Reducing delirium and cognitive dysfunction after off-pump coronary bypass: A randomized trial

BackgroundNeuropsychiatric complications of surgical coronary revascularization are inconspicuous but frequent and clinically relevant. So far, attempts to reduce their occurrence, such as the introduction of off-pump coronary artery bypass (OPCAB) grafting method, have not brought the desired results. The aim of this trial was to determine whether using any of the 2 selected modifications of OPCAB could decrease the incidence of these undesired sequelae.MethodsIn this single-center, assessor- and patient-blinded, superiority, randomized controlled trial, 192 patients scheduled for elective isolated OPCAB were randomized to 3 parallel arms. The control arm underwent “conventional” OPCAB with vein grafts. The first study arm underwent anaortic OPCAB (ANA) with total arterial revascularization. The second study arm underwent OPCAB with vein grafts using carbon dioxide surgical field flooding (CO₂FF). Outcomes included the incidence of postoperative delirium (PD) and early postoperative cognitive dysfunction (ePOCD).ResultsThe incidence of PD was 35.9% in the control (OPCAB) arm, 32.8% in the CO₂FF arm, and 12.5% in the ANA arm (χ² [2, N = 191] = 10.17; P = .006). Post hoc tests revealed that the incidence of PD in the ANA arm differed from that in the OPCAB arm (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.09-0.68; P = .002). The incidence of ePOCD was 34.4% in the OPCAB arm, 28.1% in the CO₂FF arm, and 9.5% in the ANA arm (χ² [2, N = 191] = 11.58; P = .003). Post hoc tests revealed that the incidence of ePOCD differed between the ANA and OPCAB arms (OR, 0.20; 95% CI, 0.06-0.58; P < .001).ConclusionsPerforming ANA significantly decreases the incidence of PD and ePOCD compared with “conventional” OPCAB with vein grafts, whereas CO₂FF is inconsequential in this regard. These results, which probably reflect decreased delivery of embolic load to the brain in ANA, may have practical applicability in daily practice to improve clinical outcomes.     

Outcomes of Donation After Circulatory Death Heart Transplantation in Australia

Background

Transplantation of hearts retrieved from donation after circulatory death (DCD) donors is an evolving clinical practice.

持续质量改进在降低ICU呼吸机相关肺炎感染管理中的作用

目的 针对ICU呼吸机相关肺炎(VAP)感染率较高和引起VAP感染的各种因素,探讨运用持续质量改进措施在降低VAP感染率和医务人员对VAP防控措施执行依从性的作用。方法 选择2017年7月1日—2018年6月30日,入住ICU行机械通气超过48 h且无肺部基础疾病的重症患者,用随机数字表法分为观察组(55例)和对照组(55例),对照组采取常规诊疗与护理措施,观察组运用持续质量改进法,比较2组VAP感染率及医护集束化控制措施执行依从率的变化。结果 观察组患者VAP千日感染率(11.3‰)明显低于对照组(27.5‰),差异有统计学意义(χ2=6.11,P<0.05)。医护人员对VAP预防措施执行项目的依从率,2组比较差异均有统计学意义(P<0.05)。结论 持续质量改进一方面能降低ICU VAP感染率,另一方面提高了医护人员对落实各项管理措施执行的依从性,提升了医护管理质量,保障了患者的诊疗安全。     

ICU护理质量评价指标的研究

目的 建立客观的、有针对性的ICU护理质量指标,补充传统的趋于共性的护理质量评价指标.方法 采用问卷调查、实地调查、专家咨询(德尔菲)方法和资料分析法对指标框架进行初步设置,根据科学、客观、可行、有效的原则,采用层次分析法及德尔菲法对指标进行筛选与论证,并计算各指标权重.结果 确立ICU护理质量评价指标体系,分为3个一级指标,12个二级指标,47个三级指标.结论 专家对指标评价结果的意见一致程度均较高,显示指标体系的可信度较高,为ICU指标体系的进一步构建提供客观依据.     

ICU患者意外拔管的观察与预防

目的分析我院重症监护室（ICU）置管患者意外拔管、脱管的原因并提出有效的防护措施。方法对我院261例次ICU置管患者的临床资料进行回顾性分析。结果有16例次发生意外拔管，因护理评估不足，没有及时采取相应措施而拔管的14例次，占87．5％；因医护人员操作不当而拔管的2例次，占12．5％。结论对意外拔管、脱管的风险评估和防护、正确可靠的固定、充分的沟通、适度镇静和肢体约束，是防止ICU患者意外拔管脱管的有效预防措施。     

The association between hepatitis C infection and survival after orthotopic liver transplantation

BACKGROUND & AIMS: The effect of hepatitis C viral (HCV) infection on patient and allograft survival after orthotopic liver transplantation is controversial. Hepatitis C recurrence after transplant is inevitable, but studies to date have not found a survival difference between recipients with and without HCV. METHODS: Using data from the United Network for Organ Sharing, we performed a retrospective cohort study of 11,036 patients who underwent 11,791 liver transplants between 1992 and 1998. The hazard rates of patient and allograft survival for patients who were HCV-positive as compared with patients who were HCV-negative were assessed by proportional-hazards analysis, with adjustment for potential confounding variables, including donor, recipient, and transplant center characteristics. RESULTS: Liver transplantation in HCV-positive recipients was associated with an increased rate of death (hazard ratio, 1.23; 95% confidence interval [CI], 1.12-1.35) and allograft failure (hazard ratio, 1.30; 95% CI, 1.21-1.39), as compared with transplantation in HCV-negative recipients. This reduction in survival persisted after adjusting for potential confounders. There was an interaction between HCV and sex (P < 0.001) with the effect of HCV on survival being most pronounced in female recipients (patient survival hazard ratio, 1.56; 95% CI, 1.35-1.81; allograft survival hazard ratio, 1.51; 95% CI, 1.34-1.70). CONCLUSIONS: HCV infection significantly impairs patient and allograft survival after liver transplantation.