1
|
Li ZQ, Zhang W, Guo Z, Du XW, Wang W. Risk factors of gastrointestinal bleeding after cardiopulmonary bypass in children: a retrospective study. Front Cardiovasc Med 2023; 10:1224872. [PMID: 37795489 PMCID: PMC10545956 DOI: 10.3389/fcvm.2023.1224872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/08/2023] [Indexed: 10/06/2023] Open
Abstract
Background During cardiac surgery that involved cardiopulmonary bypass (CPB) procedure, gastrointestinal (GI) system was known to be vulnerable to complications such as GI bleeding. Our study aimed to determine the incidence and risk factors associated with GI bleeding in children who received CPB as part of cardiac surgery. Methods This retrospective study enrolled patients aged <18 years who underwent cardiac surgery with CPB from 2013 to 2019 at Shanghai Children's Medical Center. The primary outcome was the incidence of postoperative GI bleeding in children, and the associated risk factors with postoperative GI bleeding episodes were evaluated. Results A total of 21,893 children who underwent cardiac surgery with CPB from 2013 to 2019 were included in this study. For age distribution, 636 (2.9%) were neonates, 10,984 (50.2%) were infants, and 10,273 (46.9%) were children. Among the 410 (1.9%) patients with GI bleeding, 345 (84.2%) survived to hospital discharge. Incidence of GI bleeding in neonates, infants and children were 22.6% (144/636), 2.0% (217/10,984) and 0.5% (49/10,273), respectively. The neonates (22.6%) group was associated with highest risk of GI bleeding. Patients with GI bleeding showed longer length of hospital stays (25.8 ± 15.9 vs. 12.5 ± 8.9, P < 0.001) and higher mortality (15.9% vs. 1.8%, P < 0.001). Multivariate logistic regression analysis showed that age, weight, complicated surgery, operation time, use of extracorporeal membrane oxygenation (ECMO), low cardiac output syndrome (LCOS), hepatic injury, artery lactate level, and postoperative platelet counts were significantly associated with increased risk of GI bleeding in children with congenital heart disease (CHD) pediatric patients that underwent CPB procedure during cardiac surgery. Conclusion The study results suggest that young age, low weight, long operation time, complicated surgery, use of ECMO, LCOS, hepatic injury, high arterial lactate level, and low postoperative platelet counts are independently associated with GI bleeding after CPB in children.
Collapse
Affiliation(s)
| | | | | | | | - Wei Wang
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
2
|
Basylev VV, Evdokimov ME, Pantyukhina MA. [Gastrointestinal complications after on-pump cardiac surgery]. Khirurgiia (Mosk) 2021:39-48. [PMID: 34363444 DOI: 10.17116/hirurgia202108139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the incidence and independent predictors of gastrointestinal complications (GICs) following on-pump cardiac surgery. MATERIAL AND METHODS We retrospectively analyzed data of 9559 adults who underwent cardiac surgery in 2012-2017. Two groups of patients were distinguished: group 1 - 47 (0.5%) patients with abdominal complications followed by urgent surgery; group 2 - 9512 (95.5%) patients without complications or effective therapy. CONCLUSION 1. Predictors of gastrointestinal complications: age >65 years, previous AF (p=0.011) and multifocal atherosclerosis (p=0.016), LV EF <40% (p=0.039), aortic cross-clamping time > 90 min (p=0.021), intraoperative blood loss over 600 ml (p=0.002), postoperative serum creatinine >140 μmol/l (p=0.005), mechanical ventilation >24 hours (p=0.023). 2. Reduced hemodilution during CPB, warm blood cardioplegia, higher perioperative values of Hb, Ht and IDO2 during cardiopulmonary bypass can prevent ischemic injury of abdominal organs during prolonged cardiac surgery.
Collapse
Affiliation(s)
- V V Basylev
- Federal Center for Cardiovascular Surgery, Penza, Russian Federation
| | - M E Evdokimov
- Federal Center for Cardiovascular Surgery, Penza, Russian Federation
| | - M A Pantyukhina
- Federal Center for Cardiovascular Surgery, Penza, Russian Federation
| |
Collapse
|
3
|
Risk Factors Associated with In-Hospital Mortality for Patients with Acute Abdomen After Cardiac Surgery. World J Surg 2020; 44:277-284. [PMID: 31605181 DOI: 10.1007/s00268-019-05227-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Management of acute abdomen (AA) differs due to the heterogeneity of underlying pathophysiology. Complications of AA and its overall outcome after cardiac surgery are known to be associated with poor results. The aim of this retrospective analysis was to evaluate risk factors for AA in patients undergoing cardiac surgery. METHODS Between December 2011 and December 2014, a total of 131 patients with AA after cardiac surgery were identified and retrospectively analyzed using our institutional database. Statistical analysis of risk factors concerning in-hospital mortality of mentioned patient cohort was performed using IBM SPSS Statistics. RESULTS Overall in-hospital mortality was 54.2% (71/131). Analyzing in-hospital non-survivors (NS) versus in-hospital survivors (S) peripheral artery disease (28.2% vs. 11.7%; p = 0.03), the need for assist device therapy (33.8% vs. 16.7%; p = 0.03) and the requirement of hemodialysis (67.6% vs. 23.3%; p < 0.01) were significantly higher in NS. Furthermore, lactic acid values at onset of symptoms were shown to be significantly higher in NS (5.7 ± 5.7 mmol/L vs. 2.8 ± 2.9 mmol/L; p < 0.01). Assured diagnosis of mesenterial ischemia was strongly associated with worse outcome (odds ratio 10.800, 95% confidence interval 2.003-58.224; p = 0.006). CONCLUSION In conclusion, in critically ill patients after performed cardiac surgery peripheral vascular disease, need for supportive hemodynamic assist device systems and occurrence of renal failure are risk factors associated with worsen outcome. Additionally, rise of lactic acid could potentially be associated with onset of intestinal malperfusion and should be taken into account in therapeutic decisions preventing fatal mesenterial ischemia.
Collapse
|
4
|
Sato H, Nakamura M, Uzuka T, Kondo M. Detection of patients at high risk for nonocclusive mesenteric ischemia after cardiovascular surgery. J Cardiothorac Surg 2018; 13:115. [PMID: 30445964 PMCID: PMC6240249 DOI: 10.1186/s13019-018-0807-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/05/2018] [Indexed: 01/26/2023] Open
Abstract
Objectives Nonocclusive mesenteric ischemia (NOMI) is a rare but life-threatening complication after cardiovascular surgery. Early diagnosis and treatment is essential for a chance to cure. The aim of this study is to identify the independent risk factors for NOMI based on the evaluation of 12 cases of NOMI after cardiovascular surgery. Methods We retrospectively analyzed 12 patients with NOMI and 674 other patients without NOMI who underwent cardiovascular surgery in our hospital. We reviewed the clinical data on NOMI patients, including their characteristics and the clinical course. In addition, we performed a statistical comparison of each factor from both NOMI and non-NOMI groups to identify the independent risk factors for NOMI. Results The median duration between the cardiac surgery and the diagnosis of NOMI was 14.0 (10.3–20.3) days. The in-hospital mortality of NOMI patients was 75.0%. Age (p < 0.05), peripheral arterial disease (p < 0.001), postoperative hemodialysis (p < 0.001), intraaortic balloon pump (p < 0.05), norepinephrine (NOE) > 0.10γ (p < 0.0001), percutaneous cardiopulmonary support (p < 0.001), sepsis (p < 0.05), loss of sinus rhythm (p < 0.05), prolonged ventilation (p < 0.0001), and resternotomy for bleeding (p < 0.05) showed significant differences between NOMI and non-NOMI groups. In the multivariate logistic regression model, prolonged ventilation [odds ratio (OR) = 18.1, p < 0.001] and NOE > 0.10 μg/kg/min (OR = 130.0, p < 0.0001) were detected as independent risk factors for NOMI. Conclusions We have identified the risk factors for NOMI based on the evaluation of the 12 cases of NOMI after cardiovascular surgery. This result may be useful in predicting NOMI, which is considered difficult in clinical practice. For the patient with suspected of NOMI who has these risk factors, early CT scan and surgical exploration should be performed without delay.
Collapse
Affiliation(s)
- Hiroshi Sato
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, S1W16, Chuo-ku, Sapporo, 060-8543, Japan.
| | - Masanori Nakamura
- Department of Cardiovascular Surgery, Sapporo City General Hospital, N11W13, Chuo-ku, Sapporo, 060-8604, Japan
| | - Takeshi Uzuka
- Department of Cardiovascular Surgery, Sapporo City General Hospital, N11W13, Chuo-ku, Sapporo, 060-8604, Japan
| | - Mayo Kondo
- Department of Cardiovascular Surgery, Sapporo City General Hospital, N11W13, Chuo-ku, Sapporo, 060-8604, Japan
| |
Collapse
|
5
|
Ge YP, Li CN, Cheng LJ, Zheng T, Zheng J, Liu YM, Zhu JM, Sun LZ. One-Stage Repair of Adult Aortic Coarctation and Concomitant Cardiac Diseases: Ascending to Abdominal Aorta Extra-Anatomical Bypass Combined with Cardiac Surgery. Heart Lung Circ 2018; 28:1740-1746. [PMID: 30274696 DOI: 10.1016/j.hlc.2018.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/25/2018] [Accepted: 08/30/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND To evaluate one-stage repair with ascending to abdominal aorta extra-anatomical bypass combined with cardiac surgery for adult aortic coarctation (COA) concomitant with cardiac diseases. METHODS Between February 2009 and September 2016, 24 consecutive patients (79.17% male, mean age 36.04±13.67years) with COA and concomitant cardiac diseases underwent one-stage repair (ascending to abdominal aorta extra-anatomical bypass combined with cardiac surgery). Two (2) patients who underwent off-pump coronary artery surgery combined with ascending to abdominal aorta bypass did not require cardiopulmonary bypass. Twenty-two (22) patients underwent one-stage repair under cardiopulmonary bypass. RESULTS No in-hospital mortality was observed. There was a significant reduction in baseline systolic blood pressure from 159.80±23.58 to 127.0±6.86mmHg. Mean upper-lower limb blood gradient pressure decreased significantly from 37.80±8.73 to 11.47±2.12mmHg after surgery. Two (2) patients required prolonged mechanical ventilation for respiratory dysfunction. One patient needed temporary continuous renal replacement therapy. No re-exploration for bleeding and gastrointestinal complications was needed. There was no postoperative paraplegia or permanent neurological abnormalities. Grafts were patent for all patients and no graft-related complications were observed in the hospital. Median follow-up was 41.50 months (interquartile range [IQR] 16.75-64.50 months) and 6-year survival was 76.39%. Median number of antihypertensive drugs was 0 (IQR 0-1), which was a significant reduction compared with preoperative drugs (2, IQR 1-3). CONCLUSIONS Ascending to abdominal extra-anatomical aorta bypass combined with cardiac surgery is a safe and effective one-stage repair technique for patients with COA concomitant with cardiac diseases.
Collapse
Affiliation(s)
- Yi-Peng Ge
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Cheng-Nan Li
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Li-Jian Cheng
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Tie Zheng
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jun Zheng
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yong-Min Liu
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jun-Ming Zhu
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
| | - Li-Zhong Sun
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
6
|
Boyd WD, Desai ND, Novick RJ, McKenzie FN, DelRizzo DF, Menkis AH. Use of Cardiopulmonary Bypass in High-Risk Patients Is a Predictor of Adverse Outcome. Semin Cardiothorac Vasc Anesth 2016. [DOI: 10.1053/vc.2000.6480] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
High-risk patients experience substantially more compli cations after coronary artery bypass grafting (CABG). We hypothesized that these patients are uniquely vulner able to cardiopulmonary bypass and compared postop erative outcomes between high-risk patients undergo ing off-pump CAB (OPCAB) and conventional CABG. Prospective provincial cardiac care registry and retro spective chart data were reviewed for 1,850 consecutive patients at our institution between January 1996 and January 1999. From this, 235 patients, 36 OPCAB and 199 CABG, were identified as high risk (modified Parson net score ≥15). Risk factor analysis showed the popula tions were equivalent in perioperative risk with mean modified Parsonnet scores of 18.1 ± 3.4 (OPCAB) and 18.7 ± 4.2 (CABG) (P = .4). In total, 6% of OPCAB and 40% of CABG patients suffered major complications leading to extended hospital/intensive care unit (ICU) stay or death ( P ≤ .001). Mean hospital stays were 7.0 ± 4.0 days (OPCAB) and 10.6 ± 10.2 days (CABG) ( P ≤ .001). Mean ICU stays were 23.9 ± 9.7 hours (OPCAB) and 64.9 ± 128.3 hours (CABG) ( P ≤ .001). Mortality was 0% in the OPCAB group and 6% in the CABG group (P = .2). Multivariate predictors of experiencing a major complication were: use of cardiopulmonary bypass (OR 5.1, 95 Cl 2.1-12.1), age > 80 (OR 2.5, 95 Cl 1.7-7.5), female (OR 3.0, 95 Cl 1.6-5.4), repeat operation (OR 2.5, 95 Cl 1.2-5.4), and ejection fraction <40% (OR 2.4, 95 Cl 1.2-4.7). Extracorporeal circulation is the most impor tant predictor of postoperative complications after CABG in high-risk patients. Off-pump surgery substantially reduces morbidity in this group, and further study of the protective effects of this emerging modality are war ranted.
Collapse
Affiliation(s)
- W. Douglas Boyd
- Department of Cardiac Surgery, London Health Sciences Centre, University of Western Ontario, London, Ontario
| | - Nimesh D. Desai
- Department of Cardiac Surgery, London Health Sciences Centre, University of Western Ontario, London, Ontario
| | - Richard J. Novick
- Department of Cardiac Surgery, London Health Sciences Centre, University of Western Ontario, London, Ontario
| | - F. Neil McKenzie
- Department of Cardiac Surgery, London Health Sciences Centre, University of Western Ontario, London, Ontario
| | | | - Alan H. Menkis
- Department of Cardiac Surgery, London Health Sciences Centre, University of Western Ontario, London, Ontario
| |
Collapse
|
7
|
Akpinar B, Săgbaş E, Güden M, Kemertaş K, Sönmez B, Bayindir O, Demiroğlu C. Acute Gastrointestinal Complications after Open Heart Surgery. Asian Cardiovasc Thorac Ann 2016. [DOI: 10.1177/021849230000800204] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Retrospective analysis revealed that 24 of 4401 adult patients (0.5%) developed severe gastrointestinal complications after open heart surgery during a 3-year period from January 1995. There were 4 women (17%) and 20 men (83%). Mean age was 61.7 ± 2.02 years. Gastrointestinal bleeding (33.3%), mesenteric ischemia (20.8%), pancreatitis (20.8%), hepatic dysfunction (16.7%), and cholecystitis (16.7%) were the most common complications. Mortality was 41.7% (10 patients). During the same period, mortality in the patients who did not develop gastrointestinal complications was 1.89% (p < 0.0001). Emergency basis, reoperation, combined operations, peripheral vascular disease, diabetes mellitus, chronic lung disease, and impaired left ventricle function were found to be risk factors for the development of postoperative gastrointestinal complications.
Collapse
Affiliation(s)
| | | | | | - Kubilay Kemertaş
- Department of General Surgery Kadir Has University Medical Faculty Florence Nightingale Hospital Istanbul, Turkey
| | | | - Osman Bayindir
- Department of Anesthesia Kadir Has University Medical Faculty Florence Nightingale Hospital Istanbul, Turkey
| | - Cem'i Demiroğlu
- Department of Cardiology Kadir Has University Medical Faculty Florence Nightingale Hospital Istanbul, Turkey
| |
Collapse
|
8
|
Sastry P, Hardman G, Page A, Parker R, Goddard M, Large S, Jenkins DP. Mesenteric ischaemia following cardiac surgery: the influence of intraoperative perfusion parameters. Interact Cardiovasc Thorac Surg 2014; 19:419-24. [PMID: 24939960 DOI: 10.1093/icvts/ivu139] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Mesenteric ischaemia (MesI) remains a rare but lethal complication following cardiac surgery. Previously identified risk factors for MesI mortality (age, poor left ventricular (LV) function, cardiopulmonary bypass time and blood loss) are non-specific and cannot necessarily be modified. This study aims to identify potentially modifiable risk factors for MesI mortality through analysis of peri- and intraoperative perfusion data. METHODS Patients who underwent cardiac surgery between 2006 and 2011 at Papworth Hospital were retrospectively divided into 3 outcome categories: death caused by MesI; death due to other causes and survival to discharge. A published MesI risk calculator was used to estimate risk of MesI for each patient and then to create 3 cohorts of matched patients from each outcome group. Pre-, intra- and postoperative variables were collected and conditional logistic regression methods were used to identify parameters associated specifically with MesI deaths after cardiac surgery. RESULTS A total of 10 409 patients underwent cardiac surgery between 2006 and 2011. The incidence of MesI was 0.3% (30 patients). Two hundred and sixty-one patients died of non-MesI causes and 10 118 survived. It was possible to identify 25 patients in each group at equivalent risk of MesI. The following parameters were found to be associated with MesI mortality: recent myocardial infarction [odds ratio (OR) 4.98, 95% confidence interval (CI) 1.58-15.71, P = 0.01], standard EuroSCORE (OR 1.12, 95% CI 1.03-1.21, P = 0.01), vasopressor dose on bypass (OR 1.28, 95% CI 1.04-1.57, P = 0.02), metaraminol dose on bypass (OR 1.52, 95% CI 1.12-2.06, P = 0.01) and lowest documented mean arterial pressure (OR 0.90, 95% CI 0.83-0.97, P = 0.01). No other intraoperative perfusion-related parameters (e.g. flow, average activated clotting time or pressure) were associated with MesI mortality. CONCLUSIONS Our study not only confirms previously known predictive factors, but also demonstrates a new association between intraoperative vasopressor use and MesI mortality.
Collapse
Affiliation(s)
- Priya Sastry
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Gillian Hardman
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Aravinda Page
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Richard Parker
- Department of Public Health and Primary Care, Centre for Applied Medical Statistics, Robinson Way, UK
| | - Martin Goddard
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Stephen Large
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| |
Collapse
|
9
|
Acute bowel ischemia after heart operations. Ann Thorac Surg 2014; 97:2219-27. [PMID: 24681032 DOI: 10.1016/j.athoracsur.2014.01.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 01/08/2014] [Accepted: 01/14/2014] [Indexed: 01/10/2023]
Abstract
Acute bowel ischemia is a perioperative complication that is frequently unrecognized as a cause of death after cardiac surgical procedures, with an in-hospital mortality of 50% to 100%. In recent years, controversy regarding the most appropriate approach to resolve clinical or laboratory suspicion and the limited therapeutic options have led to very little improvement in patient prognosis. This article reviews the related literature examining the actual prevalence, pathophysiologic mechanisms, predisposing factors, diagnostic tests, and therapeutic approaches providing a glance at new promising tools in diagnostic workup.
Collapse
|
10
|
Gulkarov I, Trocciola SM, Yokoyama CC, Girardi LN, Krieger KK, Isom OW, Salemi A. Gastrointestinal Complications after Mitral Valve Surgery. Ann Thorac Cardiovasc Surg 2014; 20:292-8. [DOI: 10.5761/atcs.oa.13.02245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
11
|
Nilsson J, Hansson E, Andersson B. Intestinal ischemia after cardiac surgery: analysis of a large registry. J Cardiothorac Surg 2013; 8:156. [PMID: 23777600 PMCID: PMC3688391 DOI: 10.1186/1749-8090-8-156] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 06/06/2013] [Indexed: 12/17/2022] Open
Abstract
Background Intestinal ischemia after cardiac surgery is a rare but severe complication with a high mortality. Early surgery can be lifesaving. The aim was to analyze the incidence, outcome, and risk factors for these patients. Methods A prospectively collected database with patients who underwent 18,879 cardiac surgical procedures between 1996 and 2011 was investigated. All patients with registered gastrointestinal complications were retrospectively reviewed. Univariate and multivariate analyses were performed to compare patients with and without intestinal ischemia. Results Seventeen patients suffered from intestinal ischemia (0.09%), 10 of whom (59%) died. By investigating preoperative parameters independent risk factors were steroids, peripheral vascular disease, cardiogenic shock, and New York Heart Association class 4. When including pre-, per-, and postoperative parameters, only postoperative ones were significant, including elevated creatinine (> 200 μmol/L), prolonged ventilator time, need for intra-aortic balloon pump, and cerebrovascular insult (CVI). The gastrointestinal complications score (GICS) showed a ROC area of 0.87. This was superior compared with EuroSCORE (0.74), to predict intestinal ischemia. Conclusions Intestinal ischemia after cardiac surgery is more common in patients with a poor cardiac state, but the use of steroids, peripheral vascular disease, postoperative kidney failure, and CVI were also predictive. GICS score, developed for all GI complications after cardiac surgery, is also of value in predicting this particular complication. The risk factors presented can be used as an aid in the diagnosis of these patients.
Collapse
Affiliation(s)
- Johan Nilsson
- 1Department of Cardiothoracic Surgery, Clinical Sciences, Lund University and Skane University Hospital, Lund, Sweden
| | | | | |
Collapse
|
12
|
Sever K, Ozbek C, Goktas B, Bas S, Ugurlucan M, Mansuroglu D. Gastrointestinal complications after open heart surgery: incidence and determinants of risk factors. Angiology 2013; 65:425-9. [PMID: 23574750 DOI: 10.1177/0003319713482357] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Acute mesenteric ischemia is a rare but serious complication of open heart surgery. Between January 2009 and January 2012, 1360 adult patients underwent open heart surgery with cardiopulmonary bypass at our institution; 29 patients presented gastrointestinal complications. Eight patients developed acute mesenteric ischemia and all of them died. Significant predictors of the complication were New York Heart Association functional class III/IV, history of extensive atherosclerosis and chronic renal failure, acute renal failure following surgery, low cardiac output, use of 2 or more vasoconstrictor drugs, prolonged mechanical ventilation, and multiorgan failure. Atherosclerosis is a multisystemic disease that affects several organs. Radiologic evaluation of mesenteric arterial system should be performed in high-risk patient populations. Perioperative percutaneous and open vascular procedures will reduce the risk of acute mesenteric ischemia that may develop after cardiac surgery and consequent morbidity and mortality rates.
Collapse
Affiliation(s)
- Kenan Sever
- 1Cardiovascular Surgery Clinic, Gaziosmanpasa Hospital, Istanbul, Turkey
| | | | | | | | | | | |
Collapse
|
13
|
Viana FF, Chen Y, Almeida AA, Baxter HD, Cochrane AD, Smith JA. Gastrointestinal complications after cardiac surgery: 10-year experience of a single Australian centre. ANZ J Surg 2013; 83:651-6. [PMID: 23530720 DOI: 10.1111/ans.12134] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND Gastrointestinal (GI) complications after cardiac surgery are uncommon, but are associated with high morbidity and mortality as well as significant hospital resource utilization. METHODS We analysed a prospectively collected database containing all adult cardiac surgery procedures performed from July 2001 to March 2011 at Monash Medical Centre and Jessie McPherson Private Hospital. Patients with post-operative GI complications were compared to patients without GI complications who were operated in the same period. RESULTS The incidence of GI complications was 1.1% (61 out of 5382 patients) with an overall 30-day mortality of 33% (versus 3% in the non-GI complication group). The most common complications were GI bleeding, gastroenteritis and bowel ischaemia. Patients who had GI complications were significantly older, had higher incidence of renal impairment, chronic lung disease and anticoagulation therapy and were more likely to be in cardiogenic shock. Emergency procedures, combined coronary artery bypass grafting and valve surgery and aortic dissection cases were more common in the GI complication group. The GI complication group also had higher incidence of return to theatre, renal failure, stroke, septicaemia and multi-organ failure. CONCLUSIONS GI complications after cardiac surgery remain an uncommon but dreadful complication associated with high mortality. Our findings should prompt a high degree of clinical vigilance in order to make an early diagnosis especially in high risk patients. Further studies aiming to identify independent predictors for GI complications after cardiac surgery are warranted.
Collapse
Affiliation(s)
- Fabiano F Viana
- Department of Cardiothoracic Surgery, Monash Medical Centre, Clayton, Victoria, Australia.
| | | | | | | | | | | |
Collapse
|
14
|
Guler M, Yamak B, Erdogan M, Aydin U, Kul S, Asil R, Kisacikoglu B. Risk factors for gastrointestinal complications in patients undergoing coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 2011; 25:637-41. [PMID: 21262572 DOI: 10.1053/j.jvca.2010.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2010] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the risk factors for the development of gastrointestinal complications (GICs) after coronary artery bypass graft (CABG) surgery. DESIGN A single-center, retrospective study. SETTING A tertiary care hospital. PARTICIPANTS Six thousand seven hundred ninety-four patients undergoing isolated CABG surgery between 2002 and 2006. INTERVENTIONS Clinical characteristics of the patients with GICs and control group patients were analyzed by stepwise logistic regression analysis. The control group consisted of a total of 95 patients randomly selected among the ones who had no gastrointestinal finding or symptoms (cohort: control, 1:5 ratio). MEASUREMENTS AND MAIN RESULTS Nineteen patients (0.3%) developed major surgical GICs after CABG surgery. Overall, the 30-day mortality was 42.1% among patients with GICs and 2.6% without GICs. Multivariate analysis identified 4 independent predictors for GICs: age greater than 70 years (p = 0.001; odds ratio [OR] = 5.6; 95% confidence interval [CI], 2.1-25.9), reoperation for bleeding (p = 0.005; OR = 7.7; 95% CI, 2.8-56.2), a prolonged cardiopulmonary bypass time (p = 0.007; OR = 3.7; 95% CI, 1.3-15.6), and an increased postoperative creatinine level (p = 0.036; OR = 2.3; 95% CI, 1.1-13.4). CONCLUSION A delayed diagnosis of complications is an important problem in the management of major surgical GICs. The present results suggest that surgeons and intensivists must be alert to patients older than 70 years, a cardiopulmonary bypass time longer than 60 minutes, reoperation for bleeding after CABG surgery, and postoperative creatinine level higher than 1.7 mg/dL.
Collapse
Affiliation(s)
- Mehmet Guler
- Department of Surgery, Gaziantep University, Gaziantep, Turkey.
| | | | | | | | | | | | | |
Collapse
|
15
|
Díaz-Gómez JL, Nutter B, Xu M, Sessler DI, Koch CG, Sabik J, Bashour CA. The effect of postoperative gastrointestinal complications in patients undergoing coronary artery bypass surgery. Ann Thorac Surg 2010; 90:109-15. [PMID: 20609758 DOI: 10.1016/j.athoracsur.2010.03.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Revised: 03/16/2010] [Accepted: 03/22/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Gastrointestinal (GI) complications after coronary artery bypass graft surgery (CABG) are uncommon but associated with a disproportionate share of mortality. We thus identified variables associated with GI complications and analyzed their effect on postoperative mortality in patients undergoing isolated CABG. METHODS Information from patients who underwent isolated CABG at our institution during a 12-year period was obtained from the Anesthesiology Institute patient registry. Patients who experienced one or more postoperative GI complication(s) during their initial intensive care unit stay were identified. Multivariable logistic regression with backward variable selection was used to determine variables associated with GI complications and to evaluate their effect on mortality. RESULTS Among 16,043 patients who underwent isolated CABG, 213 (1.43%) had one or more GI complication(s). The main patient variables associated with postoperative GI complications included preoperative (odds ratio, 2.43; 95% confidence interval [CI], 1.39 to 4.23; p < 0.001) and intraoperative (odds ratio, 5.07; 95% CI, 3.08 to 8.35; p < 0.001) intraaortic balloon pump insertion, patient age (odds ratio, 1.65; 95% CI, 1.41 to 1.94; p < 0.001), intraoperative fresh-frozen plasma transfusion (odds ratio, 3.38; 95% CI, 2.12 to 5.41; p < 0.001), and cardiogenic shock (odds ratio, 3.04; 95% CI, 1.12 to 8.24). No difference was detected in complication rates between off-pump and on-pump CABG procedures (1.50% versus 1.30%, respectively; p = 0.63). Postoperative GI complication(s) after CABG was associated with a 12.98 times increase in mortality (p < 0.001). CONCLUSIONS This single-center cohort study indicates that GI complications after isolated CABG remain rare with an incidence 1.43%. However, GI complications portend a significant mortality. The implications of intraoperative administration of fresh-frozen plasma and insertion of an intraaortic balloon pump deserve further investigation as they are associated with GI complications.
Collapse
Affiliation(s)
- José L Díaz-Gómez
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, Ohio 45195, USA.
| | | | | | | | | | | | | |
Collapse
|
16
|
Gupta-Malhotra M, Kern JH, Flynn PA, Schiller MS, Quaegebeur JM, Friedman DM. Early pleural effusions related to the myocardial injury after open-heart surgery for congenital heart disease. CONGENIT HEART DIS 2010; 5:256-61. [PMID: 20576044 DOI: 10.1111/j.1747-0803.2010.00403.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The degree of effusion immediately after cardiopulmonary bypass (CPB) can vary and may reflect several factors including the degree of myocardial injury. We compared the degree of pleural effusions after CPB to the overall myocardial injury as determined by serum cardiac troponin I (cTnI) levels after elective repair of a variety of congenital heart defects, including univentricular surgeries via cavopulmonary shunts. METHODS Serum was collected pre-CPB, post-CPB, and daily after that and cTnI level measured. The postoperative pleural effusion was measured each day until the chest tube was removed. Results. The 21 study patients were of average age of 5.5 years (+/-5.6). The duration of chest-tube drainage after open-heart surgery was 4.3 days (+/-3.5) and the amount was 2.4 mL/kg/hour (+/-2.9). For the biventricular repairs, cTnI levels on the postoperative day (POD) 1 best correlated with amount of effusion (n = 16, r = 0.5, P = 0.02) and the average (POD 0-3) cTnI levels with the total duration (n = 16, r = 0.4, P = 0.01) and also the amount (n = 16, r = 0.5, P = 0.02) of effusions. For the cavopulmonary shunts, the post-CBP cTnI level best correlated with the duration (n = 5, r = 0.8, P = 0.02) and amount (n = 5, r = 0.9, P = 0.02) of effusions. A cTnI level on the first postoperative day >or=15 microg/L was associated with effusions >2 days (sensitivity of 81% and specificity of 80%). CONCLUSION We found that higher the cTnI released, especially >or=15 microg/L, longer the duration and greater the amount of early pleural effusions for a variety of congenital heart surgeries including cavopulmonary shunts. A number of factors may lead to excessive pleural effusions and the degree of myocardial injury may be one of them.
Collapse
Affiliation(s)
- Monesha Gupta-Malhotra
- Division of Pediatric Cardiology, The New York Presbyterian Hospital, Weill Medical College of Cornell University and College of Physicians and Surgeons of Columbia University, New York, USA.
| | | | | | | | | | | |
Collapse
|
17
|
Rodriguez R, Robich MP, Plate JF, Trooskin SZ, Sellke FW. Gastrointestinal Complications following Cardiac Surgery: A Comprehensive Review. J Card Surg 2010; 25:188-97. [DOI: 10.1111/j.1540-8191.2009.00985.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
|
18
|
Gastric bleeding detected by transesophageal echocardiography during cardiopulmonary bypass. J Anesth 2010; 24:110-3. [DOI: 10.1007/s00540-009-0825-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Accepted: 07/22/2009] [Indexed: 11/24/2022]
|
19
|
Abstract
Hepatic injury in cardiac surgery is a rare complication but is associated with significant morbidity and mortality. A high index of suspicion postoperatively will lead to earlier treatment directed at eliminating or minimizing ongoing hepatic injury while preventing additional metabolic stress from ischemia, hemorrhage, or sepsis. The evidence-basis for perioperative renal risk factors remains hampered by the inconsistent definitions for renal injury. Although acute kidney injury (as defined by the Risk, Injury, Failure, Loss, End-stage criteria) has become accepted, it does not address pathogenesis and bears little relevance to cardiac surgery. Although acute renal failure requiring renal replacement therapy after cardiac surgery is rare, it has a devastating impact on morbidity and mortality, and further studies on protective strategies are essential.
Collapse
Affiliation(s)
- Geraldine C Diaz
- Department of Anesthesiology, University of Arizona, Tucson, AZ 85724, USA
| | | | | |
Collapse
|
20
|
Aljarallah B, Wong W, Modry D, Fedorak R. Prevalence and Outcome of Upper Gastrointestinal Bleeding Post-coronary Artery Bypass Graft. Int J Health Sci (Qassim) 2008; 2:69-76. [PMID: 21475474 PMCID: PMC3068711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB), a potentially fatal occurrence, can sometimes follow coronary artery bypass graft (CABG) surgery. However, little has been published about its prevalence, risk factors, and outcomes. AIM This study aimed to determine the rate, etiologies, predisposing factors, and outcomes of UGIB following CABG. METHOD The authors conducted a retrospective chart review of all UGIBs which followed CABGs performed at the University of Alberta Hospital from January 1, 1998 to December 31, 2002. RESULTS During the study period, 4,502 CABGs were performed at the UAH. Eighteen patients (0.4%) had a documented major UGIB (defined as evidence of melena, red or coffee-grounds emesis, blood per NG tube, or a decrease of Hgb by > 20 g/l and requiring a confirmation by endoscopy or radiological study). Two of these 18 patients (11%) had a past history of peptic ulcer disease, and one of these patients had had previous UGIB. Three patients (17%) had been taking proton pump inhibitors (PPI) before the UGIB occurred. At the time of UGIB, PPIs were prescribed for 16 patients (89%), and the PPIs achieved effective hemostasis as a single agent for 10 (62.5%). Of the 18 patients, 16 (89%) underwent upper GI endoscopy. Bleeding was found to be due to duodenal ulceration in 9 (56%), esophagitis in 4 (22%) and gastritis in 6 cases (33%); fifty percent of these patients had multiple sites of bleeding. Endoscopic therapeutic intervention was needed by 6 patients (37.5%), and successful hemostasis was achieved for 5 of these patients (83%). One patient had a recurrence of bleeding and required surgery. One patient underwent surgery as the primary hemostatic therapy after a diagnostic endoscopy. The overall surgical rate was 11.1% for this patient cohort. In this cohort, three patients died, two from multi-organ failure, and the third, a surgically managed patient, had a cardiac arrest 72 hours post-surgery. The number of complication increased as both cardiopulmonary bypass and cross clamp time increased. There were no endoscopy-related complications. CONCLUSIONS UGI bleeding following CABGs is relatively infrequent, occurring at a rate of 0.4% in this study. Upper gastrointestinal bleeding post-CABG is most frequently related to a duodenal ulcer, though 50% of the patients had multiple bleeding sites. prolonged bypass and cross clamp time associated with more complications.
Collapse
|
21
|
Rodriguez F, Nguyen TC, Galanko JA, Morton J. Gastrointestinal complications after coronary artery bypass grafting: a national study of morbidity and mortality predictors. J Am Coll Surg 2007; 205:741-7. [PMID: 18035256 DOI: 10.1016/j.jamcollsurg.2007.07.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Revised: 06/26/2007] [Accepted: 07/03/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Previous single-institution studies have documented a 0.6% to 2.4% incidence of gastrointestinal (GI) complications after coronary artery bypass grafting (CABG), with an associated 14% to 63% mortality rate. To better determine the incidence and impact of GI complications after CABG, national outcomes for CABG were examined from 1998 to 2002. STUDY DESIGN The Nationwide Inpatient Sample was queried for all patients undergoing CABG (ICD9 procedure codes 36.10 to 36.16). Two cohorts were compared: CABGs with and without GI complications. Both demographic and outcomes variables were compared by either t-test or chi-square analysis. Logistic regression analyses indicated potential predictors of CABG inpatient mortality and GI complications after CABG. RESULTS The incidence of GI complications among 2.7 million CABGs identified was 4.1%. Total hospital length of stay (19.3 versus 8.8 days) and inpatient mortality (12.0% versus 2.5%, both p < 0.0001) were increased in CABG patients having GI complications. Factors associated with increased risk of GI complications included: age greater than 65 years (odds ratio [OR], 2.1); hemodialysis (OR, 3.4); intraaortic balloon pump (OR, 1.6); concomitant valve procedure (OR, 1.5); and procedure urgency (OR, 1.22). Use of an internal mammary graft was protective (OR, 0.5), but GI complications increased inpatient mortality risk (OR, 2.6). CONCLUSIONS This national population-based study indicates that GI complications after CABG occur at a higher rate than previously described, leading to increased hospital length of stay and mortality.
Collapse
Affiliation(s)
- Filiberto Rodriguez
- Division of General Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA 94305-5655, USA
| | | | | | | |
Collapse
|
22
|
Filsoufi F, Rahmanian PB, Castillo JG, Scurlock C, Legnani PE, Adams DH. Predictors and outcome of gastrointestinal complications in patients undergoing cardiac surgery. Ann Surg 2007; 246:323-9. [PMID: 17667513 PMCID: PMC1933566 DOI: 10.1097/sla.0b013e3180603010] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine the incidence and independent predictors of gastrointestinal complications (GICs) following cardiac surgery. SUMMARY BACKGROUND DATA Gastrointestinal ischemia and hemorrhage represent a rare but devastating complication following heart surgery. The profile of patients referred for cardiac surgery has changed during the last decade, questioning the validity of previously reported incidence and risk factors. METHODS We retrospectively analyzed prospectively collected data from 4819 patients undergoing cardiac surgery between 1998 and 2004. Patients with GICs were compared with the entire patient population. Study endpoints were mortality, postoperative morbidities, and long-term survival. RESULTS GICs occurred in 51 (1.1%) patients. Etiologies were intestinal ischemia (n = 30; 59%) and hemorrhage (n = 21; 41%). The incidence decreased during the study period (1998-2001: 1.3%, 2002-2004: 0.7%; P = 0.04). The incidence per type of procedure was as follows: coronary artery bypass grafting (CABG)/valve (2.4%), aortic surgery (1.7%), valve surgery (1.0%), and CABG (0.5%; P = 0.001). Multivariate analysis revealed age (odds ratio [OR] = 2.1), myocardial infarction (OR = 2.5), CHF (OR = 2.4), hemodynamic instability (OR = 2.8), cardiopulmonary bypass time >120 minutes (OR = 6.2), peripheral vascular disease (OR = 2.2), renal (OR = 3.2), and hepatic failure (OR = 10.8) as independent predictors of GICs. The overall hospital mortality among patients with GICs was 33%. Long-term survival was significantly decreased in patients with GICs compared with the control group. CONCLUSIONS Gastrointestinal complications following cardiac surgery remain rare with an incidence <1% in a contemporary series. The key to a lower incidence of GICs lies in systematic application of preventive measures and new advances in intraoperative management. Identification of independent risk factors would facilitate the determination of patients who would benefit from additional perioperative monitoring. Future resources should therefore be redirected to mitigate GICs in high-risk patients.
Collapse
Affiliation(s)
- Farzan Filsoufi
- Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA.
| | | | | | | | | | | |
Collapse
|
23
|
Ait Houssa M, Selkane C, Moutaki Allah Y, Elbekkali Y, Amahzoune B, Wahid F, Abdou A, Bamouss M, Boulahya A, Elkirat A, Drissi M, Ibat D, Jabrani K. [Upper digestive bleedings after cardiac surgery]. Ann Cardiol Angeiol (Paris) 2007; 56:126-9. [PMID: 17572172 DOI: 10.1016/j.ancard.2007.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2006] [Accepted: 02/19/2007] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Upper gastrointestinal haemorrhage (UGH) following cardiac surgery is infrequent with high mortality. The aim of this study is to compare the frequency and outcome of UGH in patients who had undergone open heart surgery at our institution. PATIENTS AND METHODS From January 1994 to December 2005, 1278 cardiac operations were performed. A systematic prophylaxis antiacid was used by antagonists of histaminic receptor (anti-H2, ranitidine 150 mg/12 h) in all patients. The diagnosis was based on clinical symptoms (haematemesis and/or melaena) in the postoperative period and confirmed by fibroscopy. We conducted a retrospective study of these patients. RESULTS Only 8 of the 1278 (0,6%) cardiac operations were complicated by UGH. Demographic data were reported in Table 1. The mean interval between surgery and UGH was 10+/-3,7 days (range 5,15 days). Gastro-duodenal ulcer was the most common cause of UGH in 5 patients (62%), ulcero-hemorrhagic eosophagitis was developed in one patient (12,5%), candidosic eosophagitis in one and multiple gastric ulcer in one patient (12,5%). Medical treatment was applied in 6 patients (72%) with successful result. Surgical intervention was necessary in 2 patients (25%). 2 patients had repeat gastrointestinal bleeding. One patient was died; he was recorded as having severe sepsis and multiple organ failure in addition to UGH. CONCLUSION UGH in patients undergoing heart operation is rare but associated with poor prognosis despite antiacid prophylaxis. These complications occurred in patients who had in postoperative bad hemodynamic conditions.
Collapse
Affiliation(s)
- M Ait Houssa
- Service de chirurgie cardiovasculaire Hay-Riad, hôpital militaire d'instruction Mohammed-V, 10100 Rabat, Maroc.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Abstract
Cardiac surgery is associated with a low incidence of GI complications, but with a disproportionate mortality. A number of risk factors have become established which identify patients at risk. CPB is associated with profound reductions in mucosal blood flow. Mesenteric perfusion is altered by primary endothelial dysfunction, which may further be exacerbated by the use of vasoconstrictors during CPB; inflammatory mediators can 'prime' the mesenteric vasculature. Cardiac surgery with or without CPB is associated with increased tissue oxygen demands, particularly by the splanchnic bed. The disparity in general and regional oxygen supply and demand results in the development of mucosal hypoxia and this cannot be attributed to CPB alone. This injury is measurable by reductions in both absorptive and barrier functions of the gut. Protection may be conferred by modulating the perfusion protocol during bypass and pharmacological interventions which modify the inflammatory response to surgery.
Collapse
Affiliation(s)
- Sunil K Ohri
- Wessex Cardiothoracic Centre, Southampton General Hospital, Southampton, UK
| | | |
Collapse
|
25
|
Perez A, Ito H, Farivar RS, Cohn LH, Byrne JG, Rawn JD, Aranki SF, Zinner MJ, Tilney NL, Brooks DC, Ashley SW, Banks PA, Whang EE. Risk factors and outcomes of pancreatitis after open heart surgery. Am J Surg 2005; 190:401-5. [PMID: 16105526 DOI: 10.1016/j.amjsurg.2005.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2004] [Revised: 01/10/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND We sought to analyze the risk factors and natural history associated with post-cardiac surgery acute pancreatitis. METHODS Retrospective analysis of all patients having undergone cardiac surgery at our hospital between January 1, 1992, and October 1, 2001. RESULTS A total of 10,249 cardiac operations were performed. Thirty-nine (0.4%) patients developed postoperative pancreatitis. There was a higher incidence during the period spanning 1992 through 1996 than 1997 through 2001 (0.6% versus 0.2%, P< .05). Patients with pancreatitis had longer postoperative length of stay (51+/-5 days versus 10+/-1 days, P<.05) and a greater in-hospital mortality rate (28% versus 4%, P<.05) than patients who did not develop pancreatitis. A history of alcohol abuse, cardiac surgery performed during 1992 to 1996, increased cardiopulmonary bypass time, and increased cross-clamp time were independent risk factors for the development of pancreatitis. Multiple-organ failure was an independent predictor for death among patients with pancreatitis. CONCLUSIONS Although the frequency of post-cardiac surgery pancreatitis is diminishing, it is still associated with significant mortality.
Collapse
Affiliation(s)
- Alexander Perez
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Harvard Medical School, Boston, MA 02115, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Andersson B, Nilsson J, Brandt J, Höglund P, Andersson R. Gastrointestinal complications after cardiac surgery. Br J Surg 2005; 92:326-33. [PMID: 15672438 DOI: 10.1002/bjs.4823] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Gastrointestinal complications after cardiac surgery are often difficult to diagnose, and are associated with high morbidity and mortality rates. The aim of this study was to determine risk factors for these complications. METHOD Between 1996 and 2001 data were collected prospectively from 6119 patients who underwent 6186 cardiac surgical procedures. Data from patients who experienced major gastrointestinal complications were analysed retrospectively by univariate and multivariate analysis. RESULTS Fifty major gastrointestinal complications were identified in 47 patients (incidence 0.8 per cent). Thirteen of these patients died within 30 days. The most common complication was upper gastrointestinal bleeding (16 patients). Intestinal ischaemia was the most lethal complication (eight of ten patients died). Abdominal surgical operations were performed in 12 patients. Multivariate analysis identified nine variables that independently predicted major gastrointestinal complications: age over 80 years, active smoker, need for preoperative inotropic support, New York Heart Association class III-IV, cardiopulmonary bypass time more than 150 min, postoperative atrial fibrillation, postoperative heart failure, reoperation for bleeding and postoperative vascular complications. CONCLUSION Nine risk factors for the development of major gastrointestinal complications after cardiac surgery were identified. Gastrointestinal complications were often lethal but did not independently predict death within 30 days.
Collapse
Affiliation(s)
- B Andersson
- Department of Surgery, Lund University Hospital, S-221 85 Lund, Sweden.
| | | | | | | | | |
Collapse
|
27
|
Abstract
Gastrointestinal complications occur in about 2.5% of patients undergoing cardiac surgery, are associated with a high mortality (about 33%), and account for nearly 15% (and perhaps increasing) of all postoperative deaths. The various complications and risk factors are reviewed. Splanchnic ischemia prior to, during, and especially postoperatively appears to be an important cause of these complications. In addition, splanchnic ischemia is hypothesized to be one cause of the systemic inflammatory response syndrome and multiorgan failure that may follow cardiac surgery. The physiology of splanchic perfusion and the effects of cardiac surgery, including cardiopulmonary bypass, on it are reviewed. Finally, possible methods to minimize splanchnic ischemia and reduce the incidence of abdominal complications are discussed.
Collapse
Affiliation(s)
- Eugene A Hessel
- University of Kentucky College of Medicine, Lexington, Kentucky, USA.
| |
Collapse
|
28
|
McSweeney ME, Garwood S, Levin J, Marino MR, Wang SX, Kardatzke D, Mangano DT, Wolman RL. Adverse gastrointestinal complications after cardiopulmonary bypass: can outcome be predicted from preoperative risk factors? Anesth Analg 2004; 98:1610-1617. [PMID: 15155313 DOI: 10.1213/01.ane.0000113556.40345.2e] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Adverse gastrointestinal (GI) outcome after cardiac surgery is an infrequent event but is a clinically important health care problem because of associated increased morbidity and mortality. The ability to identify patients at greatest risk before surgery may be helpful in planning appropriate perioperative management strategies. We examined the pre- and intraoperative characteristics of 2417 patients from 24 diverse United States medical centers enrolled in the Multicenter Study of Perioperative Ischemia Study who were undergoing cardiac surgery using cardiopulmonary bypass as predictors for adverse GI outcome. Resource utilization was evaluated for patients with and without adverse GI outcomes. Adverse GI outcomes occurred in 5.5% of patients (133 of 2417), increased in-hospital mortality 6.5-fold, prolonged the mean intensive care unit length of stay by 1 wk, and more than doubled the mean postoperative hospital stay (P < 0.0001). Predictors of adverse GI outcome included decreased left ventricular function, hyperbilirubinemia, thrombocytopenia, prolonged partial thromboplastin time, prior cardiovascular surgery, combined coronary artery bypass graft surgery and intracardiac or proximal aortic surgery, pharmacological cardiovascular support, and intraoperative transfusion. The literature suggests that adverse GI outcome after cardiac surgery is secondary to poor splanchnic perfusion, which many of these risk factors may predict. Therefore, patients deemed to be at risk before surgery may benefit from tightly controlled hemodynamic management and other strategies that optimize perioperative organ perfusion. IMPLICATIONS We identified the preoperative and intraoperative predictors associated with an increased incidence of postoperative gastrointestinal complications after cardiac surgery using cardiopulmonary bypass. Because these complications are associated with frequent morbidity and mortality, these predictors may be helpful in identifying patients at increased risk so that risk stratification can be modified and perioperative management can be appropriately adjusted.
Collapse
Affiliation(s)
- Mary E McSweeney
- *Multicenter Study of Perioperative Ischemia Research Group and University of Wisconsin Medical School, Madison, Wisconsin; †Yale University School of Medicine, New Haven, Connecticut; ‡School of Medicine and VA Medical Center, San Francisco, California; §Centro Cardiologico Monzino, Milano, Italy; and ‖The Ischemia Research and Education Foundation, San Francisco, California
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Alpagut U, Kalko Y, Dayioglu E. Gastrointestinal complications after transperitoneal abdominal aortic surgery. Asian Cardiovasc Thorac Ann 2003; 11:3-6. [PMID: 12692013 DOI: 10.1177/021849230301100102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A major gastrointestinal complication after transperitoneal aortic surgery, though unusual, may be disastrous. We determined retrospectively the risk factors, associated events, and outcomes of gastrointestinal complications that developed after transperitoneal aortic revascularization to treat aneurysmal or occlusive disease over a 10-year period. Among 750 patients reviewed, gastrointestinal complications developed postoperatively in 65 of them (8.6%), including paralytic ileus in 35 patients, gastrointestinal bleeding and mechanical ileus in 6 patients each, colonic necrosis in 2, ischemic colitis and diarrhea in 10, acute cholecystitis in 2, ascites in 1, as well as aortoduodenal fistula, which developed about 2 months postoperatively in 3 patients. Five of the patients died of multiorgan failure. Mean stay in the intensive care unit was 3 days, and hospital stay ranged from 15 to 60 days. No risk factors were identified for the occurrence of gastrointestinal complications. These results show that gastrointestinal complications after transperitoneal aortic surgery prolong hospital stay and may have serious consequences.
Collapse
Affiliation(s)
- Ufuk Alpagut
- Department of Cardiovascular Surgery, University of Istanbul Medical Faculty, Istanbul, Turkey.
| | | | | |
Collapse
|
30
|
D'Ancona G, Baillot R, Poirier B, Dagenais F, de Ibarra JIS, Bauset R, Mathieu P, Doyle D. Determinants of gastrointestinal complications in cardiac surgery. Tex Heart Inst J 2003; 30:280-5. [PMID: 14677737 PMCID: PMC307712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
We designed this study to define determinants of gastrointestinal complications after cardiac surgery. From January 1992 through December 2000, 11,058 patients underwent cardiac surgery on cardiopulmonary bypass at our institution. Data were prospectively collected and univariate and multivariate analyses conducted. A total of 147 gastrointestinal complications occurred in 129 patients (129/11,058; 1.2%) including gastroesophagitis (18, 12.2%), upper gastrointestinal hemorrhage (42, 28.6%), perforated peptic ulcer (7, 4.7%), cholecystitis (10, 6.8%), pancreatitis (13, 8.8%), intestinal ischemia (17, 11.5%), colitis (18, 12.2%), diverticulitis (5, 3.4%), intestinal occlusion (2, 1.1%), lower gastrointestinal hemorrhage (1, 0.7%), and mixed gastrointestinal complications (14, 9.5%). Patients with gastrointestinal complications were significantly older and had significantly higher comorbidity (unstable angina, chronic renal failure, and peripheral vascular disease), morbidity (prolonged mechanical ventilation, intraaortic balloon pumping, bleeding, acute renal failure, stroke, and infection), and mortality rates (22.5% vs 4%, P < 0.0001). They also had longer cardiopulmonary bypass times and higher valvular surgery rates. Multivariate analysis identified 6 independent predictors for gastrointestinal complications: prolonged mechanical ventilation (odds ratio [OR], 5.5), postoperative renal failure (OR, 4.2), sepsis (OR, 3.6), valve surgery (OR, 3.2), preoperative chronic renal failure (OR, 2.7), and sternal infection (OR, 2.4). Factors such as mechanical ventilation, renal failure, and sepsis are the stronger predictors for GI complications, causing splanchnic hypoperfusion, hypomotility, and hypoxia. Furthermore, excessive anticoagulation after valve replacement may lead to GI hemorrhage. Valve surgery, often requiring anticoagulation, increases bleeding. Monitoring mechanical ventilation and hemodynamic parameters, adopting early extubation and mobilization measures, preventing infections, and strictly monitoring renal function and anticoagulation may prevent catastrophic abdominal complications.
Collapse
Affiliation(s)
- Giuseppe D'Ancona
- Department of Cardiovascular Surgery, Laval Hospital, Quebec Heart Institute, Sainte-Foy, Quebec, Canada G1V 4G5.
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Bocsi J, Hambsch J, Osmancik P, Schneider P, Valet G, Tárnok A. Preoperative prediction of pediatric patients with effusions and edema following cardiopulmonary bypass surgery by serological and routine laboratory data. Crit Care 2002; 6:226-33. [PMID: 12133183 PMCID: PMC125311 DOI: 10.1186/cc1494] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2002] [Accepted: 02/22/2002] [Indexed: 11/21/2022] Open
Abstract
AIM Postoperative effusions and edema and capillary leak syndrome in children after cardiac surgery with cardiopulmonary bypass constitute considerable clinical problems. Overshooting immune response is held to be the cause. In a prospective study we investigated whether preoperative immune status differences exist in patients at risk for postsurgical effusions and edema, and to what extent these differences permit prediction of the postoperative outcome. METHODS One-day preoperative serum levels of immunoglobulins, complement, cytokines and chemokines, soluble adhesion molecules and receptors as well as clinical chemistry parameters such as differential counts, creatinine, blood coagulation status (altogether 56 parameters) were analyzed in peripheral blood samples of 75 children (aged 3-18 years) undergoing cardiopulmonary bypass surgery (29 with postoperative effusions and edema within the first postoperative week). RESULTS Preoperative elevation of the serum level of C3 and C5 complement components, tumor necrosis factor-alpha, percentage of leukocytes that are neutrophils, body weight and decreased percentage of lymphocytes (all P < 0.03) occurred in children developing postoperative effusions and edema. While single parameters did not predict individual outcome, >86% of the patients with postoperative effusions and oedema were correctly predicted using two different classification algorithms. Data mining by both methods selected nine partially overlapping parameters. The prediction quality was independent of the congenital heart defect. CONCLUSION Indicators of inflammation were selected as risk indicators by explorative data analysis. This suggests that preoperative differences in the immune system and capillary permeability status exist in patients at risk for postoperative effusions. These differences are suitable for preoperative risk assessment and may be used for the benefit of the patient and to improve cost effectiveness.
Collapse
Affiliation(s)
- József Bocsi
- Director, Flow Cytometry Unit, 1st Department of Pathology, Semmelweis University, Budapest, Hungary
| | - Jörg Hambsch
- Assistant Medical Director, Pediatric Cardiology, Heart Center Leipzig GmbH, University of Leipzig, Germany
| | - Pavel Osmancik
- Assistant Cardiologist, Cardiac Center, University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - Peter Schneider
- Director, Pediatric Cardiology, Heart Center Leipzig GmbH, University of Leipzig, Germany
| | - Günter Valet
- Head, Cell Biochemistry Group, Max-Planck-Institute for Biochemistry, Martinsried, Munich, Germany
| | - Attila Tárnok
- Head, Research Facility, Pediatric Cardiology, Heart Center Leipzig GmbH, University of Leipzig, Germany
| |
Collapse
|
32
|
Zacharias A, Schwann TA, Parenteau GL, Riordan CJ, Durham SJ, Engoren M, Fenn-Buderer N, Habib RH. Predictors of gastrointestinal complications in cardiac surgery. Tex Heart Inst J 2000; 27:93-9. [PMID: 10928493 PMCID: PMC101040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Gastrointestinal problems are infrequent but serious complications of cardiac surgery, with high rates of morbidity and mortality. Predictors of these complications are not well developed, and the role of fundamental variables remains controversial. In a retrospective review of our cardiac surgery experience from July 1991 through December 1997 we found that postoperative gastrointestinal complications were diagnosed in 86 of 4,463 consecutive patients (1.9%). We categorized these 86 patients into 2 groups--Surgical and Medical--according to the method of treatment used for their complications. In the Medical group, 9 of 52 patients (17%) died; in the Surgical group, 17 of 34 (50%) died. By logistic multivariate analysis, we identified 8 parameters that predicted gastrointestinal complications: age greater than 70 years, duration of cardiopulmonary bypass, need for blood transfusions, reoperation, triple-vessel disease, New York Heart Association functional class IV, peripheral vascular disease, and congestive heart failure. Postoperative re-exploration for bleeding was a predictor specific to the Surgical group. Use of an intraaortic balloon pump was markedly higher in the Gastrointestinal group than in the Control group (30% vs 10%, respectively), as was the use of inotropic support in the immediate postoperative period (27% vs 5.6%). Our results suggest that intra-abdominal ischemic injury is a likely contributing factor in most gastrointestinal complications. In turn, the ischemia is probably caused by hypoperfusion due to low cardiac output, hypotension due to blood loss, and intra-abdominal atheroemboli. The derived models are useful for identifying patients whose risk of gastrointestinal complications after cardiac surgery may be reduced by clinical measures designed to counter these mechanisms.
Collapse
Affiliation(s)
- A Zacharias
- Department of Cardiovascular Surgery, St. Vincent Mercy Medical Center, Toledo, Ohio 43608, USA
| | | | | | | | | | | | | | | |
Collapse
|
33
|
Herline A, Pinson C, Wright J, Debelak J, Shyr Y, Harley D, Merrill W, Starkey T, Pierson R, Chapman WC. Acute Pancreatitis after Cardiac Transplantation and Other Cardiac Procedures: Case-Control Analysis in 24,631 Patients. Am Surg 1999. [DOI: 10.1177/000313489906500904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Previous series have identified an increased risk of developing acute postoperative pancreatitis in heart transplant recipients and other cardiac surgical patients, and some suggest that mortality is significantly increased when pancreatitis occurs in the transplant setting. We conducted a retrospective case-control analysis of adult patients undergoing orthotopic heart transplant or other cardiac procedures from April 1985 through June 1996 at our medical center. Specific risk factors for outcome were assessed including low cardiac output, intra-aortic balloon pump usage, exogenous calcium repletion, immunosuppression, cytomegalovirus infection, cholelithiasis, prior pancreatitis, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores. There was a 30-fold increase in the incidence of pancreatitis in the heart transplant group [12 of 394 (3%) vs 27 of 24,237 (0.1%); P < 0.01]. Compared with the nontransplant cardiopulmonary bypass patients, the transplant patients experienced a statistically significant increased incidence of immunosuppression and three or more risk factors. Transplant patients with pancreatitis demonstrated a significant increase in APACHE II scores and the incidence of three or more risk factors compared with their transplant control group. Patients undergoing nontransplant cardiac procedures and developing pancreatitis had significantly increased cross-clamp times, incidence of low cardiac output, APACHE II scores, and incidence of three or more risk factors compared with their nontransplant cohort. In conclusion, there is a significant increase in the incidence of pancreatitis after orthotopic heart transplant compared with other cardiac procedures. Analysis demonstrates the additive effect of multiple individual risk factors. Immunosuppression confers significant additional risk for pancreatitis in the orthotopic heart transplant patient.
Collapse
Affiliation(s)
- A.J. Herline
- Departments of Surgery and Cardiovascular Surgery, Vanderbilt University Medical Center and St. Thomas Hospital, Nashville, Tennessee
| | - C.W. Pinson
- Departments of Surgery and Cardiovascular Surgery, Vanderbilt University Medical Center and St. Thomas Hospital, Nashville, Tennessee
| | - J.K. Wright
- Departments of Surgery and Cardiovascular Surgery, Vanderbilt University Medical Center and St. Thomas Hospital, Nashville, Tennessee
| | - J. Debelak
- Departments of Surgery and Cardiovascular Surgery, Vanderbilt University Medical Center and St. Thomas Hospital, Nashville, Tennessee
| | - Y. Shyr
- Departments of Surgery and Cardiovascular Surgery, Vanderbilt University Medical Center and St. Thomas Hospital, Nashville, Tennessee
| | - D. Harley
- Departments of Surgery and Cardiovascular Surgery, Vanderbilt University Medical Center and St. Thomas Hospital, Nashville, Tennessee
| | - W. Merrill
- Departments of Surgery and Cardiovascular Surgery, Vanderbilt University Medical Center and St. Thomas Hospital, Nashville, Tennessee
| | - T. Starkey
- Departments of Surgery and Cardiovascular Surgery, Vanderbilt University Medical Center and St. Thomas Hospital, Nashville, Tennessee
| | - R. Pierson
- Departments of Surgery and Cardiovascular Surgery, Vanderbilt University Medical Center and St. Thomas Hospital, Nashville, Tennessee
| | - William C. Chapman
- Departments of Surgery and Cardiovascular Surgery, Vanderbilt University Medical Center and St. Thomas Hospital, Nashville, Tennessee
| |
Collapse
|
34
|
Aouifi A, Piriou V, Bastien O, Joseph P, Blanc P, Chiari P, Diab C, Villard J, Lehot JJ. [Severe digestive complications after heart surgery using extracorporeal circulation]. Can J Anaesth 1999; 46:114-21. [PMID: 10083990 DOI: 10.1007/bf03012544] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To determine the incidence, circumstances of occurrence and evolution of gastrointestinal complications after cardiac surgery with extracorporeal circulation (ECC). METHODS Retrospective chart study of gastrointestinal complications in 6.281 patients undergoing ECC between january 1994 and December 1997. RESULTS Sixty patients developed 68 gastrointestinal complications (1%). Complications included: upper gastrointestinal bleeding (n = 23), intestinal ischemia (n = 19), cholecystitis (n = 7), pancreatitis (n = 6), and paralytic ileus (n = 16). The incidence of these complications was low after coronary artery (0.4%) or valvular surgery (0.8%) and high after cardiac transplantation (6%) and after surgery for acute aortic dissection (9%). Compared with a control population, patients with gastrointestinal complication had a higher Parsonnet score (29 +/- 15 vs 13 +/- 12 points; P = 0.002), were more frequently operated upon as an emergency (40/60, 66% vs 1120/6221, 18%; P = 0.01), underwent ECC of longer duration (114 +/- 66 vs 74 +/- 42 min; P = 0.01), and presented more frequently with low cardiac output after surgery (45/60, 75% vs 435/6221, 7%; P = 0.001). The mortality rate after gastrointestinal complications was 52%. The major factor associated with mortality was the occurrence of sepsis (OR = 38.7). Other factors were: renal failure (OR = 7.9), age > 75 yr (OR = 3.5), mechanical ventilation for more than seven days (OR = 2.7), associated cerebral damage (OR = 3.9). CONCLUSION Gastrointestinal complications after ECC occur in high risk surgical patients. These complications are frequently associated with other complications leading to a high mortality rate.
Collapse
Affiliation(s)
- A Aouifi
- Service d'Anesthésie-Réanimation, Hôpital Cardiovasculaire et Pneumologique Louis Pradel, Lyon, France.
| | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Valentine RJ, Hagino RT, Jackson MR, Kakish HB, Bengtson TD, Clagett GP. Gastrointestinal complications after aortic surgery. J Vasc Surg 1998; 28:404-11; discussion 411-2. [PMID: 9737449 DOI: 10.1016/s0741-5214(98)70125-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND PURPOSE A major gastrointestinal complication (GIC) after aortic surgery may be disastrous, but these complications have received scant attention. This study was performed to determine the risk factors, associated events, and outcomes for patients with GIC. METHODS We performed a secondary analysis of a prospective study that examined 120 consecutive patients who underwent transperitoneal aortic revascularization for aneurysmal or occlusive disease. RESULTS The following 29 GICs developed in 25 patients (21%) within 30 days of aortic surgery: paralytic ileus that required replacement of nasogastric tubes (n = 12), upper gastrointestinal bleeding (n = 5), Clostridium difficile enterocolitis (n = 5), acute cholecystitis (n = 2), mechanical obstruction (n = 2), ascites (n = 2), and colon ischemia (n = 1). Seven patients required operations for GICs after aortic revascularization. A comparison of patients with and without GICs showed no differences in the prevalence of risk factors, presence of mesenteric artery stenoses, coexisting medical illnesses, antecedent gastrointestinal history, operative indication, preoperative fluid administration, or duration of operation. However, patients with GICs had more intraoperative complications (P = .004), greater intraoperative blood loss (P = .02), and more fluids during the postoperative period (P = .008). The mean duration of mechanical ventilation was 71 +/- 23 hours for patients with GICs versus 7 +/- 2 hours for patients without GICs (P = .006). A higher prevalence of pulmonary (P = .004) and renal (P = .001) complications was seen in the patients with GICs. The mean stay in the intensive care unit was 16 +/- 2 days for patients with GICs as compared with 5 +/- 0.4 days for patients without GICs (P < .001). Four deaths occurred, all caused by multisystem organ failure: 3 patients had GICs, and 1 did not have a GIC (P = .007). CONCLUSIONS These results show that GICs are prevalent in transperitoneal aortic surgery and are associated with severe morbidity rates, increased hospital costs because of prolonged stay, and increased mortality rates. Some GICs appear to be associated with intraoperative events that lead to visceral hypoperfusion, and others can be attributed to mechanical causes. However, none of the variables examined in this study were predictive of GICs. In all, GICs should be considered serious adverse sequela after aortic revascularization. Because no risk factors for GICs have been identified, these complications currently cannot be prevented.
Collapse
Affiliation(s)
- R J Valentine
- Department of Surgery, the University of Texas Southwestern Medical Center, and the Department of Veterans Affairs Medical Center, Dallas 75235-9157, USA
| | | | | | | | | | | |
Collapse
|
36
|
O'Dwyer C, Woodson LC, Conroy BP, Lin CY, Deyo DJ, Uchida T, Johnston WE. Regional perfusion abnormalities with phenylephrine during normothermic bypass. Ann Thorac Surg 1997; 63:728-35. [PMID: 9066392 DOI: 10.1016/s0003-4975(96)01116-2] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Hypotension and vasopressors during cardiopulmonary bypass may contribute to splanchnic ischemia. The effect of restoring aortic pressure on visceral organ, brain, and femoral muscle perfusion during cardiopulmonary bypass by increasing pump flow or infusing phenylephrine was examined. METHODS Twelve anesthetized swine were stabilized on normothermic cardiopulmonary bypass. After baseline measurements, including regional blood flow (radioactive microspheres), aortic pressure was reduced to 40 mm Hg by decreasing the pump flow. Next, aortic pressure was restored to 65 mm Hg either by increasing the pump flow or by titrating phenylephrine. The animals had both interventions in random order. RESULTS At 40 mm Hg aortic pressure, perfusion to all visceral organs and femoral muscle, but not to the brain, was significantly reduced. Increasing pump flow improved perfusion to the pancreas, colon, and kidneys. In contrast, infusing phenylephrine (2.4 +/- 0.6 micrograms.kg-1.min-1) increased aortic pressure but failed to improve splanchnic perfusion, so that significant perfusion differences existed between the pump flow and phenylephrine intervals. CONCLUSIONS Increasing systemic pressure during cardiopulmonary bypass with phenylephrine causes significantly lower values of splanchnic blood flow than does increasing the pump flow. Administering vasoconstrictors during normothermic cardiopulmonary bypass may mask substantial hypoperfusion of splanchnic organs despite restoration of perfusion pressure.
Collapse
Affiliation(s)
- C O'Dwyer
- Department of Anesthesiology, University of Texas Medical Branch, Galveston 77555-0591, USA
| | | | | | | | | | | | | |
Collapse
|