Unrecognized indication for robot-assisted cardiac surgery: Patients with acute psychotic disorders

Patients with acute psychotic disorders are often considered as inappropriate candidates for cardiac surgery as well as for other surgical interventions. Post-operative care and patient compliance, which are the main problems associated with such patients, are the most important issues for conventional cardiac surgery. Robot-assisted cardiac surgery may be a new solution in this respect. In this report we aimed to present our acute psychotic patient with serious mitral insufficiency secondary to huge atrial myxoma, treated with robotic cardiac surgery.     

Pain status and sedation level in Chinese children after cardiac surgery: an observational study

Aims and objectives. This study explored current pain status, sedation level and their trajectories in Chinese children after cardiac surgery. Background. Pain and sedation management are fundamental care practices in the critical care setting, yet they both are frequently under‐implemented for children after major surgery. Design. Repeated observational design. Methods. This study was conducted in a paediatric medical centre in Shanghai, China where 170 children who underwent cardiac surgery were recruited. Pain was measured with the face, legs, activity, cry, consolability scale and sedation levels with the COMFORT Behaviour Scale at 18 fixed time‐points for three consecutive postoperative days. Results. The study indicated that 95 children (55·9%) received continuous opioids for pain relief, and 61 children (35·9%) received no analgesics. Multiple sedatives were used for these children, including bolus phenobarbital for 117 children (68·8%), phenergan for 81 children (47·6%) and midazolam for three children (1·8%). The mean pain scores significantly decreased throughout the operation day (POD‐0) to the 2nd postoperative day (POD‐2) with the lowest score on POD‐2. Less than 5% of pain assessments were identified as moderate to severe across all 2815 observations. The sedation scores significantly increased through POD‐0 to POD‐2 with the highest score on POD‐2. The rate of over‐sedation was 50·3% with <1% under‐sedation occurring among all the observations. Results also suggested that the length of stay in the cardiac intensive care unit was a predictor of increased analgesic usage in the critical care setting (odds ratio: 1·72). Conclusions. Usage of analgesic and sedative agents in cardiac intensive care unit was variable and children experienced low pain scores but a high rate of over‐sedation, indicating that healthcare providers should address ways to improve postoperative pain and sedation management in this population. Relevance to clinical practice. The pain and sedation status for children after cardiac surgery changed across the postoperative days. Healthcare providers should be trained in the use of reliable tools to accurately monitor children’s pain and sedation levels.     

医护合作策略对预防心脏手术病人精神障碍的效果观察

[目的]探讨医护合作策略对预防心脏手术病人精神障碍的效果。[方法]病人按治疗时间先后分为两组,对照组采用临床路径护理及健康教育方法,观察组在临床路径护理及健康教育的基础上,医护合作对病人进行干预,对比两组病人焦虑水平、满意度以及护理安全风险事件发生情况。[结果]观察组病人满意度均显著高于对照组,病人焦虑水平、护理安全风险事例数明显低于对照组(P0.05)。[结论]医护合作策略模式的实施,提高了心脏手术病人心理应激能力和满意度,降低护理安全风险例数,深化了优质医疗护理服务工作。     

The vasopressin and copeptin response in patients with vasodilatory shock after cardiac surgery: a prospective,controlled study

Objective  To evaluate arginine vasopressin (AVP) and copeptin plasma concentrations in patients with vasodilatory shock after cardiac surgery. Design  Prospective, controlled, clinical study. Setting  Surgical intensive care unit and cardiac surgery ward in a tertiary university teaching hospital. Patients and participants  Thirty-three critically ill patients with vasodilatory shock after cardiac surgery and ten control patients undergoing uncomplicated aorto-coronary bypass surgery. Measurements and results  Hemodynamic, laboratory and clinical data were recorded daily in all patients during the first 7 days after cardiac surgery. At the same time, points blood was withdrawn to determine plasma concentrations of AVP (radioimmunoassay) and copeptin (immunoluminometric assy). Standard tests, a mixed effects model and regression analyses were used for statistical analysis. The course of AVP was significantly different between groups (P  < 0.001). While AVP concentrations were lower in the study group on the first postoperative day, they were higher than that in the control group from postoperative day 3 on. There was no difference in the postoperative AVP response between study patients with or without chronic angiotensin-converting enzyme inhibitor therapy. Except during continuous veno-venous hemofiltration, AVP and copeptin correlated significantly with each other (P  < 0.001; r = 0.749). Conclusions  The AVP response to cardiac surgery is significantly different between patients with vasodilatory shock and patients undergoing uncomplicated aorto-coronary bypass surgery. Although no causative relationship between AVP concentrations and cardiovascular instability can be drawn from these results, our data support the hypothesis that inadequately low AVP plasma levels contribute to the failure to restore vascular tone in vasodilatory shock after cardiac surgery. Parts of this work were presented as an abstract at the 20th Congress of the European Society of Intensive Care Medicine in Berlin, 7–10 October 2007.     

Regional cerebral oxygen saturation monitoring for predicting interventional outcomes in patients following out-of-hospital cardiac arrest of presumed cardiac cause: A prospective,observational, multicentre study

AimThis study investigated the value of regional cerebral oxygen saturation (rSO₂) monitoring upon arrival at the hospital for predicting post-cardiac arrest intervention outcomes.MethodsWe enrolled 1195 patients with out-of-hospital cardiac arrest of presumed cardiac cause from the Japan-Prediction of Neurological Outcomes in Patients Post-cardiac Arrest Registry. The primary endpoint was a good neurologic outcome (cerebral performance categories 1 or 2 [CPC1/2]) 90 days post-event.ResultsA total of 68 patients (6%) had good neurologic outcomes. We found a mean rSO₂ of 21% ± 13%. A receiver operating characteristic curve analysis indicated an optimal rSO₂ cut-off of ≥40% for good neurologic outcomes (area under the curve 0.92, sensitivity 0.81, specificity 0.96). Good neurologic outcomes were observed in 53% (55/103) and 1% (13/1092) of patients with high (≥40%) and low (<40%) rSO₂, respectively. Even without return of spontaneous circulation (ROSC) upon arrival at the hospital, 30% (9/30) of patients with high rSO₂ had good neurologic outcomes. Furthermore, 16 patients demonstrating ROSC upon arrival at the hospital and low rSO₂ had poor neurologic outcomes. Multivariate analyses indicated that high rSO₂ was independently associated with good neurologic outcomes (odds ratio = 14.07, P < 0.001). Patients with high rSO₂ showed favourable neurologic prognoses if they had undergone therapeutic hypothermia or coronary angiography (CPC1/2, 69% [54/78]). However, 24% (25/103) of those with high rSO₂ did not undergo these procedures and exhibited unfavourable neurologic prognoses (CPC1/2, 4% [1/25]).ConclusionrSO₂ is a good indicator of 90-day neurologic outcomes for post-cardiac arrest intervention patients.     

Lack of improved outcomes with increased use of targeted temperature management following out-of-hospital cardiac arrest: A multicenter retrospective cohort study

Study aims

To assess whether increased use of targeted temperature management (TTM) within an integrated healthcare delivery system resulted in improved rates of good neurologic outcome at hospital discharge (Cerebral Performance Category score of 1 or 2).

Methods

Retrospective cohort study of patients with OHCA admitted to 21 medical centers between January 2007 and December 2012. A standardized TTM protocol and educational program were introduced throughout the system in early 2009. Comatose patients eligible for treatment with TTM were included. Adjusted odds of good neurologic outcome at hospital discharge and survival to hospital discharge were assessed using multivariate logistic regression.

Results

A total of 1119 patients were admitted post-OHCA with coma, 59.1% (661 of 1119) of which were eligible for TTM. The percentage of patients treated with TTM markedly increased during the study period: 10.5% in the years preceding (2007–2008) vs. 85.1% in the years following (2011–2012) implementation of the practice improvement initiative. However, unadjusted in-hospital survival (37.3% vs. 39.0%, p = 0.77) and good neurologic outcome at hospital discharge (26.3% vs. 26.6%, p = 1.0) did not change. The adjusted odds of survival to hospital discharge (AOR 1.0, 95% CI 0.85–1.17) or a good neurologic outcome (AOR 0.94, 95% CI 0.79–1.11) were likewise non-significant.

Interpretation

Despite a marked increase in TTM rates across hospitals in an integrated delivery system, there was no appreciable change in the crude or adjusted odds of in-hospital survival or good neurologic outcomes at hospital discharge among eligible post-arrest patients.     

Introducing intravascular microdialysis for continuous lactate monitoring in patients undergoing cardiac surgery: a prospective observational study

Introduction

Lactate is a marker of hypoperfusion and may be used for risk assessment in critically ill patients. Although evidence suggests that repeated lactate measurements are of clinical interest, how and when lactate should be analyzed is controversial. Intravascular microdialysis provides a novel method for the continuous monitoring of lactate, which may be clinically beneficial in critically ill patients.

Methods

Circulating lactate levels were continuously monitored in 80 patients undergoing cardiac surgery using either a separate single-lumen microdialysis catheter or a triple-lumen central venous catheter with an integrated microdialysis function. The catheter was placed with the tip positioned in the superior vena cava. Arterial blood gas samples were taken every hour to obtain reference values, and the lactate levels were analyzed in a blood gas analyzer.

Results

A total of 1,601 paired microdialysis–arterial blood gas lactate samples were obtained. Bland-Altman analysis showed a bias (mean difference) ± limits of agreement (±1.96 SD) of 0.02 ± 0.42 mmol/L. The regression coefficient was 0.98 (P = 0.0001).

Conclusions

Central venous microdialysis is an accurate and reliable method for continuous blood lactate monitoring in patients undergoing cardiac surgery. The system may be useful for early lactate-guided therapy in critically ill patients.     

Contrast-enhanced ultrasound to evaluate changes in renal cortical perfusion around cardiac surgery: a pilot study

Introduction

Contrast-enhanced ultrasound (CEUS) is a new technique that might enable portable and non-invasive organ perfusion quantification at the bedside. However, it has not yet been tested in critically ill patients. We sought to establish CEUS''s feasibility, safety, reproducibility and potential diagnostic value in the assessment of renal cortical perfusion in the peri-operative period in cardiac surgery patients.

Methods

We recruited twelve patients deemed at risk of acute kidney injury (AKI) planned for elective cardiac surgery. We performed renal CEUS with destruction-replenishment sequences before the operation, on ICU arrival and the day following the admission. Enhancement was obtained with Sonovue^® (Bracco, Milano, Italy) at an infusion rate of 1 ml/min. We collected hemodynamic parameters before, during and after contrast agent infusion. At each study time, we obtained five video sequences, which were analysed using dedicated software by two independent radiologists blinded to patient and time. The main output was a perfusion index (PI), corresponding to the ratio of relative blood volume (RBV) over mean transit time (mTT).

Results

All 36 renal CEUS studies, including 24 in the immediate post-operative period could be performed and were well tolerated. Correlation between readers for PI was excellent (R² = 0.96, P < 0.0001). Compared with baseline, there was no overall difference in median PI''s on ICU admission. However, the day after surgery, median PI''s had decreased by 50% (P < 0.01) (22% decrease in RBV (P = 0.09); 48% increase in mTT (P = 0.04), both suggestive of decreased perfusion). These differences persisted after correction for haemoglobin; vasopressors use and mean arterial pressure. Four patients developed AKI in the post-operative period.

Conclusions

CEUS appears feasible and well-tolerated in patients undergoing cardiac surgery even immediately after ICU admission. CEUS derived-parameters suggest a decrease in renal perfusion occurring within 24 hours of surgery.     

Incidence of venous thromboembolism following major abdominal surgery: a multi-center, prospective epidemiological study in Japan

BACKGROUND: Venous thromboembolism (VTE) has been considered to be a rare surgical complication in Japan. AIM: To investigate the incidence and risk factors of VTE in Japanese patients undergoing major abdominal surgery. METHODS: A prospective, multi-center epidemiological study was conducted from December, 2001 to August 2002 in 39 medical institutes throughout Japan. A total of 173 patients with general (n = 128), gynecologic (n = 23), and urologic (n = 22) surgery were analyzed. For the diagnosis of deep vein thrombosis (DVT), bilateral venography was performed in all patients. Lung ventilation/perfusion scintigraphy was carried out in patients suspected of pulmonary thromboembolism (PTE). RESULTS: There were 36 patients with distal DVT (20.8%) and five patients with proximal DVT (2.9%). One patient was diagnosed as PTE. Overall, VTE was diagnosed in 42 patients (24.3%). By univariate analysis, only age (60 years or older) was identified as a significant risk factor in the whole study population. When analyzed by the stepwise multiple logistic regression model, female gender, operation site, age, and operation time were four risk factors found to be significant. The incidence of VTE was closely related to the number of risk factors that patients had. As many as 44% of patients with three or four risk factors developed VTE while those with one or two risk factors showed about a 17% incidence of VTE. Four patients lacking any risk factors did not develop VTE. CONCLUSIONS: Venous thromboembolism is common in Japanese patients undergoing major abdominal surgery. Pharmacologic thromboprophylaxis is considered essential, particularly in those patients with multiple, potential risk factors.     

Performance of temporary epicardial stainless steel wire electrodes used to treat atrial fibrillation: a study in patients following open heart surgery

AF is the most common arrhythmia following open heart surgery. Transthoracic cardioversion is used when pharmacological treatment fails to restore SR, or is ineffective in controlling ventricular response rate. We report on the performance of temporary atrial defibrillation wire electrodes implanted on the epicardium of patients undergoing open heart surgery. Epicardial stainless steel wire electrodes for both pacing/sensing and atrial defibrillation were placed at the left and right atrium during open heart surgery in 100 consecutive patients (age 65 +/- 9 years; male/female 77/23). Electrophysiological studies performed postoperatively revealed a test shock (0.3 J) impedance of 96 +/- 12 omega (monophasic) and 97 +/- 13 omega (biphasic). AF was induced by burst stimulation in 84 patients. All patients were successfully converted to SR. The mean energy of successful shocks was 3.1 +/- 1.9 J. Atrial pacing and sensing were accomplished in all patients. Pacing threshold was 1.9 +/- 1.7 V (0.5 ms) in the left atrium and 2.1 +/- 2 V in the right atrium. P wave sensing was 2.5 +/- 1.6 mV in the left atrium and 2.3 +/- 1.4 mV in the right atrium. No complications were observed with shock application, nor with lead extraction. Atrial defibrillation using temporary epicardial wire electrodes can be performed successfully and safely in patients following cardiac operations. The shock energy required to restore SR is low. Electrical cardioversion in the absence of anesthesia should be feasible.     

Exercise is feasible in patients receiving vasoactive medication in a cardiac surgical intensive care unit: A prospective observational study

BackgroundPatients may require vasoactive medication after cardiac surgery. The effect and safety profile of exercise on haemodynamic parameters in these patients is unclear.ObjectivesThe objective of this study was to measure the effect of upright positioning and low-level exercise on haemodynamic parameters in patients after cardiac surgery who were receiving vasoactive therapy and to determine the incidence of adverse events.MethodsThis was a prospective, single-centre, observational study conducted in an adult intensive care unit of a tertiary, cardiothoracic university–affiliated hospital in Australia. The Flotrac-Vigileo™ system was used to measure haemodynamic changes, including cardiac output, cardiac index, and stroke volume. Normally distributed variables are presented as n (%) and mean (standard deviation), and non-normally distributed variables are presented as median [interquartile range].ResultsThere were a total of 20 participants: 16 (80%) male, with a mean age of 65.9 (10.6) years. Upright positioning caused significant increases (p = 0.018) in the mean arterial pressure (MAP), with MAP readings increasing from baseline (supine), from 72.31 (11.91) mmHg to 77.44 (9.55) mmHg when back in supine. There were no clinically significant changes in cardiac output, heart rate, stroke volume, or cardiac index with upright positioning. The incidence of adverse events was low (5%). The adverse event was transient hypotension of low severity.ConclusionsLow-level exercise in patients after cardiac surgery receiving vasoactive medication was well tolerated with a low incidence of adverse events and led to significant increases in MAP. Upright positioning and low-level exercise appeared safe and feasible in this patient cohort.     

Effectiveness of early cardiac rehabilitation in patients with heart valve surgery: a randomized,controlled trial

ObjectiveComplications of heart valve surgery lead to physical inactivity and produce harmful effects. This study aimed to investigate the role of a cardiac rehabilitation program and its long-term effect in patients after heart valve surgery.MethodsWe performed a single-blind, randomized, controlled trial. Patients with heart valve surgery were randomly assigned to receive early cardiac rehabilitation (intervention group, 44 patients) or the usual care (control group, 43 patients). The intervention group performed sitting, standing, and walking exercises, followed by endurance training. The control group received usual care and did not engage in any physical activity. Physical function was assessed by the Short Physical Performance Battery (SPPB) and other measurement tools.ResultsThe intervention group showed a significant beneficial effect regarding physical capacity as shown by the SPPB and the 6-minute walking test at hospital discharge, and a better long-term effect was achieved at 6 months compared with the control group. An improvement in physical function (e.g., the SPPB) after hospital discharge predicted follow-up mortality (odds ratio = 0.416, 95% confidence interval: 0.218–0.792).ConclusionEarly cardiac rehabilitation appears to be an effective approach to improve the physical function and survival of patients with heart valve surgery.     

Urinary interleukin-18 does not predict acute kidney injury after adult cardiac surgery: a prospective observational cohort study

Introduction  

Urinary interleukin-18 (IL-18) measured during the immediate postoperative period could be a promising predictor of acute kidney injury following adult cardiac surgery.     

Indocyanine green clearance as an outcome prediction tool in cardiac surgery: A prospective study

Purpose

To evaluate the role of plasma disappearance rate of indocyanine green (PDR-ICG) as an outcome prediction tool in cardiac surgery.

Patients and Methods

One hundred ninety patients undergoing coronary artery bypass grafting, valve surgery or combined procedures were enrolled. PDR-ICG measurements along with standard lab values were performed preoperative and on postoperative days 1, 2, and on discharge from the intensive care unit. Adverse outcomes were defined as prolonged length of stay in the intensive care unit and/or mortality. Two groups were defined according to length of stay in the intensive care unit (≤ 3 days vs > 3 days).

Results

PDR-ICG values differed significantly for all time points between the groups. In a multivariate model, in patients over 65 years with a EuroSCORE below 8.5, a preoperative PDR-ICG value below 12.85%/min was the strongest independent predictor for prolonged intensive care unit stay (> 3 days). A preoperative PDR-ICG value below 8.2%/min was the strongest independent predictor for mortality in a multivariate analysis including age, cardiac function, and EuroSCORE.

Conclusions

In addition to the established scores, PDR-ICG may provide valuable information for the assessment of perioperative morbidity and mortality in cardiac surgery. Pre- and early postoperative measurements may help to identify patients at risk for developing perioperative complications.     

Endotoxemia related to cardiopulmonary bypass is associated with increased risk of infection after cardiac surgery: a prospective observational study

Introduction  

Previous studies have documented a high frequency of endotoxemia associated with cardiopulmonary bypass (CPB). Endotoxemia may be responsible for some of the complications associated with cardiac surgery. The purpose of the study was to examine the prevalence of endotoxemia during cardiopulmonary bypass supported aortocoronary bypass grafting surgery (ACB) using a new assay, the Endotoxin Activity Assay (EAA), and explore the association between endotoxemia and post-operative infection.