Do intraoperative variables have an effect on the timing of tracheal extubation after coronary artery bypass graft surgery?

Postoperative Changes in Pulmonary Function after Valve Surgery: Oxygenation Index Early after Cardiopulmonary Is a Predictor of Postoperative Course

Objective: To determine pulmonary functional changes that predict early clinical outcomes in valve surgery requiring long cardiopulmonary bypass (CPB). Methods: This retrospective study included 225 consecutive non-emergency valve surgeries with fast-track cardiac anesthesia between January 2014 and March 2020. Blood gas analyses before and 0, 2, 4, 8, and 14 h after CPB were investigated. Results: Median age and EuroSCORE II were 71.0 years (25–75 percentile: 59.5–77.0) and 2.46 (1.44–5.01). Patients underwent 96 aortic, 106 mitral, and 23 combined valve surgeries. The median CPB time was 151 min (122–193). PaO₂/FiO₂ and AaDO₂/PaO₂ significantly deteriorated two hours, but not immediately, after CPB (both p < 0.0001). Decreased PaO₂/FiO₂ and AaDO₂/PaO₂ were correlated with ventilation time (r² = 0.318 and 0.435) and intensive care unit (ICU) (r² = 0.172 and 0.267) and hospital stays (r² = 0.164 and 0.209). Early and delayed extubations (<6 and >24 h) were predicted by PaO₂/FiO₂ (377.2 and 213.1) and AaDO₂/PaO₂ (0.683 and 1.680), measured two hours after CPB with acceptable sensitivity and specificity (0.700–0.911 and 0.677–0.859). Conclusions: PaO₂/FiO₂ and AaDO₂/PaO₂ two hours after CPB were correlated with ventilation time and lengths of ICU and hospital stays. These parameters suitably predicted early and delayed extubations.

Pulmonary complications following cardiac surgery

Coronary heart disease is a common diseases of atherosclerosis. Despite the development of noninvasive therapies and the advancement of pharmacological methods and extensive drug regimens, coronary artery bypass grafting surgery is still the ultimate treatment option in many patients. Among the various complications following open heart surgery, one of the common difficulties is pulmonary complications associated with subsequent morbidity and mortality, which should be studied according to preoperative, perioperative, and postoperative factors. Preoperative factors include genetics, age, family history of pulmonary disease, smoking, coexisting disease, etc. Perioperative factors include surgical procedures like sternotomy incision, cardioplegia, and internal mammary artery harvesting; anaesthesia procedure effects like pulmonary collapse, maintenance drugs and morphine administration; and cardiopulmonary bypass pump by systemic inflammatory response syndromes. And finally, postoperative factors, especially mediastinitis and the role of nursing in the intensive care unit. Pulmonary complications after cardiac surgery include atelectasis, pleural effusions, pneumonia, pulmonary oedema, cardiogenic pulmonary oedema, acute respiratory distress syndrome, pulmonary embolism, phrenic nerve injury, pneumothorax, sternal wound infection, and mediastinitis, with different outbreaks in patients reported. Although the preoperative, perioperative, and postoperative factors play an important role in the occurrence of these complications, the preoperative factors, as factors that can be adjusted, should be considered more than the others and explained to the patient, and the preoperative patient’s assessment should be noted. Also, postoperative care with the goal of reducing infections and pulmonary complications should be addressed by the nursing team.

Impact of Intubation Time on Survival following Coronary Artery Bypass Grafting: Insights from the Surgical Treatment for Ischemic Heart Failure (STICH) Trial

OBJECTIVE

The authors aimed to assess determinants of intubation time and evaluate its impact on 30-day and 1-year postoperative survival in Surgical Treatment for Ischemic Heart Failure (STICH) trial patients.

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS

A multivariable Cox proportional hazards model was used among the 1,446 surgical patients from the STICH trial who survived 36 hours after operation, in order to identify perioperative factors associated with 30-day and 1-year postoperative mortality. A multivariable logistic regression model was used to determine risk factors associated with intubation time.

MEASUREMENTS AND MAIN RESULTS

At 36 hours post-operation, 1,298 (out of 1,446) were extubated and 148 (10.2%) still intubated. Median postoperative intubation time was 11.4 hours. Among patients surviving 36 hours, a multivariable model was developed to predict 30-day (c-index = 0.88) and 1-year (c-index = 0.78) mortality. Intubation time was the strongest independent predictor of 30-day (hazard ratio [HR] 5.50) and 1-year mortality (HR 3.69). Predictors of intubation time >36 hours included mitral valve procedure, New York Heart Association class, left ventricular systolic volume index, creatinine, previous coronary artery bypass grafting (CABG), and age. Results were similar in patients surviving 24 hours post-operation, where intubation time was also the strongest predictor of 30-day (HR 4.18, c-index 0.87) and 1-year (HR 2.81, c-index 0.78) mortality.

CONCLUSIONS

Intubation time is the strongest predictor of 30-day and 1-year mortality among patients with ischemic heart failure undergoing CABG. Combining intubation time with other mortality risk factors may allow the identification of patients at the highest risk for whom the development of specific strategies may improve outcomes.

The Comparison Effects of Two Methods of (Adaptive Support Ventilation Minute Ventilation: 110% and Adaptive Support Ventilation Minute Ventilation: 120%) on Mechanical Ventilation and Hemodynamic Changes and Length of Being in Recovery in Intensive Care Units

Background:

The conventional method for ventilation is supported by accommodative or adaptive support ventilation (ASV) that the latter method is done with two methods: ASV minute ventilation (mv): 110% and ASV mv: 120%. Regarding these methods this study compared the differences in duration of mechanical ventilation and hemodynamic changes during recovery and length of stay in Intensive Care Units (ICU).

Materials and Methods:

In a clinical trial study, forty patients candidate for ventilation were selected and randomly divided into two groups of A and B. All patients were ventilated by Rafael ventilator. Ventilator parameters were set on ASV mv: 110% or ASV mv: 120% and patients were monitored on pulse oximetry, electrocardiography monitoring, central vein pressure and arterial pressure. Finally, the data entered to computer and analyzed by SPSS software.

Results:

The time average of connection to ventilator in two groups in modes of ASV mv: 110% and 120% was 12.3 ± 3.66 and 10.8 ± 2.07 days respectively, and according to t-test, there was no significant difference between two groups (P = 0.11). The average of length of stay in ICU in two groups of 110% and 120% was 16.35 ± 3.51 and 15.5 ± 2.62 days respectively, and according to t-test, there found to be no significant difference between two groups (P = 0.41).

Conclusion:

Using ASV mv: 120% can decrease extubation time compared with ASV mv: 110%. Furthermore, there is not a considerable side effect on hemodynamic of patients.

Factors influencing prolonged ICU stay after open heart surgery

Background:

There are different risk factors that affect the intensive care unit (ICU) stay after cardiac surgery.

Objectives:

The aim of this study was to evaluate possible risk factors influencing prolonged ICU stay in a large referral hospital.

Patients and Methods:

We conducted a case-control study to determinate causes of prolonged ICU stay in 280 adult patients undergoing cardiac surgery in a tertiary care center for cardiovascular patients, Tehran, Iran. These patients were divided into two groups according to ICU stay ≤ 96 and > 96 hours. We evaluated perioperative risk factors of ICU stay > 96 hours.

Results:

Among the 280 patients studied, 184 (65.7%) had stayed ≤ 96 hours and 96 (34.3%) had stayed > 96 hours in ICU. Frequency of prolonged ICU stay was 34.2% in patients undergoing coronary artery bypass graft (CABG), 30.8% in patients with valve surgery, and 44.8% in patients with CABG plus valve surgery. Patients with > 96 hours of ICU stay received more blood transfusion and intravenous inotropes. They also had longer anesthesia, cardiopulmonary bypass, and postoperative intubation time. There were higher incidence of postoperative tamponade, re-exploration, re-intubation, hemodialysis, and hypotension in this group (P < 0.05 for all comparisons).

Conclusions:

In this study, about one-third of patients had prolonged ICU stay. Factors influencing prolonged ICU stay were medical and some non-medical factors. In the present study, up to 30% of the patients had a prolonged ICU stay of > 96 hours. Additional data from well-designed investigations are needed for further assessment of the factors influencing prolonged ICU stay after cardiac surgery.

Postoperative Pulmonary Dysfunction in Adults After Cardiac Surgery With Cardiopulmonary Bypass: Clinical Significance and Implications for Practice

Postoperative pulmonary complications are the most frequent and significant contributor to morbidity, mortality, and costs associated with hospitalization. Interestingly, despite the prevalence of these complications in cardiac surgical patients, recognition, diagnosis, and management of this problem vary widely. In addition, little information is available on the continuum between routine postoperative pulmonary dysfunction and postoperative pulmonary complications. The course of events from pulmonary dysfunction associated with surgery to discharge from the hospital in cardiac patients is largely unexplored. In the absence of evidence-based practice guidelines for the care of cardiac surgical patients with postoperative pulmonary dysfunction, an understanding of the pathophysiological basis of the development of postoperative pulmonary complications is fundamental to enable clinicians to assess the value of current management interventions. Previous research on postoperative pulmonary dysfunction in adults undergoing cardiac surgery is reviewed, with an emphasis on the pathogenesis of this problem, implications for clinical nursing practice, and possibilities for future research.

Early extubation for adult cardiac surgical patients

BACKGROUND

Over 30 studies reported that early extubation (within eight hours) appears to be safe without an increased incidence of morbidity. A benefit of the practice may be cost savings associated with shorter Intensive Care Unit and hospital length of stays.

OBJECTIVES

To assess the effects of early extubation and the impact of the extubating clinician's profession on morbidity, mortality, intensive care unit and hospital length of stay, with a subgroup analysis for extubation within four hours or four to eight hours.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL)(issue 1, 2003), MEDLINE (January 1966 to June 2003), EMBASE (January 1980 to June 2003), CINAHL (January 1982 to December 2002), SIGLE(January 1980 to December 2002). We searched reference lists of articles and contacted researchers in the field.

SELECTION CRITERIA

Randomized controlled trials and controlled clinical trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement, aortic aneurysm repair).

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. A meta-analysis for most outcomes was conducted.

MAIN RESULTS

Six trials were included in the review. There was no evidence of a difference between early and conventionally extubated patients shown in the relative risk and 95% confidence interval for the following outcomes: mortality in intensive care was 0.8 (0.42 to 1.52); thirty day mortality was 1.2 (0.63 to 2.27); myocardial ischaemia was 0.96 (0.71 to 1.30); reintubation within 24 hours of surgery was 5.93 (0.72 to 49.14). Time spent in intensive care and in hospital were significantly shorter for patients extubated early (7.02 hours (- 7.42 to - 6.61) and 1.08 days ( - 1.35 to - 0.82) respectively).

REVIEWER'S CONCLUSIONS

There is no evidence of a difference in mortality and morbidity rates between the study groups. Early extubation reduces intensive care unit and hospital length of stay. Studies were underpowered and designed to show differences between study groups rather than equivalence between the groups. Suggested future areas of investigation: establishing the safety and efficacy of immediate extubation compared with early extubation; establishing the most effective means of pain control and reducing anxiety for patients; systematic reviews of the evidence for different parts of the patients journey through a cardiac surgery episode; and the impact of the profession of the clinician making the decision to extubate.