Elective pneumonectomy: factors associated with morbidity and operative mortality.

We have retrospectively reviewed hospital records of 197 consecutive patients undergoing pneumonectomy for neoplastic disease between 1985 and 1990 to identify predictors of outcome. Seventeen of the 197 patients died during their hospital stay (8.6%; 95% confidence intervals, 6.7% to 11.2%). The most significant predictors of in-hospital mortality were presence of coexisting medical conditions (p less than 0.001), respiratory function tests showing an obstructive picture with a forced expiratory volume in 1 second/forced vital capacity ratio of less than 0.55 (p less than 0.001), 24-hour fluid replacement of more than 3 L (p less than 0.05), postoperative pulmonary edema (p less than 0.001), respiratory tract infection with positive sputum culture (p less than 0.01), postoperative renal failure (p less than 0.001), and cardiac arrhythmias (p less than 0.001). There were 232 postoperative management, problems occurring in 197 patients. The most significant predictors of postoperative morbidity were continued cigarette smoking up to the time of operation (p less than 0.05), perioperative blood loss or more than 2 L (p less than 0.05), and infusion of more than 3 L of fluid in the first 24 hours (p less than 0.05). Although retrospective analyses must be interpreted with caution, this study has identified preoperative and perioperative factors associated with in-hospital morbidity and mortality after pneumonectomy.     

Experience with sphincteroplasty and sphincterotomy in pancreatobiliary surgery.

Review of a 26-year experience with transduodenal sphincteroplasty and sphincterotomy was undertaken (1) to analyze critically the indications for and results of these procedures and (2) to determine which preoperative factors correlate with a good or poor outcome. Of 109 patients, 78 underwent sphincteroplasty, whereas 31 had a transduodenal sphincterotomy. Surgical indications included: group 1, 53 patients with common duct stones; group 2, 28 patients with dyskinesia or stenosis of the sphincter of Oddi (without choledocholithiasis or recurrent pancreatitis); and group 3, 28 patients with recurrent pancreatitis. Three elderly group 1 patients who presented with cholangitis died after surgery (a hospital mortality of 2.7%). Seventy-nine of the 103 patients (77%) in whom follow-up was obtained achieved an excellent or good result. Results were almost identical with sphincteroplasty and sphincterotomy. Abnormal preoperative liver function tests were the only predictors of a good postoperative outcome (p less than 0.05). Group 3 patients (good results in 63%) had significantly poorer (p less than 0.05) outcome than group 1 and 2 patients. Results were worst in group 3 patients who had undergone previous abdominal or pelvic surgery (p less than 0.025) and in group 2 patients who were narcotic users (p less than 0.025). The authors conclude that transduodenal sphincteroplasty or sphincterotomy can be performed relatively safely, but caution that careful selection of patients is important when the indication for surgery is either ampullary stenosis or recurrent pancreatitis.     

A cost/benefit analysis of randomized invasive monitoring for patients undergoing cardiac surgery

The aim of this study was to determine the effect of choice of invasive monitoring on cost, morbidity, and mortality in cardiac surgery. Two hundred and twenty-six adults undergoing elective cardiac surgery were initially assigned at random to receive either a central venous pressure monitoring catheter (group I), a conventional pulmonary artery (PA) catheter (group II), or a mixed venous oxygen saturation (SvO2) measuring PA catheter (group III). If the attending anesthesiologist believed that the patient initially randomized to group I should have a PA catheter, that patient was then reassigned to receive either a conventional PA catheter (group IV) or SvO2 measuring PA catheter (group V). The total costs were defined as the total amount billed to the patient for the catheter used; the professional cost of its insertion; and the determinations of cardiac output, arterial blood gas tensions, hemoglobin level, and hematocrit. Mean total monitoring and laboratory costs in Group I ($591 +/- 67) were statistically significantly (P less than 0.05) less than costs in Group II ($856 +/- 231). Further, mean monitoring and laboratory costs in Group II were statistically significantly (P less than 0.05) less than those in Group III ($1128 +/- 759). Patients in group IV incurred mean total costs of $986 +/- 578, while those in group V had mean total costs of $1126 +/- 382 (NS). There were no significant differences between any of the groups with respect to length of stay in the intensive care unit, morbidity, or mortality.(ABSTRACT TRUNCATED AT 250 WORDS)     

Octogenarians undergoing coronary artery bypass graft surgery: resource utilization, postoperative mortality, and morbidity

OBJECTIVE: The purpose of the present study was to examine resource utilization in octogenarians undergoing coronary artery bypass grafting (CABG) and compare it with usage in their younger cohorts at a tertiary care heart center. The resources examined were time to extubation, packed red blood cell transfusions, intensive care unit (ICU) length of stay (LOS), and preoperative and postoperative LOS. The study also examined differences in postoperative morbidity and mortality. DESIGN: Retrospective hospital follow-up study of consecutive patients undergoing CABG using a prospectively designed database. SETTING: University teaching tertiary care referral center for cardiac surgery. PARTICIPANTS: Seventeen hundred forty-six male and female patients undergoing CABG surgery, including 155 octogenarians and 1591 patients younger than 80 years. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic, mortality, morbidity, and resource utilization data were collected from the records of patients undergoing CABG at the authors' institution over 3 years. There were 1746 patients: 155 octogenarians and 1591 nonoctogenarians. Octogenarians had a significantly higher incidence of preoperative stroke, peripheral vascular disease, chronic obstructive lung disease, congestive heart failure, and left main disease. They weighed significantly less, and had lower preoperative and postoperative hematocrit. There was a significantly higher percentage of women in the octogenarian group. Mean time from the end of surgery to endotracheal extubation was 9.3 hours for octogenarians and 6.3 hours for their younger cohorts (p < 0.001). Blood transfusion was required in 88.4% of octogenarians compared with 58.6% of nonoctogenarians (p < 0.001). Mean ICU LOS was 1.9 days for octogenarians and 1.4 days for nonoctogenarians (p < 0.001). Mean postoperative LOS was 8.7 days for octogenarians and 5.8 days for nonoctogenarians (p < 0.001). Clinical and demographic variables were correlated with age 80 years or older. Multivariate linear and logistic regression models were constructed to show the combined effects of age and comorbid conditions on outcomes. Octogenarians had a significantly higher incidence of postoperative renal failure and neurologic complications. The 30-day mortality rate was 9.0% for the octogenarian group v 1.2% for the younger group (p < 0.001). Age 80 years or older was significantly associated with outcome, and was an independent predictor of increased resource utilization and postoperative mortality and morbidity. CONCLUSIONS: The results demonstrated that octogenarians undergoing CABG required increased resource utilization and had significantly higher morbidity, with increased incidence of postoperative renal failure, neurologic complications, and 30- day mortality. Age 80 years or older was an independent predictor of increased resource utilization, postoperative morbidity, and mortality.     

Coronary artery bypass grafting in elderly patients. Comparative results in a consecutive series of 469 patients older than 75 years

A consecutive series of 7104 patients undergoing isolated coronary artery bypass grafting during an 18-year period (1971 to 1988) included 469 patients older than 75 years. Results were analyzed to determine comparative risk factors for morbidity, early and late survival, and functional outcome. Patients younger than 75 years (group I) and patients older than 75 years (group II) were identical for ejection fraction and standard hemodynamic indices. Mean number of grafts and crossclamp time were greater for group II patients (p less than 0.01). Mean age of group I was 58.6 years and group II, 77.6 years (p less than 0.01). Women composed 19.7% (1308/6635) of group I and 36.2% (170/469) of group II patients (p less than 0.05). Mammary grafts were placed in 57.7% (3830/6635) of group I and 41.6% (195/469) of group II patients (p less than 0.05). Overall perioperative mortality rate was 2.1% for group I and 6.8% for group II (p less than 0.05). Perioperative myocardial infarction rate was similar for the two groups. Ventricular and supraventricular arrhythmias, renal insufficiency, neurologic complications, prolonged ventilatory support, increased hospital cost, and prolonged hospitalization were significantly more prevalent (all p less than 0.05) in patients older than 75 years. Five and 10 years postoperatively, there were no significant differences between groups I and II with regard to event-free status including angina, myocardial infarction, and reoperation. The 5-year survival rate was 92% for group I and 80% for group II (p less than 0.05), similar to that of age-matched control subjects. The significantly increased potential for complications and expense of coronary bypass in patients over 75 years of age mandates judicious patient selection and preoperative counseling. Despite a significantly increased early mortality and an anticipated decreased long-term survival paralleling normal life table survival curves, good intermediate functional improvement can be realized in patients older than 75 years, comparable with that expected in a much younger age group.     

Optimal timing of preoperative intraaortic balloon pump support in high-risk coronary patients.

BACKGROUND: Beneficial effects of preoperative intraaortic balloon pump (IABP) treatment, on outcome and cost, in high-risk patients who have coronary artery bypass grafting have been demonstrated. We conducted a prospective, randomized study to determine the optimal timing for preoperative IABP support in a cohort of high-risk patients. METHODS: Sixty consecutive high-risk patients who had coronary artery bypass grafting (presenting with two or more of the following criteria: left ventricular ejection fraction less than 0.30, unstable angina, reoperation, or left main stenosis greater than 70%) entered the study. Thirty patients did not receive preoperative IABP (controls), 30 patients had preoperative IABP therapy starting 2 hours (T2), 12 hours (T12), or 24 hours (T24), by random assignment, before the operation. Fifty patients had preoperative left ventricular ejection fraction mean, less than 0.30 (less than 0.26+/-0.08), (n = 40) unstable angina, 28% (n = 17) left main stenosis, and 32% (n = 19) were reoperations. RESULTS: Cardiopulmonary bypass was shorter in the IABP groups. There was one death in the IABP group and six in the control group. The complication rate for IABP was 8.3% (n = 5) without group differences. Cardiac index was significantly higher postoperatively (p<0.001) in patients with preoperative IABP treatment compared with controls. There were no significant differences between the three IABP subgroups at any time. The incidence of postoperative low cardiac output was significantly lower in the IABP groups (p<0.001). Intubation time, length of stay in the intensive care unit and the hospital was shorter in the IABP groups (p = 0.211, p<0.001, and p = 0.002, respectively). There were no differences between the IABP subgroups in any of the studied variables. CONCLUSIONS: The beneficial effect of preoperative IABP in high-risk patients who have coronary artery bypass grafting was confirmed. There were no differences in outcome between the subgroups; therefore, at 2 hours preoperatively, IABP therapy can be started.     

Obesity and increased mortality in blunt trauma

To determine the effect of admission body weight on blunt trauma victims, a chart review of all patients greater than 12 years of age admitted to Sentara Norfolk General Hospital between January 1 and July 31, 1987 was undertaken. The charts of 351 patients were reviewed; 184 records contained admission height and weight. These 184 patients made up the study group and age, gender, injuries, Injury Severity Score (ISS), ventilator days (VD), complications, length of stay (LOS), and outcome were noted. Body Mass Index (BMI) (weight (kg)/(height(m))2, was calculated for each patient. The average ISS was 21.87 (range, 1-66) and the average BMI was 25.15 kg/m2 (range, 16-46 kg/m2). The overall mortality for the population was 9%. The population was grouped according to BMI: average (less than 27 kg/m2), overweight (27-31 kg/m2), and severely overweight (greater than 31 kg/m2). The mortality of 5.0% and 8.0% in the average and overweight groups was not different. The severely overweight group had a higher mortality at 42.1% compared with the other two groups (p less than 0.0001). The groups did not differ in age, ISS, LOS, nor VD. Age, BMI, and ISS were subjected to regression analysis. By this method BMI and ISS were independent determinants of outcome (p less than 0.0001). There was an increase in complications, mainly pulmonary problems, in the SO group (p less than 0.05). The three groups were subdivided into survivors and nonsurvivors. The nonsurvivors had a longer average LOS at 26.6 days compared with nonsurvivors in the overweight (5.0 days) or severely overweight (8.62 days) groups (p less than 0.007). The severely group was characterized by a rapid deterioration and demise that was unresponsive to intervention. ISS did not differ among nonsuvivors. Among survivors the severely overweight group had a lower ISS, 9.73. This was different from the overweight group (21.57) and from the average group (20.21) (p less than 0.04).     

Pulmonary artery banding revisited.

Pulmonary artery (PA) banding to reduce pulmonary blood flow was described by Muller and Dammann in 1952. This review describes the outcome of 170 children who had PA banding at the University of Virginia Medical Center between 1955 and 1988. One hundred and one of the patients were banded between 1958 and 1970; fewer bands were placed in later years because early total correction was feasible for certain conditions. When analyzed by preoperative diagnoses, the data reveal that children with a single ventricle undergoing banding had a significantly lower 30-day mortality rate of 12% compared to other preoperative diagnoses, including atrioventricular canal, truncus arteriosus, and ventricular septal defect (VSD) at 30% (p less than 0.05). The late overall mortality for all patients was approximately 10%, an attrition rate of 1% per year. PA banding still has a role in management of patients with congenital heart disease, particularly for infants with a single ventricle. Actuarial survival at 10 years for patients with this condition is 92%. Interestingly, this indication for pulmonary banding is the same one cited in the original report.     

Costs and results of cardiac operations in infants less than 4 months old. Are they worthwhile?

From 1979 through 1983, 328 of 1,388 pediatric cardiac operations involved patients undergoing their first procedure at less than 4 months of age. Of these, 220 patients had 265 nonductal procedures, and their case histories are reviewed for results and total hospital cost. Initial operative mortality was 20% (43 patients). Infants with lower operative age and operative weight tended to have closed procedures. Mortality and cure were not related to gestational age, birth weight, age at operation, number of operations, or type of operation. Lower operative weight was associated with a greater mortality. Evaluated survivors (142 patients) were followed for a mean of 24 months. Fifteen percent (33 patients) died during follow-up. Of survivors, 80% (114 patients) had optimized general health; a subset of 29% had normal cardiac function, and 17% were cured. Lower birth weight was associated with curable lesions and normalcy (p less than 0.04). Longer preoperative hospital stay and lower weight at operation were associated with higher hospital cost (p less than 0.05). Hospital cost was not related to type of operation, gestational age, birth weight, age at operation, mortality, cure, or normalcy. Acquired neurologic dysfunction and long-term disability were uncommon. The mean hospital cost for surviving infants was +80,000 (1984 dollars). Effective hospital cost per survivor was +110,000. Mortality, cure, and normal function after cardiac operations in infants less than 4 months of age were not related to gestational age, birth weight, or age at operation. Mortality was higher in patients with a lower weight at operation. Separation into distinct fiscal cost groups is not reasonable in this series. Because most survivors are in normal or optimized cardiac health, intensive cardiovascular care in this population is justified.     

Emergency and elective coronary artery bypass grafting: comparisons of risk profiles, postoperative outcomes, and resource requirements

OBJECTIVE: To investigate the association between preoperative risk factors and postoperative outcomes in emergency and elective coronary artery bypass graft (CABG) patients and to quantify resource requirements. DESIGN: Retrospective database review. SETTING: New York State SPARCS database. PARTICIPANTS: Data from 4,001 emergency and 7,489 elective CABG patients were evaluated retrospectively. INTERVENTIONS: Data were compared between groups using chi-squares, t tests, and logistic regression analysis. MEASUREMENTS AND MAIN RESULTS: Preoperatively, 47.1% of patients in the emergency group had unstable angina and 34.1% had acute myocardial infarction compared with 33.9% and 15.2% in the elective group, respectively (p < 0.0001). There were no marked differences in the preoperative noncardiac risk factors between groups. The mortality rate was 4.7% in the emergency group and 2.6% in the elective group (p < 0.0001). The emergency group had more postoperative cardiac complications (18.3% v 8.3%, p < 0.0001). The length of hospital stay in the emergency group was 17.5 +/- 15.8 days (median 14 days) compared with 12.9 +/- 15.1 days (median 9 days) in the elective group (p < 0.00001). Total hospital charges in the emergency and elective groups were 46,700 US dollars +/- 42,400 US dollars (median 35,600 US dollars ) and 34,800 US dollars +/- 36,400 US dollars (median 26,500 US dollars) (p < 0.00001), respectively. The median total cost was 26,300 US dollars for emergency and 19,600 US dollars for elective group (p < 0.00001). CONCLUSION: Patients undergoing emergency CABG had greater postoperative morbidity and mortality, longer LOS, and higher total costs than patients undergoing elective surgery. This difference is predictable on the basis of preoperative cardiac risk factors. Emergency operations have a major impact on the rates of morbidity, mortality, and use of resources.     

The effects of continuous blood gas monitoring during cardiopulmonary bypass: a prospective, randomized study--Part II

The impact of blood gas management during cardiopulmonary bypass (CPB) on patient care has not been examined and remains controversial. The purpose of this study was to determine whether precise blood gas management during CPB influences patient outcome. Fifty-nine patients were enrolled in an Institutional Review Board-approved, prospective, randomized study. An in-line blood gas monitor (CDI 500) was placed into the arterial and venous lines for all patients. Blood gas monitoring in the control group was managed by intermittent sampling (every 20-30 min), while the treatment group was managed with continuous monitoring. Blood gas control and measured parameters were as follows: pH 7.40 +/- 0.05, PaCO2 40 +/- 5 mmHg, PaO2 200 +/- 50 mmHg. The treatment group had the CDI 500 guide clinical decisions. Compared to the control group, the treatment group consisted of significantly more diabetic (7% vs. 47%, p < or = 0.001), renal failure (3% vs. 13%, p < or = 0.01), and chronic obstructive pulmonary disease patients (7% vs. 20%, p < or = 0.01). Internal thoracic artery utilization was higher in treatment patients than control patients (67% vs. 95%, p < or = 0.02). No other differences existed in demographic, pharmacological, surgical, or anesthetic parameters. In the perioperative period, the control group required antiarrythmic support more frequently than the treatment group (10% vs. 0%, p < or = 0.05). Compared to the control group, the treatment group required antiarrythmic (18% vs. 10%, p < or = 0.05) and cardiac glycoside therapy (11% vs. 0%, p < or = 0.05) less frequently in the postoperative period. Although treatment patients required less intraoperative pacing and cardioversion and spent less time on mechanical ventilation, in the intensive care unit (ICU), and in the hospital than control patients, statistical significance was not achieved. In conclusion, the use of continuous, in-line blood gas monitoring resulted in improvement in a number of postoperative outcome variables, although ICU and hospital stay was not effected.     

Survival after trauma in geriatric patients.

In contrast to other studies, a recent report from the authors' institution has shown a good prognosis for functional recovery in geriatric patients that survive trauma. Because most survivors regained their pre-injury function, the authors examined factors related to nonsurvival in this population of 82 consecutive blunt trauma victims older than the age of 65. Seventeen patients died (21%). Compared with survivors, nonsurvivors were older, had more severe overall injury, and had more severe head and neck trauma but did not differ in severity of trauma that did not involve the head and neck, number of body regions injured, mechanism of injury, or incidence of surgery after injury. Nonsurvivors experienced more frequent complications (82% vs. 33%, p less than 0.05), including a higher incidence of cardiac complications (53% vs. 15%, p less than 0.05) and ventilator dependence for 5 or more days (41% vs. 14%, p less than 0.05). Mortality rates were increased in patients who were 80 years of age or older compared with those ages 65-79 (46% vs. 10%, p less than 0.01), despite injury of similar severity. More frequent complications may contribute to an increased mortality rate in the older group, including an increased incidence of prolonged mechanical ventilation (36% vs. 12%, p less than 0.025), cardiac complications (54% vs. 10%, p less than 0.01), and pneumonia (36% vs. 16%, p less than 0.06). Severely injured patients (Injury Severity Score [ISS] greater than or equal to 25) older than 80 years old had a mortality rate of 80%, and the survivors required permanent nursing home care. Discriminant analysis yielded a reliable method of differentiating survivors from nonsurvivors based on age, ISS, and the presence of cardiac and septic complications. To assess the accuracy of the discriminant function, 61 consecutive patients admitted during 1985 were reviewed prospectively. Discriminant scoring predicted outcome correctly in 92% of these patients. A Geriatric Trauma Survival Score (GTSS) based on the discriminant function was calculated for each of the 143 patients studied and was highly correlated with mortality rate (r = 0.99, p less than 0.001). Thus, the GTSS may serve as a valuable tool for evaluating death in geriatric trauma victims. Furthermore, because complications are potentially avoidable and contribute to increased mortality rates, routine aggressive care for geriatric patients with moderate overall injury is indicated.     

Analysis of postoperative complications after esophagectomy for esophageal cancer in patients receiving neoadjuvant therapy.

Postoperative complications were investigated in 72 patients who received neoadjuvant therapy with esophagectomy. Preoperative chemotherapy consisted of 5-fluorouracil (700 mg/m2/day, on days 1 to 5), cisplatinum (70 mg/m2/day, on day 1) and leucovorin (20 mg/m2/day, on days 1 to 5). Preoperative chemoradiotherapy consisted of cisplatinum combined chemotherapy and radiotherapy (total dosage of 30-70 Gy). The incidence of postoperative pneumonia (16%) and anastomotic leakage (24%) in the preoperative chemotherapy group was slightly higher than that in the control group (n = 506), and mortality (6.0%) after esophagectomy in the preoperative chemotherapy group was higher than that (2.4%) of the control group. Postoperative morbidity and mortality were observed more frequently in patients who received two cycles of the chemotherapy than those receiving only one cycle. Postoperative complications occurred more frequently in patients suffering high grade toxicities due to the preoperative chemotherapy. The highest preoperative serum creatinine value correlated to that of postoperative period (r = 0.6494). The use of the preoperative chemoradiotherapy with a total exposure dosage of 60 Gy or more significantly increased the postoperative pneumonia rate (67%; p < 0.05) compared to the group receiving 40 Gy or less. The mortality rate (33%) also increased. The second cycle of the preoperative chemotherapy should be cancelled if patients suffer high grade toxicities during or after the first cycle, and the total exposure dosage of the preoperative chemoradiotherapy should be limited to 40 Gy or less.     

Coronary sinus cardioplegia: clinical trial with only retrograde approach.

The cases of 100 consecutive patients who underwent coronary artery bypass grafting with coronary sinus (retrograde) cardioplegia (group R) without the antegrade-retrograde approach were reviewed. To evaluate the safety and the efficacy of this technique, another 100 consecutive patients who underwent a similar procedure but with conventional aortic root (antegrade) cardioplegia (group A) were used as a comparison. The two groups were similar with respect to age, male to female ratio, associated medical problems, extent of coronary artery disease, mean preoperative ejection fraction (0.56 +/- 0.13 versus 0.53 +/- 0.18), pump time (113.1 +/- 43 versus 111.7 +/- 38 minutes), aortic cross-clamp time (57.4 +/- 20 versus 60.8 +/- 23 minutes), number of grafts per patient, level of hypothermia, complication rate, rate of postoperative myocardial infarction (4% versus 3%), and mortality rate (2% versus 2%). Hemodynamic measurements were made 6 hours after operation in 59 patients in group R and 47 patients in group A. The cardiac index, left ventricular stroke work index, and right ventricular stroke work index were better in group R but not significantly so (p greater than 0.05). However, only 27% of patients in group R required a temporary pacemaker, and only 9% needed inotropic agents after 6 hours of operation in contrast to 51% and 42%, respectively, in group A (p less than 0.05). There were no complications from catheter intubation. In group R, right ventricular wall temperature (11 degrees +/- 3.6 degrees C) was higher than the septal (10.8 degrees +/- 3.2 degrees C) and left ventricular wall temperatures (9.1 degrees +/- 2.8 degrees C) (p greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

The role of intra-aortic counterpulsation in high-risk OPCAB surgery: a prospective randomized study

BACKGROUND: High-risk patients would benefit the most of OPCAB revascularization. This prospective and randomized study evaluates the efficacy and safety of pre- and perioperative IABC in high-risk OPCAB. MATERIAL: Group A-IABC started prior to induction of anesthesia (n = 15); group B-no preoperative IABC (n = 15). Adult high-risk coronary patients to undergo OPCAB. High risk = (minimum 2) EF < 0.30, left main stenosis, unstable angina, redo. Bailout if hemodynamic instability CPB or IABC in group B. Study endpoints (a) cardiac protection (troponin 1, cardiac index (CI), ECG), (b) inflammatory response (lactate, IL-6), (c) clinical outcome (mortality, morbidity). Emergency operations 33%, re-operation 13%, unstable angina 100%, left main 60% and EF 0.29, without group differences. RESULTS: No bailout group A, 10 in group B, p < 0.0001. Postoperative IABC six (group A) and seven patients (group B), during 6.8 +/- 5.1 hours (group A) versus 41.2 +/- 25.5 hours (group B), p = 0.0110. Myocardial protection without group differences, but CI significantly better in group A. Inflammatory response significantly less in group A. CLINICAL OUTCOMES: one death, one MI and two renal failure in group B, none in group A. Intensive care unit (ICU) stay 27 +/- 3 hours (group A) versus 65 +/- 28 hours (group B), p = 0.0017. LOS 8 +/- 2 days (group A) versus 15 +/- 10 (group B), p = 0.0351. No IABC related complications. CONCLUSIONS: Pre- and perioperative IABC therapy offers efficient hemodynamic support during high-risk OPCAB surgery, lowers the risk of hemodynamic instability, is safe and shortens both ICU and hospital length of stay significantly, and is a cost-effective therapy.     

Ruptured abdominal aortic aneurysms: repair should not be denied.

The records of 231 patients (189 men, 42 women) treated during the last decade for ruptured infrarenal abdominal aortic aneurysm were reviewed to evaluate complications and mortality rates and to determine if preoperative factors would preclude attempt at surgical repair. Mean age was 73.7 years (range, 50 to 95 years). Fifty-seven patients (24.7%) were greater than or equal to 80 years of age. Sixty-eight patients (29.4%) had known abdominal aortic aneurysm before rupture. Preoperative systolic blood pressure was less than or equal to 90 mm Hg in 155 patients (67.1%). Fifty-six patients (24.2%) had cardiac arrest before operation. The overall mortality rate from admission until the end of the hospital stay was 49.4% (114 of 231). Seventeen patients (7.4%) died in the emergency department, 40 (17.3%) in the operating room, 27 (11.7%) during the first 48 postoperative hours, and 30 (13.0%) died later but during the same hospitalization. The 30-day operative mortality rate was 41.6%. Mean age of those who died was higher (75.3 years) than of those who survived (72.2 years) (p less than 0.02). Of patients greater than or equal to 80 years, 43.9% survived. Survival was lower among women (35.7%) than men (54.0%; p less than 0.04). A high APACHE II score, a low initial hematocrit, preoperative hypotension, and chronic obstructive pulmonary disease were associated multivariately with increased mortality rates (p less than 0.02). However, 59 of the 155 patients (38.1%) with preoperative hypotension survived. Deaths were high (80.4%) among patients with cardiac arrest (45 of 56); still, 28.2% of patients (11 of 39) survived repair after cardiac arrest.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous catheter drainage compared with internal drainage in the management of pancreatic pseudocyst.

The records of 92 patients with symptomatic pancreatic pseudocysts referred for surgical management over a 27-year period were retrospectively reviewed to compare outcome in 42 patients managed with operative internal drainage procedures (group I) with that in 52 patients managed with computed tomography-directed percutaneous catheter drainage (PCD) (group II). The two groups were similar for patient age, sex, pseudocyst location, and cause. The frequency of antecedent pseudocyst-associated complications was less in group I (16.7 versus 38.5%, p less than 0.05). Seven group I patients and four group II patients had major complications (16.7 versus 7.7%, not significant). Group II mean duration of catheter drainage was 42.1 days, and the drain track infection rate was 48.1%. The frequency of antecedent operative cyst drainage was similar (14.2 versus 13.5%), as was the frequency of subsequent operations for complications related to chronic pancreatitis (9.5 versus 19.2%, not significant). Mortality rate was greater in group I (7.1% versus 0%, p less than 0.05). Pseudocysts can be effectively managed either by open operation with internal drainage or by PCD. Drawbacks of PCD include the controlled external pancreatic fistula and the risk of drain track infection. Percutaneous catheter drainage has the following advantages: (1) low mortality rate, (2) does not require a major operation, (3) does not violate the operative field in cases when subsequent retrograde duct drainage procedures are required. Neither PCD nor internal drainage is definitive, and with either technique subsequent correction of underlying pancreatic pathology may be necessary.     

Fast-track cardiac anesthesia in patients with sickle cell abnormalities.

We conducted a retrospective review of 10 patients with sickle cell trait (SCT) and 30 patients (cohort control) without SCT undergoing first-time coronary artery bypass graft surgery with cardiopulmonary bypass. Demographic, perioperative management, and outcome data were collected. Both groups were matched according to age, weight, duration of surgery, and preoperative hemoglobin (Hb) concentration. Distribution of gender, medical conditions, pharmacological treatment, and preoperative left ventricular function were similar between the groups. The comparisons were analyzed in respect to postoperative blood loss and transfusion rates, as well as duration of intubation, intensive care unit, and hospital length of stay (LOS). All patients underwent fast-track cardiac anesthesia. A combination of cold crystalloid and blood cardioplegia was used. The lowest nasopharyngeal temperature was 33 degrees C. There were no episodes of significant hypoxemia, hypercarbia, or acidosis. None of the patients had sickling crisis during the perioperative period. The postoperative blood loss was 687 +/- 135 vs 585 +/-220 mL in the SCT and control groups, respectively. The trigger for blood transfusion during cardiopulmonary bypass was hematocrit <20% and Hb <75 g/L postoperatively. Three SCT patients (30%) and 10 control patients (33%) received a blood transfusion. Median extubation time was 4.0 vs 3.9 h; intensive care unit LOS was 27 vs 28 h; and hospital LOS was 6.0 vs 5.5 days in the SCT and control groups, respectively. There were no intraoperative deaths. One patient in the SCT group died from multiorgan failure 2 mo after surgery. IMPLICATIONS: Fast-track cardiac anesthesia can be used safely in patients with sickle cell trait undergoing first-time coronary artery bypass graft surgery. Extubation time and intensive care unit and hospital length of stay are comparable to those of matched controls, and blood loss and transfusion requirements are not increased. A hematocrit of 20% seems to be a safe transfusion trigger during cardiopulmonary bypass in these patients.     

Pulmonary embolism in the cardiac surgical patient.

Pulmonary embolism (PE) is thought to occur infrequently after cardiac operations, possibly because systemic heparinization during cardiopulmonary bypass prevents deep vein thrombosis. This retrospective study was undertaken to determine the actual incidence of PE after cardiac operations and to identify risk factors. Between January 1, 1985, and December 31, 1989, 5,694 adult patients (greater than 18 years old) had open heart operations at the Johns Hopkins Hospital. Thirty-two patients (20 men and 12 women) had PE within 60 days of operation, an overall PE incidence of 0.56%. The diagnosis of PE was established by ventilation/perfusion scan, pulmonary angiogram, or autopsy. Mortality among patients with PE was 34%. Using a case-control method, preoperative and postoperative risk factors for PE were identified by multivariate and multiple logistic regression analyses. Preoperative risk factors included bed rest (p less than 0.003), prolonged hospitalization before operation (p less than 0.004), and cardiac catheterization performed through the groin within 15 days before operation (p less than 0.01). Post-operative risk factors were congestive heart failure (p less than 0.008), prolonged bed rest (p less than 0.05), and deep vein thrombosis (p less than 0.03). This study demonstrates that PE is an unusual complication after cardiac operations, has a high mortality rate, and is often related to perioperative immobility and recent groin catheterization. These results also suggest that minimizing preoperative hospital stay may be important in PE prophylaxis.     

A reappraisal of surgical intervention for acute myocardial infarction

Eighty-three patients underwent coronary artery bypass during acute evolving myocardial infarction 6.8 +/- 2.8 hours after the onset of symptoms. Linear discriminant analysis of preoperative variables identified predictors of mortality with an accuracy of 84%. Significant predictors in decreasing order of importance were cardiogenic shock, age over 65 years, left ventricular ejection fraction less than or equal to 0.30, cardiac index less than or equal to 2.0 L/min/m2, and absent collateral flow. Time to reperfusion did not influence outcome nor did the infarct-related artery. Hospital mortality was 15.6% (13/83). Among 51 low-risk patients under 65 years of age without cardiogenic shock, there were three deaths (5.9%). Follow-up angiography was performed in 21 patients. The graft patency rate was 94%. Left ventricular ejection fraction improved from 0.39 +/- 0.10 to 0.49 +/- 0.11 (p less than 0.05). Left ventricular end-systolic volume decreased from 53.2 +/- 19.3 ml/m2 to 41.4 +/- 16.8 ml/m2 (p less than 0.05), and end-diastolic volume remained unchanged: 86.2 +/- 21.2 ml/m2 before operation and 78.7 +/- 24.0 ml/m2 after operation (no significant difference). Regional ejection fraction of the infarct area, determined by the centerline method, increased 0.23 +/- 0.15. In contrast, among 215 patients treated by nonsurgical reperfusion (intracoronary thrombolysis or angioplasty, or both), mortality was 13.5%. In this group, reperfusion was successful in 144 patients (67%) and 89 underwent follow-up angiography. Persistent patency of the infarct artery was demonstrated in 73 (82%). Ejection fraction increased from 0.45 +/- 0.10 to 0.50 +/- 0.15 (p less than 0.05). We conclude that preoperative variables enable identification of patients with evolving acute myocardial infarction in whom coronary artery bypass is associated with low operative mortality and improved ventricular performance.