Very prolonged stay in the intensive care unit after cardiac operations: early results and late survival

Predicting Extended Intensive Care Unit Stay Following Coronary Artery Bypass Grafting and Its Impact on Hospitalization and Mortality

Background

Coronary artery bypass grafting (CABG) is a prevalent surgical procedure aimed at alleviating symptoms and improving survival in patients with coronary artery disease (CAD). Postoperative care typically necessitates an intensive care unit (ICU) stay, which is ideally less than 24 h. However, various preoperative, intraoperative, and postoperative factors can prolong ICU stays, adversely affecting hospital resources, patient outcomes, and overall healthcare costs. This study investigates the factors contributing to prolonged ICU stay (> 48 h) following CABG and CABG combined with valve surgery, and examines the associated impacts on complications and mortality.

Methods

This retrospective cohort study analyzed 1,395 patients who underwent isolated CABG or CABG combined with heart valve surgery at King Abdullah University Hospital (KAUH) between January 2004 and December 2022. Patients were categorized into two groups: those with ICU stays ≤ 48 h (group 1, n = 1,082) and those with ICU stays > 48 h (group 2, n = 313). Clinical, laboratory, and demographic data were collected and evaluated to identify risk factors for prolonged ICU stays.

Results

Patients in group 2 were older, with a mean age of 61.5 years compared to 58.7 years in group 1 (P < 0.001). Significant predictors of prolonged ICU stay included preoperative conditions such as recent myocardial infarction (odds ratio (OR) = 1.69, P = 0.015), chronic obstructive pulmonary disease or asthma (OR = 1.49, P = 0.003), and preoperative renal impairment (OR = 1.89, P = 0.002). Intraoperative factors such as emergency or urgent procedures (OR = 2.19, P < 0.001) and prolonged ventilator support (OR = 5.92, P < 0.001) were also significant. Postoperative complications, including renal impairment (OR = 6.78, P < 0.001) and pneumonia or sepsis (OR = 8.92, P < 0.001), were strongly associated with extended ICU stays.

Conclusions

Prolonged ICU stays are indicative of patients with more severe baseline conditions, greater surgical complexity, and higher rates of postoperative complications, which collectively contribute to increased risks of severe adverse outcomes and mortality. Prolonged ICU stays after CABG are strongly associated with preoperative comorbidities, intraoperative challenges, and postoperative complications, leading to increased mortality and significant healthcare resource utilization. Identifying these risk factors and implementing targeted strategies to address them can help minimize ICU stay durations, improve patient outcomes, and enhance the efficiency of cardiac surgery care. Future research should focus on refining predictive models and optimizing perioperative management to further reduce the burden of prolonged ICU stays on healthcare systems.

The effect of a selenium-based anti-inflammatory strategy on postoperative functional recovery in high-risk cardiac surgery patients - A nested sub-study of the sustain CSX trial

AIM

The cardiac surgery-related ischemia-reperfusion-related oxidative stress triggers the release of cytotoxic reactive oxygen and nitrogen species, contributing to organ failure and ultimately influencing patients' short- and long-term outcomes. Selenium is an essential co-factor for various antioxidant enzymes, thereby contributing to the patients' endogenous antioxidant and anti-inflammatory defense mechanisms. Given these selenium's pleiotropic functions, we investigated the effect of a high-dose selenium-based anti-inflammatory perioperative strategy on functional recovery after cardiac surgery.

MATERIALS AND METHODS

This prospective study constituted a nested sub-study of the SUSTAIN CSX trial, a double-blinded, randomized, placebo-controlled multicenter trial to investigate the impact of high-dose selenium supplementation on high-risk cardiac surgery patients' postoperative recovery. Functional recovery was assessed by 6-min walk distance, Short Form-36 (SF-36) and Barthel Index questionnaires.

KEY FINDINGS

174 patients were included in this sub-study. The mean age (SD) was 67.3 (8.9) years, and 78.7 % of the patients were male. The mean (SD) predicted 30-day mortality by the European System for Cardiac Operative Risk Evaluation II score was 12.6 % (9.4 %). There was no difference at hospital discharge and after three months in the 6-min walk distance between the selenium and placebo groups (131 m [IQR: not performed - 269] vs. 160 m [IQR: not performed - 252], p = 0.80 and 400 m [IQR: 299-461] vs. 375 m [IQR: 65-441], p = 0.48). The SF-36 and Barthel Index assessments also revealed no clinically meaningful differences between the selenium and placebo groups.

SIGNIFICANCE

A perioperative anti-inflammatory strategy with high-dose selenium supplementation did not improve functional recovery in high-risk cardiac surgery patients.

The impact of cardiopulmonary bypass time on the Sequential Organ Failure Assessment score after cardiac surgery

OBJECTIVES

Postoperative organ dysfunction is common after cardiac surgery, particularly when cardiopulmonary bypass (CPB) is used. The Sequential Organ Failure Assessment (SOFA) score is validated to predict morbidity and mortality in cardiac surgery. However, the impact of CPB duration on postoperative SOFA remains unclear.

METHODS

This is a retrospective study. Categorical values are presented as percentages. The comparison of SOFA groups utilized the Kruskal-Wallis chi-squared test, complemented by ad hoc Dunn's test with Bonferroni correction. Multinomial logistics regressions were employed to evaluate the relationship between CPB time and SOFA.

RESULTS

A total of 1032 patients were included. CPB time was independently associated with higher postoperative SOFA scores at 24 h. CPB time was significantly higher in patients with SOFA 4-5 (**P = 0.0022) or higher (***P < 0.001) when compared to SOFA 0-1. The percentage of patients with no/mild dysfunction decreased with longer periods of CPB, down to 0% for CPB time >180min (50% of the patients with >180m in of CPB presented SOFA ≥ 10). The same trend is observed for each of the SOFA variables, with higher impact in the cardiovascular and renal systems. Severe dysfunction occurs especially >200 min of CPB (cardiovascular system >100 min; other systems mainly >200 min).

CONCLUSIONS

CPB time may predict the probability of postoperative SOFA categories. Patients with extended CPB durations exhibited higher SOFA scores (overall and for each variable) at 24 h, with higher proportion of moderate and severe dysfunction with increasing times of CPB.

Effect of High-Dose Selenium on Postoperative Organ Dysfunction and Mortality in Cardiac Surgery Patients: The SUSTAIN CSX Randomized Clinical Trial

Importance

Selenium contributes to antioxidative, anti-inflammatory, and immunomodulatory pathways, which may improve outcomes in patients at high risk of organ dysfunctions after cardiac surgery.

Objective

To assess the ability of high-dose intravenous sodium selenite treatment to reduce postoperative organ dysfunction and mortality in cardiac surgery patients.

Design, Setting, and Participants

This multicenter, randomized, double-blind, placebo-controlled trial took place at 23 sites in Germany and Canada from January 2015 to January 2021. Adult cardiac surgery patients with a European System for Cardiac Operative Risk Evaluation II score-predicted mortality of 5% or more or planned combined surgical procedures were randomized.

Interventions

Patients were randomly assigned (1:1) by a web-based system to receive either perioperative intravenous high-dose selenium supplementation of 2000 μg/L of sodium selenite prior to cardiopulmonary bypass, 2000 μg/L immediately postoperatively, and 1000 μg/L each day in intensive care for a maximum of 10 days or placebo.

Main Outcomes and Measures

The primary end point was a composite of the numbers of days alive and free from organ dysfunction during the first 30 days following cardiac surgery.

Results

A total of 1416 adult cardiac surgery patients were analyzed (mean [SD] age, 68.2 [10.4] years; 1043 [74.8%] male). The median (IQR) predicted 30-day mortality by European System for Cardiac Operative Risk Evaluation II score was 8.7% (5.6%-14.9%), and most patients had combined coronary revascularization and valvular procedures. Selenium did not increase the number of persistent organ dysfunction-free and alive days over the first 30 postoperative days (median [IQR], 29 [28-30] vs 29 [28-30]; P = .45). The 30-day mortality rates were 4.2% in the selenium and 5.0% in the placebo group (odds ratio, 0.82; 95% CI, 0.50-1.36; P = .44). Safety outcomes did not differ between the groups.

Conclusions and Relevance

In high-risk cardiac surgery patients, perioperative administration of high-dose intravenous sodium selenite did not reduce morbidity or mortality. The present data do not support the routine perioperative use of selenium for patients undergoing cardiac surgery.

Trial Registration

ClinicalTrials.gov Identifier: NCT02002247.

Predicting prolonged intensive care unit stay following surgery in adults with Tetralogy of Fallot

Background

As more patients with congenital heart disease survive into adulthood, the number of patients with tetralogy of Fallot (TOF) has also increased. However, long-term sequelae are common, and most patients with TOF require surgical reintervention in adulthood. Prolonged intensive care unit (ICU) stay is associated with poor long-term outcomes following cardiac surgery. This study aimed to investigate whether the PErioperative Adult Congenital Heart disease (PEACH) score can predict prolonged postoperative ICU stay in this population.

Methods

Of 1217 patients with congenital heart disease who were ≥18 years old at the time of surgery performed from February 2004 and August 2021, 145 consecutive patients with TOF who underwent right ventricular outflow tract procedures were examined in this single-institution retrospective study. The primary endpoint was ICU stay of ≥3 days.

Results

The population had a history of one sternotomies (median) (1, 2; 1st and 3rd quartiles) at a median age of 35 years (25, 42; 1st and 3rd quartiles). The median duration of ICU stay was one day (1, 2; 1st and 3rd quartiles). Significantly more patients experienced major bleeding and ventilator dependence after surgery than those without prolonged ICU stay. Cardiopulmonary bypass time was significantly longer in patients with prolonged ICU stay than in those without. The PEACH score was independently associated with prolonged ICU stay after adjusted multivariate analyses and had acceptable discriminatory performance for predicting prolonged ICU stay after surgery.

Conclusion

The PEACH score is a useful predictor of prolonged postoperative ICU stay in this population.

Outcomes of Prolonged ICU Stay for Patients Undergoing Cardiac Surgery in Australia and New Zealand

OBJECTIVE

To determine the effect of intensive care unit (ICU) length of stay (LOS) on hospital mortality and non-home discharge for patients undergoing cardiac surgery over a 16-year period in Australia and New Zealand.

DESIGN

A retrospective, multicenter cohort study covering the period January 1, 2004 to December 31, 2019.

SETTING

One hundred one hospitals in Australia and New Zealand that submitted data to the Australia New Zealand Intensive Care Society Adult Patient Database.

PARTICIPANTS

Adult patients (aged >18) who underwent coronary artery bypass grafting, valve surgery, or combined valve + coronary artery surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The authors analyzed 252,948 cardiac surgical patients from 101 hospitals, with a median age of 68.3 years (IQR 60-75.5), of whom 74.2% (187,632 of 252,948) were male patients. A U-shaped relationship was observed between ICU LOS and hospital mortality, with significantly elevated mortality at short (<20 hours) and long (>5 days) ICU LOS, which persisted after adjustment for illness severity and across clinically important subgroups (odds ratio for mortality with ICU LOS >5 days = 3.21, 95% CI 2.88-3.58, p < 0.001).

CONCLUSIONS

Prolonged duration of ICU LOS after cardiac surgery is associated with increased hospital mortality in a U-shaped relationship. An ICU LOS >5 days should be considered a meaningful definition for prolonged ICU stay after cardiac surgery.

Preoperative Nutritional Optimization and Physical Exercise for Patients Scheduled for Elective Implantation for a Left-Ventricular Assist Device—The PROPER-LVAD Study

Background: Prehabilitation is gaining increasing interest and shows promising effects on short- and long-term outcomes among patients undergoing major surgery. The effect of multimodal, interdisciplinary prehabilitation has not yet been studied in patients with severe heart failure scheduled for the implantation of a left-ventricular assist device (LVAD). Methods: This randomized controlled multi-center study evaluates the effect of preoperative combined optimization of nutritional and functional status. Patients in the intervention group are prescribed daily in-bed cycling and oral nutrition supplements (ONS) from study inclusion until the day before LVAD-implantation. Patients in the control group receive standard of care treatment. The primary outcomes for the pilot study that involves 48 patients are safety (occurrence of adverse events), efficacy (group separation regarding the intake of macronutrients), feasibility of the trial protocol (compliance (percentage of received interventions) and confirmation of recruitment rates. Secondary outcomes include longitudinal measurements of muscle mass, muscle strength, physical function and quality of life, next to traditional clinical outcomes (30-day mortality, hospital and ICU length of stay, duration of mechanical ventilation and number of complications and infections). If the pilot study is successful, a larger confirmatory, international multicenter study is warranted.

The long-term effects of prolonged intensive care stay postcardiac surgery

OBJECTIVES

Short-term outcomes for those with a prolonged length of stay (LOS) in intensive care (ITU) following cardiac surgery are poor, with higher rates of in-hospital mortality and morbidity. Consequently, discharge from hospital has been considered the key measure of success. However, there has been a shift towards long-term outcomes, functional recovery and quality of life (QoL) as measures of surgical quality. The aim of this review is to compare and critique the findings of multiple studies to determine the long-term effects of prolonged ITU stay postcardiac surgery.

METHODS

A computerized literature search of CINAHL, EMBASE and Google Scholar databases, based on keywords "long-term effects," "prolonged ITU stay," "cardiac surgery," with rigorous CASP critique was undertaken.

RESULTS

The search yielded 12 papers meeting the inclusion criteria, with eight retrospective and four prospective studies. Eight of these 12 papers identified inferior long-term survival or higher mortality rates for those who had prolonged LOS in ITU in comparison to "normal" LOS or a control. The greatest burden of mortality was 6 months to 1 year postdischarge. Three papers found that quality of life was adversely affected or worse for those who had experienced prolonged LOS in ITU.

CONCLUSIONS

Further research is required to provide better quality evidence into QoL, following prolonged stay in ICU postcardiac surgery. The evidence reviewed suggests that the risk of mortality in this demographic of patients is higher, especially within the first year and, therefore, more frequent medical surveillance of these patients is recommended.

Preoperative Treatment of Malnutrition and Sarcopenia in Cardiac Surgery: New Frontiers

Cardiac surgery is performed more often in a population with an increasing number of comorbidities. Although these surgeries can be lifesaving, they disturb homeostasis and may induce a temporary overall loss of physiologic function. The required postoperative intensive care unit and hospital stay often lead to a mid- to long-term decline of nutritional and physical status, mental health, and health-related quality of life. Prehabilitation before elective surgery might be an opportunity to optimize the state of the patient. This article discusses current evidence and potential effects of preoperative optimization of nutrition and physical status before cardiac surgery.

Morbidity After cardiac surgery under cardiopulmonary bypass and associated factors: A retrospective observational study

Background

The present study aimed to assess the morbidity after cardiac surgery and identify the preoperative and intraoperative factors associated with postoperative morbidity.

Methods

A retrospective observational study was conducted including 362 adult patients aged 18–75 years who underwent open-heart surgery under cardiopulmonary bypass at Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India, during the period from June 2016 to May 2017. Using a structured schedule, preoperative and intraoperative data were collected from the hospital's cardiac surgery database, whereas the postoperative data were collected from the intensive care unit (ICU) database and the hospital's clinical information system database.

Results

Of 362 patients, 254 (70.2%) had at least one major complication, and the most frequently occurring complication was low cardiac output state (29.8%). The ICU length of stay (LOS) was for > 2 days in 23.2% of patients, and the hospital LOS was for > 7 days in almost 60% of the patients. Multivariate logistic regression analyses revealed that gender, type of surgery, body weight, blood lactate level at ICU admission, and 12-h blood lactate level were significant predictors of complications; gender and 24-h blood lactate level were significantly associated with the prolonged ICU LOS, whereas type of surgery and 24-h blood lactate level were significantly associated with prolonged hospital LOS.

Conclusion

The appropriate patient management strategy can be tailored based on the personal attributes, surgery type, and blood lactate level for individual patients undergoing cardiac surgery to reduce the likelihood of postoperative complications, ICU LOS, and hospital LOS.

Survival, Quality of Life, and Functional Status Following Prolonged ICU Stay in Cardiac Surgical Patients: A Systematic Review

OBJECTIVES

Compared with noncardiac critical illness, critically ill postoperative cardiac surgical patients have different underlying pathophysiologies, are exposed to different processes of care, and thus may experience different outcome trajectories. Our objective was to systematically review the outcomes of cardiac surgical patients requiring prolonged intensive care with respect to survival, residential status, functional recovery, and quality of life in both hospital and long-term follow-up.

DATA SOURCES

MEDLINE, Embase, CINAHL, Web of Science, and Dissertations and Theses Global up to July 21, 2017.

STUDY SELECTION

Studies were included if they assessed hospital or long-term survival and/or patient-centered outcomes in adult patients with prolonged ICU stays following major cardiac surgery. After screening 10,159 citations, 114 articles were reviewed in full; a final 34 articles met criteria for data extraction.

DATA EXTRACTION

Two reviewers independently extracted data and assessed risk of bias using the National Institutes of Health Quality Assessment Tool for Observational Studies. Extracted data included the used definition of prolonged ICU stay, number and characteristics of prolonged ICU stay patients, and any comparator short stay group, length of follow-up, hospital and long-term survival, residential status, patient-centered outcome measure used, and relevant score.

DATA SYNTHESIS

The definition of prolonged ICU stay varied from 2 days to greater than 14 days. Twenty-eight studies observed greater in-hospital mortality among all levels of prolonged ICU stay. Twenty-five studies observed greater long-term mortality among all levels of prolonged ICU stay. Multiple tools were used to assess patient-centered outcomes. Long-term health-related quality of life and function was equivalent or worse with prolonged ICU stay.

CONCLUSIONS

We found consistent evidence that patients with increases in ICU length of stay beyond 48 hours have significantly increasing risk of hospital and long-term mortality. The significant heterogeneity in exposure and outcome definitions leave us unable to precisely quantify the risk of prolonged ICU stay on mortality and patient-centered outcomes.

Predictive Factors of Long-Term Stay in the ICU after Cardiac Surgery: Logistic CASUS Score, Serum Bilirubin Dosage and Extracorporeal Circulation Time

Objective

To test the capacity of the Logistic CASUS Score on the second postoperative day, the total serum bilirubin dosage on the second postoperative day and the extracorporeal circulation time, as possible predictive factors of long-term stay in Intensive Care Unit after cardiac surgery.

Methods

Eight-two patients submitted to cardiac surgery with extracorporeal circulation were selected. The Logistic CASUS Score on the second postoperative day was calculated and bilirubin dosage on the second postoperative day was measured. The extracorporeal circulation time was also registered. Patients were divided into two groups: Group A, those who were discharged up to the second day of postoperative care; Group B, those who were discharged after the second day of postoperative care.

Results

In this study, 40 cases were listed in Group A and 42 cases in Group B. The mean extracorporeal circulation time was 83.9±29.4 min in Group A and 95.8±29.31 min in Group B. Extracorporeal circulation time was not significant in this study (P=0.0735). The level of P significance of bilirubin dosage on the second postoperative day was 0.0003 and an area under the ROC curve of 0.708 with a cut-off point at 0.51 mg/dl was registered. The level of P significance of Logistic CASUS Score on the second postoperative day was 0.0001 and an area under the ROC curve of 0.723 with a cut-off point at 0.40% was registered.

Conclusion

The Logistic CASUS Score on the second postoperative day has shown to be better than the bilirubin dosage on the second postoperative day as a predictive tool for calculating the length of stay in intensive care unit during the postoperative care period of patients. Notwithstanding, extracorporeal circulation time has failed to prove itself as an efficient tool to predict an extended length of stay in intensive care unit.

Prolonged Intensive Care Unit Stay Following Transcatheter Aortic Valve Replacement

PURPOSE

Postoperative intensive care unit (ICU) stay after cardiac surgeries has been extensively studied, but little attention has been given to ICU stay following transcatheter aortic valve replacement (TAVR). This study examined ICU stay after TAVR.

METHODS

Two hundred and forty-five patients who underwent TAVR between April 2010 and October 2016 were studied retrospectively. We investigated the status of ICU stay, the predictors of prolonged ICU stay (PICUS), and its impact on short- and long-term outcomes. Prolonged ICU stay was defined as post-TAVR ICU stay longer than 2 days (day of TAVR + 1 day).

RESULTS

Length of ICU stay was 2.6 ± 4.9 days, and PICUS was identified in 14.7% of the patients. The predominant reason for PICUS was congestive heart failure or circulatory failure (41.7%). Pulmonary dysfunction and nontransfemoral approach were independent predictors of PICUS (pulmonary dysfunction: odds ratio = 2.64, 95% confidence interval [CI]: 1.05-7.35; nontransfemoral approach: odds ratio = 2.81, 95% CI: 1.15-6.89). Prolonged ICU stay was associated with higher rate of 30-day combined end point (PICUS vs non-PICUS: 44.4% vs 3.3%, P < .0001), longer postoperative hospital stay (49.9 ± 141.9 days vs 12.0 ± 6.0 days, P < .0001), and lower rate of discharge home (77.8% vs 95.2%, P = .0002). Patients with PICUS had worse long-term survival (P < .0001), and PICUS was a predictor of mortality (hazard ratio: 4.21, 95% CI: 2.09-8.22).

CONCLUSION

Prolonged ICU stay following TAVR was found in 14.7%, and pulmonary dysfunction and nontransfemoral approach were associated with PICUS. Short- and long-term prognoses were worse in patients with PICUS than those without.

Long-term outcomes and healthcare utilization following critical illness--a population-based study

BACKGROUND

The purpose of this study was to examine hospital mortality, long-term mortality, and health service utilization among critically ill patients. We also determined whether these outcomes differed according to demographic and clinical characteristics.

METHODS

We conducted a retrospective cohort study of adults (age ≥ 18 years) who survived admission to an intensive care unit (ICU) in Ontario, Canada, between 1 April 2002 and 31 March 2012, excluding isolated admissions to step-down or intermediate ICUs, coronary care ICUs, or cardiac surgery ICUs. Adults (age ≥ 18 years) who survived an acute hospitalization that did not include an ICU stay formed the comparator group. The primary outcome was mortality following hospital discharge. Secondary outcomes were healthcare utilization, including emergency room admissions and hospital readmissions during follow-up.

RESULTS

Over the study interval, 500,124 patients were admitted to ICUs and 420,187 (84%) survived to hospital discharge. Median follow-up for survivors was 5.3 (interquartile range 2.5, 8.2) years. Patients admitted to an ICU were more likely to subsequently visit the emergency department, be readmitted to the hospital and ICU, receive home care support, require rehabilitation, and be admitted for long-term care. Those requiring more resources within the ICU required more resources after discharge. One-third of patients admitted to the ICU died during long-term follow-up, with overall probabilities of death of 11% and 29% at 1 year and 5 years, respectively. In the adjusted analysis, there was an increasing hazard of death with increasing age, reaching a hazard ratio of 18.08 (95 % confidence interval 16.60-19.68) for those ≥ 85 years of age compared with those aged 18-24 years.

CONCLUSIONS

Healthcare utilization after hospital discharge was higher among ICU patients, and also among those requiring more healthcare resources during their ICU admission, than among all hospitalized patients as a group. One-third of ICU patients died within the 5 years following discharge, and age was the most influential determinant of outcome. These findings should help target post-ICU discharge services for high-risk groups and better inform goals-of-care discussions for elderly critically ill patients.

Outcomes of Patients With Prolonged Intensive Care Unit Length of Stay After Cardiac Surgery

OBJECTIVE

To determine in-hospital and post-discharge long-term survival in patients with prolonged intensive care unit (ICU) stays after cardiac surgery.

DESIGN

Retrospective, cohort study of cardiac surgery patients from May 2007 to June 2012.

SETTING

Single-center cardiac surgery ICU.

PARTICIPANTS

Patients were grouped according to length of ICU stay: between 1 and 2 weeks, between 2 and 4 weeks, and>4 weeks.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 4,963 patients, 3.3%, 1.6%, and 2.9% of patients stayed 1 to 2 weeks, 2 to 4 weeks, and>4 weeks in the ICU, respectively. In-hospital mortality was 11.1%, 26.6%, and 31.0% for patients with 1 to 2 weeks, 2 to 4 weeks, and>4 weeks ICU stay, respectively. Patients with ICU stays between 1 and 2 weeks had 6 months, 1 year, and 2 year survival rates of 84.4%, 80.0%, and 75.3% after discharge, respectively. Patients with ICU stay between 2 and 4 weeks had similar 6 months, 1 year, and 2 year survival rates of 84.7%, 79.9%, and 74.1%, respectively. In contrast, patients with>4 week ICU stays had significantly lower postdischarge survival rates of 63.3%, 56.4%, and 41.1% at 6 months, 1 year, and 2 years, respectively. Postoperative stroke conferred the greatest risk of death within 1 year after discharge (odds ratio 7.6, p = 0.0140).

CONCLUSIONS

In-hospital mortality rates post-cardiac surgery correlate with length of ICU stay but appear to plateau after 4 weeks. However, a>4 week ICU length of stay confers a worse long-term outcome post-hospital discharge, especially in patients with postoperative stroke.

Inclusion of 'ICU-Day' in a Logistic Scoring System Improves Mortality Prediction in Cardiac Surgery

Background

Prolonged intensive care unit (ICU) stay is a predictor of mortality. The length of ICU stay has never been considered as a variable in an additive scoring system. How could this variable be integrated into a scoring system? Does this integration improve mortality prediction?

Material/Methods

The ‘modified CArdiac SUrgery Score’ (CASUS) was generated by implementing the length of stay as a new variable to the ‘additive CASUS’. The ‘logistic CASUS’ already considers this variable. We defined outcome as ICU mortality and statistically compared the three CASUS models. Discrimination, comparison of receiver operating characteristic curves (DeLong’s method), and calibration (observed/expected ratio) were analyzed on days 1–13.

Results

Between 2007 and 2010, we included 5207 cardiac surgery patients in this prospective study. The mean age was 67.2±10.9 years. The mean length of ICU stay was 4.6±7.0 days and ICU mortality was 5.9%. All scores had good discrimination, with a mean area under the curve of 0.883 for the additive and modified, and 0.895 for the ‘logistic CASUS’. DeLong analysis showed superiority in favor of the logistic model as from day 5. The calibration of the logistic model was good. We identified overestimation (days 1–5) and accurate (days 6–9) calibration for the additive and ‘modified CASUS’. The ‘modified CASUS’ remained accurate but the ‘additive CASUS’ tended to underestimate the risk of mortality (days 10–13).

Conclusions

The integration of length of ICU stay as a variable improves mortality prediction significantly. An ‘ICU-day’ variable should be included into a logistic but not an additive model.

SodiUm SeleniTe Adminstration IN Cardiac Surgery (SUSTAIN CSX-trial): study design of an international multicenter randomized double-blinded controlled trial of high dose sodium-selenite administration in high-risk cardiac surgical patients

Background

Cardiac surgery has been shown to result in a significant decrease of the antioxidant selenium, which is associated with the development of multiorgan dysfunction and increased mortality. Thus, a large-scale study is needed to investigate the effect of perioperative selenium supplementation on the occurrence of postoperative organ dysfunction.

Methods/Design

We plan a prospective, randomized double-blind, multicenter controlled trial, which will be conducted in North and South America and in Europe. In this trial we will include 1,400 high-risk patients, who are most likely to benefit from selenium supplementation. This includes patients scheduled for non-emergent combined and/or complex procedures, or with a predicted operative mortality of ≥5% according to the EuroSCORE II. Eligible patients will be randomly assigned to either the treatment group (bolus infusion of 2,000 μg sodium selenite immediately prior to surgery, followed by an additional dosage of 2,000 μg at ICU admission, and a further daily supplementation of 1,000 μg up to 10 days or ICU discharge) or to the control group (placebo administration at the same time points).

The primary endpoint of this study is a composite of 'persistent organ dysfunction’ (POD) and/or death within 30 days from surgery (POD + death). POD is defined as any need for life-sustaining therapies (mechanical ventilation, vasopressor therapy, mechanical circulatory support, continuous renal replacement therapy, or new intermittent hemodialysis) at any time within 30 days from surgery.

Discussion

The SUSTAIN-CSX™ study is a multicenter trial to investigate the effect of a perioperative high dosage sodium selenite supplementation in high-risk cardiac surgical patients.

Trial registration

This trial was registered at Clinicaltrials.gov (identifier: NCT02002247) on 28 November 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/1745-6215-15-339) contains supplementary material, which is available to authorized users.

The incidence of adverse events in an Italian acute care hospital: findings of a two-stage method in a retrospective cohort study

Background

The promotion of safer healthcare interventions in hospitals is a relevant public health topic. This study is aimed to investigate predictors of Adverse Events (AEs) taking into consideration the Charlson Index in order to control for confounding biases related to comorbidity.

Methods

The study was a retrospective cohort study based on a two-stage assessment tool which was used to identify AEs. In stage 1, two physicians reviewed a random sample of patient records from 2008 discharges. In stage 2, reviewers independently assessed each screened record to confirm the presence of AEs. A univariable and multivariable analysis was conducted to identify prognostic factors of AEs; socio-demographic and some main organizational variables were taken into consideration. Charlson comorbidity Index was calculated using the algorithm developed by Quan et al.

Results

A total of 1501 records were reviewed; mean patients age was 60 (SD: 19) and 1415 (94.3%) patients were Italian. Forty-six (3.3%) AEs were registered; they most took place in medical wards (33, 71.7%), followed by surgical ones (9, 19.6%) and intensive care unit (ICU) (4, 8.7%). According to the logistic regression model and controlling for Charlson Index, the following variables were associated to AEs: type of admission (emergency vs elective: OR 3.47, 95% CI: 1.60-7.53), discharge ward (surgical and ICU vs medical wards: OR 2.29, 95% CI: 1.00-5.21 and OR 4.80, 95% CI: 1.47-15.66 respectively) and length of stay (OR 1.03, 95% CI 1.01-1.04). Among patients experiencing AEs a higher frequency of elderly (≥65 years) was shown (58.7% vs 49.3% among patients without AEs) but this difference was not statistically significant. Interestingly, a higher percentage of patients admitted through emergency department was found among patients experiencing AEs (69.7% vs 55.1% among patients without AEs).

Conclusions

The incidence of AEs was associated with length of stay, type of admission and unit of discharge, independently by comorbidity. On the basis of our results, it appears that organizational characteristics, taking into account the adjustment for comorbidity, are the main factors responsible for AEs while patient vulnerability played a minor role.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6963-14-358) contains supplementary material, which is available to authorized users.

Does intraoperative ulinastatin improve postoperative clinical outcomes in patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials

INTRODUCTION

The systematic meta-analysis of randomized controlled trials (RCTs) evaluated the effects of intraoperative ulinastatin on early-postoperative recovery in patients undergoing cardiac surgery.

METHODS

RCTs comparing intraoperative ulinastatin with placebo in cardiac surgery were searched through PubMed, Cochrane databases, Medline, SinoMed, and the China National Knowledge Infrastructure (1966 to May 20th, 2013). The primary endpoints included hospital mortality, postoperative complication rate, length of stay in intensive care unit, and extubation time. The physiological and biochemical parameters illustrating postoperative cardiac and pulmonary function as well as inflammation response were considered as secondary endpoints.

RESULTS

Fifteen RCTs (509 patients) met the inclusion criteria. Ulinastatin did not affect hospital mortality, postoperative complication rate, or ICU length of stay but reduced extubation time. Ulinastatin also increased the oxygenation index on postoperative day 1 and reduced the plasma level of cardiac troponin-I. Additionally, ulinastatin inhibited the increased level of tumor necrosis factor-alpha, polymorphonuclear neutrophil elastase, interleukin-6, and interleukin-8 associated with cardiac surgery.

CONCLUSION

Ulinastatin may be of value for the inhibition of postoperative increased inflammatory agents and most likely provided pulmonary protective effects in cardiac surgery. However, larger adequately powered RCTs are required to define the clinical effect of ulinastatin on postoperative outcomes in cardiac surgery.