Effect of local warming for arterial catheterization in adult cardiac surgery: a randomized controlled trial

Background

The increase in internal diameter (ID) and cross-sectional area (CSA) may facilitate better arterial catheterization. Since an increase in body temperature can cause peripheral vasodilation, we aimed to determine if local warming of the radial artery (RA) catheterization site could improve the success rate of catheterization.

Methods

This randomized, controlled study enrolled 160 patients aged >18 years who were scheduled for heart surgery. They were randomized into non-warming palpation (NP), non-warming ultrasonography-guided (NU), warming palpation (WP), and warming ultrasonography-guided (WU) groups. After induction, the baseline RA ultrasonography images were collected. In the warming groups (WP, WU), local warming was applied on the catheterization site. Before catheterization, the RA ultrasonography images were collected. The primary outcome was the first-attempt success rate. The secondary outcomes included the ID and CSA of the RA and overall complications.

Results

Totally 152 adults were included in the analysis. The first-attempt success rates in each of the four groups were not significantly different (P=0.985). The rates in the non-warming (NP + NU) and warming (WP + WU) groups were also not different (P=0.827). Unlike non-warming group, the warming group had increased ID (3.34±0.78 vs. 3.02±0.73 mm; P<0.001) and CSA (6.9±2.8 vs. 5.8±2.4 mm2; P<0.001) compared with baseline.

Conclusions

Local warming for peripheral artery catheterization does not increase the first-attempt success rate in adults undergoing cardiac surgery; however, it can increase the ID and CSA of the RA and prevent vasospasm.

Trial Registration

ClinicalTrials.gov NCT04969692.

Blood Products Utilization Status in Off-Pump Cardiac Surgery Patients

Background: Transfusion support has an essential role in coronary artery bypass graft (CABG). The time-honored gold standard for CABG is the on-pump procedure (ONCAB); however, off-pump coronary artery bypass (OPCAB) is also a safe, cost-benefit procedure with fewer blood transfusion requirements. This study was performed to evaluate transfusion patterns in OPCAB due to the diversity of transfusion practices. Materials and Methods: This retrospective study was performed to determine the transfusion rate and triggers in OPCAB patients. Medical files of all patients undergoing OPCAB surgery at Sanandaj Tohid Hospital in 2014 were reviewed. Patients' demographics data, preoperative laboratory tests (PT, aPTT, Hb, Hct, Platelet count), underlying medical conditions, and their possible relation to further transfusions and the ward department in which the transfusion had taken place were extracted. SPSS 16 Chicago software, T-student Test, One Way Anova, and χ2 exam were applied for data analysis. P values ≤0.05was considered significant. Results: Among 91 elective OPCAB patients: 28(30.8%) women and 63(69.2%) men with mean age of 64.80±9.02 years, 63(69.23%) received a blood product. Mean utilization of PRBC, FFP, Platelet, and Cryoprecipitate were 2.17±2.044, 2.46±2.86, 2.86±3.80 and 0.40±2.10 units, respectively. ICU revealed the highest consumption rate for all products.  Female sex (p<0.001), Hypertension (P=0.002), and low hemoglobin(P=0.004) were noted as predictive factors for transfusion.  Conclusion: This study concluded that the transfusion rate in OPCAB is still very high in Iran (regarding a study in a countryside hospital) and that the highest utilization rate is seen in the ICU.

Acute Effects of Vasopressin Arginine Infusion in Children with Congenital Heart Disease: Higher Blood Pressure Does Not Equal Improved Systemic Oxygen Delivery

The use of vasopressin has been increased in recent years in children after congenital heart surgery. However, there is limited information regarding its effects on cardiac output, systemic oxygen delivery, and myocardial energetics. The purpose of this study is to characterize the effects of vasopressin infusions on hemodynamics and systemic oxygen delivery in children with congenital heart disease. A retrospective, single-center study of patients with congenital heart disease who received vasopressin infusions in a pediatric cardiac intensive care unit between January 2019 and May 2020. The measured values collected for study were systolic and diastolic blood pressure, heart rate, arterial oxygen saturation as determined by pulse oximetry, arterial pH, arterial partial pressure of oxygen, arterial partial pressure of carbon dioxide, serum lactate, serum sodium, and renal and cerebral oximetry based on near-infrared spectroscopy. The calculated values for this study were the difference between arterial and NIRS oximetry, the reno-cerebral near-infrared spectroscopy gradient and the vasoinotrope score. A Wilcoxon signed-rank test was utilized to compare values of paired continuous variables before and after initiation of the vasopressin infusion. Correlations were assessed using Spearman correlation analyses and stepwise regressions were completed. A total of 26 vasopressin infusions among 20 unique patients were included in the final analyses. Of these 26 vasopressin infusions, 18 were in patients with biventricular circulation and 8 were in patients with functionally univentricular circulation. The median vasopressin infusion dose at initiation was 0.4 (0.1-1) milliunits/kg/min. For the entire cohort 2 h after the initiation of vasopressin, systolic blood pressure increased to 8.4 mmHg, p < 0.01, but no significant correlation was found to markers of systemic oxygen delivery. Similar results were obtained when only those with biventricular circulation were considered. Those with functionally univentricular circulation were not found to have any statistically significant rise in blood pressure. Vasopressin infusions appear to statistically significantly increase systolic blood pressure in children with congenital heart disease who have a biventricular but not functionally univentricular circulation. Even when an increase in systolic blood pressure is present, systemic oxygen delivery did not improve.

Cardiac surgery under cardiopulmonary bypass in pregnancy: report of four cases

Background

Open heart surgery during pregnancy is relatively rare at home and abroad, and there is a higher risk and probability of maternal and infant death. How to carry out heart valve replacement under cardiopulmonary bypass (CPB) under the premise of ensuring the safety of mother and child is the focus of attention at home and abroad.

Case introduction

We reported four cases of cardiac surgeries under CPB during pregnancy performed in our hospital from March 2020 to March 2021. Two of the patients continued their pregnancy after cardiac surgery under CPB. Three patients had infective endocarditis and the other one had an ascending aortic aneurysm. Three patients underwent heart valve placement with the mechanical mitral valve when the other one underwent Bentall surgery. The operations of four cases were all successful, and further follow-up evaluation of the pregnant women and fetuses showed no abnormalities. The patients' detailed information is shown in the following table.

Conclusion

Heart disease during pregnancy should be treated actively and proactively when the patient has obvious symptoms. Heart valve replacement under CPB will be the first choice, and this may become the primary surgical treatment for symptomatic heart disease during pregnancy.

The effect of foot reflexology massage on delirium and sleep quality following cardiac surgery: A randomized clinical trial

BACKGROUND

Delirium is the most common neurologic disorder after cardiac surgery and affects both short and long-term outcomes. This study was conducted to evaluate the effect of foot reflexology massage on the incidence of delirium and sleep quality in patients undergoing cardiac surgery.

METHODS

In this randomized clinical trial, 60 patients who were candidates for CABG surgery were randomly assigned into two equal groups (n = 30); intervention and control groups. In the intervention group, foot reflexology massage was done on each foot for 15 min, for two consecutive days. Delirium observation screening scale, the Richard Campbell sleep questionnaire (RSCQ), and pain intensity using VAS were compared.

RESULTS

in the second postoperative day, delirium was observed in 8 (26.7 %) and 7 (23.3 %) of patients in the intervention and control groups, respectively (p > 0.05). The measured odds ratio for the effect of massage on delirium is 0.83 (95 %CI 0.71-2.69, p = 0.76). The difference in RSCQ scores was not significant between groups of intervention and control (68.32 ± 10.41 VS. 62.80 ± 11.86, P = 0.06). The pain intensity was lower in the intervention group (P < 0.001).

CONCLUSION

Foot reflexology was not effective in reducing delirium and improving the sleep quality, but the pain intensity was decreased. It seems that the precise pathology and predicting model of delirium should be identified, and appropriate interventions should be planned accordingly.

Medical Interventions for Chylothorax and their Impacts on Need for Surgical Intervention and Admission Characteristics: A Multicenter, Retrospective Insight

The incidence of chylothorax is reported from 1-9% in pediatric patients undergoing congenital heart surgery. Effective evidenced-based practice is limited for the management of post-operative chylothorax in the pediatric cardiac intensive care unit. The study characterizes the population of pediatric patients with cardiac surgery and chylothorax who eventually require pleurodesis and/or thoracic duct ligation; it also establishes objective data on the impact of various medical interventions. Data were obtained from the Pediatric Health Information System database from 2004-2015. Inclusion criteria for admissions for this study were pediatric admissions, cardiac diagnosis, cardiac surgery, and chylothorax. These data were then divided into two groups: those that did and did not require surgical intervention for chylothorax. Other data points obtained included congenital heart malformation, age, gender, length of stay, billed charges, and inpatient mortality. A total of 3503 pediatric admissions with cardiac surgery and subsequent chylothorax were included. Of these, 236 (9.4%) required surgical intervention for the chylothorax. The following cardiac diagnoses, cardiac surgeries, and comorbidities were associated with increased odds of surgical intervention: d-transposition, arterial switch, mitral valvuloplasty, acute kidney injury, need for dialysis, cardiac arrest, and extracorporeal membrane oxygenation. Statistically significant medical interventions which did have an impact were specific steroids (hydrocortisone, dexamethasone, methylprednisolone) and specific diuretics (furosemide). These were significantly associated with decreased length of stay and costs. Dexamethasone, methylprednisolone, and furosemide were associated with decreased odds for surgical intervention. These analyses offer objective data regarding the effects of interventions for chylothorax in pediatric cardiac surgery admissions. Results from this study seem to indicate that most post-operative chylothoraxes should improve with furosemide, a low-fat diet, and steroids.

Effects of Vasopressin Infusion After Pediatric Cardiac Surgery: A Meta-analysis

Vasopressin has been used to augment blood pressure; however, cardiovascular effects after cardiac surgery have not been well established. The primary objective of this study was to survey the current literature and quantify the pooled effect of vasopressin on hemodynamic parameters in children after pediatric cardiac surgery. A systematic review was conducted to identify studies characterizing the hemodynamic effects of vasopressin after pediatric cardiac surgery. Studies were assessed and those of satisfactory quality with pre- and post-vasopressin hemodynamics for each patient were included in the final analyses. 6 studies with 160 patients were included for endpoints during the first 2 h of infusions. Patients who received vasopressin infusion had greater mean, systolic, and diastolic blood pressures and lower heart rates at 2 h after initiation. 8 studies with 338 patients were included for the effects at 24 h. Patients who received vasopressin infusion had lower central venous pressures and decreased lactate concentrations 24 h after initiation. A subset analysis for children with functionally univentricular hearts found significant decrease in inotrope score and central venous pressure. A subset analysis for neonates found significant decrease in inotrope score and fluid balance. Vasopressin leads to decrease in heart rate and increase in blood pressure in the first 2 h of initiation. Later effects include decrease in inotrope score, central venous pressure, fluid balance, and in lactate within the first 24 h. Findings vary in neonates and in those with functionally univentricular hearts although beneficial effects are noted in both.

Effects of non-invasive ventilation in subjects undergoing cardiac surgery on length of hospital stay and cardiac-pulmonary complications: a systematic review and meta-analysis

Background

Cardiac surgery often leads to pulmonary complications. Non-invasive ventilation (NIV) is a mechanical ventilation modality that may help to prevent the pulmonary complications, and the role of the prophylactic use of NIV in patients after cardiac surgery remains controversial.

Methods

We searched PubMed, Embase, Web of Science and Cochrane Central for randomized controlled trials comparing the use of NIV (continues positive airway pressure or bi-level positive airway pressure) with standard treatment in post-cardiac surgery subjects without language restriction. Two investigators screened the eligible studies up to July, 2019. Meta-analysis using random effect model or fixed effect model was conducted for pulmonary complications, mortality, rate of reintubation and cardiac complications, and mean difference (MD) or standard mean difference for length of hospital stay and length of ICU stay.

Results

We included nine randomized controlled trails with 830 subjects. The use of NIV failed to reduce the risk of pulmonary complications, including atelectasis [risk rate (RR) 0.60; 95% confidence interval (CI): 0.28 to 1.28, P=0.19] and pneumonia (RR 0.27; 95% CI: 0.05 to 1.64, P=0.16). However, it has shortened the length of ICU stay (MD -1.00 h, 95% CI: -1.38 to -0.63, P<0.00001) and the length of hospital stay (MD -1.00 d, 95% CI: -1.12 to -0.87, P<0.00001). NIV also failed to reduce the rate of reintubation (RR 0.68; 95% CI: 0.21 to 2.26, P=0.53) or the risk of cardiac complications (RR 0.81; 95% CI: 0.59 to 1.13, P=0.22).

Conclusions

The prophylactic use of NIV immediately in post-cardiac subjects who underwent cardiac surgery might be able to shorten the length of hospital stay and the length of ICU stay, but it has no significant effect on pulmonary complications, rate of reintubation or cardiac complications.

Immature granulocytes as a sepsis predictor in patients undergoing cardiac surgery

OBJECTIVES

Usefulness of immature granulocyte percentage (IG%) to discriminate between postoperative non-infective systemic inflammatory response syndrome (SIRS) and sepsis was tested in cardiac surgical patients.

METHODS

A retrospective analysis of 124 patients who developed non-infective SIRS and sepsis after elective cardiac surgery was performed. Predictive ability of IG% to predict sepsis was compared to procalcitonin (PCT), white blood cell count, temperature and different biomarker combinations using receiver operating characteristic and logistic regression analysis. The optimal cut-off points, diagnosis sensitivity and specificity were calculated.

RESULTS

There were 44 patients diagnosed with sepsis and 80 patients with non-infective SIRS. In receiver operating characteristic analysis, area under the curve was higher for IG% (0.71) and PCT (0.72) compared to white blood cell count (0.62) and temperature (0.58). The best cut-off value for IG% was 1.45% (sensitivity 70.5%, specificity 60%) and 1.43 µg/l for PCT (sensitivity 65.9%, specificity 75%). The combination of IG% and PCT provided the best sepsis prediction (area under the curve of 0.8, sensitivity 63.6% and specificity 88.8%).

CONCLUSIONS

In cardiac surgical patients, IG% is a helpful marker with the moderate ability to discriminate between sepsis and non-infective SIRS, comparable to serum PCT. A combination of these parameters increased the test's overall predictive ability by improving its specificity.

Thirteen-year experience with universal Staphylococcus aureus nasal decolonization prior to cardiac surgery: a quasi-experimental study

INTRODUCTION

Sternal wound infection (SWI) after cardiac surgery is a severe complication. Among preventive measures, pre-operative decolonization of nasal carriage of Staphylococcus aureus has recently been shown to be beneficial. This quasi-experimental study assessed the effect of decolonization on the incidence of S. aureus-associated SWI based on 19 years of prospective surveillance.

METHODS

Segmented negative binomial regression was used to analyse the change over time in the incidence of S. aureus mediastinitis requiring re-operation after cardiac surgery in a French university hospital between 1996 and 2014. Universal nasal decolonization with mupirocin was introduced in December 2001. The association between pre-operative nasal carriage and SWI due to S. aureus was analysed between 2006 and 2012.

RESULTS

Among 17,261 patients who underwent a cardiac surgical procedure, 565 developed SWI (3.3%), which was caused by S. aureus in 181 cases (1%). The incidence of mediastinitis caused by S. aureus decreased significantly over the study period (1.43% in 1996-2001 vs 0.61% and 0.64% in 2002-2005 and 2006-2014, respectively; P<0.001). In segmented analysis, there was a significant break in 2002, corresponding to the introduction of decolonization. Despite this intervention, pre-operative nasal carriage remained a significant risk factor for S. aureus mediastinitis (adjusted odds ratio 2.2; 95% confidence interval 1.2-4.2), as were obesity, critical pre-operative status, coronary artery bypass grafting (CABG), and combined surgery with valve replacement and CABG.

CONCLUSION

Universal nasal decolonization before cardiac surgery was effective in decreasing the incidence of mediastinitis caused by S. aureus. Nasal carriage of S. aureus remained a risk factor for S. aureus-associated SWI.

Prognostic factors of infective endocarditis in patients on hemodialysis: A case series from a National Multicenter Registry

BACKGROUND

Infective endocarditis (IE) is a severe complication associated with high mortality.

OBJECTIVES

To examine the clinical characteristics of IE in hemodialysis (HD) patients and to determine prognostic factors related to HD.

METHODS

From January 2008 to April 2015, 2488 consecutive patients with definite IE were included. Clinical characteristics of IE patients on HD were compared with those of IE patients who were not on HD.

RESULTS

A total of 126 patients (63% male, median age: 66years; IQR: 54-74years) with IE (5.1%) were on HD. Fifty-two patients died during hospitalization (41%) and 17 additional patients (14%) died during the first year. The rate of patients who underwent surgery during hospitalization was lower in HD patients (38 patients, 30%) than in non-HD patients (1177 patients, 50%; p<0.001). Age >70years (OR: 4.1, 95% CI: 1.7-10), heart failure (OR: 3.3, 95% CI: 1.4-7-6), central nervous system (CNS) vascular events (OR: 6.7, 95% CI: 2.1-22) and septic shock (OR: 4.1, 95% CI: 1.4-12.1) were independently associated with fatal outcome in HD patients. Of the 38 patients who underwent surgery, 15 (39.5%) died during hospitalization.

CONCLUSIONS

HD patients with IE present a high mortality. Advanced age and complications, such as heart failure, CNS stroke or septic shock, are associated with mortality.

High thoracic anesthesia offers no major benefit over general anesthesia in on-pump cardiac surgery patients: a retrospective study

BACKGROUND

Thoracic epidural anesthesia (TEA) has been proposed to improve and facilitate early postoperative outcome in cardiac surgery. The aim of our study was to analyze early postoperative outcome data of patients undergoing cardiac surgery under general anesthesia (GA) with comparison to patients receiving combined TEA and GA.

METHODS

Medical records data from 288 patients who underwent elective on-pump cardiac surgery were retrieved and analyzed. Patients were divided into two study groups according to the type of anesthesia used: GA group (n = 141) and TEA group (n = 147). Early postoperative outcome data including quality of analgesia and major organ outcome parameters were compared between the study groups.

RESULTS

There was no major difference in early postoperative outcome data between the study groups, except for shorter time to extubation (6.0 ± 10.0 vs. 6.9 ± 8.8 h, respectively, P < 0.05) and hospital stay (10.7 ± 5.9 vs. 12.9 ± 8.8 days, respectively, P < 0.05) in TEA group compared to GA group. Also TEA group as compared to GA group had lower pain numeric rating scale scores (1 ± 1.1 vs. 1.4 ± 1.5 at 24 h, respectively, P < 0.05) and morphine requirements during the first 24 h after surgery (148.2 vs. 193 ± 85.4 μg/kg, respectively, P < 0.05).

CONCLUSION

Both anesthetic methods were equivalent in most postoperative outcome measures. Thoracic epidural analgesia provided superior pain relief, shorter time to extubation and earlier hospital discharge.

Comparison of the single-lumen endotracheal tube and double-lumen endobronchial tube used in minimally invasive cardiac surgery for the fast track protocol

BACKGROUND

Minimally invasive cardiac surgery (MICS) has been more commonly performed due to the reduced amount of bleeding and transfusion and length of hospital stay. We investigated the feasibility of performing MICS using single-lumen endotracheal tube (SLT).

METHODS

We conducted a retrospective review of clinical data of 112 patients who underwent MICS between July 2012 and March 2015. The patients underwent MICS using a SLT or a double lumen endotracheal tube (DLT). The duration of intensive care unit (ICU) stay and mechanical ventilation were recorded and analyzed.

RESULTS

Of the 96 patients, 50 were intubated with a SLT and 46 were intubated with a DLT. Anesthetic induction to skin incision time, surgical time and total anesthetic time were significant decreased in the SLT group (P<0.05). However, there was no difference in the duration of ICU stay and mechanical ventilation, and the incidence of extubation in operation room between the two groups.

CONCLUSIONS

Comparing with insertion of a SLT, insertion of a DLT provided equivalent duration of ICU stay and mechanical ventilation after the MICS. Therefore, the type of inserted endotracheal tube would not influence on failure of the fast track protocol and insertion of a SLT is feasible and could be an alternative method to a DLT.

Implantation technique of the 50-cm3 SynCardia Total Artificial Heart: does size make a difference?

Despite downsizing, implantation technique of the 50-cm(3) SynCardia Total Artificial Heart and settings of the Companion driver remain unchanged. Owing to the absence of de-airing nipples, de-airing procedure is even more crucial and has to be performed carefully.

Association between Perioperative Parameters and Cognitive Impairment in Post-Cardiac Surgery Patients

BACKGROUND

Postoperative cognitive dysfunction (POCD) has been an important complication of cardiac surgery over the years. Neurocognitive dysfunction can affect quality of life and lead to social, functional, emotional, and financial problems in the patient's life. To reduce POCD, we sought to identify the association between cognitive dysfunction and perioperative factors in patients undergoing cardiac surgery.

METHODS

One hundred one patients aged between 45 and 75 years undergoing elective cardiac surgery were enrolled in this study. All the surgeries were performed on-pump by the same medical team. A brief Wechsler Memory Test (WMT) was administered before surgery, 3 to 5 days after the surgery, and 3 months after discharge. All related perioperative parameters were collected in order to study the effect of these parameters on the postoperative WMT scores and WMT score change.

RESULTS

The study population consisted of 101 patients, comprising 14 (13.8%) females and 87 (86.2%) males aged between 45 and 75 years. In univariate analysis, the baseline WMT score, serum levels of lactate dehydrogenase and T3, cross-clamp time, and preexistence of chronic obstructive pulmonary disease showed significant effects on the postoperative WMT score (p value < 0.05), whereas only the baseline WMT score and chronic obstructive pulmonary disease showed strong effects on the postoperative WMT score in the multiple regression model. In addition, the multiple regression model demonstrated a significant association between the baseline WMT score, serum creatinine level, and nitrate administration and the WMT score change.

CONCLUSION

Our study showed that preexisting chronic obstructive pulmonary disease and preoperative high serum creatinine levels negatively affected cognitive function after surgery. In addition, there was a strong relationship between the patients' basic cognition and POCD. Preoperative nitrate administration led to a significant improvement in POCD. It is also concluded that the preoperative administration of specific medicines like nitrates can reduce neurological complications after cardiac surgery.

Thirty-three years old modified senning operation

Numerous technical modifications and various complications of the Senning procedure have been described in the literature. We describe the excellent clinical status and anatomic result of a 33-year-old patient who underwent a modified Senning operation using the left atrial appendage for reconstruction more than 30 years prior to presentation.

A pilot study of systolic dyssynchrony index by real-time three-dimensional echocardiography predicting clinical outcomes to surgical ventricular reconstruction in patients with left ventricular aneurysm

OBJECTIVES

The aim of the study was to detect whether the systolic dyssynchrony index (SDI) assessed by real-time 3D echocardiography (RT3DE) could predict clinical outcomes of patients with ventricular aneurysm in response to surgical ventricular reconstruction (SVR).

METHODS

In total, 120 individuals underwent RT3DE, including 30 healthy volunteers and 90 patients with ventricular aneurysm. All patients underwent clinical and echocardiographic assessments at baseline and at 12 months after SVR. The SDI was defined as the SD of time to minimum systolic volume of the 16 left ventricular (LV) segments, expressed in percent RR duration. SVR responder was defined as a >15% decrease in LV end-systolic volume, reduction in NYHA functional class or 20% relative increase in the LV ejection fraction (LVEF).

RESULTS

The SDI was significantly higher in patients with aneurysm, at 14.3% compared with 2.0% in healthy volunteers (P <0.047). The SDI was negatively correlated with the LVEF. After SVR, 86 patients were responders. In this patient subgroup, the SDI exhibited an immediate significant decrease (to 7.7%; P <0.034) and a progressive decrease during 12 months of follow-up (to 4.9%; P <0.044). The SDI can discriminate SVR responders. Receiver-operating characteristic curve analysis yielded cut-off values of SDI 14.3% best associated with SVR response; area under the curve was 0.79 with reduction in NYHA class, 0.86 with increase in EF and 0.66 with decrease in the end-systolic volume.

CONCLUSIONS

RT3DE can be used to assess LV mechanical dyssynchrony in patients with aneurysm. SVR produces a mechanical intraventricular resynchronization and SDI can predict improvement following SVR.

Preadmission interventions to prevent postoperative complications in older cardiac surgery patients: a systematic review

OBJECTIVE(S)

The literature on postoperative complications in cardiac surgery patients shows high incidences of postoperative complications such as delirium, depression, pressure ulcer, infection, pulmonary complications and atrial fibrillation. These complications are associated with functional and cognitive decline and a decrease in the quality of life after discharge. Several studies attempted to prevent one or more postoperative complications by preoperative interventions. Here we provide a comprehensive overview of both single and multiple component preadmission interventions designed to prevent postoperative complications.

METHODS

We systematically reviewed the literature following the PRISMA statement guidelines.

RESULTS

Of 1335 initial citations, 31 were subjected to critical appraisal. Finally, 23 studies were included, of which we derived a list of interventions that can be applied in the preadmission period to effectively reduce postoperative depression, infection, pulmonary complications, atrial fibrillation, prolonged intensive care unit stay and hospital stay in older elective cardiac surgery patients. No high quality studies were found describing effective interventions to prevent postoperative delirium. We did not find studies specifically targeting the prevention of pressure ulcers in this patient population.

CONCLUSIONS

Multi-component approaches that include different single interventions have the strongest effect in preventing postoperative depression, pulmonary complications, prolonged intensive care unit stay and hospital stay. Postoperative infection can be best prevented by disinfection with chlorhexidine combined with immune-enhancing nutritional supplements. Atrial fibrillation might be prevented by ingestion of N-3 polyunsaturated fatty acids. High quality studies are urgently needed to evaluate preadmission preventive strategies to reduce postoperative delirium or pressure ulcers in older elective cardiac surgery patients.

Cardiac variables as main predictors of endotracheal reintubation rate after cardiac surgery

BACKGROUND

Reintubation in patients after cardiac surgery is associated with undesirable consequences. The purpose of the present study was to identify variables that could predict reintubation necessity in this group of patients.

METHODS

We performed a prospective study in 1000 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass. The patients who required reintubation after extubation were compared with patients not requiring reintubation regarding demographic and preoperative clinical variables, including postoperative complications and in-hospital mortality.

RESULTS

Postoperatively, 26 (2.6%) of the 1000 patients studied required reintubation due to respiratory, cardiac, or neurological reasons. Advanced age and mainly cardiac variables were determined as univariate intra- and postoperative predictors of reintubation (all p values < 0.05). Multiple logistic regression analysis revealed lower preoperative (p = 0.014; OR = 3.00, 95%CI: 1.25 - 7.21), and postoperative ejection fraction (p = 0.001; OR = 11.10, 95%CI: 3.88 - 31.79), valvular disease (p = 0.043; OR = 1.84, 95%CI: 1.05 - 3.96), arrhythmia (p = 0.006; OR = 3.84, 95%CI: 1.47 - 10.03), and postoperative intra-aortic balloon pump requirement (p = 0.019; OR = 4.20, 95%CI: 1.26 - 14.00) as the independent predictors of reintubation.

CONCLUSIONS

These findings reveal that cardiac variables are more common and significant predictors of reintubation after cardiac surgery in adult patients than are respiratory variables. The incidence of this complication, reintubation, is low, although it could result in significant postoperative morbidity and mortality.