Arginine vasopressin and serum nitrite/nitrate concentrations in advanced vasodilatory shock

BACKGROUND: Arginine-vasopressin (AVP) can successfully stabilize hemodynamics in patients with advanced vasodilatory shock. It has been suggested that inhibition of cytokine-induced nitric oxide production may be an important mechanism underlying AVP-induced vasoconstriction. Therefore, serum concentrations of nitrite/nitrate (NOx), the stable metabolite of nitric oxide, were measured in patients suffering from advanced vasodilatory shock treated with either AVP in combination with norepinephrine (NE) or NE alone. METHODS: This trial was a separate study arm of a previously published prospective, randomized, controlled study on the effects of AVP in advanced vasodilatory shock. Thirty-eight patients were prospectively randomized to receive a combined infusion of AVP (4 U h(-1)) and NE, or NE infusion alone. Serum NOx concentrations were measured at baseline, 24, and 48 h after randomization. The increase in mean arterial pressure during the first hour after study enrollment was documented in all patients. RESULTS: No difference in NOx concentrations was found between groups throughout the study period. AVP patients demonstrated a significantly greater increase in mean arterial pressure than NE patients (22 +/- 10 vs. 5 +/- 9 mmHg; P < 0.001). The magnitude of pressure response to AVP was not correlated with NOx concentrations before start of AVP infusion (Pearson's correlation coefficient, -.009; P = 0.971). CONCLUSION: Cardiovascular effects of AVP infusion in advanced vasodilatory shock are not mediated by a clinically relevant reduction in serum NOx concentrations. Therefore, hemodynamic improvement of patients in advanced vasodilatory shock during continuous infusion of AVP has to be attributed to other mechanisms than inhibition of nitric oxide synthase. In addition, the magnitude of pressure response to AVP is not correlated with baseline concentrations of NOx.     

Does arginine vasopressin influence the coagulation system in advanced vasodilatory shock with severe multiorgan dysfunction syndrome?

Arginine vasopressin (AVP) is a potent supplementary vasopressor in advanced vasodilatory shock, but decreases in platelet count have been reported during AVP therapy. In this study we evaluated the effects of AVP infusion on the coagulation system in advanced vasodilatory shock when compared to norepinephrine (NE) infusion alone. Forty-two patients with advanced vasodilatory shock (NE requirements >0.5 microg x kg(-1) x min(-1), mean arterial blood pressure <70 mm Hg) were prospectively randomized to receive an additional AVP infusion (4 U/h) or NE infusion alone. Most patients received coagulation active treatment (fresh-frozen plasma, thrombocyte concentrates, coagulation factors, and continuous veno-venous hemofiltration with heparin). At baseline and 1, 24, and 48 h after randomization, coagulation laboratory variables and a modified thrombelastography were measured. There were no differences between groups in plasmatic coagulation variables. Although there was no significant difference between groups, platelet count significantly decreased in AVP patients (P = 0.036). There were no differences in results of modified thrombelastography analyses between groups. AVP infusion in advanced vasodilatory shock with severe multiorgan dysfunction syndrome does not increase plasma concentrations of Factor VIII, von Willebrand Factor antigen, and ristocetin Co-Factor but may stimulate platelet aggregation and induce thrombocytopenia. Global coagulation, assessed by modified thrombelastography, is not different from patients receiving NE infusion alone.     

European system for cardiac operative risk evaluation predicts long-term survival in patients with coronary artery bypass grafting.

OBJECTIVE: To evaluate the accuracy of predicting long-term mortality in patients with coronary artery bypass grafting (CABG) by using the European system for cardiac operative risk evaluation (EuroSCORE). METHODS: Medical records of patients with CABG (n=3760) between January 1992 and March 2002 were retrospectively reviewed and their predicted surgical risk was calculated according to the standard (study A) and logistic (study B) EuroSCORE. In study A the patients were divided into six groups: 0-2 (n=610), 3-5 (n=1479), 6-8 (n=1099), 9-11 (n=452), 12-14 (n=103) and >14 (n=17). In study B the patients were divided into seven groups: 0.00-2.00 (n=447), 2.01-5.00 (n=1190), 5.01-10.00 (n=890), 10.01-20.00 (n=686), 20.01-30.00 (n=234), 30.01-60.00 (n=254) and >60.00 (n=59). Long-term survival was obtained by the National Death Index and Kaplan-Meier curves were constructed and compared employing the log-rank test. Multivariate Cox regression analysis was performed in order to control for pre, intra and postoperative factors and adjusted hazard ratios were calculated for standard and logistic EuroSCORE groups. The receiver operating characteristic (ROC) curves were plotted to assess the discrimination ability of the EuroSCORE. RESULTS: In study A there were differences among the six groups in 30-day mortality (0.7%, 1.0%, 3.1%, 4.6%, 13.6% and 23.5%; P<0.001), in major complications (8.5%, 10.4%, 16.2%, 20.4%, 31.1% and 35.3%; P<0.001) as well as in actuarial long-term survival (86.2%, 79.6%, 53.6%, 37.9%, 24.9% and 0% from EuroSCORE 0-2 to >14; P<0.001). In study B there were differences among the seven groups in 30-day mortality (0.9%, 1.1%, 1.2%, 3.6%, 3.4%, 8.7% and 15.3%; P<0.001), major complications (8.5%, 10.1%, 12.1%, 18.4%, 16.2%, 26.0% and 30.5%; P<0.001) as well as in actuarial long-term survival (89.5%, 79.9%, 66.9%, 51.0%, 40.3%, 38.4% and 13.7% from EuroSCORE 0.00-2.00 to >60.00; P<0.001). Multivariate Cox regression analysis confirmed that EuroSCORE (standard or logistic) was a statistically significant predictor for long-term mortality, while the area under the ROC curve was 0.72 for either standard or logistic EuroSCORE. CONCLUSION: The predicted surgical risk in CABG patients as calculated by standard or logistic EuroSCORE is a strong predictor for long-term survival in addition to predicting operative survival for which it was originally designed.     

Risk evaluation of cardiac surgery in octogenarians

OBJECTIVE: To assess the predictive value of risk factors in the European System for Cardiac Operative Risk Evaluation (EuroSCORE) for cardiac surgery on octogenarians. DESIGN: An observational study of octogenarians undergoing cardiac surgery and average-aged controls matched according to the cardiac surgical procedure. SETTING: A university hospital. PARTICIPANTS: One hundred sixty-two consecutive patients 80 years or older who underwent cardiac surgery between January 1, 2001, and June 30, 2003, and 162 average-aged controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Risk factors according to the EuroSCORE (The European System for Cardiac Risk Evaluation) model and EuroScore algorithm without an age component (EuroSCOREex) were evaluated. The EuroSCORE model and EuroSCOREex predicted mortality (odds ratio 1.4) and morbidity (odds ratio 1.2 and 1.3, respectively) equally well in both age groups. Adding age group information into the EuroSCOREex model in combined data, the odds ratio estimate was 3.5 for age group. The 30-day mortality of octogenarians was 8.6% versus 1.9% in controls (p < 0.01). Incidences of organ-related complications were comparable. Octogenarians spent more days in the hospital's intensive care unit and surgical ward than did controls (3.4 +/- 3.3 days v 2.7 +/- 3.1 days, p < 0.01; 9.9 +/- 5.8 days v 8.6 +/- 3.8 days, p = 0.02). Only 31 (19.1%) octogenarians were discharged home, whereas the corresponding number was 66 (40.7%) in controls (p < 0.01). CONCLUSIONS: Risk factors other than age were not higher in octogenarians, and the EuroSCORE model predicted mortality and morbidity. Age was an important single risk factor predicting mortality.     

Off pump coronary artery bypass grafting in EuroSCORE high and low risk patients.

OBJECTIVE: Off pump coronary artery bypass grafting (OPCAB) is claimed to reduce the operative morbidity and mortality in high risk patients. It was the aim of the study to compare the outcome of OPCAB patients classified as high- and low risk according to the EuroSCORE. METHODS: Medical records of patients undergoing off pump coronary artery bypass grafting (n=126) at our institution between 1998 and 2001 were retrospectively reviewed. We classified them into two subgroups: low risk (EuroSCORE < or = 5, n=72, male 58 (81%), female 14 (19%), age 61 (37-78) years) and high risk (EuroSCORE >5, n=54, male 32 (59%), female 22 (41%), age 73 (42-83) years). RESULTS: EuroSCORE high risk patients showed significantly higher rates of blood transfusion (70 vs 31%; P<0.0001), intraaortic balloon pump insertion (16 vs 3%; P=0.013), atrial fibrillation (43 vs 22%; P=0.014), and renal failure (13 vs 3%; P=0.028). ICU length of stay was significantly longer in the high risk group (25 vs 22 h; P=0.002). There was also a higher perioperative mortality in the high risk group (9 vs 0%; P=0.008). CONCLUSION: From these data we conclude that using off pump coronary artery bypass grafting results as predicted by the EuroSCORE can be achieved. OPCAB is safe for low risk patients. Major complications seem to occur preferentially in the high risk group.     

Predictive Power and Implication of EuroSCORE,EuroSCORE II and STS Score for Isolated Repeated Aortic Valve Replacement

Objective: We evaluated the predictive power of the EuroSCORE, EuroSCORE II and Society of Thoracic Surgeons (STS) score for isolated redo aortic valve replacement.Materials and Methods: 78 consecutive patients underwent the aforementioned procedure mainly with a stentless valve prosthesis at our institution. Observed mortality was compared to the predicted mortality, Receiver Operating Characteristics (ROC) curves were calculated and the area under the curve (AUC) analyzed.Result: Observed mortality was 11.5%. EuroSCORE and EuroScore II predicted a mortality of 28.2 ± 21.6% (p <0.001) and 10.2 ± 11.8% (p = 0.75), respectively. AUC of the EuroSCORE was 0.74 (95% CI: 0.62–0.83), p = 0.009 and of the EuroSCORE II 0.86 (95% CI: 0.76–0.93), p <0.0001. Optimal Youden index of the EuroSCORE II was 0.59 refering to a predicted mortality of 9.9% (sensitivity: 77.8% and specificity: 81.2%). Predicted mortality of STS score was 17.8 ± 10.6% (p = 0.08) and AUC was 0.64 (95% CI: 0.53–0.75), p = 0.06.Conclusion: EuroSCORE II calculation was not only superior to EuroSCORE and STS score but led to a very realistic mortality prediction for this special procedure at our institution. A EuroSCORE II greater 10 should encourage to consider an alternative treatment.     

Does EuroSCORE predict length of stay and specific postoperative complications after cardiac surgery?

OBJECTIVE: To evaluate the performance of EuroSCORE in the prediction of in-hospital postoperative length of stay and specific major postoperative complications after cardiac surgery. METHODS: Data on 5051 consecutive patients (isolated [74.4%] or combined coronary artery bypass grafting [11.1%], valve surgery [12.0%] and thoracic aortic surgery [2.5%]) were prospectively collected. The EuroSCORE model (standard and logistic) was used to predict in-hospital mortality, 3-month mortality, prolonged length of stay (>12 days) and major postoperative complications (intraoperative stroke, stroke over 24 h, postoperative myocardial infarction, deep sternal wound infection, re-exploration for bleeding, sepsis and/or endocarditis, gastrointestinal complications, postoperative renal failure and respiratory failure). A C statistic (or the area under the receiver operating characteristic curve) was used to test the discrimination of the EuroSCORE. The calibration of the model was assessed by the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS: In-hospital mortality was 3.9% and 16.1% of patients had one or more major complications. Standard EuroSCORE showed very good discriminatory ability and good calibration in predicting in-hospital mortality (C statistic: 0.76, Hosmer-Lemeshow: P=0.449) and postoperative renal failure (C statistic: 0.79, Hosmer-Lemeshow: P=0.089) and good discriminatory ability in predicting sepsis and/or endocarditis (C statistic: 0.74, Hosmer-Lemeshow: P=0.653), 3-month mortality (C statistic: 0.73, Hosmer-Lemeshow: P=0.097), prolonged length of stay (C statistic: 0.71, Hosmer-Lemeshow: P=0.051) and respiratory failure (C statistic: 0.71, Hosmer-Lemeshow: P=0.714). There were no differences in terms of the discriminatory ability in predicting these outcomes between standard and logistic EuroSCORE. However, logistic EuroSCORE showed no calibration (Hosmer-Lemeshow: P<0.05) except for sepsis and/or endocarditis (Hosmer-Lemeshow: P=0.078). EuroSCORE was unable to predict other major complications such as intraoperative stroke, stroke over 24 h, postoperative myocardial infarction, deep sternal wound infection, gastrointestinal complications and re-exploration for bleeding. CONCLUSIONS: EuroSCORE can be used to predict not only in-hospital mortality, for which it was originally designed, but also 3-month mortality, prolonged length of stay and specific postoperative complications such as renal failure, sepsis and/or endocarditis and respiratory failure in the whole context of cardiac surgery. These outcomes can be predicted accurately using the standard EuroSCORE which is very simple and easy in its calculation.     

Assessment of EuroSCORE in patients undergoing aortic valve replacement

Abstract Aims: The logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) is a risk stratification system used to predict the operative risk in patients undergoing surgical aortic valve replacement (AVR). The aim of this study is to investigate how accurate this system is, and how it compares to the observed risk. Methods and results: From January 1, 2004 through December 31, 2009, 1389 patients underwent AVR ± coronary artery bypass grafting (CABG) (865 primary isolated AVR and 524 AVR + CABG) at the New Royal Infirmary Edinburgh. The logistic EuroSCORE was calculated for each patient and summed up for expected in‐hospital mortality. Expected and observed mortalities were compared. On the whole, the in‐hospital mortality was 3% and was overestimated by the logistic EuroSCORE that predicted 7.2% mortality (p = 0.05). This discrepancy was even more pronounced in high‐risk patients, where the in‐hospital mortality was 8%, while the logistic EuroSCORE predicted 19.5% (p = 0.03). Conclusion: The logistic EuroSCORE overestimates the risks for AVR. Therefore, it should not be used to deny high‐risk patients a surgical AVR . (J Card Surg 2011;26:124‐129)     

Acute vagotomy does not augment the systemic inflammatory response in patients with peptic ulcer disease

Recent accumulating evidence suggests that the vagus nerve modulates the response to peripheral immunologic stimuli and that intact vagal mediation decreases the systemic inflammatory response. We hypothesized that patients who had vagotomy for complicated peptic ulcer disease would be at increased risk of an enhanced systemic inflammatory response compared to patients that did not have a vagotomy as part of their operative treatment. Ninety-six patients were identified from 1985 to 2000 and their medical records were reviewed. Patients were assigned to three groups based on the performance of a truncal vagotomy: truncal vagotomy (TV; N = 62 patients), nontruncal vagotomy (NTV; N = 34 patients), or a subgroup of the TV group, acute truncal vagotomy (ATV; N = 40 patients). Operative indications in the NTV and ATV groups were perforation (94% vs 47%) and bleeding (6% vs 53%). Systemic or organ-specific complications did not differ between groups (NTV vs ATV), and the sepsis (24% vs 23%) and mortality rates (29% vs 20%) were similar. The ICU and hospital length of stay did not differ substantially among the groups. This clinical study demonstrated that acute truncal vagotomy does not increase the risk of the systemic inflammatory response in surgical patients with complicated peptic ulcer disease.     

Validation of Euroscore model in an Australian patient population

BACKGROUND: The purpose of the present paper was to assess the performance of the European system for cardiac operative risk evaluation (EuroSCORE) model in an Australian adult cardiac surgical population. METHODS: The additive and logistic EuroSCORE models were retrospectively applied to predict operative mortality in 2106 consecutive patients undergoing cardiac surgery at St Vincent's Hospital, Melbourne between June 2001 and August 2003, and at Geelong Hospital between June 2001 and April 2004. The entire cohort and a subset of patients undergoing isolated coronary artery bypass graft (CABG) surgery were analysed. Model discrimination and calibration was tested by determining the area under the receiver operating characteristic (ROC) curve and Hosmer-Lemeshow chi2, respectively. RESULTS: There were significant differences in the prevalence of risk factors between the Australian and European cardiac surgical populations. There were 81 deaths (observed mortality 3.85%) in the entire cohort and 39 deaths in the isolated CABG group (observed mortality 2.60%). The EuroSCORE models overestimated mortality (entire cohort: additive predicted 5.75%, logistic predicted 9.93%; isolated CABG: additive predicted 4.87%, logistic predicted 7.71%). Discriminative power was very good for the entire cohort (area under ROC curve, 0.81 (additive) and 0.82 (logistic)). Calibration of both models was poor. CONCLUSION: The additive and logistic EuroSCORE model of risk prediction was not validated in the present population of cardiac surgical patients. The models may not accurately predict outcomes of patients undergoing cardiac surgery in Australia.     

Assessment of pulmonary complications after lung resection.

BACKGROUND: We assessed the utility of maximum oxygen consumption during exercise (MVO2) and diffusing capacity for carbon monoxide (DL(CO)) in the prediction of postoperative pulmonary complications, and the effect of such complications on postoperative length of hospital stay and the cost of hospitalization. METHODS: Candidates for lung resection were prospectively studied by preoperative measurement of DL(CO) (expressed as a percentage of predicted [DL(CO)%]) and MVO2. Postoperative pulmonary complications, duration of postoperative hospitalization, and the cost of hospitalization were assessed. RESULTS: Forty patients had lung resection with no operative mortality. The postoperative length of hospitalization was longer for the 13 patients who developed pulmonary complications compared with the 27 patients who did not (7.7+/-0.8 vs 5.0+/-0.4 days, respectively; p = 0.007), and the cost of hospitalization in the former group was higher ($11,530+/-$1,959 vs $6,578+/-$406, respectively; p = 0.031). Diffusing capacity was higher in patients without than in patients with pulmonary complications (DL(CO)% 90.1+/-5.0 vs 65.3+/-5.9; p = 0.0034). The mean MVO2 did not differ between the groups (17.8+/-0.9 vs 16.3+/-1.2). DL(CO)% predicted pulmonary complications (p = 0.006). CONCLUSIONS: DL(CO)% predicts the likelihood of pulmonary complications after major lung resection, which are associated with increased length of hospital stay and cost.     

Validation of European System for Cardiac Operative Risk Evaluation (EuroSCORE) in North American cardiac surgery.

OBJECTIVE: To assess the performance of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) when applied in a North American cardiac surgical population. METHODS: The simple additive EuroSCORE model was applied to predict operative mortality (in-hospital or 30-day) in 401684 patients undergoing coronary or valve surgery in 1998 and 1999 as well as in 188913 patients undergoing surgery in 1995 in the Society of Thoracic Surgeons (STS) database. RESULTS: The proportion of isolated coronary artery bypass grafting (CABG) was greater in STS patients (84%) than in Europe (65%). STS patients were also older (mean age 65.3 versus 62.5), and had more diabetes (30 versus 17%) and prior cardiac surgery (11 versus 7%). Other comorbidity was also significantly more prevalent in STS patients. EuroSCORE predicted overall mortality was virtually identical to the observed mortality (1998/1999: predicted 3.994%, observed 3.992%; 1995: observed and predicted 4.156%). Predicted mortality also closely matched observed mortality across the risk groups. Discrimination was good to very good for the population overall and for isolated CABG in both time periods, with the area under the receiver operating characteristic curve between 0.75 and 0.78. CONCLUSION: Despite substantial demographic differences between Europe and North America, EuroSCORE performs very well in the STS database, and can be recommended as a simple, additive risk stratification system on both sides of the Atlantic.     

Off-pump coronary surgery in selected patients: better early outcome but more recurrence of angina?

This non-randomized retrospective study included all patients operated on for CABG through median sternotomy between January 2000 and December 2002 by the same surgeon trained to both techniques. Using risk-adjusted comparison where expected mortality was given by the EuroSCORE value assessed pre-operatively, and studying mid-term survival and functional results we aimed to evaluate our indications for OPCAB versus conventional CABG through a consecutive series of 308 patients. Selected indications for OPCAB (n=154) were isolated LAD coronary system lesions and multivessel diseases with suitable anatomy in high surgical risk patients (EuroSCORE > or = 5). The first 154 patients operated on conventionally during the time-study interval were included in the control group. Expected mortality was significantly higher in the OPCAB group: 4.29 [95% CI: 3.83-4.77] vs. 3.54 [95% CI: 3.17-3.91] (P=0.024). Observed mortality was 1.3% and 2.6% for patients treated OPCAB and with conventional technique, respectively. Survival at three years was 91.5 and 93.8% in the conventional and OPCAB groups, respectively. Angina-free survival at three years was 95.8% and 89.6% in the conventional and OPCAB groups, respectively (P=0.04). To promote OPCAB in selected patients results in decreasing operative risk to the price of worsening late functional results.     

Logistic or additive EuroSCORE for high-risk patients?

OBJECTIVES: To assess whether the use of the full logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) is superior to the standard additive EuroSCORE in predicting mortality in high-risk cardiac surgical patients. METHODS: Both the simple additive EuroSCORE and the full logistic EuroSCORE were applied to 14,799 cardiac surgical patients from across Europe, of whom there were 4293 high-risk patients (additive EuroSCORE of 6 or more). The systems were compared for absolute prediction and discrimination (area under the receiver operating characteristic (ROC) curve). RESULTS: Actual mortality was 4.72%. The logistic model was closer to this than the additive model (4.84% (4.72-4.94) versus 4.21 (4.21-4.26)). Most of this difference was due to high-risk patients where actual mortality was 11.18% and predicted was 7.83% (additive) and 11.23% (logistic). Discrimination was similar in both systems as measured by the area under the ROC curve (additive 0.783, logistic 0.785). CONCLUSIONS: The additive EuroSCORE model remains a simple "gold standard" for risk assessment in European cardiac surgery, usable at the bedside without complex calculations or information technology. The logistic model is a better risk predictor especially in high-risk patients and may be of interest to institutions engaged in the study and development of risk stratification.     

The logistic EuroSCORE predicts the hospital mortality of the thoracic aortic surgery in consecutive 327 Japanese patients better than the additive EuroSCORE.

OBJECTIVE: Risk stratification in thoracic aortic surgery is a topic of major interest. Recent studies have shown the European System for Cardiac Operative Risk Evaluation (EuroSCORE) to be an extremely useful and reliable risk stratification score and also a good indicator of quality of care in cardiac surgery. The purpose of this study was to evaluate the significance of the additive and logistic EuroSCOREs in patients undergoing surgery on the thoracic aorta in Japan. METHODS: We calculated the predicted mortality according to the additive and logistic EuroSCORE algorithms in 327 consecutive patients who underwent surgery of the thoracic aorta during a 30-year period (between 1976 and 2005). We compared the score validity between the two algorithms and also evaluated the score validity for the patients who underwent thoracic aortic surgery. The score validity was assessed by calculating the area under the receiver operating characteristic (ROC) curve. RESULTS: The overall in-hospital mortality was 13%. The area under the ROC curve was satisfactorily high for the additive (0.68, 0.73, 0.73) as well as the logistic EuroSCORE (0.69, 0.74, 0.75) in the patients who underwent thoracic aortic surgery during 30-, 20-, and 10-year periods, respectively. The actual mortality was 7% (Group 1; an additive EuroSCORE of 3-6), 16% (Group 2; 7-11), and 37% (Group 3; >12). The mortality expected by the additive and logistic EuroSCORE in the three different risk groups were (5%, 9%, 19%) and (5%, 14%, 43%), respectively. Namely, the mortality expected by the logistic EuroSCORE perfectly matched with the actual mortality in any of the three risk groups. In contrast, the mortality expected by the additive EuroSCORE tended to dissociate when the number of risks increased. Significant difference was observed between the observed mortality and the mortality expected by the additive EuroSCORE algorithm in the high-risk group (p=0.0473). CONCLUSIONS: Although both the additive and the logistic EuroSCORE reliably predicted the overall operative mortality for thoracic aortic surgery in 327 Japanese patients, the logistic EuroSCORE better matched with the actual mortality in the operative risk especially in the high-risk group.     

Vasopressin as a rescue vasopressor agent. Treatment of selected cardiogenic shock states

Vasodilatory shock is the most common form of shock in the critically ill patient. As a consequence of overwhelming and prolonged mediator production, vasodilatory shock can be the common final pathway of primary non-vasodilatory shock (e.g. cardiogenic or hypovolemic shock). A supplementary infusion of arginine vasopressin (AVP) showed beneficial effects on hemodynamics and potentially on the outcome in patients with vasodilatory shock due to sepsis or after major surgery. In this case series, successful administration of AVP in three surgical patients with primary cardiogenic shock forms is reported. The hemodynamic effects of AVP were comparable to those AVP-induced alterations described in septic shock and seem to be predominantly mediated by potent vasoconstriction and the facilitated reduction of higher, potentially toxic catecholamine doses. Thus, an AVP-induced decrease in heart rate and pulmonary arterial pressures may be particularly beneficial in patients with impaired cardiac function.     

Vasopressin als Reservevasopressor

Vasodilatory shock is the most common form of shock in the critically ill patient. As a consequence of overwhelming and prolonged mediator production, vasodilatory shock can be the common final pathway of primary non-vasodilatory shock (e.g. cardiogenic or hypovolemic shock). A supplementary infusion of arginine vasopressin (AVP) showed beneficial effects on hemodynamics and potentially on the outcome in patients with vasodilatory shock due to sepsis or after major surgery. In this case series, successful administration of AVP in three surgical patients with primary cardiogenic shock forms is reported. The hemodynamic effects of AVP were comparable to those AVP-induced alterations described in septic shock and seem to be predominantly mediated by potent vasoconstriction and the facilitated reduction of higher, potentially toxic catecholamine doses. Thus, an AVP-induced decrease in heart rate and pulmonary arterial pressures may be particularly beneficial in patients with impaired cardiac function.     

Validation of the EuroSCORE model in Australia.

OBJECTIVE: There is an important role for accurate risk prediction models in current cardiac surgical practice. Such models enable benchmarking and allow surgeons and institutions to compare outcomes in a meaningful way. They can also be useful in the areas of surgical decision-making, preoperative informed consent, quality assurance and healthcare management. The aim of this study was to assess the performance of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) model on the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) patient database. METHODS: The additive and logistic EuroSCORE models were applied to all patients undergoing cardiac surgery at six institutions in the state of Victoria between 1st July 2001 and 4th July 2005 within the ASCTS database who have complete data. The entire cohort and a subgroup of patients undergoing coronary artery bypass grafting (CABG) only were analysed. Observed and predicted mortalities were compared. Model discrimination was tested by determining the area under the receiver operating characteristic (ROC) curve. Model calibration was tested by the Hosmer-Lemeshow chi-square test. RESULTS: Eight thousand three hundred and thirty-one patients with complete data were analysed. There were significant differences in the prevalence of risk factors between the ASCTS and European cardiac surgical populations. Observed mortality was 3.20% overall and 2.00% for the CABG only group. The EuroSCORE models over estimated mortality (entire cohort: additive predicted 5.31%, logistic predicted 8.76%; CABG only: additive predicted 4.25%, logistic predicted 6.19%). Discriminative power of both models was very good. Area under ROC curve was 0.83 overall and 0.82 for the CABG only group. Calibration of both models was poor as mortality was over predicted at nearly all risk deciles. Hosmer-Lemeshow chi-square test returned P-values less than 0.05. CONCLUSIONS: The additive and logistic EuroSCORE does not accurately predict outcomes in this group of cardiac surgery patients from six Australian institutions. Hence, the use of the EuroSCORE models for risk prediction may not be appropriate in Australia. A model, which accurately predicts outcomes in Australian cardiac surgical patients, is required.     

Single centre, single domain validation of the EuroSCORE on a consecutive sample of primary and repeat CABG

Objectives: Intra- and interdepartmental benchmarking require scoring systems with excellent performance on several properties: discrimination (resolution), reliability (calibration) and stability over the complete spectrum of peri-procedural risk. This single centre, single domain study validates the European system for cardiac operative risk evaluation (EuroSCORE) on an independent sample of primary and repeat coronary artery bypass grafting (CABG) patients and will evaluate these different properties. Methods: The study population is a consecutive series of 2051 isolated primary and repeat CABG patients, inclusive of patients in cardiogenic shock or resuscitation, operated on in a single institution from January 1997 to July 2000. The age of the patients was 66±9 years, 77% were males and 7% were repeat procedures. The EuroSCORE was 5.0±3%, with a range from 0 to 22. The studied event was in-hospital death, defined as mortality during hospital stay, which was unlimited in time and included a stay in a secondary hospital without discharge home. Results: The EuroSCORE predicted 102 deaths versus 81 deaths observed (P=0.14, Fisher exact test). The EuroSCORE described only 20% of the variance of in-hospital mortality. The EuroSCORE created an area under the receiver operating characteristic curve of 0.83±0.03. The highest discriminative accuracy was obtained with 8% EuroSCORE risk (only 64% sensitivity and 87% specificity). Further exploration identified an over score in the EuroSCORE range 0–8 (57%, P<0.0001). There was an equal score (−2%, P=1) in the range 9–11, but an under score in the range 12–22 (−133%, P=0.003). Conclusions: On the condition that these single centre results could be extended to any European cardiac surgery centre, it can be concluded that the overall acceptable performance of the EuroSCORE is the result of an over score in the lower risk and insufficient correction in the higher risk spectrum. The EuroSCORE is probably refined enough for improved informed consent versus aggregated results but should only be used for inter-institutional benchmarking with great caution, preferably below the 12% risk pivot.     

Delayed massive hemorrhage after pancreatic and biliary surgery: embolization or surgery?

OBJECTIVE: To analyze the management of delayed massive hemorrhage (DMH) after major pancreatic and biliary surgery. SUMMARY BACKGROUND DATA: Despite a decreased mortality rate for pancreatic and biliary surgery, DMH is still an important cause of postoperative mortality. The aim of the present study was to analyze the management of DMH after pancreatic and biliary surgery, and specifically to assess the role of embolization and surgical intervention. METHODS: The study group (SG) consisted of 1010 patients from 1994 to 2002 who underwent pancreatic or biliary surgery (cholecystectomy excluded). Patients from a previous study (1983-1993, n = 686) were used as a historical control group (HCG). RESULTS: The incidence of DMH (SG 2.3% vs. HCG 3.2%) declined somewhat but did not differ significantly between both periods. The number of patients with a septic complication (SG 74% vs. HCG 50%) and a sentinel bleed (SG 78% vs. HCG 100%) before the onset of DMH did not differ significantly. Embolization (SG 2 of 2 patients vs. HCG 0 of 2 patients) was not used frequently. Successful outcome after surgical intervention (SG 14 of 16 patients vs. HCG 8 of 14 patients) and the surgical procedures performed to obtain hemostasis were comparable and overall mortality (SG 22% vs. HCG 29%) was comparable. CONCLUSIONS: The incidence of DMH declined somewhat from 3.2% to 2.3% over the past years. Most patients present with septic complications and a sentinel bleed before onset of DMH. Despite general acceptance of embolization in our unit, it was used infrequently in patients with DMH. Aggressive surgical intervention was the treatment of choice in patients with DMH after pancreatic or biliary surgery.