, and atelectasis. There is a significant difference in percentage predicted of FVC and FEV1 in patients who developed atelectasis and respiratory tract infection.
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Affiliation(s)
- Masood Alam
- Pulmonology, Chaudhary Pervaiz Elahi Institute of Cardiology, Multan, PAK
| | | | - Shafqat Hussain
- Cardiac Surgery, Chaudhary Pervaiz Elahi Institute of Cardiology, Multan, PAK
| | - Iftikhar Paras
- Cardiac Surgery, Chaudhary Pervaiz Elahi Institute of Cardiology, Multan, PAK
| | - Masooma Kanwal
- Physical Therapy, Choudhary Pervez Elahi Institute of Cardiology, Multan, PAK
| | - Azam Mushtaq
- Pulmonology, Quaid-e-Azam Medical College, Bahawalpur, PAK
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9
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Hiromoto A, Maeda M, Murata T, Shirakawa M, Okamoto J, Maruyama Y, Imura H. Early extubation in current valve surgery requiring long cardiopulmonary bypass: Benefits and predictive value of preoperative spirometry. Heart Lung 2020; 49:709-715. [PMID: 32861890 DOI: 10.1016/j.hrtlng.2020.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 06/11/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Atsushi Hiromoto
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, 1-396, Kosugi-cho Nakahara-ku, Kawasaki, Kanagawa, 211-8533 Japan.
| | - Motohiro Maeda
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, 1-396, Kosugi-cho Nakahara-ku, Kawasaki, Kanagawa, 211-8533 Japan.
| | - Tomohiro Murata
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, 1-396, Kosugi-cho Nakahara-ku, Kawasaki, Kanagawa, 211-8533 Japan.
| | - Makoto Shirakawa
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, 1-396, Kosugi-cho Nakahara-ku, Kawasaki, Kanagawa, 211-8533 Japan.
| | - Junichi Okamoto
- Department of Thoracic Surgery, Nippon Medical School Musashikosugi Hospital, 1-396, Kosugi-cho Nakahara-ku, Kawasaki, Kanagawa, 211-8533 Japan.
| | - Yuji Maruyama
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, 1-396, Kosugi-cho Nakahara-ku, Kawasaki, Kanagawa, 211-8533 Japan.
| | - Hajime Imura
- Department of Cardiovascular Surgery, Tokyo Heart Center Osaki Hospital 5-4-12, Kitashinagawa Shinagawa-ku, Tokyo 141-0001 Japan.
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10
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Szylińska A, Rotter I, Listewnik M, Lechowicz K, Brykczyński M, Dzidek S, Żukowski M, Kotfis K. Postoperative Delirium in Patients with Chronic Obstructive Pulmonary Disease after Coronary Artery Bypass Grafting. MEDICINA-LITHUANIA 2020; 56:medicina56070342. [PMID: 32660083 PMCID: PMC7404780 DOI: 10.3390/medicina56070342] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/06/2020] [Accepted: 07/06/2020] [Indexed: 11/16/2022]
Abstract
Background and Objectives: The incidence of postoperative delirium (POD) in patients with chronic obstructive pulmonary disease (COPD) is unclear. It seems that postoperative respiratory problems that may occur in COPD patients, including prolonged mechanical ventilation or respiratory-tract infections, may contribute to the development of delirium. The aim of the study was to identify a relationship between COPD and the occurrence of delirium after cardiac surgery and the impact of these combined disorders on postoperative mortality. Materials and Methods: We performed an analysis of data collected from 4151 patients undergoing isolated coronary artery bypass grafting (CABG) in a tertiary cardiac-surgery center between 2012 and 2018. We included patients with a clinical diagnosis of COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. The primary endpoint was postoperative delirium; Confusion Assessment Method in the Intensive Care Unit (CAM-ICU) was used for delirium assessment. Results: Final analysis included 283 patients with COPD, out of which 65 (22.97%) were diagnosed with POD. Delirious COPD patients had longer intubation time (p = 0.007), more often required reintubation (p = 0.019), had significantly higher levels of C-reactive protein (CRP) three days after surgery (p = 0.009) and were more often diagnosed with pneumonia (p < 0.001). The CRP rise on day three correlated positively with the occurrence of postoperative pneumonia (r = 0.335, p = 0.005). The probability of survival after CABG was significantly lower in COPD patients with delirium (p < 0.001). Conclusions: The results of this study confirmed the relationship between chronic obstructive pulmonary disease and the incidence of delirium after cardiac surgery. The probability of survival in COPD patients undergoing CABG who developed postoperative delirium was significantly decreased.
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Affiliation(s)
- Aleksandra Szylińska
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University in Szczecin, Żołnierska 48, 71-210 Szczecin, Poland; (A.S.); (I.R.)
| | - Iwona Rotter
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University in Szczecin, Żołnierska 48, 71-210 Szczecin, Poland; (A.S.); (I.R.)
| | - Mariusz Listewnik
- Department of Cardiac Surgery, Pomeranian Medical University in Szczecin, al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (M.L.); (M.B.)
| | - Kacper Lechowicz
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (K.L.); (M.Ż.)
| | - Mirosław Brykczyński
- Department of Cardiac Surgery, Pomeranian Medical University in Szczecin, al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (M.L.); (M.B.)
| | - Sylwia Dzidek
- Student Science Club at the Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, 70-111 Szczecin, Poland;
| | - Maciej Żukowski
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (K.L.); (M.Ż.)
| | - Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (K.L.); (M.Ż.)
- Correspondence: ; Tel.: +48-91-466-1144
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11
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Sankar A, Thorpe KE, Gershon AS, Granton JT, Wijeysundera DN. Association of preoperative spirometry with cardiopulmonary fitness and postoperative outcomes in surgical patients: A multicentre prospective cohort study. EClinicalMedicine 2020; 23:100396. [PMID: 32529180 PMCID: PMC7280772 DOI: 10.1016/j.eclinm.2020.100396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Preoperative spirometry and cardiopulmonary exercise testing (CPET) may stratify risk for respiratory complications. This secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) study examined whether CPET performance (i.e., cardiopulmonary fitness) confounds associations of spirometry with outcomes. METHODS The analysis included 1200 participants having major non-cardiac surgery at 25 hospitals in Canada, Australia, New Zealand and UK. Forced expiratory volume in 1 s (FEV1), and ratio of FEV1 to forced vital capacity (FVC) were measured during preoperative spirometry, and peak oxygen consumption and ventilatory efficiency during preoperative CPET. Outcomes were respiratory morbidity (Postoperative Morbidity Survey) and pulmonary complications (pneumonia or respiratory failure). We used multivariable logistic regression models to estimate associations of FEV1 with outcomes after adjustment for risk factors and either peak oxygen consumption or ventilatory efficiency. FINDINGS 128 participants (11%) developed respiratory morbidity, and 48 (4%) developed pulmonary complications. There was no strong evidence that FEV1 predicted respiratory morbidity after adjustment for peak oxygen consumption (p = 0·80) or ventilatory efficiency (p = 0·76), or FEV1 predicted pulmonary complications after adjustment for ventilatory efficiency (p = 0·37). Peak oxygen consumption (odds ratio 0·66 per 5 mL/kg/min increase; 95% CI, 0·54-0·82) was associated with respiratory morbidity. Ventilatory efficiency was associated with respiratory morbidity (p = 0·04) and pulmonary complications (p = 0·02). Peak oxygen consumption also confounded the association between FEV1 and respiratory morbidity. INTERPRETATION After accounting for fitness and clinical factors, FEV1 was not strongly predictive of respiratory complications. Prior associations between FEV1 and respiratory morbidity may be explained by confounding by peak oxygen consumption. FUNDING Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.
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Affiliation(s)
- Ashwin Sankar
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Kevin E. Thorpe
- Applied Health Research Centre, St Michael's Hospital, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Andrea S. Gershon
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES Central, Toronto, ON, Canada
| | - John T. Granton
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Duminda N. Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- ICES Central, Toronto, ON, Canada
- Department of Anesthesia, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
- Corresponding author.
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Reddi BAJ, Johnston SD, Bart S, Chan JCY, Finnis M. Abnormal pulmonary function tests are associated with prolonged ventilation and risk of complications following elective cardiac surgery. Anaesth Intensive Care 2019; 47:510-515. [DOI: 10.1177/0310057x19877188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Elective cardiac surgery accounts for a significant proportion of perioperative resource allocation in Australasia. Preoperative pulmonary function testing (PFT) is routinely undertaken in some centres to identify patients who may require prolonged ventilation and intensive care unit (ICU) stay, although there are currently no data supporting this practice. Routine PFT places a burden on respiratory diagnostic laboratories, is inconvenient to patients and may delay surgery. We aimed to identify whether PFT parameters identify patients requiring prolonged mechanical ventilation after elective cardiac surgery. Adult patients admitted to the Royal Adelaide Hospital ICU following elective cardiac surgery between July 2013 and December 2017 were identified retrospectively from the local ICU database. Preoperative PFT and operative and postoperative outcome data were retrieved from local databases, and multivariable logistic regression was undertaken to identify which PFT variables were associated with prolonged mechanical ventilation. PFT data were available for 835/1139 (73%) elective cardiac surgical cases. The best independent predictors of prolonged mechanical ventilation were post-bronchodilator forced vital capacity (FVC) and single-breath diffusing capacity for carbon monoxide (DLCO). Patients with FVC <80% predicted and DLCO <60% predicted had an odds ratio for prolonged postoperative ventilation of 7.5 (95% confidence intervals 3.6–15.6; P < 0.001). The area under the receiver operating characteristic curve derived from this model was 0.68. Abnormal PFT results were associated with prolonged postoperative mechanical ventilation. A PFT-based prediction tool does not accurately predict individual patient outcome but identifies a cohort of patients at higher risk of requiring prolonged ventilation, potentially informing ICU resource allocation and surgical planning.
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Affiliation(s)
- Benjamin AJ Reddi
- Royal Adelaide Hospital, Adelaide, Australia
- University of Adelaide, Adelaide, Australia
| | | | | | | | - Mark Finnis
- Royal Adelaide Hospital, Adelaide, Australia
- University of Adelaide, Adelaide, Australia
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13
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Risom EC, Buggeskov KB, Mogensen UB, Sundskard M, Mortensen J, Ravn HB. Preoperative pulmonary function in all comers for cardiac surgery predicts mortality†. Interact Cardiovasc Thorac Surg 2019; 29:244–251. [PMID: 30879046 DOI: 10.1093/icvts/ivz049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 02/08/2019] [Accepted: 02/13/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Although reduced lung function and chronic obstructive pulmonary disease (COPD) is associated with higher risk of death following cardiac surgery, preoperative spirometry is not performed routinely. The aim of this study was to investigate the relationship between preoperative lung function and postoperative complications in all comers for cardiac surgery irrespective of smoking or COPD history. METHODS Preoperative spirometry was performed in elective adult cardiac surgery patients. Airflow obstruction was defined as the ratio of forced expiratory volume in 1 s (FEV1)/forced vital capacity ratio below the lower limit of normal (LLN) and reduced forced ventilatory capacity defined as FEV1 <LLN. RESULTS A history of COPD was reported by 132 (19%) patients; however, only 74 (56%) had spirometry-verified airflow obstruction. Conversely, 64 (12%) of the 551 patients not reporting a history of COPD had spirometry-verified airflow obstruction. The probability of death was significantly higher in patients with airflow obstruction (8.8% vs 4.5%, P = 0.04) and in patients with a FEV1 <LLN (8.7% vs 3.7%, P = 0.007). In the multivariate analysis were age [hazard ratio (HR) 1.6, 95% confidence interval (CI) 1.0-2.5; P = 0.04], prolonged cardiopulmonary bypass time (HR 1.2, 95% CI 1.02-1.3; P = 0.03), reduced kidney function (HR 2.5, 95% CI 1.2-5.6; P = 0.02) and FEV1 <LLN (HR 2.4, 95% CI 1.1-5.2; P = 0.03) all independently associated with an increased risk of death. CONCLUSIONS Preoperative spirometry reclassified 18% of the patients. A reduced FEV1 independently doubled the risk of death. Inclusion of preoperative spirometry in routine screening of cardiac surgical patients may improve risk prediction and identify high-risk patients. CLINICAL TRIAL REGISTRATION NUMBER NCT01614951 (ClinicalTrials.gov).
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Affiliation(s)
- Emilie C Risom
- Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Katrine B Buggeskov
- Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ulla B Mogensen
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Martin Sundskard
- Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jann Mortensen
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hanne B Ravn
- Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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14
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Akasheh N, Byrne D, Coss P, Conway R, Cournane S, O'Riordan D, Silke B. Lung function and outcomes in emergency medical admissions. Eur J Intern Med 2019; 59:34-38. [PMID: 30243511 DOI: 10.1016/j.ejim.2018.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/03/2018] [Accepted: 09/12/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND We examine the ability of pre-existing measures of Forced Expiratory Volume in 1 s (FEV1), and Diffusion Capacity for Carbon Monoxide (DLCO) to determine the subsequent 30-day mortality outcome following unselected acute medical admission. METHODS Between 2002 and 2017, we studied all emergency medical admissions (106,586 episodes in 54,928 patients) of whom 8071 were classified as respiratory. We employed logisitic multiple variable regression models to evaluate the ability of FEV1 or DLCO to predict the 30-day hospital mortality outcome. RESULTS The 30-day hospital episode mortality outcome demonstrated curvilinear relationships to the underlying FEV1 or DLCO values; adjusted for major outcome predictors, a higher FEV1 - OR 0.85 (95% CI: 0.82, 0.89) or DLCO OR 0.76 (95% CI: 0.73, 0.79) values predicted survival. The range of predicted mortalities was from 3.3% (95% CI: 2.5, 4.0) to 23.5% (95% CI: 20.8, 26.2); the FEV1 (Model1) and DLCO (Model2) outcome prediction was essentially equivalent (Chi2 = 2.9: p = 0.08). CONCLUSION The 30-day mortality outcome was clearly related to the pre-admission FEV1 and DLCO value. The outcome relationship was curvilinear. Either parameter appears a useful tool to explore hospital outcomes. Previously suggested cut-points are likely an artefact and not supported by these data.
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Affiliation(s)
- Nadim Akasheh
- Department of Internal Medicine, St James's Hospital, Dublin 8, Ireland.
| | - Declan Byrne
- Department of Internal Medicine, St James's Hospital, Dublin 8, Ireland
| | - Peter Coss
- Pulmonary Function Laboratory, St James's Hospital, Dublin 8, Ireland
| | - Richard Conway
- Department of Internal Medicine, St James's Hospital, Dublin 8, Ireland
| | - Seán Cournane
- Medical Physics and Bioengineering Department, St James's Hospital, Dublin 8, Ireland
| | - Deirdre O'Riordan
- Department of Internal Medicine, St James's Hospital, Dublin 8, Ireland
| | - Bernard Silke
- Department of Internal Medicine, St James's Hospital, Dublin 8, Ireland
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15
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Tam A, Chen S, Schauer E, Grafe I, Bandi V, Shapiro JR, Steiner RD, Smith PA, Bober MB, Hart T, Cuthbertson D, Krischer J, Mullins M, Byers PH, Sandhaus RA, Durigova M, Glorieux FH, Rauch F, Sutton VR, Lee B, Rush ET, Nagamani SCS. A multicenter study to evaluate pulmonary function in osteogenesis imperfecta. Clin Genet 2018; 94:502-511. [PMID: 30152014 PMCID: PMC6235719 DOI: 10.1111/cge.13440] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 01/04/2023]
Abstract
Pulmonary complications are a significant cause for morbidity and mortality in osteogenesis imperfecta (OI). However, to date, there have been few studies that have systematically evaluated pulmonary function in individuals with OI. We analyzed spirometry measurements, including forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1 ), in a large cohort of individuals with OI (n = 217) enrolled in a multicenter, observational study. We show that individuals with the more severe form of the disease, OI type III, have significantly reduced FVC and FEV1 which do not follow the expected trends of the normal population. We also show that "normalization" of FVC and FEV1 using general population data to generate percent predicted values underestimates the pulmonary involvement in OI. Within each subtype of OI, we used linear mixed models to find potential correlations between FEV1 and FVC with the clinical variables including mobility, bisphosphonate use, and scoliosis. Our results are an important step in understanding the extent of pulmonary involvement in individuals with OI and for developing pulmonary endpoints for use in the routine patient care as well as in the investigation of new therapies.
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Affiliation(s)
- Allison Tam
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Shan Chen
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Evan Schauer
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Ingo Grafe
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Venkata Bandi
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jay R Shapiro
- Department of Bone and Osteogenesis Imperfecta, Kennedy Krieger Institute, Baltimore, MD, USA
- Department of Medicine at Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Robert D Steiner
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Oregon Health & Science University, and Shriners Hospital for Children, Portland, OR USA
| | | | - Michael B Bober
- Division of Medical Genetics, Alfred I du Pont Hospital for Children, Wilmington, DE, USA
| | - Tracy Hart
- Osteogenesis Imperfecta Foundation, Gaithersburg, MD, USA
| | | | - Jeff Krischer
- College of Medicine, University of South Florida, Tampa, FL, USA
| | - Mary Mullins
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Peter H Byers
- Departments of Medicine and Pathology, Division of Medical Genetics, University of Washington, Seattle, WA, USA
| | | | | | | | - Frank Rauch
- Shriner’s Hospital for Children and McGill University, Montreal
| | - V Reid Sutton
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Brendan Lee
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | | | - Eric T Rush
- Children’s Mercy Hospital, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Sandesh CS Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
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16
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Szylińska A, Listewnik M, Rotter I, Rył A, Kotfis K, Mokrzycki K, Kuligowska E, Walerowicz P, Brykczyński M. The Efficacy of Inpatient vs. Home-Based Physiotherapy Following Coronary Artery Bypass Grafting. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E2572. [PMID: 30453599 PMCID: PMC6266912 DOI: 10.3390/ijerph15112572] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 11/08/2018] [Accepted: 11/11/2018] [Indexed: 11/16/2022]
Abstract
Background: Intensive post-operative physiotherapy after cardiac surgery helps to reduce the number of complications, accelerating convalescence and decreasing peri-operative mortality. Cardiac rehabilitation is aimed at regaining lost function and sustaining the effect of cardiac surgery. The aim of this study was to compare the efficacy of inpatient and home-based phase II physiotherapy following coronary artery bypass grafting, and inpatient phase II post-operative physiotherapy based on the analysis of the spirometry results. Methods: A prospective observational study included 104 adult patients of both sexes undergoing planned coronary artery bypass grafting and were randomized to one of the two groups-inpatients (InPhysio) and home-based (HomePhysio) at a 1:1 ratio. All patients had undergone spirometry testing prior to surgery (S1) and on the fifth day after the operation (S2), i.e., on the day of completion of the first phase (PI) of physiotherapy. Both the study group (InPhysio) and the control group (HomePhysio) performed the same set of exercises in the second phase (PII) of cardiac physiotherapy, either in the hospital or at home, respectively, according to the program obtained in the hospital. Both groups have undergone spirometry testing (S3) at 30 days after the operation. Results: The demographic and peri-operative data for both groups were comparable and showed no statistically significant differences. An analysis of gradients between the results of spirometry tests before surgery and at 30 days after the surgery showed a smaller decrease in forced vital capacity (FVC) in the study group than in the control group (p < 0.001). The results at five and 30 days after the surgery showed a greater increase in FVC in the study group than in the control group (680 mL vs. 450 mL, p = 0.009). There were no statistically significant differences in other parameters studied. Conclusions: The advantage of inpatient over home-based physiotherapy was evidenced by much smaller decreases in FVC between the initial and final tests, and greater increases between the fifth day after surgery and the final test. Our analysis showed greater efficacy of inpatient physiotherapy as compared with home-based exercises and raises concerns about patient adherence.
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Affiliation(s)
- Aleksandra Szylińska
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University in Szczecin, ul. Żołnierska 54, 70-204 Szczecin, Poland.
| | - Mariusz Listewnik
- Department of Cardiac Surgery, Pomeranian Medical University in Szczecin, al. Powstańców Wlkp. 72, 70-111 Szczecin, Poland.
| | - Iwona Rotter
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University in Szczecin, ul. Żołnierska 54, 70-204 Szczecin, Poland.
| | - Aleksandra Rył
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University in Szczecin, ul. Żołnierska 54, 70-204 Szczecin, Poland.
| | - Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, al. Powstańców Wlkp. 72, 70-111 Szczecin, Poland.
| | - Krzysztof Mokrzycki
- Department of Cardiac Surgery, Pomeranian Medical University in Szczecin, al. Powstańców Wlkp. 72, 70-111 Szczecin, Poland.
| | - Ewelina Kuligowska
- Department of Cardiac Surgery, Pomeranian Medical University in Szczecin, al. Powstańców Wlkp. 72, 70-111 Szczecin, Poland.
| | - Paweł Walerowicz
- Department of Cardiac Surgery, Pomeranian Medical University in Szczecin, al. Powstańców Wlkp. 72, 70-111 Szczecin, Poland.
| | - Mirosław Brykczyński
- Department of Cardiac Surgery, Pomeranian Medical University in Szczecin, al. Powstańców Wlkp. 72, 70-111 Szczecin, Poland.
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17
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Ponomarev D, Kamenskaya O, Klinkova A, Loginova I, Vedernikov P, Kornilov I, Shmyrev V, Lomivorotov V, Chernavskiy A, Karaskov A. Chronic Lung Disease and Mortality after Cardiac Surgery: A Prospective Cohort Study. J Cardiothorac Vasc Anesth 2018; 32:2241-2245. [DOI: 10.1053/j.jvca.2017.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Indexed: 11/11/2022]
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18
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Zochios V, Collier T, Blaudszun G, Butchart A, Earwaker M, Jones N, Klein AA. The effect of high-flow nasal oxygen on hospital length of stay in cardiac surgical patients at high risk for respiratory complications: a randomised controlled trial. Anaesthesia 2018; 73:1478-1488. [PMID: 30019747 PMCID: PMC6282568 DOI: 10.1111/anae.14345] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2018] [Indexed: 01/27/2023]
Abstract
There has been increased interest in the prophylactic and therapeutic use of high‐flow nasal oxygen in patients with, or at risk of, non‐hypercapnic respiratory failure. There are no randomised trials examining the efficacy of high‐flow nasal oxygen in high‐risk cardiac surgical patients. We sought to determine whether routine administration of high‐flow nasal oxygen, compared with standard oxygen therapy, leads to reduced hospital length of stay after cardiac surgery in patients with pre‐existing respiratory disease at high risk for postoperative pulmonary complications. Adult patients with pre‐existing respiratory disease undergoing elective cardiac surgery were randomly allocated to receive high‐flow nasal oxygen (n = 51) or standard oxygen therapy (n = 49). The primary outcome was hospital length of stay and all analyses were carried out on an intention‐to‐treat basis. Median (IQR [range]) hospital length of stay was 7 (6–9 [4–30]) days in the high‐flow nasal oxygen group and 9 (7–16 [4–120]) days in the standard oxygen group (p=0.012). Geometric mean hospital length of stay was 29% lower in the high‐flow nasal group (95%CI 11–44%, p = 0.004). High‐flow nasal oxygen was also associated with fewer intensive care unit re‐admissions (1/49 vs. 7/45; p = 0.026). When compared with standard care, prophylactic postoperative high‐flow nasal oxygen reduced hospital length of stay and intensive care unit re‐admission. This is the first randomised controlled trial examining the effect of prophylactic high‐flow nasal oxygen use on patient‐centred outcomes in cardiac surgical patients at high risk for postoperative respiratory complications.
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Affiliation(s)
- V Zochios
- Department of Intensive Care Medicine, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, University of Birmingham, UK
| | - T Collier
- Medical Statistics Department, London School of Hygiene and Tropical Medicine, London, UK
| | - G Blaudszun
- Department of Anaesthesia, Pharmacology and Intensive Care Medicine, Geneva University Hospitals, Genève, Switzerland
| | - A Butchart
- Department of Cardiothoracic Anaesthesia and Intensive Care Medicine, Royal Papworth Hospital National Health Service Foundation Trust, Cambridge, UK
| | - M Earwaker
- Research and Development Department, Royal Papworth Hospital National Health Service Foundation Trust, Cambridge, UK
| | - N Jones
- Department of Cardiothoracic Anaesthesia and Intensive Care Medicine, Royal Papworth Hospital National Health Service Foundation Trust, Cambridge, UK.,Department of Anaesthesia and Intensive Care, Royal Papworth Hospital National Health Service Foundation Trust, Cambridge, UK
| | - A A Klein
- Department of Cardiothoracic Anaesthesia and Intensive Care Medicine, Royal Papworth Hospital National Health Service Foundation Trust, Cambridge, UK.,Department of Anaesthesia and Intensive Care, Royal Papworth Hospital National Health Service Foundation Trust, Cambridge, UK
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19
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Szylińska A, Listewnik M, Ciosek Ż, Ptak M, Mikołajczyk A, Pawlukowska W, Rotter I. The Relationship between Diabetes Mellitus and Respiratory Function in Patients Eligible for Coronary Artery Bypass Grafting. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15050907. [PMID: 29751547 PMCID: PMC5981946 DOI: 10.3390/ijerph15050907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/27/2018] [Accepted: 04/30/2018] [Indexed: 01/22/2023]
Abstract
Introduction: Spirometry performed prior to surgery provides information on the types of lung disorders in patients. The purpose of this study was to look for a relationship between the prevalence of diabetes and spirometry parameters. Material and Methods: The study was conducted in patients with coronary artery disease who were eligible for an isolated coronary artery bypass graft in 2013. The study group included 367 patients (287 men and 80 women) aged 68.7 ± 8.4 years. They were divided into those with diagnosed diabetes (group I, n = 138, 37.6%) and without diabetes (group II, n = 229, 62.4%). Spirometry tests were performed on the day of admission to the hospital. Results: Patients with diabetes (group I) had a significantly higher body mass index than those without diabetes (group II). Spirometry tests also showed that patients with diabetes had statistically significantly lower forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1.0). Both FVC and FEV1.0 were also statistically significantly lower for overweight and obese individuals in group I than those in group II. Conclusion: Patients with diabetes eligible for coronary artery bypass grafting with concurrent overweight or obesity are more likely to have lower spirometry parameters than those without diabetes.
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Affiliation(s)
- Aleksandra Szylińska
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, 70-210 Szczecin, Poland.
| | - Mariusz Listewnik
- Department of Cardiac Surgery, Pomeranian Medical University, 70-111 Szczecin, Poland.
| | - Żaneta Ciosek
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, 70-210 Szczecin, Poland.
| | - Magdalena Ptak
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, 70-210 Szczecin, Poland.
| | - Anna Mikołajczyk
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, 70-210 Szczecin, Poland.
| | - Wioletta Pawlukowska
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, 70-210 Szczecin, Poland.
| | - Iwona Rotter
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, 70-210 Szczecin, Poland.
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20
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Ponomarev D, Kamenskaya O, Klinkova A, Loginova I, Vedernikov P, Kornilov I, Shmyrev V, Lomivorotov V, Chernavskiy A, Karaskov A. Response: "Outcomes of Patients With COPD Undergoing Cardiac Surgery: Don't Hold Your Breath". J Cardiothorac Vasc Anesth 2018; 32:e1-e2. [PMID: 29673762 DOI: 10.1053/j.jvca.2018.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Dmitry Ponomarev
- Department of Anesthesia and Intensive Care, Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | - Oksana Kamenskaya
- Department of Physiology, Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | - Asya Klinkova
- Department of Physiology, Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | - Irina Loginova
- Department of Physiology, Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | - Pavel Vedernikov
- Department of Anesthesia and Intensive Care, Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | - Igor Kornilov
- Department of Anesthesia and Intensive Care, Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | - Vladimir Shmyrev
- Department of Anesthesia and Intensive Care, Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | - Vladimir Lomivorotov
- Department of Anesthesia and Intensive Care, Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | - Aleksander Chernavskiy
- Department of Cardiac Surgery, Meshalkin National Medical Research Centre, Novosibirsk, Russia
| | - Aleksander Karaskov
- Department of Cardiac Surgery, Meshalkin National Medical Research Centre, Novosibirsk, Russia
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Parhar K, Zochios V. Outcomes of Patients With COPD Undergoing Cardiac Surgery: Don't Hold Your Breath. J Cardiothorac Vasc Anesth 2018. [PMID: 29530398 DOI: 10.1053/j.jvca.2018.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Ken Parhar
- Department of Critical Care Medicine, University of Calgary, Calgary, Canada
| | - Vasileios Zochios
- Department of Critical Care Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham, National Health Service Foundation Trust, Edgbaston, Birmingham, United Kingdom; Perioperative Acute and Critical Care and Translational Research Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, United Kingdom
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Szylińska A, Listewnik MJ, Rotter I, Rył A, Biskupski A, Brykczyński M. Analysis of the influence of respiratory disorders observed in preoperative spirometry on the dynamics of early inflammatory response in patients undergoing isolated coronary artery bypass grafting. Clin Interv Aging 2017; 12:1123-1129. [PMID: 28769557 PMCID: PMC5529085 DOI: 10.2147/cia.s138862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Preoperative spirometry provides measurable information about the occurrence of respiratory disorders. The aim of this study was to assess the association between preoperative spirometry abnormalities and the intensification of early inflammatory responses in patients following coronary artery bypass graft in extracorporeal circulation. Material and methods The study involved 810 patients (625 men and 185 women) aged 65.4±7.9 years who were awaiting isolated coronary artery bypass surgery. On the basis of spirometry performed on the day of admittance to the hospital, the patients were divided into three groups. Patients without respiratory problems constituted 78.8% of the entire group. Restricted breathing was revealed by spirometry in 14.9% and obstructive breathing in 6.3% of patients. Results Inter-group analysis showed statistically significant differences in C-reactive protein (CRP) between patients with restrictive spirometry abnormalities and patients without any pulmonary dysfunction. CRP concentrations differed before surgery (P=0.006) and on the second (P<0.001), fourth (P=0.005) and sixth days after surgery (P=0.029). There was a negative correlation between CRP levels and FEV1. Conclusion In our study, the most common pulmonary disorders in the coronary artery bypass graft patients were restrictive. Patients with abnormal spirometry results from restrictive respiratory disorders have an elevated level of generalized inflammatory response both before and after the isolated coronary artery bypass surgery. Therefore, this group of patients should be given special postoperative monitoring and, in particular, intensive respiratory rehabilitation immediately after reconstitution.
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Affiliation(s)
| | | | | | - Aleksandra Rył
- Department of Histology and Developmental Biology, Pomeranian Medical University, Szczecin, Poland
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Ponomarev D, Kamenskaya O, Klinkova A, Loginova I, Lomivorotov V, Kornilov I, Shmyrev V, Chernavskiy A, Landoni G, Karaskov A. Prevalence and Implications of Abnormal Respiratory Patterns in Cardiac Surgery: A Prospective Cohort Study. J Cardiothorac Vasc Anesth 2016; 31:2010-2016. [PMID: 28242146 DOI: 10.1053/j.jvca.2016.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the prevalence and impact of abnormal respiratory patterns in cardiac surgery patients. DESIGN Prospective cohort study. SETTING Tertiary hospital. PARTICIPANTS Patients scheduled for elective coronary artery bypass graft surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pulmonary function tests were performed in 454 patients before surgery. Abnormal respiratory patterns were defined as follows: obstructive (forced expiratory volume in 1 s [FEV1]/forced vital capacity [FVC]<0.70), restrictive (FEV1/FVC≥0.70 and FVC<80% of predicted), and mixed (FEV1/FVC<0.70 and both FEV1 and FVC<80% of predicted). Of the 31 patients with a history of chronic obstructive pulmonary disease, no abnormal respiratory pattern was confirmed in 5. Of the 423 patients without a history of lung disease, the authors newly identified 57 obstructive, 46 restrictive, and 4 mixed patterns. Therefore, lung disease was reclassified in 24.7% of cases. Independent predictors of obstructive pattern were age, male sex, history of smoking, and chronic obstructive pulmonary disease. Obstructive lung disease was associated with 16 hours or longer ventilation. A reduced FEV1 was associated with a likelihood of atrial fibrillation (1-L decrement, odds ratio: 1.38, 95% confidence interval: 1.01-to-1.90, p = 0.04) and hospitalization time (regression coefficient: 1.23, 95% confidence interval: 0.54-to-1.91, p<0.001). CONCLUSIONS Abnormal respiratory patterns are common and often underdiagnosed in the cardiac surgery setting. Pulmonary function tests help reveal patients at risk of complications and may provide an opportunity for intervention.
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Affiliation(s)
- Dmitry Ponomarev
- Department of Anesthesia and Intensive Care, Academician EN Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Novosibirsk, Russia.
| | - Oksana Kamenskaya
- Department of Physiology, Academician EN Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Asya Klinkova
- Department of Physiology, Academician EN Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Irina Loginova
- Department of Physiology, Academician EN Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Vladimir Lomivorotov
- Department of Anesthesia and Intensive Care, Academician EN Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Igor Kornilov
- Department of Anesthesia and Intensive Care, Academician EN Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Vladimir Shmyrev
- Department of Anesthesia and Intensive Care, Academician EN Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Aleksander Chernavskiy
- Department of Cardiac Surgery, Academician EN Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Aleksander Karaskov
- Department of Cardiac Surgery, Academician EN Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Novosibirsk, Russia
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Ivanov A, Yossef J, Tailon J, Worku BM, Gulkarov I, Tortolani AJ, Sacchi TJ, Briggs WM, Brener SJ, Weingarten JA, Heitner JF. Do pulmonary function tests improve risk stratification before cardiothoracic surgery? J Thorac Cardiovasc Surg 2016; 151:1183-9.e3. [DOI: 10.1016/j.jtcvs.2015.10.102] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 10/15/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
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Silvay G, Zafirova Z. Ten Years Experiences With Preoperative Evaluation Clinic for Day Admission Cardiac and Major Vascular Surgical Patients: Model for "Perioperative Anesthesia and Surgical Home". Semin Cardiothorac Vasc Anesth 2015; 20:120-32. [PMID: 26620138 DOI: 10.1177/1089253215619236] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Admission on the day of surgery for elective cardiac and noncardiac surgery is the prevalent practice in North America and Canada. This approach realizes medical, psychological and logistical benefits, and its success is predicated on an effective outpatient preoperative evaluation. The establishment of a highly functional preoperative clinic with a comprehensive set up and efficient logistical pathways is invaluable. This notion in recent years has included the entire perioperative period, and the concept of a perioperative anesthesia/surgical home (PASH) is gaining popularity. The anesthesiologists as perioperative physicians can organize and lead the entire process from the preoperative evaluation, through the hosptial discharge. The functions of the PASH include preoperative optimization of medical conditions and psychological preparation of the patients and their support system; the care in the operating room and intensive care unit; pain management; respiratory therapy; cardiac rehabilitation; and specialized nutrition. Along with oversight of the medical issues, the preoperative visit is an opportune time for counseling, clarification of expectations and discussion of research, as well as for utilization of various informatics systems to consolidate the pertinent information and distribute it to relevant health care providers. We review the scientific foundation and practical applications of a preoperative visit and share our experience with the development of the preoperative evaluation clinic, designed specifically for cardiac and major vascular patients scheduled for day admission surgery. The ultimate goal of preoperative evaluation clinic is to ensure a safe, efficient, and cost-effective perioperative care for patients undergoing a complex type of surgery.
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Affiliation(s)
- George Silvay
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Shih T, Paone G, Theurer PF, McDonald D, Shahian DM, Prager RL. The Society of Thoracic Surgeons Adult Cardiac Surgery Database Version 2.73: More Is Better. Ann Thorac Surg 2015; 100:516-21. [DOI: 10.1016/j.athoracsur.2015.02.085] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 02/09/2015] [Accepted: 02/18/2015] [Indexed: 01/14/2023]
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The association of chronic lung disease with early mortality and respiratory adverse events after aortic valve replacement. Ann Thorac Surg 2014; 98:2068-77. [PMID: 25443011 DOI: 10.1016/j.athoracsur.2014.06.087] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 05/27/2014] [Accepted: 06/02/2014] [Indexed: 01/23/2023]
Abstract
BACKGROUND We studied the association between components of chronic lung disease (CLD) assessment and operative outcomes in patients undergoing aortic valve replacement (AVR) for aortic stenosis. METHODS From 2011 to 2012, 9,177 patients included in The Society of Thoracic Surgeons (STS) Cardiac Surgery Database underwent AVR for aortic stenosis with complete pulmonary function tests (PFT) and CLD data (31% of AVRs). We evaluated markers of CLD and their association with operative mortality, pulmonary morbidity, and length of hospital stay using multivariable logistic regression analysis. RESULTS In a selected population of AVR patients with PFTs, CLD was prevalent in 50% (mild, 25.6%; moderate, 13.2%; severe, 11.2%). Predicted forced expiratory volume in 1 second (FEV1) was obtained in all patients and diffusion capacity of the lung for carbon monoxide (DLCO), arterial oxygen tension (PaO2), and arterial carbon dioxide tension (PaCO2) in 31%. The STS predicted risk of operative mortality, mortality, pulmonary morbidity, and hospital stay increased with severity of CLD and with low FEV1, DLCO, and PaO2. Moderate and severe CLD were independently associated with operative mortality (odds ratio [OR] 2.88, 95% confidence interval [CI]: 2.0-4.5), pulmonary morbidity (OR 2.33, 95% CI: 1.93-2.8), and prolonged hospital stay (OR 2.73, 95% CI: 2.17-3.45). Low FEV1 was independently associated with pulmonary morbidity and prolonged hospital stay. Low PaO2 and DLCO were independently associated with a combined mortality and pulmonary morbidity endpoint. CONCLUSIONS CLD is associated with adverse operative outcomes in selected patients with aortic stenosis undergoing AVR. FEV1, DLCO, and PaO2 may add important information to current risk adjustment models beyond the broad CLD classification.
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