scholarly journals Comparison of Two Major Perioperative Bleeding Scores for Cardiac Surgery Trials

2018 ◽  
Vol 129 (6) ◽  
pp. 1092-1100 ◽  
Author(s):  
Justyna Bartoszko ◽  
Duminda N. Wijeysundera ◽  
Keyvan Karkouti ◽  
Jeannie Callum ◽  
Vivek Rao ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Major Bleeding ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Severe Bleeding ◽  
Logistic Regression Models ◽  
C Statistic ◽  
Perioperative Bleeding ◽  
Universal Definition ◽  
Bleeding Severity

Abstract Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Research into major bleeding during cardiac surgery is challenging due to variability in how it is scored. Two consensus-based clinical scores for major bleeding: the Universal definition of perioperative bleeding and the European Coronary Artery Bypass Graft (E-CABG) bleeding severity grade, were compared in this substudy of the Transfusion Avoidance in Cardiac Surgery (TACS) trial. Methods As part of TACS, 7,402 patients underwent cardiac surgery at 12 hospitals from 2014 to 2015. We examined content validity by comparing scored items, construct validity by examining associations with redo and complex procedures, and criterion validity by examining 28-day in-hospital mortality risk across bleeding severity categories. Hierarchical logistic regression models were constructed that incorporated important predictors and categories of bleeding. Results E-CABG and Universal scores were correlated (Spearman ρ = 0.78, P < 0.0001), but E-CABG classified 910 (12.4%) patients as having more severe bleeding, whereas the Universal score classified 1,729 (23.8%) as more severe. Higher E-CABG and Universal scores were observed in redo and complex procedures. Increasing E-CABG and Universal scores were associated with increased mortality in unadjusted and adjusted analyses. Regression model discrimination based on predictors of perioperative mortality increased with additional inclusion of the Universal score (c-statistic increase from 0.83 to 0.91) or E-CABG (c-statistic increase from 0.83 to 0.92). When other major postoperative complications were added to these models, the association between Universal or E-CABG bleeding with mortality remained. Conclusions Although each offers different advantages, both the Universal score and E-CABG performed well in the validity assessments, supporting their use as outcome measures in clinical trials.

scholarly journals Effect of sevoflurane on the inflammatory response during cardiopulmonary bypass in cardiac surgery: the study protocol for a randomized controlled trial

Trials ◽  
2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Thiago Augusto Azevedo Maranhão Cardoso ◽  
Gudrun Kunst ◽  
Caetano Nigro Neto ◽  
José de Ribamar Costa Júnior ◽  
Carlos Gustavo Santos Silva ◽  
...  
Keyword(s):  
Randomized Controlled Trial ◽  
Cardiac Surgery ◽  
Cardiopulmonary Bypass ◽  
Inflammatory Response ◽  
Controlled Trial ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Volatile Anesthetic ◽  
Serum Levels ◽  
Randomized Controlled

Abstract Background Recent experimental evidence shows that sevoflurane can reduce the inflammatory response during cardiac surgery with cardiopulmonary bypass. However, this observation so far has not been assessed in an adequately powered randomized controlled trial. Methods We plan to include one hundred patients undergoing elective coronary artery bypass graft with cardiopulmonary bypass who will be randomized to receive either volatile anesthetics during cardiopulmonary bypass or total intravenous anesthesia. The primary endpoint of the study is to assess the inflammatory response during cardiopulmonary bypass by measuring PMN-elastase serum levels. Secondary endpoints include serum levels of other pro-inflammatory markers (IL-1β, IL-6, IL-8, TNFα), anti-inflammatory cytokines (TGFβ and IL-10), and microRNA expression in peripheral blood to achieve possible epigenetic mechanisms in this process. In addition clinical endpoints such as presence of major complications in the postoperative period and length of hospital and intensive care unit stay will be assessed. Discussion The trial may determine whether adding volatile anesthetic during cardiopulmonary bypass will attenuate the inflammatory response. Trial registration ClinicalTrials.gov NCT02672345. Registered on February 2016 and updated on June 2020.

Pharmacokinetics of Propofol in Adult Patients Undergoing Coronary Revascularization

1996 ◽  
Vol 84 (6) ◽  
pp. 1288-1297 ◽  
Author(s):  
James M. Bailey ◽  
Christina T. Mora ◽  
Stephen L. Shafer ◽  
Keyword(s):  
Cardiac Surgery ◽  
Cross Validation ◽  
Predictive Accuracy ◽  
Coronary Revascularization ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Adult Patients ◽  
Pharmacokinetic Parameters ◽  
Surgery Patient ◽  
Prospective Comparison

Background Propofol is increasingly used for cardiac anesthesia and for perioperative sedation. Because pharmacokinetic parameters vary among distinct patient populations, rational drug dosing in the cardiac surgery patient is dependent on characterization of the drug's pharmacokinetic parameters in patients actually undergoing cardiac procedures and cardiopulmonary bypass (CPB). In this study, the pharmacokinetics of propofol was characterized in adult patients undergoing coronary revascularization. Methods Anesthesia was induced and maintained by computer-controlled infusions of propofol and alfentanil, or sufentanil, in 41 adult patients undergoing coronary artery bypass graft surgery. Blood samples for determination of plasma propofol concentrations were collected during the predefined study periods and assayed by high-pressure liquid chromatography. Three-compartment model pharmacokinetic parameters were determined by nonlinear extended least-squares regression of pooled data from patients receiving propofol throughout the perioperative period. The effect of CPB on propofol pharmacokinetics was modeled by allowing the parameters to change with the institution and completion of extracorporeal circulation and selecting the optimal model on the basis of the logarithm of the likelihood. Predicted propofol concentrations were calculated by convolving the infusion rates with unit disposition functions using the estimated parameters. The predictive accuracy of the parameters was evaluated by cross-validation and by a prospective comparison of predicted and measured levels in a subset of patients. Results Optimal pharmacokinetic parameters were: central compartment volume = 6.0 l; second compartment volume = 49.5 l; third compartment volume = 429.3 l; Cl1 (elimination clearance) = 0.68 l/min; Cl2 (distribution clearance) = 1.97 l/min1; and Cl3 (distribution clearance) = 0.70 l/min. The effects of CPB were optimally modeled by step changes in V1 and Cl1 to values of 15.9 and 1.95, respectively, with the institution of CPB. Median absolute prediction error was 18% in the cross-validation assessment and 19% in the prospective evaluation. There was no evidence for nonlinear kinetics. Previously published propofol pharmacokinetic parameter sets poorly predicted the observed concentrations in cardiac surgical patients. Conclusions The pharmacokinetics of propofol in adult patients undergoing cardiac surgery with CPB are dissimilar from those reported for other adult patient populations. The effect of CPB was best modeled by an increase in V1 and Cl1. Predictive accuracy of the derived pharmacokinetic parameters was excellent as measured by cross-validation and a prospective test.

Cardiac Surgery Nurse Practitioner Home Visits Prevent Coronary Artery Bypass Graft Readmissions

2014 ◽  
Vol 97 (5) ◽  
pp. 1488-1495 ◽  
Author(s):  
Michael H. Hall ◽  
Rick A. Esposito ◽  
Renee Pekmezaris ◽  
Martin Lesser ◽  
Donna Moravick ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Coronary Artery ◽  
Coronary Artery Bypass Graft ◽  
Coronary Artery Bypass ◽  
Nurse Practitioner ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Home Visits ◽  
Artery Bypass Graft

Impact of atrial fibrillation on in-hospital outcomes among hospitalizations for cardiac surgery: an analysis of the National Inpatient Sample

2022 ◽  
pp. jim-2021-001864
Author(s):  
Kanishk Agnihotri ◽  
Paris Charilaou ◽  
Dinesh Voruganti ◽  
Kulothungan Gunasekaran ◽  
Jawahar Mehta ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Cardiac Surgery ◽  
Valve Replacement ◽  
Failure Time ◽  
Artery Bypass ◽  
Bypass Graft ◽  
National Inpatient Sample ◽  
Inpatient Mortality ◽  
Hospitalization Costs ◽  
The Impact

The short-term impact of atrial fibrillation (AF) on cardiac surgery hospitalizations has been previously reported in cohorts of various sizes, but results have been variable. Using the 2005–2014 National Inpatient Sample, we identified all adult hospitalizations for cardiac surgery using the International Classification of Diseases, Ninth Revision, Clinical Modification as any procedure code and AF as any diagnosis code. We estimated the impact of AF on inpatient mortality, length of stay (LOS), and cost of hospitalization using survey-weighted, multivariable logistic, accelerated failure-time log-normal, and log-transformed linear regressions, respectively. Additionally, we exact-matched AF to non-AF hospitalizations on various confounders for the same outcomes. A total of 1,269,414 hospitalizations were noted for cardiac surgery during the study period. Coexistent AF was found in 44.9% of these hospitalizations. Overall mean age was 65.6 years, 40.9% were female, mean LOS was 11.6 days, and inpatient mortality was 4.5%. Stroke rate was lower in AF hospitalizations (1.8% vs 2.1%, p<0.001). Mortality was lower in the AF (3.9%) versus the non-AF (5%) group (exact-matched OR or emOR=0.48, 95% CI 0.29 to 0.80, p<0.001; 987 matched pairs, n=2423), with similar results after procedural stratification: isolated valve replacement/repair (emOR=0.38, p<0.001), isolated coronary artery bypass graft (CABG) (emOR=0.33, p<0.001), and CABG with valve replacement/repair (emOR=0.55, p<0.001). A 12% increase was seen in LOS in the AF subgroup (exact-matched time ratio=1.12, 95% CI 1.10 to 1.14, p<0.001) among hospitalizations which underwent valve replacement/repair with or without CABG. Hospitalizations for cardiac surgery which had coexistent AF were found to have lower inpatient mortality risk and stroke prevalence but higher LOS and hospitalization costs compared with hospitalizations without AF.

Abstract 358: Annual Quality of Care Evaluations of Cardiac Surgery in British Columbia

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
James G Abel ◽  
Daniel R Wong ◽  
Carmen H Ng ◽  
Lillian Ding ◽  
Andrew Kmetic
Keyword(s):  
British Columbia ◽  
Cardiac Surgery ◽  
Quality Of Care ◽  
Risk Model ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Administrative Databases ◽  
Annual Review ◽  
Rbc Transfusion

Background: Cardiac Services BC (CSBC) is responsible for planning, coordinating, monitoring, and, in some cases, funding cardiac services across British Columbia (BC) in collaboration with senior administrators and physicians from five regional health authorities. CSBC maintains the BC Cardiac Registry (BCCR), a longitudinal clinical registry of all invasive cardiac procedures performed in BC. For over 10 years, CSBC has used BCCR data to evaluate annually quality of care indicators for isolated coronary artery bypass graft (CABG), isolated valve, and CABG+valve surgeries. Methods: In preparation for each annual review, CSBC meets with an established Planning Committee of representative surgeons. BCCR data is linked to provincial Vital Statistics data, to the national Discharge Abstract Database, and for the last 3 yearly analyses to the provincial Central Transfusion Registry which provides robust data on red blood cell (RBC) transfusion. At the annual review, CSBC meets with surgeons who are included in the analyses to present the indicator data. Results: In the 2012 evaluation, the following quality of care indicators were presented for the 2007-2011 period: 30-day mortality and 30-day stroke; 30-day RBC transfusion; and indicators for evidence-based medications at discharge. Risk-adjusted analyses were prepared for the 30-day mortality and 30-day stroke indicators to provide valid comparisons over time and according to hospital and surgeon. Patient characteristics and pre-procedural factors were included in the risk models. The risk-adjusted models performed well with C-statistics for the 30-day mortality models for isolated CABG, isolated valve, and CABG+valve surgeries of 0.86, 0.89, and 0.81, and for the 30-day stroke models 0.80, 0.83, and 0.74, respectively. Expected rates by hospital and by surgeon were determined from each risk model, and observed to expected (O/E) ratios were used for comparison of hospitals and surgeons. Rates of RBC transfusion varied by hospital, and a large reduction in transfusion rates from 69% (378 of 546) in 2007 to 43% (252 of 589) in 2011 was observed at one site with historically higher rates. Conclusion: Presenting quality of care indicators annually has raised awareness of outcome rates and variations which existed across the province. The annual process of engaging surgeons in the evaluation process and linkage with other administrative databases to obtain outcome data has been associated with a reduction in use of RBC transfusion and instigated further investigations into regional variation in mortality rates. The addition of new indicators and other risk-adjusted analyses in the future may further improve quality of care in cardiac surgery in BC.

Abstract 4776: Prophylactic Intravenous Magnesium Sulphate in Addition to Oral Beta Blockade does not Prevent Atrial Arrhythmias after Cardiac Surgery

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Richard C Cook ◽  
Karin H Humphries ◽  
Ken Gin ◽  
Michael T Janusz ◽  
Victoria Bernstein ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Magnesium Sulphate ◽  
Controlled Trial ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Standard Of Care ◽  
Beta Blockade ◽  
Atrial Arrhythmias ◽  
Hemodynamic Compromise ◽  
To Receive

Background Atrial arrhythmias (AA) affect up to 40% of patients following cardiac surgery. The best strategy for prevention of AA remains undetermined, however, beta blocker (BB) administration is the standard of care at many centers (including ours). Although there is now compelling evidence demonstrating the utility of magnesium sulphate (MgSO4) for treatment of AA, the effectiveness of MgSO4 for prophylaxis of AA remains controversial. This study is the largest randomized, placebo-controlled trial of intravenous (IV) MgSO4 for the prevention of AA following cardiac surgery. Methods Eligible patients requiring either coronary artery bypass graft surgery (CABG), or valve surgery ± CABG, were randomized to receive either 5g IV MgSO4, or placebo upon removal of the crossclamp, followed by daily infusions of IV MgSO4 or placebo over 4 hours, from the day of surgery until post-operative day 4. All patients were treated according to an established protocol with oral BB (atenolol). Patients were monitored by continuous telemetry for the first 5 post-operative days. The primary endpoint was an AA lasting ≥ 30 minutes, or requiring treatment because of hemodynamic compromise. Results Table 1 summarizes the results. There was no difference in the incidence of AA between patients who received IV MgSO4 or those who received placebo. Conclusions In patients proactively treated with atenolol using an established protocol, the addition of daily IV MgSO4 infusions for 5 days post-operatively did not reduce the incidence of clinically important AA following cardiac surgery. Results For Primary Outcome (Post-Operative AA)

Abstract 18: Center Variation in 90-Day Episode Expenditures for Cardiac Surgery - The Role of Healthcare-Associated Pnuemonia

2018 ◽  
Vol 11 (suppl_1) ◽  
Author(s):  
Michael P Thompson ◽  
Steven D Harrington ◽  
Raymond J Strobel ◽  
Lourdes Cabrera ◽  
Min Zhang ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Rank Order ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Random Effect ◽  
Average Risk ◽  
Hospital Level ◽  
Patient Factors ◽  
Healthcare Associated ◽  
New Onset

Objective: Pneumonia is the most common healthcare-associated infection following cardiac surgery, and associated with poorer clinical outcomes and substantially higher hospital costs. Less understood is the role that the care and treatment of post-operative pneumonia may have on a hospital’s 90-day episode payments. We hypothesize that expenditures associated with pneumonia may significantly impact a hospital’s 90-day episode payments for coronary artery bypass graft (CABG) surgery. Methods and Results: Using Medicare Part A and B claims data, we identified 49,573 patients undergoing isolated CABG in 1,001 hospitals with greater than 10 cases (2014-15). We applied an established claims-based algorithm to identify 3,135 (6.3%) patients as having a new onset of pneumonia during their index admission and after their surgical procedure. Using hierarchical logistic regression models, we estimated risk-adjusted hospital-level pneumonia rates, adjusted for age, sex, race, Medicaid eligibility, Elixhauser comorbidities, and hospital-random effect. There was weak correlation (r=0.20, p<0.001) between observed and predicted (adjusting for only patient factors) hospital-level pneumonia rates, indicating patient factors explained little of the variation between hospitals. We placed patients into quartiles based on rank-order of hospital risk-adjusted pneumonia rates; the pneumonia rate in the lowest and highest quartile was 3.4% and 13.9% (p<0.001), respectively (Table). Average risk-adjusted 90-day episode expenditures were 10% higher for patients in the highest quartile hospitals compared to the lowest quartile ($41,936 vs. $46,095 vs., p<0.001). Payments for outlier hospitalizations were 100% greater in the highest quartile hospitals compared to the lowest quartile, and accounted for 28.5% of the total difference between high and low spending hospitals. Conclusion: New onset pneumonia after cardiac surgery varies widely across hospitals, and counter to conventional wisdom, is not driven by patient risk. Cardiac surgical programs should consider the prevention and management post-operative pneumonia as a component of their overall strategy for reducing 90-day episode payments.

scholarly journals The relationship between intraoperative cerebral oximetry and postoperative delirium in patients undergoing off-pump coronary artery bypass graft surgery: a retrospective study

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Leerang Lim ◽  
Karam Nam ◽  
Seohee Lee ◽  
Youn Joung Cho ◽  
Chan-Woo Yeom ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Coronary Artery ◽  
Postoperative Delirium ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Cerebral Oximetry ◽  
Artery Bypass Graft ◽  
Off Pump ◽  
Pump Coronary Artery Bypass ◽  
The Relationship

Abstract Background Cerebral oximetry has been widely used to measure regional oxygen saturation in brain tissue, especially during cardiac surgery. Despite its popularity, there have been inconsistent results on the use of cerebral oximetry during cardiac surgery, and few studies have evaluated cerebral oximetry during off pump coronary artery bypass graft surgery (OPCAB). Methods To evaluate the relationship between intraoperative cerebral oximetry and postoperative delirium in patients who underwent OPCAB, we included 1439 patients who underwent OPCAB between October 2004 and December 2016 and among them, 815 patients with sufficient data on regional cerebral oxygen saturation (rSO2) were enrolled in this study. We retrospectively analyzed perioperative variables and the reduction in rSO2 below cut-off values of 75, 70, 65, 60, 55, 50, 45, 40, and 35%. Furthermore, we evaluated the relationship between the reduction in rSO2 and postoperative delirium. Results Delirium occurred in 105 of 815 patients. In both univariable and multivariable analyses, the duration of rSO2 reduction was significantly longer in patients with delirium at cut-offs of < 50 and 45% (for every 5 min, adjusted odds ratio (OR) 1.007 [95% Confidence interval (CI) 1.001 to 1.014] and adjusted OR 1.012 [1.003 to 1.021]; p = 0.024 and 0.011, respectively). The proportion of patients with a rSO2 reduction < 45% was significantly higher among those with delirium (adjusted OR 1.737[1.064 to 2.836], p = 0.027). Conclusions In patients undergoing OPCAB, intraoperative rSO2 reduction was associated with postoperative delirium. Duration of rSO2 less than 50% was 40% longer in the patients with postoperative delirium. The cut-off value of intraoperative rSO2 that associated with postoperative delirium was 50% for the total patient population and 55% for the patients younger than 68 years.

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