Hyperglycemia is associated with increased mortality and morbidity in critically ill patients. Surgical patients commonly develop hyperglycemia related to the hypermetabolic stress response, which ...increases glucose production and causes insulin resistance. Although hyperglycemia is associated with worse outcomes, the treatment of hyperglycemia with insulin infusions has not provided consistent benefits. Despite early results, which suggested decreased mortality and other advantages of "tight" glucose control, later investigations found either no benefit or increased mortality when hyperglycemia was aggressively treated with insulin. Because of these conflicting data, the optimal glucose concentration to improve outcomes in critically ill patients is unknown. There is agreement, however, that hypoglycemia is an undesirable complication of intensive insulin therapy and should be avoided. In addition, the risk of increased glucose variability should be recognized, because of the associated increased risk for worse outcomes. Patients with diabetes mellitus experience chronic hyperglycemia and often require more intensive perioperative glucose management. When diabetic patients are evaluated before surgery, appropriate management of oral hypoglycemic agents is necessary as several of these agents warrant special consideration. Current recommendations for perioperative glucose management from national societies are varied, but, most suggest that tight glucose control may not be beneficial, while mild hyperglycemia appears to be well-tolerated.
Long-axis right ventricular (RV) function, which provides nearly 80% of RV ejection, acutely decreases during cardiac surgery. RV dysfunction increases risk for perioperative morbidity and mortality. ...Our objective was to characterize the change in perioperative RV long-axis and global function by determining the influence of procedure type, surgical approach, and reoperative status and examining its temporal relationship to pericardiotomy versus cardiopulmonary bypass (CPB) and cardioplegia.
Standardized transesophageal echocardiographic examinations (TEEs) were prospectively performed in 109 patients undergoing coronary artery bypass grafting, mitral or aortic valve surgery, and/or aortic surgery via full sternotomy, mini-sternotomy, or right thoracotomy. Mid-esophageal, 4-chamber views centered on the RV were recorded at 4 intraoperative time points, following: (1) anesthetic induction; (2) pericardiotomy; (3) CPB; and (4) chest closure. Long-axis RV function was assessed by tricuspid annular plane systolic excursion and 2-dimensional longitudinal RV strain, and global RV function by fractional area change (FAC), calculated off-line from 2-dimensional TEE images.
TEE measures of RV function were significantly reduced after CPB compared with baseline (baseline vs after CPB: TAPSE 2.2 Q1, Q3: 1.8, 2.5 vs 1.5 1.1, 1.7 mm; RV strain −22 −24, −18 vs −16 −20, −14 %; FAC 45 35, 51 vs 42 34, 49 %), but not after pericardiotomy. Reduced RV function persisted after chest closure: tricuspid annular plane systolic excursion 1.3 1.0, 1.6 mm, RV strain −16 −18, −13%, FAC 38 31, 46 %. Reduced function was demonstrated across cardiac surgical procedures, approaches, and primary and reoperative surgery.
Acute intraoperative reduction in RV function occurs following CPB, independent of procedural characteristics and pericardiotomy. Etiology and clinical implications of reduced perioperative RV function remain to be determined.
Right ventricular (RV) function, measured echocardiographically using tricuspid annular plane systolic excursion (TAPSE), RV peak systolic longitudinal strain, and fractional area change (FAC), was examined in 109 patients having cardiac surgery after anesthetic induction, after pericardiotomy, after separation from cardiopulmonary bypass (CPB), and after chest closure. RV function was reduced at end of surgery in patients having diverse surgical procedures, diverse surgical approaches, and in patients having primary versus reoperative surgery. Display omitted
Severe hyperglycemia is associated with adverse outcomes after cardiac surgery. Whether intraoperative and postoperative glucose concentrations equally impact outcomes is unknown. The objective of ...this investigation was to compare the ability of perioperative glucose concentrations and glycemic variability to predict adverse outcomes. Risk associated with decreasing increments of glucose concentrations, hypoglycemia, and diabetic status was also examined.
This retrospective analysis of prospectively collected data included 4,302 patients who underwent cardiac surgery between October 3, 2005 and May 31, 2007 at the Cleveland Clinic. Time-weighted mean intraoperative (GlcOR) and postoperative (GlcICU) glucose concentrations were calculated. Patients were categorized as follows: Glc more than 200, 171-200, 141-170, and less than or equal to 140 mg/dl. Coefficient of variation was used to calculate glycemic variability. Logistic regression model with backward selection assessed the relationship between glucose concentrations, variability, and adverse outcomes while adjusting for potential confounders. Another model assessed the predictability of GlcOR and GlcICU on adverse outcomes.
Both GlcOR and GlcICU predicted risk for mortality and morbidity. Increased postoperative glycemic variability was associated with increased risk for adverse outcomes. Severe hyperglycemia (GlcOR and GlcICU > 200 mg/dl) was associated with worse outcomes; however, decreasing increments of GlcOR did not consistently reduce risk. GlcOR less than or equal to 140 mg/dl was not associated with improved outcomes compared with severe hyperglycemia, despite infrequent hypoglycemia. Diabetic status did not influence the effects of hyperglycemia.
Perioperative glucose concentrations and glycemic variability are important in predicting outcomes after cardiac surgery. Incremental decreases of intraoperative glucose concentrations did not consistently reduce risk. Despite rare hypoglycemia, intraoperative glucose concentrations closest to normoglycemia were associated with worse outcomes.
Risk factors, resource use, and cost of postoperative low cardiac output syndrome Duncan, Andra E.; Kartashov, Alex; Robinson, Scott B. ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
20/May , Volume:
163, Issue:
5
Journal Article
Peer reviewed
Open access
Low cardiac output syndrome complicates recovery after cardiac surgery. We examined the incidence and risk factors for low cardiac output syndrome and its association with postoperative mortality, ...morbidity, resource use, and cost.
This cross-sectional retrospective observational study examined patients having cardiac surgery captured in the Premier Healthcare Database. Low cardiac output syndrome was defined as the requirement for postoperative mechanical circulatory support and/or hemodynamic instability requiring prolonged inotropic support. Incidence, risk factors, and association of low cardiac output syndrome with postoperative outcomes, including mortality, hospital and intensive care unit length of stay, hospital readmission, and cost at 30 days, 90 days, and 6 months, were examined.
Among 59,810 patients from 164 hospitals having cardiac surgery between July 1, 2012, and June 30, 2014, low cardiac output syndrome developed in 6067 (10.1%) patients. Patients presenting in cardiogenic shock or systolic (± diastolic) heart failure were at greatest risk. Risk-adjusted in-hospital mortality was 12-fold greater with low cardiac output syndrome (odds ratio, 12.0; 95% confidence interval, 10.6-13.5). Risk-adjusted hospital costs (2019$; median Q1, Q3) were $64,041 21,439 in patients who developed low cardiac output syndrome versus $48,086 16,098 without; P < .001. Increased costs were driven by longer risk-adjusted hospital stay (10.1 4.5 vs 8.5 3.8 days); P < .001, intensive care unit (5.5 2.5 vs 3.3 1.5 days; P < .001) stay, and all-cause 30-day adjusted hospital readmission rates (mean SD 16.6 8.2% vs 13.9 7.2%; P < .001).
Cardiac surgical patients who develop postoperative low cardiac output syndrome suffer greater mortality and have greater resource use, health care costs, and all-cause readmission, which informs perioperative decision making, and impacts hospital performance metrics and federal priority to reduce health care costs.
Graphical abstract that describes the study population, provides the definition of low cardiac output syndrome, and includes the percentage of patients who experience postoperative low cardiac output syndrome overall and by procedure. The adjusted hospital costs, ICU stay, and readmission data are compared in patients with and without low cardiac output syndrome. Most important risk factors for low cardiac output syndrome and adjusted risk for mortality are also shown. Display omitted
Postoperative pulmonary complications increase mortality after cardiac surgery. Conventional ultrafiltration may reduce pulmonary complications by removing mediators of bypass-induced inflammation ...and countering hemodilution. We tested the primary hypothesis that conventional ultrafiltration reduces postoperative pulmonary complications, and secondarily, improves early pulmonary function assessed by the ratio of PaO
to fractional inspired oxygen concentration.
This retrospective analysis compared the incidence of postoperative pulmonary complications in adult patients who underwent cardiac surgery, with and without the use of conventional ultrafiltration, by using logistic regression with adjustment for confounding variables. The primary outcome was a composite of reintubation, prolonged ventilation, pneumonia, or pleural effusion. Secondarily, we examined early postoperative lung function using a quantile regression model. We also explored whether red blood cell transfusion differed between groups.
Of 8026 patients, 1043 (13%) received conventional ultrafiltration. After adjustment for confounding variables, the incidence of the composite primary outcome was higher in the conventional ultrafiltration group (12.1% vs 9.9%; P = .03), with an estimated odds ratio of 1.25 (95% CI, 1.02-1.53; P = .03). The median (quantiles) PaO
-to-fractional inspired oxygen concentration ratio was 373 (303-433) vs 368 (303-428), with the estimated adjusted difference in medians of 5 (95% CI, -5.9 to 16; P = .37). The estimated odds ratio of intraoperative transfusion was 1.38 (95% CI, 1.19-1.60; P < .0001) and for postoperative transfusion was 1.30 (95% CI, 1.14-1.49; P = .0001).
Use of conventional ultrafiltration was not associated with a reduction in the composite of postoperative pulmonary complications or improved early pulmonary function. We found no evidence of benefit from use of conventional ultrafiltration during cardiac surgery.
Right ventricular failure after left ventricular assist device implantation increases postoperative morbidity and mortality. Whether intraoperative echocardiographic and hemodynamic measurements ...predict right ventricular failure is unclear. Speckle-tracking-derived tricuspid annulus displacement may provide a useful, effective, and straightforward predictor of severe right ventricular failure in patients having left ventricular device implantation. The aim of this study was to determine if intraoperative tricuspid annulus displacement is a stronger discriminator compared with the global longitudinal strain and modified tricuspid annular plane systolic excursion, the Michigan risk score, and pulmonary artery pulsatility index.
Retrospective analysis.
A tertiary-care referral center.
Patients scheduled for left ventricular assist device implantation from January 2010 to December 2017.
None
The authors examined 86 patients undergoing left ventricular assist device implantation with adequate intraoperative echocardiographic images. The analyses did not demonstrate an association between tricuspid annulus displacement and severe right ventricular failure (univariate C-statistics <0.60 for all 4 echocardiographic measures). The discrimination ability was not significantly better than strain (DeLong test p = 0.44) and modified tricuspid annular plane systolic excursion (p = 0.89). The discrimination ability of tricuspid annulus displacement measurements was not better than the Michigan risk score (p = 0.65) and pulmonary artery pulsatility index (p = 0.73).
Intraoperative echocardiographic parameters, including tricuspid annulus displacement, modified tricuspid annular plane systolic excursion, and strain, are poor discriminators of severe right ventricular failure after left ventricular assist device implantation. The preoperative Michigan risk-scoring system and intraoperative pulmonary artery pulsatility index are equally unreliable.
Perioperative right ventricular function is a significant predictor of patient outcomes after cardiac surgery. This prospective study aimed to identify perioperative factors associated with reduced ...intraoperative right ventricular function.
Right ventricular function was assessed at the beginning and end of surgery by standardized transesophageal echocardiographic measurements, including tricuspid annular plane systolic excursion, peak systolic longitudinal right ventricular strain, and fractional area change, in 109 adult patients undergoing cardiac surgery at Cleveland Clinic. Associations between right ventricular function and 33 patient characteristics and perioperative factors were analyzed by random forest machine learning. The relative importance of each variable in predicting right ventricular function at the end of surgery was determined.
Longer aortic clamp duration and lower baseline right ventricular function were highly important variables for predicting worse right ventricular function measured by tricuspid annular plane systolic excursion, right ventricular strain, and fractional area change at the end of surgery. For example, right ventricular function after longer aortic clamp times of 100-120 minutes was worse (median Q1, Q3 tricuspid annular plane systolic excursion 1.0 0.9, 1.1 cm) compared with right ventricular function after shorter aortic clamp times of 50 to 70 minutes (tricuspid annular plane systolic excursion 1.5 1.3, 1.7; P = .001). Right ventricular strain at the end of surgery was reduced in patients with worse baseline right ventricular function compared with those with higher baseline right ventricular function (end of surgery right ventricular strain in lowest quartile −13.7 −16.6, −12.4% vs highest quartile −17.7 −18.6, −15.3% of baseline right ventricular function; P = .043).
Intraoperative decline in right ventricular function is associated with longer aortic clamp time and worse baseline right ventricular function. Efforts to optimize these factors, including better myocardial protection strategies, may improve perioperative right ventricular function.
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