The effect of postoperative gastrointestinal complications in patients undergoing coronary artery bypass surgery

Risk factors for ischemic gastrointestinal complications in patients undergoing open cardiac surgical procedures: A single-center retrospective experience

BACKGROUND

Ischemic gastrointestinal complications (IGIC) following cardiac surgery are associated with high morbidity and mortality and remain difficult to predict. We evaluated perioperative risk factors for IGIC in patients undergoing open cardiac surgery.

METHODS

All patients that underwent an open cardiac surgical procedure at a tertiary academic center between 2011 and 2017 were included. The primary outcome was IGIC, defined as acute mesenteric ischemia necessitating a surgical intervention or postoperative gastrointestinal bleeding that was proven to be of ischemic etiology and necessitated blood product transfusion. A backward stepwise regression model was constructed to identify perioperative predictors of IGIC.

RESULTS

Of 6862 patients who underwent cardiac surgery during the study period, 52(0.8%) developed IGIC. The highest incidence of IGIC (1.9%) was noted in patients undergoing concomitant coronary artery, valvular, and aortic procedures. The multivariable regression identified hypertension (odds ratio [OR] = 5.74), preoperative renal failure requiring dialysis (OR = 3.62), immunocompromised status (OR = 2.64), chronic lung disease (OR = 2.61), and history of heart failure (OR = 2.03) as independent predictors for postoperative IGIC. Pre- or intraoperative utilization of intra-aortic balloon pump or catheter-based assist devices (OR = 4.54), intraoperative transfusion requirement of >4 RBC units(OR = 2.47), and cardiopulmonary bypass > 180 min (OR = 2.28) were also identified as independent predictors for the development of IGIC.

CONCLUSIONS

We identified preoperative and intraoperative risk factors that independently increase the risk of developing postoperative IGIC after cardiac surgery. A high index of suspicion must be maintained and any deviation from the expected recovery course in patients with the above-identified risk factors should trigger an immediate evaluation with the involvement of the acute care surgical team.

[Gastrointestinal complications after on-pump cardiac surgery]

OBJECTIVE

To determine the incidence and independent predictors of gastrointestinal complications (GICs) following on-pump cardiac surgery.

MATERIAL AND METHODS

We retrospectively analyzed data of 9559 adults who underwent cardiac surgery in 2012-2017. Two groups of patients were distinguished: group 1 - 47 (0.5%) patients with abdominal complications followed by urgent surgery; group 2 - 9512 (95.5%) patients without complications or effective therapy.

CONCLUSION

1. Predictors of gastrointestinal complications: age >65 years, previous AF (p=0.011) and multifocal atherosclerosis (p=0.016), LV EF <40% (p=0.039), aortic cross-clamping time > 90 min (p=0.021), intraoperative blood loss over 600 ml (p=0.002), postoperative serum creatinine >140 μmol/l (p=0.005), mechanical ventilation >24 hours (p=0.023).

2. Reduced hemodilution during CPB, warm blood cardioplegia, higher perioperative values of Hb, Ht and IDO2 during cardiopulmonary bypass can prevent ischemic injury of abdominal organs during prolonged cardiac surgery.

Serious Gastrointestinal Complications After Cardiac Surgery and Associated Mortality

BACKGROUND

Severe gastrointestinal (GI) complications (GICs) after cardiac surgery are associated with poor outcomes. Herein, we characterize the severe forms of GICs and associated risk factors of mortality.

METHODS

We retrospectively analyzed the clinically significant postoperative GICs after cardiac surgical procedures performed at our institution from January 2010 to April 2017. Multivariable analysis was used to identify predictors for in-hospital mortality.

RESULTS

Of 29,909 cardiac surgical procedures, GICs occurred in 1037 patients (3.5% incidence), with overall in-hospital mortality of 14% compared with 1.6% in those without GICs. GICs were encountered in older patients with multiple comorbidities who underwent complex prolonged procedures. The most lethal GICs were mesenteric ischemia (n = 104), hepatopancreatobiliary (HPB) dysfunction (n = 139), and GI bleeding (n = 259), with mortality rates of 45%, 27%, and 17%, respectively. In the mesenteric ischemia subset, coronary artery disease (odds ratio [OR], 4.57; P = .002], coronary bypass grafting (OR, 6.50; P = .005), reoperation for bleeding/tamponade (OR, 12.07; P = .01), and vasopressin use (OR, 11.27; P < .001) were predictors of in-hospital mortality. In the HPB complications subset, hepatic complications occurred in 101 patients (73%), pancreatitis in 38 (27%), and biliary disease in 31 (22%). GI bleeding occurred in 20 patients (31%) with HPB dysfunction. In the GI bleeding subset, HPB disease (OR, 10.99; P < .001) and bivalirudin therapy (OR, 12.84; P = .01) were predictors for in-hospital mortality.

CONCLUSIONS

Although relatively uncommon, severe forms of GICs are associated with high mortality. Early recognition and aggressive treatment are mandatory to improve outcomes.

Gastrointestinal complications following cardiac surgery

Gastrointestinal complications after cardiac surgery may be uncommon but they carry high mortality rates. Incidences range from 0.5% to 5.5%, while mortality rates of such complications vary from 0.3% to 87%. They range from small gastrointestinal bleeds, ileus, and pancreatitis to life-threatening complications such as liver failure and ischemic bowel. Due to the vague and often absence of specific signs and symptoms, diagnosis of a gastrointestinal complication is often late. This article aims to review and summarize the literature concerning gastrointestinal complications after cardiac surgery. We discuss the causes, risk factors, diagnosis, preventative measures, and management of these complications. In general, risk factor identification, preventive measures, early diagnosis, and swift management are the keys to reducing the occurrence of gastrointestinal complications and their associated morbidity and mortality.

Predicting cardiovascular intensive care unit readmission after cardiac surgery: derivation and validation of the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) cardiovascular intensive care unit clinical prediction model from a registry cohort of 10,799 surgical cases

Introduction

In medical and surgical intensive care units, clinical risk prediction models for readmission have been developed; however, studies reporting the risks for cardiovascular intensive care unit (CVICU) readmission have been methodologically limited by small numbers of outcomes, unreported measures of calibration or discrimination, or a lack of information spanning the entire perioperative period. The purpose of this study was to derive and validate a clinical prediction model for CVICU readmission in cardiac surgical patients.

Methods

A total of 10,799 patients more than or equal to 18 years in the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry who underwent cardiac surgery (coronary artery bypass or valvular surgery) between 2004 and 2012 and were discharged alive from the first CVICU admission were included. The full cohort was used to derive the clinical prediction model and the model was internally validated with bootstrapping. Discrimination and calibration were assessed using the AUC c index and the Hosmer-Lemeshow tests, respectively.

Results

A total of 479 (4.4%) patients required CVICU readmission. The mean CVICU length of stay (19.9 versus 3.3 days, P <0.001) and in-hospital mortality (14.4% versus 2.2%, P <0.001) were higher among patients readmitted to the CVICU. In the derivation cohort, a total of three preoperative (age ≥70, ejection fraction, chronic lung disease), two intraoperative (single valve repair or replacement plus non-CABG surgery, multivalve repair or replacement), and seven postoperative variables (cardiac arrest, pneumonia, pleural effusion, deep sternal wound infection, leg graft harvest site infection, gastrointestinal bleed, neurologic complications) were independently associated with CVICU readmission. The clinical prediction model had robust discrimination and calibration in the derivation cohort (AUC c index = 0.799; Hosmer-Lemeshow P = 0.192). The validation point estimates and confidence intervals were similar to derivation model.

Conclusions

In a large population-based dataset incorporating a comprehensive set of perioperative variables, we have derived a clinical prediction model with excellent discrimination and calibration. This model identifies opportunities for targeted therapeutic interventions aimed at reducing CVICU readmissions in high-risk patients.

Clinical effectiveness of fresh frozen plasma compared with fibrinogen concentrate: a systematic review

Introduction

Haemostatic therapy in surgical and/or massive trauma patients typically involves transfusion of fresh frozen plasma (FFP). Purified human fibrinogen concentrate may offer an alternative to FFP in some instances. In this systematic review, we investigated the current evidence for the use of FFP and fibrinogen concentrate in the perioperative or massive trauma setting.

Methods

Studies reporting the outcome (blood loss, transfusion requirement, length of stay, survival and plasma fibrinogen level) of FFP or fibrinogen concentrate administration to patients in a perioperative or massive trauma setting were identified in electronic databases (1995 to 2010). Studies were included regardless of type, patient age, sample size or duration of patient follow-up. Studies of patients with congenital clotting factor deficiencies or other haematological disorders were excluded. Studies were assessed for eligibility, and data were extracted and tabulated.

Results

Ninety-one eligible studies (70 FFP and 21 fibrinogen concentrate) reported outcomes of interest. Few were high-quality prospective studies. Evidence for the efficacy of FFP was inconsistent across all assessed outcomes. Overall, FFP showed a positive effect for 28% of outcomes and a negative effect for 22% of outcomes. There was limited evidence that FFP reduced mortality: 50% of outcomes associated FFP with reduced mortality (typically trauma and/or massive bleeding), and 20% were associated with increased mortality (typically surgical and/or nonmassive bleeding). Five studies reported the outcome of fibrinogen concentrate versus a comparator. The evidence was consistently positive (70% of all outcomes), with no negative effects reported (0% of all outcomes). Fibrinogen concentrate was compared directly with FFP in three high-quality studies and was found to be superior for > 50% of outcomes in terms of reducing blood loss, allogeneic transfusion requirements, length of intensive care unit and hospital stay and increasing plasma fibrinogen levels. We found no fibrinogen concentrate comparator studies in patients with haemorrhage due to massive trauma, although efficacy across all assessed outcomes was reported in a number of noncomparator trauma studies.

Conclusions

The weight of evidence does not appear to support the clinical effectiveness of FFP for surgical and/or massive trauma patients and suggests it can be detrimental. Perioperatively, fibrinogen concentrate was generally associated with improved outcome measures, although more high-quality, prospective studies are required before any definitive conclusions can be drawn.

Risk factors for gastrointestinal complications in patients undergoing coronary artery bypass graft surgery

OBJECTIVE

To determine the risk factors for the development of gastrointestinal complications (GICs) after coronary artery bypass graft (CABG) surgery.

DESIGN

A single-center, retrospective study.

SETTING

A tertiary care hospital.

PARTICIPANTS

Six thousand seven hundred ninety-four patients undergoing isolated CABG surgery between 2002 and 2006.

INTERVENTIONS

Clinical characteristics of the patients with GICs and control group patients were analyzed by stepwise logistic regression analysis. The control group consisted of a total of 95 patients randomly selected among the ones who had no gastrointestinal finding or symptoms (cohort: control, 1:5 ratio).

MEASUREMENTS AND MAIN RESULTS

Nineteen patients (0.3%) developed major surgical GICs after CABG surgery. Overall, the 30-day mortality was 42.1% among patients with GICs and 2.6% without GICs. Multivariate analysis identified 4 independent predictors for GICs: age greater than 70 years (p = 0.001; odds ratio [OR] = 5.6; 95% confidence interval [CI], 2.1-25.9), reoperation for bleeding (p = 0.005; OR = 7.7; 95% CI, 2.8-56.2), a prolonged cardiopulmonary bypass time (p = 0.007; OR = 3.7; 95% CI, 1.3-15.6), and an increased postoperative creatinine level (p = 0.036; OR = 2.3; 95% CI, 1.1-13.4).

CONCLUSION

A delayed diagnosis of complications is an important problem in the management of major surgical GICs. The present results suggest that surgeons and intensivists must be alert to patients older than 70 years, a cardiopulmonary bypass time longer than 60 minutes, reoperation for bleeding after CABG surgery, and postoperative creatinine level higher than 1.7 mg/dL.