Pro: 24/7 In-House Intensivist Coverage in the CTICU Kidd, Brent; Flynn, Brigid C.
Journal of cardiothoracic and vascular anesthesia,
November 2021, 2021-11-00, 20211101, Letnik:
35, Številka:
11
Journal Article
Previous reports of early extubation after cardiac surgical procedures vary in the definition of “early” and may limit findings to patients with less preoperative risk. This study sought to determine ...whether an eight-tier multidisciplinary early extubation protocol with the goal of extubating within 6 hours postoperatively would be successful without increasing adverse events in patients with increased preoperative risk.
Postoperative adult cardiac surgical patients in a tertiary care intensive care unit (n = 459) were analyzed 6 months before and 6 months after implementation of the protocol. The Society of Thoracic Surgeons (STS) risk scores were used as surrogate markers of risk. Patients with STS scores (n = 333) were stratified into four equal groups from lowest to highest score. A composite of acute renal failure, reintubation, stroke, and mortality was the primary outcome. Secondary outcomes included intensive care unit and hospital lengths of stay, reoperation, and sternal wound infection.
In all patients, ventilation times were significantly decreased from a median of 7.4 hours to 5.7 hours after protocol implementation. When stratified by STS scores, higher-risk patients (groups 3 and 4) had the largest reduction in ventilation times from a median of 9.2 hours to 5.7 hours (p < 0.0001) without a significant increase in adverse events. The highest-risk patients (STS score >40%; n = 14) all had extubation times shorter than 6 hours after the protocol with no significant increase found in adverse events (p = 0.138).
A prudent and diligent multifaceted early extubation protocol may be successful in high-risk cardiac surgical patients without an increase in adverse outcomes. A larger study is needed in the future to confirm the finding.
This study evaluated whether the postoperative pulmonary artery pulsatility index (PAPi) is associated with postoperative right ventricular dysfunction after durable left ventricular assist device ...(LVAD) implantation.
Single-center retrospective observational cohort study.
The University of Kansas Medical Center, a tertiary-care academic medical center.
Sixty-seven adult patients who underwent durable LVAD implantation between 2017 and 2019.
All patients underwent open cardiac surgery with cardiopulmonary bypass under general anesthesia with pulmonary artery catheter insertion.
Clinical and hemodynamic data were collected before and after surgery. The Michigan right ventricular failure risk score and the European Registry for Patients with Mechanical Circulatory Support score were calculated for each patient. The primary outcome was right ventricular failure, defined as a composite of right ventricular mechanical circulatory support, inhaled pulmonary vasodilator therapy for 48 hours or greater, or inotrope use for 14 days or greater or at discharge. Thirty percent of this cohort (n = 20) met the primary outcome. Preoperative transpulmonary gradient (odds ratio OR 1.15, 95% CI 1.02-1.28), cardiac index (OR 0.83, 95% CI 0.71-0.98), and postoperative PAPi (OR 0.85, 95% CI 0.75-0.97) were the only hemodynamic variables associated with the primary outcome. The addition of postoperative PAPi was associated with improvement in the predictive model performance of the Michigan score (area under the receiver operating characteristic curve 0.73 v 0.56, p = 0.03). An optimal cutoff point for postoperative PAPi of 1.56 was found.
The inclusion of postoperative PAPi offers more robust predictive power for right ventricular failure in patients undergoing durable LVAD implantation, compared with the use of existing risk scores alone.
PDF
