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Grant MC, Crisafi C, Alvarez A, Arora RC, Brindle ME, Chatterjee S, Ender J, Fletcher N, Gregory AJ, Gunaydin S, Jahangiri M, Ljungqvist O, Lobdell KW, Morton V, Reddy VS, Salenger R, Sander M, Zarbock A, Engelman DT. Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS). Ann Thorac Surg 2024; 117:669-689. [PMID: 38284956 DOI: 10.1016/j.athoracsur.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/27/2023] [Accepted: 12/09/2023] [Indexed: 01/30/2024]
Abstract
Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.
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Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Cheryl Crisafi
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| | - Adrian Alvarez
- Department of Anesthesia, Hospital Italiano, Buenos Aires, Argentina
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mary E Brindle
- Departments of Surgery and Community Health Services, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joerg Ender
- Department of Anaesthesiology and Intensive Care Medicine, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Nick Fletcher
- Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, United Kingdom; St George's University Hospital, London, United Kingdom
| | - Alexander J Gregory
- Department of Anesthesia, Perioperative and Pain Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Marjan Jahangiri
- Department of Cardiac Surgery, St George's Hospital, London, United Kingdom
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Kevin W Lobdell
- Regional Cardiovascular and Thoracic Quality, Education, and Research, Atrium Health, Charlotte, North Carolina
| | - Vicki Morton
- Clinical and Quality Outcomes, Providence Anesthesiology Associates, Charlotte, North Carolina
| | - V Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rawn Salenger
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Sander
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Giessen, Germany
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
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Beydoun HA, Beydoun MA, Eid SM, Zonderman AB. Pulmonary artery catheter receipt among cardiac surgery patients from the national inpatient sample (1999-2019): Prevalence, predictors and hospitalization charges. Heliyon 2024; 10:e24902. [PMID: 38317919 PMCID: PMC10839978 DOI: 10.1016/j.heliyon.2024.e24902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 01/14/2024] [Accepted: 01/17/2024] [Indexed: 02/07/2024] Open
Abstract
Despite limited evidence to support its efficacy, use of pulmonary artery catheter (PAC), a relatively expensive medical device, for monitoring clinical status and guiding therapeutic interventions, has become standard of care in many settings, and especially during and after cardiac surgery. We examined the prevalence and predictors of PAC use and its association with hospitalization charges among cardiac surgery patients generally and for each selected subgroup of high-risk or complex surgical procedures. We conducted an analysis on 1,442,528 records from the National Inpatient Sample (1999-2019) that included cardiac surgery patients ≥18 years of age. Subgroups were categorized based on the presence of specific disorders like tricuspid or mitral valve disease, pulmonary hypertension, heart failure, or cardiac surgery combinations. Multivariable regression models were constructed to assess predictors of PAC use as well as PAC use as a predictor of loge hospitalization charges controlling for patient and hospital characteristics. Based on International Classification of Diseases procedure codes, PAC use was prevalent among 7.15 % of cardiac surgery hospitalizations, and hospitalization charges were estimated at $191,345, with no differences according to PAC use. Overall, being female, having Charlson comorbidity index (CCI) > 0, and non-payer (versus Medicare) status were independently associated with PAC use. Among the subgroup with the selected conditions, being female, having CCI>0, and being a Medicaid (versus Medicare) recipient were independently associated with PAC use, whereas elective admission was inversely related to PAC use. Among the subgroup without the selected conditions, having a CCI >0, elective admission, and non-payer (vs. Medicare) status were independently associated with PAC use. PAC use was not independently related to hospitalization charges overall or among subgroups. In conclusion, approximately 7 % of cardiac surgery hospitalizations received a PAC, with no differences in charges according to PAC use and disparities in PAC use driven by sex, elective admission, CCI and health insurance status. Large randomized trials are required to characterize the safety, efficacy, and cost-effectiveness of PAC use among distinct groups of patients undergoing cardiac surgery.
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Affiliation(s)
- Hind A. Beydoun
- Department of Research Programs, Fort Belvoir Community Hospital, Fort Belvoir, VA, USA
| | - May A. Beydoun
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging Intramural Research Program, Baltimore, MD, USA
| | - Shaker M. Eid
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alan B. Zonderman
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging Intramural Research Program, Baltimore, MD, USA
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Cho HY, Lee HJ, Hwang IE, Lee HC, Kim WH, Yang SM. Comparison of invasive and non-invasive measurements of cardiac index and systemic vascular resistance in living-donor liver transplantation: a prospective, observational study. BMC Anesthesiol 2023; 23:359. [PMID: 37924013 PMCID: PMC10625262 DOI: 10.1186/s12871-023-02302-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 09/28/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Based on the controversy surrounding pulmonary artery catheterization (PAC) in surgical patients, we investigated the interchangeability of cardiac index (CI) and systemic vascular resistance (SVR) measurements between ClearSight™ and PAC during living-donor liver transplantation (LDLT). METHODS This prospective study included consecutively selected LDLT patients. ClearSight™-based CI and SVR measurements were compared with those from PAC at seven LDLT-stage time points. ClearSight™-based systolic (SAP), mean (MAP), and diastolic (DAP) arterial pressures were also compared with those from femoral arterial catheterization (FAC). For the comparison and analysis of ClearSight™ and the reference method, Bland-Altman analysis was used to analyze accuracy while polar and four-quadrant plots were used to analyze the trending ability. RESULTS From 27 patients, 189 pairs of ClearSight™ and reference values were analyzed. The CI and SVR performance errors (PEs) exhibited poor accuracy between the two methods (51.52 and 51.73%, respectively) in the Bland-Altman analysis. CI and SVR also exhibited unacceptable trending abilities in both the polar and four-quadrant plot analyses. SAP, MAP, and DAP PEs between the two methods displayed favorable accuracy (24.28, 21.18, and 26.26%, respectively). SAP and MAP exhibited acceptable trending ability in the four-quadrant plot between the two methods, but not in the polar plot analyses. CONCLUSIONS During LDLT, CI and SVR demonstrated poor interchangeability, while SAP and MAP exhibited acceptable interchangeability between ClearSight™ and FAC.
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Affiliation(s)
- Hye-Yeon Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Nowon Eulji Medical Center, Eulji University, Seoul, Republic of Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - In Eob Hwang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seong-Mi Yang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Kunigo T, Oikawa R, Sonoda T, Nomura M. No association between pulmonary artery catheter use and postoperative complications in off-pump coronary artery bypass grafting: a single-center pilot study. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:541-547. [PMID: 37458732 DOI: 10.23736/s0021-9509.23.12710-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND A pulmonary artery catheter is often used in cardiac surgery despite its uncertain effectiveness. The aim of this pilot study was to investigate the associations between the use of a pulmonary artery catheter and clinical outcomes in off-pump coronary artery bypass grafting. METHODS Patients over 20 years of age who had undergone off-pump coronary artery bypass grafting between December 2018 and November 2021 were enrolled in this single-center retrospective pilot study. The propensity score of pulmonary artery catheterization was calculated. Multivariate analysis including the propensity score as a covariate was performed to assess clinical outcomes. The primary outcome was the composite outcome of in-hospital death, unplanned intraoperative conversion to cardiopulmonary bypass, resuscitated cardiac arrest, mechanical circulatory support, myocardial infarction, stroke, new initiation of renal replacement therapy, inhaled nitric oxide, re-intubation and tracheostomy. RESULTS Among the 315 patients who were enrolled, 298 were included in the final analysis. A pulmonary artery catheter was inserted in 131 patients. There were 50 patients with the composite outcome including two in-hospital deaths. Multivariate logistic regression analysis showed that pulmonary artery catheterization was not significantly related to the composite outcome. Clinical outcomes worsened significantly as the number of anastomoses increased (odds ratio: 1.450, 95% confidence interval: 1.040-2.040, P=0.029). CONCLUSIONS Pulmonary artery catheterization did not improve the clinical outcomes in off-pump coronary artery bypass grafting in this pilot study.
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Affiliation(s)
- Tatsuya Kunigo
- School of Medicine, Department of Anesthesiology, Sapporo Medical University, Sapporo, Japan -
- School of Medicine, Department of Anesthesiology, Tokyo Women's Medical University, Tokyo, Japan -
| | - Risa Oikawa
- School of Medicine, Department of Anesthesiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tomoko Sonoda
- Department of Public Health, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Minoru Nomura
- School of Medicine, Department of Anesthesiology, Tokyo Women's Medical University, Tokyo, Japan
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Beydoun HA, Beydoun MA, Eid SM, Zonderman AB. Association of pulmonary artery catheter with in-hospital outcomes after cardiac surgery in the United States: National Inpatient Sample 1999-2019. Sci Rep 2023; 13:13541. [PMID: 37598267 PMCID: PMC10439892 DOI: 10.1038/s41598-023-40615-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/14/2023] [Indexed: 08/21/2023] Open
Abstract
To examine associations of pulmonary artery catheter (PAC) use with in-hospital death and hospital length of stay (days) overall and within subgroups of hospitalized cardiac surgery patients. Secondary analyses of 1999-2019 National Inpatient Sample data were performed using 969,034 records (68% male, mean age: 65 years) representing adult cardiac surgery patients in the United States. A subgroup of 323,929 records corresponded to patients with congestive heart failure, pulmonary hypertension, mitral/tricuspid valve disease and/or combined surgeries. We evaluated PAC in relation to clinical outcomes using regression and targeted maximum likelihood estimation (TMLE). Hospitalized cardiac surgery patients experienced more in-hospital deaths and longer stays if they had ≥ 1 subgroup characteristics. For risk-adjusted models, in-hospital deaths were similar among recipients and non-recipients of PAC (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.96, 1.12), although PAC was associated with more in-hospital deaths among the subgroup with congestive heart failure (OR 1.14, 95% CI 1.03, 1.26). PAC recipients experienced shorter stays than non-recipients (β = - 0.40, 95% CI - 0.64, - 0.15), with variations by subgroup. We obtained comparable results using TMLE. In this retrospective cohort study, PAC was associated with shorter stays and similar in-hospital death rates among cardiac surgery patients. Worse clinical outcomes associated with PAC were observed only among patients with congestive heart failure. Prospective cohort studies and randomized controlled trials are needed to confirm and extend these preliminary findings.
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Affiliation(s)
- Hind A Beydoun
- Department of Research Programs, Fort Belvoir Community Hospital, 9300 DeWitt Loop, Fort Belvoir, VA, 22060, USA.
| | - May A Beydoun
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging Intramural Research Program, Baltimore, Maryland, 21224, United States
| | - Shaker M Eid
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21224, United States
| | - Alan B Zonderman
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging Intramural Research Program, Baltimore, Maryland, 21224, United States
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Wu J, Liang Q, Hu H, Zhou S, Zhang Y, An S, Sha T, Li L, Zhang Y, Chen Z, An S, Zeng Z. Early pulmonary artery catheterization is not associated with survival benefits in critically ill patients with cardiac disease: An analysis of the MIMIC-IV database. Surgery 2022; 172:1285-1290. [PMID: 35953307 DOI: 10.1016/j.surg.2022.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/29/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many studies demonstrated no improved survival in patients with pulmonary artery catheter placement. However, no consistent conclusions have been drawn regarding the impact of pulmonary artery catheter in critically ill patients with heart disease. This study aimed to investigate the association of early pulmonary artery catheter use with 28-day mortality in that population. METHODS The Multiparameter Intelligent Monitoring in Intensive Care IV (MIMIC-IV) database, a single-center critical care database, was employed to investigate this issue. This study enrolled a total of 11,887 critically ill patients with cardiac disease with or without pulmonary artery catheter insertion. The primary outcome was 28-day mortality. The multivariate regression was modeled to examine the association between pulmonary artery catheter and outcomes. Additionally, we examined the effect modification by cardiac surgeries. Propensity score matching was conducted to validate our findings. RESULTS No improvement in 28-day mortality was observed among the pulmonary artery catheter group compared to the non-pulmonary artery catheter group (odds ratio 95% confidence interval: 1.18 [1.00-1.38], P = .049). When stratified by cardiac surgeries, the results were consistent. The patients in the pulmonary artery catheter group had fewer ventilation-free days and vasopressor-free days than those in the nonpulmonary artery catheter group after surgery stratification. In the surgical patients, pulmonary artery catheter insertion was not associated with the occurrence of acute kidney injury, and it was associated with a higher daily fluid input (mean difference 95% confidence interval: 0.13 [0.05-0.20], P = .001). In nonsurgical patients, the pulmonary artery catheter group had a higher risk of acute kidney injury occurrence (odds ratio 95% confidence interval: 1.94 [1.32-2.84], P = .001). CONCLUSION Early pulmonary artery catheter placement is not associated with survival benefits in critically ill patients with cardiac diseases, either in surgical or nonsurgical patients.
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Affiliation(s)
- Jie Wu
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qihong Liang
- Department of Biostatistics, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Hongbin Hu
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shiyu Zhou
- Department of Biostatistics, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Yuan Zhang
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Sheng An
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tong Sha
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lulan Li
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yaoyuan Zhang
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhongqing Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shengli An
- Department of Biostatistics, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China.
| | - Zhenhua Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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Hardiman SC, Villan Villan YF, Conway JM, Sheehan KJ, Sobolev B. Factors affecting mortality after coronary bypass surgery: a scoping review. J Cardiothorac Surg 2022; 17:45. [PMID: 35313895 PMCID: PMC8935749 DOI: 10.1186/s13019-022-01784-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/09/2022] [Indexed: 11/29/2022] Open
Abstract
Objectives Previous research reports numerous factors of post-operative mortality in patients undergoing isolated coronary artery bypass graft surgery. However, this evidence has not been mapped to the conceptual framework of care improvement. Without such mapping, interventions designed to improve care quality remain unfounded. Methods We identified reported factors of in-hospital mortality post isolated coronary artery bypass graft surgery in adults over the age of 19, published in English between January 1, 2000 and December 31, 2019, indexed in PubMed, CINAHL, and EMBASE. We grouped factors and their underlying mechanism for association with in-hospital mortality according to the augmented Donabedian framework for quality of care. Results We selected 52 factors reported in 83 articles and mapped them by case-mix, structure, process, and intermediary outcomes. The most reported factors were related to case-mix (characteristics of patients, their disease, and their preoperative health status) (37 articles, 27 factors). Factors related to care processes (27 articles, 12 factors) and structures (11 articles, 6 factors) were reported less frequently; most proposed mechanisms for their mortality effects. Conclusions Few papers reported on factors of in-hospital mortality related to structures and processes of care, where intervention for care quality improvement is possible. Therefore, there is limited evidence to support quality improvement efforts that will reduce variation in mortality after coronary artery bypass graft surgery. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-022-01784-z.
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 490] [Impact Index Per Article: 163.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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Ylikauma LA, Lanning KM, Erkinaro TM, Ohtonen PP, Vakkala MA, Liisanantti JH, Juvonen TS, Kaakinen TI. Reliability of Bioreactance and Pulse-Power Analysis in Measuring Cardiac Index in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2021; 36:2446-2453. [PMID: 35027295 DOI: 10.1053/j.jvca.2021.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/21/2021] [Accepted: 11/29/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Less-invasive and continuous cardiac output monitors recently have been developed to monitor patient hemodynamics. The aim of this study was to compare the accuracy, precision, and trending ability of noninvasive bioreactance-based Starling SV and miniinvasive pulse-power device LiDCOrapid to bolus thermodilution technique with a pulmonary artery catheter (TDCO) when measuring cardiac index in the setting of cardiac surgery with cardiopulmonary bypass (CPB). DESIGN A prospective method-comparison study. SETTING Oulu University Hospital, Finland. PARTICIPANTS Twenty patients undergoing cardiac surgery with CPB. INTERVENTIONS Cardiac index measurements were obtained simultaneously with TDCO intraoperatively and postoperatively, resulting in 498 measurements with Starling SV and 444 with LiDCOrapid. MEASUREMENTS AND MAIN RESULTS The authors used the Bland-Altman method to investigate the agreement between the devices and four-quadrant plots with error grids to assess the trending ability. The agreement between TDCO and Starling SV was qualified with a bias of 0.43 L/min/m2 (95% confidence interval [CI], 0.37-0.50), wide limits of agreement (LOA, -1.07 to 1.94 L/min/m2), and a percentage error (PE) of 66.3%. The agreement between TDCO and LiDCOrapid was qualified, with a bias of 0.22 L/min/m2 (95% CI 0.16-0.27), wide LOA (-0.93 to 1.43), and a PE of 53.2%. With both devices, trending ability was insufficient. CONCLUSION The reliability of bioreactance-based Starling SV and pulse-power analyzer LiDCOrapid was not interchangeable with TDCO, thus limiting their usefulness in cardiac surgery with CPB.
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Affiliation(s)
- Laura Anneli Ylikauma
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.
| | - Katriina Marjatta Lanning
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Tiina Maria Erkinaro
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Pasi Petteri Ohtonen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Division of Operative Care, Oulu University Hospital, Oulu, Finland
| | - Merja Annika Vakkala
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Janne Henrik Liisanantti
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Tatu Sakari Juvonen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Central Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Timo Ilari Kaakinen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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Commentary: The uncertain fate of the pulmonary artery catheter in cardiac surgery: The difference is in the exceptions. J Thorac Cardiovasc Surg 2021; 164:1974-1975. [PMID: 33726901 DOI: 10.1016/j.jtcvs.2021.02.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 11/20/2022]
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Stevens M, Davis T, Munson SH, Shenoy AV, Gricar BLA, Yapici HO, Shaw AD. Short and Mid-Term Economic Impact of Pulmonary Artery Catheter Use in Adult Cardiac Surgery: A Hospital and Integrated Health System Perspective. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:109-119. [PMID: 33574686 PMCID: PMC7872861 DOI: 10.2147/ceor.s282253] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/14/2020] [Indexed: 11/23/2022] Open
Abstract
Objective A monitoring pulmonary artery catheter (PAC) is utilized in approximately 34% of the US cardiac surgical procedures. Increased use of PAC has been reported to have an association with complication rates: significant decreases in new-onset heart failure (HF) and respiratory failure (RF), but increases in bacteremia and urinary tract infections. We assessed the impact of increasing PAC adoption on hospital costs among cardiac surgery patients for US-based healthcare systems. Methods An Excel-based economic model calculated annualized savings for a US hospital with various cardiac surgical volumes and PAC adoption rates. A second model, for an integrated payer-provider health system, analyzed outcomes/costs resulting from the cardiac surgical admission and for the treatment of persistent HF and RF complications in the year following surgery. Model inputs were extracted from published literature, and one-way and probabilistic sensitivity analyses were performed. Results For an acute care hospital with 500 procedures/year and 34% PAC adoption, annualized savings equalled $61,806 vs no PAC utilization. An increase in PAC adoption rate led to increased savings of $134,751 for 75% and $170,685 for 95% adoption. Savings ranged from $12,361 to $185,418 at volumes of 100 and 1500 procedures/year, respectively. For an integrated payer-provider health system with the base-case scenario of 3845 procedures/year and 34% PAC adoption, estimated savings were $596,637 for the combined surgical index admission and treatment for related complications over the following year. Conclusion PAC utilization in adult cardiac surgery patients results in reduced costs for both acute care hospitals and payer-provider integrated health systems.
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Affiliation(s)
- Mitali Stevens
- Global Health Economics & Reimbursement, Edwards Lifesciences, Irvine, CA, USA
| | - Todd Davis
- Global Health Economics & Reimbursement, Edwards Lifesciences, Irvine, CA, USA
| | - Sibyl H Munson
- Department of Health Economics and Outcomes Research, Boston Strategic Partners, Inc., Boston, MA, USA
| | - Apeksha V Shenoy
- Department of Health Economics and Outcomes Research, Boston Strategic Partners, Inc., Boston, MA, USA
| | - Boye L A Gricar
- Department of Health Economics and Outcomes Research, Boston Strategic Partners, Inc., Boston, MA, USA
| | - Halit O Yapici
- Department of Health Economics and Outcomes Research, Boston Strategic Partners, Inc., Boston, MA, USA
| | - Andrew D Shaw
- Department of Anaesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
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Brown JA, Aranda-Michel E, Kilic A, Serna-Gallegos D, Bianco V, Thoma FW, Sultan I. The impact of pulmonary artery catheter use in cardiac surgery. J Thorac Cardiovasc Surg 2021; 164:1965-1973.e6. [PMID: 33642109 DOI: 10.1016/j.jtcvs.2021.01.086] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Pulmonary artery catheterization provides continuous monitoring of hemodynamic parameters that may aid in the perioperative management of patients undergoing cardiac surgery. However, prior data suggest that pulmonary artery catheterization has limited benefit in intensive care and surgical settings. Thus, this study sought to determine the impact of pulmonary artery catheter insertion on short-term postoperative outcomes in a large, contemporaneous cohort of patients undergoing open cardiac surgery compared with standard central venous pressure monitoring. METHODS This was an observational study of open cardiac surgeries from 2010 to 2018. Patients with pulmonary artery catheter insertion were identified and matched against patients without pulmonary artery catheter insertion via 1:1 nearest neighbor propensity matching. Multivariable analysis was performed to assess the impact of pulmonary artery catheterization on operative mortality in the overall cohort, as well as recent heart failure, mitral valve disease, and tricuspid insufficiency subgroups. RESULTS Of the 11,820 patients undergoing (Society of Thoracic Surgeons indexed) coronary or valvular surgery, 4605 (39.0%) had pulmonary artery catheter insertion. Propensity score matching yielded 3519 evenly balanced pairs. Compared with central venous pressure monitoring, pulmonary artery catheter use was not associated with improved operative mortality in the overall cohort or in the recent heart failure, mitral valve disease, or tricuspid insufficiency subgroups. Intensive care unit length of stay was longer (P < .001), and there were more packed red blood cell transfusions in the pulmonary artery catheterization group (P < .001); however, postoperative outcomes were otherwise similar, including stroke, sepsis, and new renal failure (P > .05). CONCLUSIONS These findings suggest that pulmonary artery catheterization may have limited benefit in cardiac surgery.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Floyd W Thoma
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Fixation of intracapsular fracture of the femoral neck using combined peripheral nerve blocks and transthoracic echocardiography in a patient with severe obstructive hypertrophic cardiomyopathy: a case report. JA Clin Rep 2019; 5:64. [PMID: 32025936 PMCID: PMC6967383 DOI: 10.1186/s40981-019-0287-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/22/2019] [Indexed: 01/08/2023] Open
Abstract
Background Hypertrophic obstructive cardiomyopathy (HOCM) is a type of hypertrophic cardiomyopathy associated with left ventricular outflow tract stenosis. The increased pressure gradients across the left ventricular outflow tract in patients with HOCM could lead to circulatory collapse. We describe our experience with perioperative management under femoral nerve block (FNB), lateral femoral cutaneous nerve block (LFCNB), and transthoracic echocardiography (TTE) monitoring during open reduction and internal fixation of a femoral neck fracture in a patient with severe HOCM. Case presentation A 72-year-old man, who was indicated to undergo open reduction and internal fixation of an intracapsular femoral neck fracture, had a history of treatment for hypertension and HOCM. He had heart failure for 4 years and was hospitalized several times. He was resuscitated after ventricular fibrillation and received an implantable cardioverter-defibrillator at that time. He also had severe physical limitations (New York Heart Association class III). We selected FNB and LFCNB as the methods for anesthesia and injected 0.25% levobupivacaine (20 mL) around the femoral nerve and 0.25% levobupivacaine (10 mL) into the lateral femoral nerve region. He underwent TTE during the perioperative period, which enabled us to perform hemodynamic and morphological evaluations of the heart. The intraoperative TTE findings remained stable from before the induction of anesthesia to the patient’s exit from the operating room. Postoperatively, his hemodynamic parameters continued to remain stable. Conclusions In this case, FNB and LFCNB contributed to hemodynamic stability during non-cardiac surgery. Additionally, TTE was useful for the perioperative evaluation of cardiac hemodynamics and morphology in our patient with severe HOCM.
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Right Heart Catheterization-Background, Physiological Basics, and Clinical Implications. J Clin Med 2019; 8:jcm8091331. [PMID: 31466390 PMCID: PMC6780851 DOI: 10.3390/jcm8091331] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/17/2019] [Accepted: 08/25/2019] [Indexed: 11/17/2022] Open
Abstract
The idea of right heart catheterization (RHC) grew in the milieu of modern thinking about the cardiovascular system, influenced by the experiments of William Harvey, which were inspired by the treatises of Greek philosophers like Aristotle and Gallen, who made significant contributions to the subject. RHC was first discovered in the eighteenth century by William Hale and was subsequently systematically improved by outstanding experiments in the field of physiology, led by Cournand and Dickinson Richards, which finally resulted in the implementation of pulmonary artery catheters (PAC) into clinical practice by Jeremy Swan and William Ganz in the early 1970s. Despite its premature euphoric reception, some further analysis seemed not to share the early enthusiasm as far as the safety and effectiveness issues were concerned. Nonetheless, RHC kept its significant role in the diagnosis, prognostic evaluation, and decision-making of pulmonary hypertension and heart failure patients. Its role in the treatment of end-stage heart failure seems not to be fully understood, although it is promising. PAC-guided optimization of the treatment of patients with ventricular assist devices and its beneficial introduction into clinical practice remains a challenge for the near future.
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Shaw AD, Mythen MG, Shook D, Hayashida DK, Zhang X, Skaar JR, Iyengar SS, Munson SH. Pulmonary artery catheter use in adult patients undergoing cardiac surgery: a retrospective, cohort study. Perioper Med (Lond) 2018; 7:24. [PMID: 30386591 PMCID: PMC6201566 DOI: 10.1186/s13741-018-0103-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/10/2018] [Indexed: 11/10/2022] Open
Abstract
Background The utility of pulmonary artery catheters (PACs) and their measurements depend on a variety of factors including data interpretation and personnel training. This US multi-center, retrospective electronic health record (EHR) database analysis was performed to identify associations between PAC use in adult cardiac surgeries and effects on subsequent clinical outcomes. Methods This cohort analysis utilized the Cerner Health Facts database to examine patients undergoing isolated coronary artery bypass graft (CABG), isolated valve surgery, aortic surgery, other complex non-valvular and multi-cardiac procedures, and/or heart transplant from January 1, 2011, to June 30, 2015. A total of 6844 adults in two cohorts, each with 3422 patients who underwent a qualifying cardiac procedure with or without the use of a PAC for monitoring purposes, were included. Patients were matched 1:1 using a propensity score based upon the date and type of surgery, hospital demographics, modified European System for Cardiac Operative Risk Evaluation (EuroSCORE II), and patient characteristics. Primary outcomes of 30-day in-hospital mortality, length of stay, cardiopulmonary morbidity, and infectious morbidity were analyzed after risk adjustment for acute physiology score. Results There was no difference in the 30-day in-hospital mortality rate between treatment groups (OR, 1.17; 95% CI, 0.65-2.10; p = 0.516). PAC use was associated with a decreased length of stay (9.39 days without a PAC vs. 8.56 days with PAC; p < 0.001), a decreased cardiopulmonary morbidity (OR, 0.87; 95% CI, 0.79-0.96; p < 0.001), and an increased infectious morbidity (OR, 1.28; 95% CI, 1.10-1.49; p < 0.001). Conclusions Use of a PAC during adult cardiac surgery is associated with decreased length of stay, reduced cardiopulmonary morbidity, and increased infectious morbidity but no increase in the 30-day in-hospital mortality. This suggests an overall potential benefit associated with PAC-based monitoring in this population. Trial registration The study was registered at clinicaltrials.gov (NCT02964026) on November 15, 2016.
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Affiliation(s)
- Andrew D Shaw
- 1Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA.,5Department of Anesthesiology and Pain Medicine, University of Alberta, 2-150 Clinical Sciences Building, Edmonton, AB T6G 2G3 Canada
| | - Michael G Mythen
- 2University College London Hospitals NIHR Biomedical Research Centre, London, UK
| | - Douglas Shook
- 3Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA USA
| | | | - Xuan Zhang
- Boston Strategic Partners, Inc., Boston, MA USA
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De Backer D, Hajjar LA, Pinsky MR. Is there still a place for the Swan‒Ganz catheter? We are not sure. Intensive Care Med 2018; 44:960-962. [PMID: 29796917 DOI: 10.1007/s00134-018-5140-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 03/16/2018] [Indexed: 01/20/2023]
Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium.
| | - Ludhmila A Hajjar
- Department of Cardiopneumology, Heart Institute, University of Sao Paulo, Sao Paulo, Brazil
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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An elevated respiratory quotient predicts complications after cardiac surgery under extracorporeal circulation: an observational pilot study. J Clin Monit Comput 2018; 33:145-153. [DOI: 10.1007/s10877-018-0137-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/31/2018] [Indexed: 01/15/2023]
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Kingeter AJ, Kingeter MA, Shaw AD. Fluids and Organ Dysfunction: A Narrative Review of the Literature and Discussion of 5 Controversial Topics. J Cardiothorac Vasc Anesth 2018; 32:2054-2066. [PMID: 29685796 DOI: 10.1053/j.jvca.2018.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Indexed: 01/24/2023]
Abstract
Evidence-based clinical decision making is at the forefront of modern cardiothoracic anesthesia practice. Therefore, as a field, cardiac anesthesiologist should strive to ensure that the available evidence is of the highest possible quality. In this narrative review, 5 important topics that the authors believe require additional investigation in cardiothoracic anesthesia and critical care related to fluid therapy and organ dysfunction are outlined briefly. In particular, the authors believe that the areas of pulmonary artery catheter use, restrictive versus liberal transfusion strategies, cardiopulmonary bypass prime composition, colloid use in resuscitation and its effects on acute kidney injury, and management of acute kidney injury after cardiac surgery hold many unanswered questions and opportunities for continued improvement in the specialty of cardiac anesthesia. This article accompanies a presentation at the 46th Association of Cardiac Anesthesiologists Annual Meeting on October 22, 2017.
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Affiliation(s)
- Adam J Kingeter
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
| | - Meredith A Kingeter
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
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Youssef N, Whitlock RP. The Routine Use of the Pulmonary Artery Catheter Should Be Abandoned. Can J Cardiol 2016; 33:135-141. [PMID: 27916322 DOI: 10.1016/j.cjca.2016.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 10/11/2016] [Accepted: 10/11/2016] [Indexed: 11/17/2022] Open
Abstract
The pulmonary artery catheter (PAC) is the most common method of measuring cardiac output in cardiac surgery. However, its use has always been questioned in terms of survival benefit, specifically with regard to the accuracy of its measurements and its invasive nature, with the potential for serious complications. In this review we aimed to develop a clear understanding of the pitfalls of the use of PAC, and discuss its risks and available alternatives. We conclude that there is no indication for the routine use of PAC such that clinicians should carefully consider the clinical risks and benefits on a patient by patient basis.
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Affiliation(s)
- Nayer Youssef
- Division of Anesthesiology, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Richard P Whitlock
- Divisions of Cardiac Surgery and Critical Care Medicine, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
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21
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Leibowitz AB, Oropello JM. The Pulmonary Artery Catheter in Anesthesia Practice in 2007: An Historical Overview With Emphasis on the Past 6 Years. Semin Cardiothorac Vasc Anesth 2016; 11:162-76. [PMID: 17711969 DOI: 10.1177/1089253207306102] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The pulmonary artery catheter has been widely used in anesthesiology and critical care medicine. Until recently, only retrospective or relatively weak prospective studies examining its effect on outcome had been performed. Over the past 6 years, however, a number of well-designed prospective trials and statistically sound retrospective studies have been completed. All of these show no benefit and some even reveal a potential for increased morbidity. Reasons for this device's inability to improve outcome are numerous, including wrong patient selection and misinterpretation, but the most impressive and convincing evidence is that filling pressures measured from the catheter, particularly the pulmonary artery “wedge” pressure, have no physiologic value. The wedge pressure has been shown to not correlate with other accepted methods of determining left ventricular filling or volume or intravascular volume and also does not help to generate cardiac function curves. Therefore, knowledge of it may actually lead to incorrect management more frequently than not.
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Affiliation(s)
- Andrew B Leibowitz
- Department of Anesthesiology, Mount Sinai School of Medicine, New York, New York, USA.
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Brovman EY, Gabriel RA, Dutton RP, Urman RD. Pulmonary Artery Catheter Use During Cardiac Surgery in the United States, 2010 to 2014. J Cardiothorac Vasc Anesth 2016; 30:579-84. [DOI: 10.1053/j.jvca.2015.11.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Indexed: 01/29/2023]
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23
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Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care. Crit Care Med 2015; 43:1477-97. [PMID: 25962078 DOI: 10.1097/ccm.0000000000001059] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. The cardiac intensivist must have a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. In this concise review, targeted at intensivists and surgeons, we discuss the routine management of the postoperative cardiac surgical patient. DATA SOURCE AND SYNTHESIS Narrative review of relevant English-language peer-reviewed medical literature. CONCLUSIONS Critical care of the cardiac surgical patient is a complex and dynamic endeavor. Adequate fluid resuscitation, appropriate inotropic support, attention to rewarming, and ventilator management are key components. Patient safety is enhanced by experienced personnel, a structured handover between the operating room and ICU teams, and appropriate transfusion strategies.
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Xu F, Wang Q, Zhang H, Chen S, Ao H. Use of pulmonary artery catheter in coronary artery bypass graft. Costs and long-term outcomes. PLoS One 2015; 10:e0117610. [PMID: 25689312 PMCID: PMC4331497 DOI: 10.1371/journal.pone.0117610] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 12/29/2014] [Indexed: 12/03/2022] Open
Abstract
Background Pulmonary artery catheters (PAC) are used widely to monitor hemodynamics in patients undergoing coronary bypass graft (CABG) surgery. However, recent studies have raised concerns regarding both the effectiveness and safety of PAC. Therefore, our aim was to determine the effects of the use of PAC on the short- and long-term health and economic outcomes of patients undergoing CABG. Methods 1361 Chinese patients who consecutively underwent isolated, primary CABG at the Cardiovascular Institute of Fuwai Hospital from June 1, 2012 to December 31, 2012 were included in this study. Of all the patients, 453 received PAC during operation (PAC group) and 908 received no PAC therapy (control group). Short-term and long-term mortality and major complications were analyzed with multivariate regression analysis and propensity score matched-pair analysis was used to yield two well-matched groups for further comparison. Results The patients who were managed with PAC more often received intraoperative vasoactive drugs dopamine (70.9% vs. 45.5%; P<0.001) and epinephrine (7.7% vs. 2.6%; P<0.001). In addition, costs for initial hospitalization were higher for PAC patients ($14,535 vs. $13,873, respectively, p = 0.004). PAC use was neither associated with the perioperative mortality or major complications, nor was it associated with long-term mortality and major adverse cardiac and cerebrovascular events. In addition, comparison between two well-matched groups showed no significant differences either in baseline characteristics or in short-term and long-term outcomes. Conclusions There is no clear indication of any benefit or harm in managing CABG patients with PAC. However, use of PAC in CABG is more expensive. That is, PAC use increased costs without benefit and thus appears unjustified for routine use in CABG surgery.
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Affiliation(s)
- Fei Xu
- Department of Anesthesiology, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Qian Wang
- Department of Anesthesiology, Inner Mongolia Medical University, Huhhot Inner Mongolia, China
| | - Heng Zhang
- Department of cardio-thoracic surgery, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Sipeng Chen
- Department of Biostatistical Unit, Capital Medical University, Beijing, China
| | - Hushan Ao
- Department of Anesthesiology, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
- * E-mail:
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Affiliation(s)
- Yatin Mehta
- Chairman, Medanta Institute of Critical Care and Anesthesia, Medanta The Medicity, Sector 38, Gurgaon (NCR), Haryana, India
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Ingrande J, Lemmens HJ. Medical devices for the anesthetist: current perspectives. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2014; 7:45-53. [PMID: 24707188 PMCID: PMC3971909 DOI: 10.2147/mder.s43428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Anesthesiologists are unique among most physicians in that they routinely use technology and medical devices to carry out their daily activities. Recently, there have been significant advances in medical technology. These advances have increased the number and utility of medical devices available to the anesthesiologist. There is little doubt that these new tools have improved the practice of anesthesia. Monitoring has become more comprehensive and less invasive, airway management has become easier, and placement of central venous catheters and regional nerve blockade has become faster and safer. This review focuses on key medical devices such as cardiovascular monitors, airway equipment, neuromonitoring tools, ultrasound, and target controlled drug delivery software and hardware. This review demonstrates how advances in these areas have improved the safety and efficacy of anesthesia and facilitate its administration. When applicable, indications and contraindications to the use of these novel devices will be explored as well as the controversies surrounding their use.
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Affiliation(s)
- Jerry Ingrande
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Hendrikus Jm Lemmens
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Schiraldi R, Calderón L, Maggi G, Brogly N, Guasch E, Gilsanz F. Transoesophageal Doppler-guided fluid management in massive obstetric haemorrhage. Int J Obstet Anesth 2014; 23:71-4. [DOI: 10.1016/j.ijoa.2013.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 07/02/2013] [Accepted: 07/06/2013] [Indexed: 01/18/2023]
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Pérez Vela J, Martín Benítez J, Carrasco González M, De la Cal López M, Hinojosa Pérez R, Sagredo Meneses V, del Nogal Saez F. Guías de práctica clínica para el manejo del síndrome de bajo gasto cardíaco en el postoperatorio de cirugía cardíaca. Med Intensiva 2012; 36:e1-44. [DOI: 10.1016/j.medin.2012.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 01/07/2012] [Indexed: 01/04/2023]
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Hessel EA, Apostolidou I. Pulmonary Artery Catheter for Coronary Artery Bypass Graft. Anesth Analg 2011; 113:987-9. [DOI: 10.1213/ane.0b013e31822dd4b0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Schwann NM, Hillel Z, Hoeft A, Barash P, Möhnle P, Miao Y, Mangano DT. Lack of Effectiveness of the Pulmonary Artery Catheter in Cardiac Surgery. Anesth Analg 2011; 113:994-1002. [DOI: 10.1213/ane.0b013e31822c94a8] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Singh S, Taylor MA. Con: the FloTrac device should not be used to follow cardiac output in cardiac surgical patients. J Cardiothorac Vasc Anesth 2011; 24:709-11. [PMID: 20673749 DOI: 10.1053/j.jvca.2010.04.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Indexed: 11/11/2022]
Affiliation(s)
- Saket Singh
- Department of Anesthesiology, The Western Pennsylvania Hospital, Temple University School of Medicine, Pittsburgh, PA 15224, USA.
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Cowie BS. Does the Pulmonary Artery Catheter Still Have a Role in the Perioperative Period? Anaesth Intensive Care 2011; 39:345-55. [DOI: 10.1177/0310057x1103900305] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The pulmonary artery catheter (PAC) was introduced into clinical practice in the early 1970s. Its use quickly expanded beyond patients with acute myocardial infarction to critically ill patients in the intensive care unit. Increasingly, it was used in the perioperative period in patients having major cardiac and noncardiac surgery. Publication of large observational studies suggested that patients with a PAC were more likely to suffer major morbidity or mortality, but this was difficult to assess because patients who had a PAC inserted were often sicker, with more severe pathology, and were therefore more likely to die. The PAC is a monitoring device and information alone is unlikely to influence outcome unless it is linked to a proven therapy. Several thousand articles on the use of the PAC now exist, but in general, the quality of this literature is poor. Much of the data are not randomised, have small sample sizes and include patients with greatly differing pathological states. It is unclear which, if any, of the PAC-guided therapies are actually beneficial for patients. Despite these flaws, there is no clear evidence of benefit, nor harm, in cardiac, intensive care or perioperative patients. Selected indications for the PAC may remain, such as complex cardiac surgery or solid organ transplantation. However, its routine use is difficult to justify and increasingly, most of the haemodynamic data available from the PAC can be obtained less invasively with echocardiography.
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Affiliation(s)
- B. S. Cowie
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria, Australia
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Nossaman BD, Scruggs BA, Nossaman VE, Murthy SN, Kadowitz PJ. History of right heart catheterization: 100 years of experimentation and methodology development. Cardiol Rev 2010; 18:94-101. [PMID: 20160536 PMCID: PMC2857603 DOI: 10.1097/crd.0b013e3181ceff67] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The development of right heart catheterization has provided the clinician the ability to diagnose patients with congenital and acquired right heart disease, and to monitor patients in the intensive care unit with significant cardiovascular illnesses. The development of bedside pulmonary artery catheterization has become a standard of care for the critically ill patient since its introduction into the intensive care unit almost 40 years ago. However, adoption of this procedure into the mainstream of clinical practice occurred without prior evaluation or demonstration of its clinical or cost-effectiveness. Moreover, current randomized, controlled trials provide little evidence in support of the clinical utility of pulmonary artery catheterization in the management of critically ill patients. Nevertheless, the right heart catheter is an important diagnostic tool to assist the clinician in the diagnosis of congenital heart disease and acquired right heart disease, and moreover, when catheter placement is proximal to the right auricle (atria), this catheter provides an important and safe route for administration of fluids, medications, and parenteral nutrition. The purpose of this manuscript is to review the development of right heart catheterization that led to the ability to conduct physiologic studies in cardiovascular dynamics in normal individuals and in patients with cardiovascular diseases, and to review current controversies of the extension of the right heart catheter, the pulmonary artery catheter.
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Affiliation(s)
- Bobby D. Nossaman
- Department of Pharmacology, Tulane University Medical Center, New Orleans, Louisiana
- Department of Anesthesiology, Critical Care Medicine Section, Ochsner Medical Center, New Orleans, Louisiana
| | - Brittni A. Scruggs
- Department of Pharmacology, Tulane University Medical Center, New Orleans, Louisiana
| | - Vaughn E. Nossaman
- Department of Pharmacology, Tulane University Medical Center, New Orleans, Louisiana
| | - Subramanyam N. Murthy
- Department of Pharmacology, Tulane University Medical Center, New Orleans, Louisiana
| | - Philip J. Kadowitz
- Department of Pharmacology, Tulane University Medical Center, New Orleans, Louisiana
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Abstract
OBJECTIVE Pulse contour cardiac output (PCCO) analysis is a technique for continuous cardiac output (CO) monitoring through an arterial catheter after calibration by transpulmonary thermodilution (TPTD). Studies in adults show good correlation with pulmonary artery thermodilution (PATD) CO. Data are limited in children and patients with hemodynamic instability. The objective was to determine whether TPTD CO and PCCO analysis correlate with PATD CO in a piglet model of severe hemorrhagic shock. Mixed venous oxygen saturation (SVO2) was also compared with PATD CO. DESIGN Prospective animal study. SETTING University animal research laboratory. SUBJECTS Domesticated piglets, 24-37 kg. INTERVENTIONS Hemorrhagic shock was created by graded hemorrhage in anesthetized piglets. Hemorrhage was initiated to achieve mean arterial pressure plateaus of 60, 50, 40, 30, and 20 mm Hg. MEASUREMENTS AND MAIN RESULTS CO was measured by PATD and simultaneously with two femoral artery PCCO catheters. At each mean arterial pressure plateau, one PCCO catheter was recalibrated by TPTD; the other catheter was not recalibrated during hemorrhage. TPTD CO, PCCO measurements from each catheter, and SVO2 were compared with PATD CO at each mean arterial pressure level. TPTD CO and recalibrated PCCO showed excellent correlation (r2 = .96 and .97) and small bias (+0.11 and +0.14 L/min), respectively, compared with PATD. Without recalibration, PCCO measurements were not accurate during rapid hemorrhage (r2 = .22). SVO2 decline did not correlate as well with PATD CO (r2 = .69). CONCLUSIONS TPTD CO and recalibrated PCCO analysis correlate well with PATD CO in this severe hemorrhagic shock model. The mean difference is small (<0.15 L/min) and is not clinically significant. With rapid changes in blood pressure or intravascular volume, PCCO is not accurate unless recalibrated by TPTD CO. SVO2 did not correlate well with CO in this model.
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Zoremba N, Bickenbach J, Krauss B, Rossaint R, Kuhlen R, Schälte G. Comparison of electrical velocimetry and thermodilution techniques for the measurement of cardiac output. Acta Anaesthesiol Scand 2007; 51:1314-9. [PMID: 17944633 DOI: 10.1111/j.1399-6576.2007.01445.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AIM To compare a new method of non-invasive determination of cardiac output based on electrical velocimetry (EV-CO) with invasive thermodilution methods. METHODS Fifty critically ill patients were enrolled into the study. EV-CO was compared with cardiac output measured by a pulmonary artery catheter (PA-CO) in one group (n= 25) and by a femoral artery catheter (PiCCO-CO) in a second group (n= 25), by simultaneous measurements. Standard electrocardiography electrodes were used for non-invasive measurements, and EV-CO was calculated using the Bernstein-Osypka equation. The invasive measurements of PA-CO and PiCCO-CO were made by the injection of iced 0.9% saline and the recording of thermodilution curves. RESULTS The precision values of EV-CO, PA-CO and PiCCO-CO measurements were +/- 0.46 [95% confidence interval (95% CI), +/- 0.06], +/- 0.57 (95% CI, +/- 0.09) and +/- 0.48 l/min (95% CI, +/- 0.08 l/min), respectively. The mean differences between EV-CO and PA-CO or PiCCO-CO were -0.05 +/- 0.71 and 0.22 +/- 0.78 l/min, respectively. The lower and upper limits of agreement for the comparison of EV-CO with PA-CO were -1.47 and 1.37 l/min (95% CI, +/- 0.25 l/min), respectively. In the comparison of EV-CO and PiCCO-CO, lower and upper limits of -1.34 and 1.78 l/min (95% CI, +/- 0.27 l/min) were found. The percentage errors between EV-CO and PA-CO or PiCCO-CO were 26.5% and 26.4%, respectively. CONCLUSIONS The values of cardiac output were statistically comparable between the groups. Therefore, electrical velocimetry is a suitable method to evaluate haemodynamic variables with clinically acceptable accuracy.
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Affiliation(s)
- N Zoremba
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Aaschen, Germany.
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Schirmer U. [Pulmonary artery catheter in anaesthesia and intensive care medicine]. Anaesthesist 2007; 56:273-5; author reply 276, 278-80. [PMID: 17333034 DOI: 10.1007/s00101-007-1139-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Kastrup M, Markewitz A, Spies C, Carl M, Erb J, Grosse J, Schirmer U. Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac surgery patients in Germany: results from a postal survey. Acta Anaesthesiol Scand 2007; 51:347-58. [PMID: 17096667 DOI: 10.1111/j.1399-6576.2006.01190.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND In Germany, more than 100,000 patients are monitored and treated in 80 intensive care units (ICUs) following cardiac surgery each year. The controversies concerning the different methods of hemodynamic monitoring and the appropriate agents for volume therapy and inotropic support are well known. However, little is known about how monitoring and treatment are currently performed. METHODS A questionnaire with 39 questions was sent to the leading physicians of 80 ICUs in Germany, treating patients after cardiac surgery. The questions to be answered covered the current practice of hemodynamic monitoring, volume replacement, inotropic/vasopressor support and transfusions in patients after cardiac surgery. RESULTS Sixty-nine per cent of the questionnaires were completed and returned. All ICUs used basic monitoring as recommended by the societies. The use of advanced hemodynamic monitoring included the pulmonary artery catheter (58.2%), transesophageal echocardiography (38.1%) and transpulmonary dilution techniques (13%). Crystalloids (21.2%) and colloids (73%) were used for volume replacement. Epinephrine (41.8%) and dobutamine (30.9%) were the first-choice inotropic drugs for the treatment of low cardiac output syndrome, followed by phosphodiesterase inhibitors (14.5%). Second-choice drugs for the treatment of low cardiac output syndrome were enoximone (29%), milrinone (25%) and dobutamine (25%). A written transfusion protocol and a transfusion threshold for red blood cells existed in 59% and 79% of ICUs, respectively. CONCLUSION Hemodynamic monitoring and the variability in clinical practice with regard to volume replacement, transfusion triggers and the use of vasopressors/inotropes in cardiac surgery patients tend to follow the results of traditional experience rather than current scientific knowledge. Guidelines are therefore necessary to help to improve the standards of intensive care after cardiac surgery and thus the outcome of patients.
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Affiliation(s)
- M Kastrup
- Department of Anesthesiology and Intensive Care Medicine, Charité--Universitätsmedizin Berlin, Berlin, Germany
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Affiliation(s)
- James Ramsay
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Resano FG, Kapetanakis EI, Hill PC, Haile E, Corso PJ. Clinical Outcomes of Low-Risk Patients Undergoing Beating-Heart Surgery With or Without Pulmonary Artery Catheterization. J Cardiothorac Vasc Anesth 2006; 20:300-6. [PMID: 16750726 DOI: 10.1053/j.jvca.2006.01.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Indexed: 11/11/2022]
Abstract
OBJECTIVE For patients who undergo off-pump coronary artery bypass (OPCAB) surgery, pulmonary artery catheterization (PAC) has been proposed as a useful intraoperative monitoring tool. This study was designed to determine if the choice of PAC versus central venous pressure monitoring (CVP) had any effect on outcome after OPCAB. This study compared these 2 methods of hemodynamic monitoring in low-risk patients undergoing beating-heart surgery via a median sternotomy and evaluated their effect on morbidity and in-hospital mortality. DESIGN Retrospective database and medical record review. SETTING Tertiary care teaching hospital. PARTICIPANTS Low-risk patients who had coronary revascularization via a median sternotomy on the beating heart. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A population of 2,414 low-risk patients who had beating-heart coronary revascularization between January 2000 and December 2003 was reviewed. Most patients (1,671 or 69.2%) received a PAC, whereas 743 (30.8%) had CVP monitoring. Risk-adjusted logistic regression analyses were performed to investigate the effect of each technique on clinical outcomes. The groups were comparable in both baseline characteristics and Parsonett's mortality risk (1.5 +/- 0.9, p = 0.58). Univariate analysis failed to show a difference in operative mortality (p = 0.76), on-pump conversion rate for completion of aortocoronary bypasses (p = 0.82), postoperative low cardiac output (p = 0.10), or prolonged inotropic agent use (p = 0.22). Similarly, in the multivariate analysis, both groups had a similar rate of conversion to an on-pump procedure for completion of coronary artery grafting (p = 0.91), intraoperative intra-aortic balloon pump use (p = 0.69), low cardiac output state (p = 0.16), or in-hospital mortality (p = 0.51). CONCLUSIONS This single-institution, retrospective study suggests that in low-risk patients undergoing beating-heart surgery, CVP monitoring may be sufficient.
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Affiliation(s)
- Fernando G Resano
- Department of Anesthesiology, Washington Hospital Center, 110 Irving Street, NW, Washington, DC 20010-2975, USA.
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Djaiani G, Karski J, Yudin M, Hynninen M, Fedorko L, Carroll J, Poonawala H, Cheng D. Clinical Outcomes in Patients Undergoing Elective Coronary Artery Bypass Graft Surgery With and Without Utilization of Pulmonary Artery Catheter–Generated Data. J Cardiothorac Vasc Anesth 2006; 20:307-10. [PMID: 16750727 DOI: 10.1053/j.jvca.2006.02.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2005] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the frequency of pulmonary artery catheter (PAC) quantitative data requirements for modifying patient management during and after elective coronary artery bypass graft (CABG) surgery. DESIGN A prospective observational clinical trial. SETTING University tertiary referral center. PARTICIPANTS Two hundred patients undergoing elective CABG surgery. INTERVENTIONS Attending anesthesiologist and surgeon were blinded to PAC numeric values. These data could be revealed in the presence of at least 2 of the following criteria: (1) systolic blood pressure <90 mmHg, (2) central venous pressure >15 mmHg, (3) urine output <0.5 mL/kg/h, (4) pH <7.35/HCO(3) <18 mmol/L, (5) SaO(2) <95%/F(I)O(2) >80%, and (6) ST changes +/- 2 mm if the empiric treatment failed to restore normal hemodynamics within 10 minutes. All patients were classified into either blinded or unblinded PAC groups. MEASUREMENTS AND MAIN RESULTS PAC data were unblinded in 46 (23%) patients. Preliminary diagnosis was confirmed in 28 (14%), and treatment was modified in 18 (9%) of these patients. Four (2%) patients were given additional fluid challenges, 10 (5%) patients received a combination of fluid challenges and inotropic support, 3 (1.5%) patients were started on vasoconstrictors, and 1 (0.5%) patient required insertion of an intra-aortic balloon pump. Patients in the unblinded PAC group had a higher prevalence of perioperative myocardial infarction, atrial fibrillation, and inotropic support; longer intubation times; and increased intensive care unit (ICU) and hospital lengths of stay. CONCLUSIONS This study confirmed the contention that insertion of a PAC can be safely delayed until the clinical need arises either in the operating room or in the ICU after elective CABG surgery.
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Affiliation(s)
- George Djaiani
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Inatsugi M, Tanaka K, Kitahata H, Nozaki J, Kawahito S, Oshita S. Minute distance obtained from pulmonary venous flow velocity using transesophageal pulsed Doppler echocardiography is related to cardiac output during cardiovascular surgery. THE JOURNAL OF MEDICAL INVESTIGATION 2005; 52:178-85. [PMID: 16167536 DOI: 10.2152/jmi.52.178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
PURPOSE We studied the relationship between minute distance calculated from pulmonary venous flow (PVF) velocity tracing and cardiac output (CO) measured with thermodilution method in patients undergoing cardiovascular surgery. METHODS In 32 patients undergoing cardiovascular surgery, simultaneous measurements of hemodynamics including CO and transesophageal pulsed Doppler signals of PVF velocity were performed before and after surgical repair. Minute distance was calculated as the product of the heart rate and the sum of time-velocity integrals of PVF. RESULTS The minute distance after surgical intervention increased from 1121 +/- 347 cm x sec(-1) to 1764 +/- 538 cm x sec(-1) (p < 0.001; mean +/- SD), while CO increased after surgical intervention from 3.5 +/- 0.9 L x min(-1) to 5.3 +/- 1.1 L x min(-1). Simple linear regression analysis showed that minute distance was related with CO before and after surgical intervention (r = 0.81 and r = 0.76, respectively). The changes in minute distance were also related with those in CO (r = 0.80). CONCLUSION The present study demonstrated that minute distance obtained from the pulsed Doppler tracings of PVF velocity was related with CO during cardiovascular surgery in adults. These results suggest that the changes in CO could be estimated from minute distance in pulmonary vein.
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Affiliation(s)
- Mikiko Inatsugi
- Department of Anesthesiology, Institute of Health Biosciences, The University of Tokushima Graduate School, Kuramoto-cho, Tokushima 770-8503, Japan
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Cokis C, Wells J. The use of a pulmonary artery catheter after emergency cardiac surgery to reduce shunt through a patent foramen ovale. J Cardiothorac Vasc Anesth 2004; 18:763-4. [PMID: 15650988 DOI: 10.1053/j.jvca.2004.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Maciel AT, Creteur J, Vincent JL. Tissue capnometry: does the answer lie under the tongue? Intensive Care Med 2004; 30:2157-65. [PMID: 15650865 DOI: 10.1007/s00134-004-2416-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2003] [Accepted: 07/26/2004] [Indexed: 10/26/2022]
Abstract
Increases in tissue partial pressure of carbon dioxide (PCO(2)) can reflect an abnormal oxygen supply to the cells, so that monitoring tissue PCO(2) may help identify circulatory abnormalities and guide their correction. Gastric tonometry aims at monitoring regional PCO(2) in the stomach, an easily accessible organ that becomes ischemic quite early when the circulatory status is jeopardized. Despite substantial initial enthusiasm, this technique has never been widely implemented due to various technical problems and artifacts during measurement. Experimental studies have suggested that sublingual PCO(2 )(P(sl)CO(2)) is a reliable marker of tissue perfusion. Clinical studies have demonstrated that high P(sl)CO(2) values and, especially, high gradients between P(sl)CO(2) and arterial PCO(2) (DeltaP(sl-a)CO(2)) are associated with impaired microcirculatory blood flow and a worse prognosis in critically ill patients. Although some questions remain to be answered about sublingual capnometry and its utility, this technique could offer new hope for tissue PCO(2) monitoring in clinical practice.
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Affiliation(s)
- Alexandre Toledo Maciel
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Route de Lennik 808, 1070 Brussels, Belgium
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Orme RML, Pigott DW, Mihm FG. Measurement of cardiac output by transpulmonary arterial thermodilution using a long radial artery catheter. A comparison with intermittent pulmonary artery thermodilution. Anaesthesia 2004; 59:590-4. [PMID: 15144300 DOI: 10.1111/j.1365-2044.2004.03710.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cardiac output can be measured accurately by transpulmonary arterial thermodilution using the PiCCO (Pulsion Medical Systems, Munich, Germany) system with a femoral artery catheter. We have investigated the accuracy of a new 50 cm 4 French gauge radial artery catheter and the ability to use the system with a shorter radial catheter. We studied 18 patients who had undergone coronary artery surgery and made three simultaneous measurements of cardiac output by arterial thermodilution and with a pulmonary artery catheter. The radial catheter was withdrawn in 5 cm increments and the measurements were repeated. We found close agreement between arterial thermodilution and pulmonary artery thermodilution with a mean (SD) bias of 0.38 (0.77) l x min(-1). Arterial thermodilution became unreliable once the catheter had been withdrawn by more than 5 cm. We conclude that cardiac output measurement with arterial thermodilution with a radial catheter is interchangeable with that derived from a pulmonary artery catheter, and that a centrally sited arterial catheter is required for accurate determination of cardiac output by transpulmonary arterial thermodilution.
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Affiliation(s)
- R M L'e Orme
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Headley Way, Headington, Oxford, UK.
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Bein B, Worthmann F, Tonner PH, Paris A, Steinfath M, Hedderich J, Scholz J. Comparison of esophageal Doppler, pulse contour analysis, and real-time pulmonary artery thermodilution for the continuous measurement of cardiac output. J Cardiothorac Vasc Anesth 2004; 18:185-9. [PMID: 15073709 DOI: 10.1053/j.jvca.2004.01.025] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Continuous measurement of cardiac output (CCO) is of great importance in the critically ill. However, pulmonary artery thermodilution has been questioned for possible complications associated with right heart catheterization. Furthermore, measurements are delayed in the continuous mode during rapid hemodynamic changes. A new pulmonary artery catheter CCO device (Aortech, Bellshill, Scotland) enabling real-time update of cardiac output was compared with 2 different, less-invasive methods of CCO determination, esophageal Doppler and pulse contour analysis. DESIGN Prospective, observational study. SETTING University hospital, single institution. PARTICIPANTS Patients scheduled for elective coronary artery bypass grafting (CABG). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS CCO measurements were analyzed using a Bland-Altman plot. Bias between CCO and pulse contour cardiac output (PCCO), and Doppler-derived cardiac output (UCCO) was (mean +/- 1 SD) -0.71 +/- 1 L/min versus -0.15 +/- 1.09 L/min, and between UCCO and PCCO -0.58 +/- 1.06 L/min. Bias was not significantly different among methods, nor were comparative values before and after cardiopulmonary bypass (p > 0.05). CONCLUSIONS Agreement between the CCO method and both less-invasive measurements was clinically acceptable. There were no adverse events associated with the use of either device.
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Affiliation(s)
- Berthold Bein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein Campus, Kiel, Germany.
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Kumar S. New horizons for critical care in cardiac surgery. Indian J Crit Care Med 2004. [DOI: 10.5005/ijccm-8-1-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Abstract
Invasive monitoring in anesthesiology is relatively safe. Arterial catheterization in particular has an extremely low rate of serious complications. Radial, brachial, and femoral artery catheterization sites appear to have similar and low complication rates. CVP and PA catheters are more dangerous and entail potentially fatal complications. The most troublesome complication with CVP catheters is perforation of the heart or cava, which should be avoidable under most circumstances if care is taken to position the catheter properly, outside the heart. Chest radiography should be used to specifically ascertain that the catheter is not in a dangerous location. The most troublesome complication with PA catheters is perforation of the pulmonary artery. This is probably a sporadic problem, and it is not necessarily avoidable by adherence to particular techniques. It should be assumed that hemoptysis in a patient with a PA catheter is caused by perforation of the pulmonary artery until proven otherwise, and it should be treated aggressively.
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Affiliation(s)
- T Andrew Bowdle
- Department of Anesthesiology, University of Washington, Box 356540, Seattle, WA 98195, USA.
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Wall MH, MacGregor DA, Kennedy DJ, James RL, Butterworth J, Mallak KF, Royster RL. Pulmonary artery catheter placement for elective coronary artery bypass grafting: before or after anesthetic induction? Anesth Analg 2002; 94:1409-15, table of contents. [PMID: 12031997 DOI: 10.1097/00000539-200206000-00006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Pulmonary arterial catheters (PACs) are often used during and after coronary artery bypass grafting. We hypothesized that placement of a PAC would be faster in anesthetized patients. We further hypothesized that the presence or absence of a PAC during the induction of anesthesia would make no difference in hemodynamics, vasoactive drug use, or IV fluid administration during the induction. Patients (n = 200) undergoing elective coronary artery bypass grafting were assigned to PAC insertion either before or after the induction of anesthesia. Total time for PAC insertion, number of finder needle and venous catheter insertion attempts, incidence of carotid artery puncture, arrhythmias or ST segment changes, arterial blood gas analysis, hemodynamic variables, IV fluids, and vasoactive drugs required during and after the anesthetic induction were recorded. Thirty-two different physicians placed the PACs. PAC placement was faster (10 versus 12 min, P = 0.0003) and required fewer punctures with a finder needle (P = 0.0107) in anesthetized patients. There were no significant differences between groups in hemodynamic values or use of vasoactive or anesthetic drugs or IV fluids during the induction. There were also no significant differences between groups in the incidence of myocardial ischemia, arterial hypoxemia, or hypercarbia. Placement of a PAC before the induction of anesthesia consumes more time and fails to improve hemodynamic stability or lessen vasoactive drug use during the induction of anesthesia. IMPLICATIONS Insertion of pulmonary artery catheters (PACs) before the induction of anesthesia requires more needle sticks and takes longer than insertion after the induction of anesthesia; moreover, previous PAC insertion has no significant effect on hemodynamics or use of vasoactive drugs or IV fluid associated with the induction of anesthesia.
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Affiliation(s)
- Michael H Wall
- Department of Anesthesiology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1009, USA.
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Costachescu T, Denault A, Guimond JG, Couture P, Carignan S, Sheridan P, Hellou G, Blair L, Normandin L, Babin D, Allard M, Harel F, Buithieu J. The hemodynamically unstable patient in the intensive care unit: hemodynamic vs. transesophageal echocardiographic monitoring. Crit Care Med 2002; 30:1214-23. [PMID: 12072671 DOI: 10.1097/00003246-200206000-00007] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Transesophageal echocardiography is a diagnostic and monitoring modality. The objectives of our study were to compare the diagnoses obtained with continuous transesophageal echocardiography and hemodynamic monitoring in the intensive care unit, to determine interobserver variability of diagnosis obtained with both modalities, and to evaluate its impact. DESIGN Prospective cohort study. SETTING Surgical intensive care unit. PATIENTS Consecutive hemodynamically unstable patients after cardiac surgery. INTERVENTIONS At admission, unstable patients were monitored during 4 hrs with transesophageal echocardiography and standard hemodynamic monitoring. The critical care physician evaluated the patients based on all information except the transesophageal echocardiography at 0, 2, and 4 hrs and formulated a hypothesis on the most likely cause of hemodynamic instability. Transesophageal echocardiography information was provided after each evaluation. To evaluate interobserver variability, all the hemodynamic and echocardiographic information was gathered, randomized, and evaluated by five clinicians for the hemodynamic data and five echocardiographers for the transesophageal echocardiography data. The evaluators were blinded to all other information. Kappa statistics were used to evaluate agreement. Impact of transesophageal echocardiography was assessed retrospectively by using the Deutsch scale. RESULTS Twenty patients qualified for the study. The agreement between the hemodynamic and echocardiographic diagnosis showed a kappa at admission, 2 hrs, and 4 hrs of 0.33, 0.47, and 0.28. The interobserver agreement for the initial diagnosis (p =.014) and between all evaluators (p <.001) was significantly higher in the echocardiographic compared with the hemodynamic group. The transesophageal echocardiographic information was considered retrospectively to be essential in 34% and valuable in 34% of cases. CONCLUSIONS These observations support the belief that transesophageal echocardiographic monitoring in the intensive care unit is associated with higher interobserver agreement in diagnosing and excluding significant causes of hemodynamic instability for postoperative cardiac surgical patients.
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Affiliation(s)
- Tudor Costachescu
- Department of Anesthesiology, CHUM, Notre-Dame Hospital, Quebec, Canada
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