Change in anaesthesia practice and postoperative sedation shortens ICU and hospital length of stay following coronary artery bypass surgery

We randomized prospectively 144 patients, undergoing elective coronary artery bypass surgery, to either early or to routine extubation [mechanical ventilatory support for 4-7 h (Group A), or 8-14 h (Group B)]. Anaesthesia was modified for both groups. The groups were well matched in terms of sex, age, NYHA class, preoperative left ventricular ejection fraction, bypass time and aortic cross-clamp time, number of grafts used, and blood units transfused. All patients had normal preoperative respiratory, renal, hepatic and cerebral functions. Mechanical ventilatory support (mean +/- SD) was 6.3 +/- 0.7 h for Group A and 11.6 +/- 1.3 h for Group B. Mean ICU stay was 17 +/- 1.3 h for Group A and 22 +/- 1.2 h for Group B, while the mean hospital stay was 7.3 +/- 0.8 days and 8.4 +/- 0.9, respectively. There were no statistically significant differences in the frequency of all postoperative complications among the two groups. There were no reintubation, readmission to the ICU or death in either group. We concluded that change in anaesthesia practice and early postoperative sedation in patients undergoing elective coronary artery bypass graft (CABG) surgery resulted in earlier tracheal extubation, shorter ICU and hospital length of stay without organ dysfunction or postoperative complications. Early extubation was only possible due to the modification of anaesthesia and ICU sedation regime.     

Effect of modified ultrafiltration in high-risk patients undergoing operations for congenital heart disease

BACKGROUND: Modified ultrafiltration (MUF) after cardiopulmonary bypass (CPB) in children decreases body water, removes inflammatory mediators, improves hemodynamics, and decreases transfusion requirements. The optimal target population for MUF needs to be defined. This prospective, randomized study attempted to identify the best candidates for MUF during operations for congenital heart disease. METHODS: Informed consent was obtained from 100 consecutive patients with complex congenital heart disease undergoing operations with CPB. They were randomized into a control group (n = 50) of conventional ultrafiltration during bypass and an experimental group using dilutional ultrafiltration during bypass and venovenous modified ultrafiltration after bypass (MUF group, n = 50). Postoperative arterial oxygenation, duration of ventilatory support, transfusion requirements, hematocrit, chest tube output, and time to chest tube removal were compared between the groups stratified by age and weight, CPB technique, existence of preoperative pulmonary hypertension, and diagnosis. RESULTS: There were no MUF-related complications. In patients with preoperative pulmonary hypertension, MUF significantly improved postoperative oxygenation (445 +/- 129 mm Hg versus control: 307 +/- 113 mm Hg, p = 0.002), shortened ventilatory support (42.9 +/- 29.5 hours versus control: 162.4 +/- 131.2 hours, p = 0.0005), decreased blood transfusion (red blood cells: 16.2 +/- 18.2 mL/kg versus control: 41.4 +/- 27.8 mL/kg, p = 0.01; coagulation factors: 5.3. +/- 6.9 mL/kg versus control: 32.3 +/- 15.5 mL/kg, p = 0.01), and led to earlier chest tube removal. In neonates (< or =30 days), MUF significantly reduced transfusion of coagulation factors (5.4 +/- 5.0 mL/kg versus control: 39.9 +/- 25.8 mL/kg, p = 0.007), and duration of ventilatory support (59.3 +/- 36.2 hours versus 242.1 +/- 143.1 hours, p = 0.0009). In patients with prolonged CPB (>120 minutes), MUF significantly reduced the duration of ventilatory support (44.7 +/- 37.0 hours versus 128.7 +/- 133.4 hours, p = 0.002). No significant differences were observed between MUF and control patients for any parameter in the presence of ventricular septal defect without pulmonary hypertension, tetralogy of Fallot, or aortic stenosis. CONCLUSIONS: Modified ultrafiltration after CPB is safe and decreases the need for homologous blood transfusion, the duration of ventilatory support, and chest tube placement in selected patients with complex congenital heart disease. The optimal use of MUF includes patients with preoperative pulmonary hypertension, neonates, and patients who require prolonged CPB.     

Decision making by elderly patients with cancer and their caregivers

Compared to patients undergoing elective or urgent coronary artery bypass grafting (CABG), those undergoing emergency CABG (EM-CABG) have a higher morbidity and mortality. The use of heparin-bonded circuits (HBC) has been shown to improve clinical outcomes in nonemergent CABG patients. It is not known, however, whether the improved hemostasis and attenuation of the inflammatory response to cardiopulmonary bypass, conferred by HBC, can overcome the high incidence of comorbid risk factors in (EM-CABG) patients and improve their outcomes. A retrospective analysis of 206 consecutive patients undergoing EM-CABG over 4 years (1993-1997) at one institution was performed. Eighty-one patients were treated with conventional non-heparin-bonded circuits (NHBC) with full anticoagulation protocol (FAP, activated clotting time [ACT] > 480 sec); 125 patients were treated with HBC and a lower anticoagulation protocol (LAP, ACT > 280 seconds). Outcomes and results were collected prospectively and are presented as mean +/- SD. Preoperative risk profiles were similar in both treatment groups. Postoperatively, compared with the NHBC group, patients treated with HBC/LAP required fewer homologous donor units (4.1 +/- 10.7 vs 8.2 +/- 13.6 units, p = 0.005), were less likely to require inotropic support (18.6% vs 38.3%, p = 0.005), and had a lower incidence of perioperative myocardial infarction (MI, 3.2% vs 12.3%, p = 0.04) and pulmonary complications (4.0% vs 12.3%, p = 0.04). The use of HBC/LAP resulted in a decreased incidence of postoperative complications (12.8% vs 28.4%, p = 0.01, odds ratio 0.37 with 95% confidence interval [CI] 0.18-0.76). This resulted in a shorter duration of ventilatory support (30.5 +/- 54.0 vs 72.8 +/- 16.7 hours, p = 0.009), ICU stay (38.2 +/- 36.5 vs 91.5 +/- 68.7 hours, p = 0.009), hospital stay (8.0 +/- 7.1 vs 11.0 +/- 8.9 days, p = 0.008), and therefore cost. In conclusion, the use of HBC/LAP in EM-CABG resulted in a reduction of homologous transfusion and postoperative complications associated with decreased hospital stays and cost.     

Morbidity, cost, and six-month outcome of minimally invasive direct coronary artery bypass grafting

BACKGROUND: Minimally invasive direct coronary artery bypass grafting (MIDCABG) promises to reduce the morbidity of coronary bypass, but this has not been proved. METHODS: This retrospective study compares the morbidity, mortality, cost, and 6-month outcome of patients less than 80 years old undergoing elective left internal mammary artery to left anterior descending artery bypass grafting via MIDCABG (n = 60) or sternotomy (n = 55) between January 1995 and December 1996. There were no differences between the groups in mean age, sex distribution, or preoperative risk level. The left internal mammary artery was mobilized from the fifth costal cartilage to the subclavian artery in all patients. The anastomoses were done with a beating heart in the MIDCABG group and with cardioplegic arrest in the sternotomy group. RESULTS: There were no operative deaths in either group. The MIDCABG patients had a lower transfusion incidence (10/60 [17%] versus 22/55 [40%]; p< or =0.02) and a shorter postoperative intubation time (2.1+/-4.2 versus 12.6+/-9 hours; p< or =0.0001). One patient in each group was reexplored for bleeding. Three sternotomy patients (3/55, 5%) required ventilatory support for greater than 48 hours, but no MIDCABG patient was ventilated for more than 24 hours. Median postoperative length of stay was 4 days for MIDCABG and 7 days for sternotomy. Estimated hospital costs were $11,200+/-3100 for MIDCABG and $15,600+/-4200 for CABG (p < 0.001). The reduced morbidity and cost of MIDCABG was found mostly in high-risk patients. At 6-month follow-up, 5 MIDCABG patients (5/60, 8%) had evidence of recurrent ischemia involving the left anterior descending artery, primarily the result of anastomotic stricture. CONCLUSIONS: This analysis shows that MIDCABG reduces the initial morbidity and cost of coronary bypass, but some patients require subsequent reintervention. Long-term follow-up is needed before MIDCABG can be judged better than traditional bypass, but the initial results are promising, especially in high-risk patients.     

Dilutional and modified ultrafiltration reduces pulmonary hypertension after operations for congenital heart disease: a prospective randomized study

OBJECTIVE: A prospective randomized study was performed to test whether removal of endothelin-1, by ultrafiltration techniques, will reduce pulmonary hypertension after operations for congenital heart disease. METHODS: Twenty-four patients with pulmonary hypertension (systolic pulmonary/systemic arterial pressure ratio > 60%) undergoing cardiac operations were randomized into a control group (n = 12) having conventional ultrafiltration and an experimental group (n = 12) undergoing dilutional ultrafiltration during and modified ultrafiltration after cardiopulmonary bypass. Plasma endothelin-1, nitric oxide metabolites, and cyclic guanosine monophosphate were assayed before bypass, 10 minutes into bypass, after bypass, and 0, 3, 6, and 12 hours after the operation in both groups, as well as in the ultrafiltrates and after modified ultrafiltration in the experimental group. Both groups received alpha-blockers (chlorpromazine and/or prazosin) postoperatively using the same guidelines. RESULTS: The ultrafiltrates contained significant amounts of endothelin-1 (1.81 +/- 0.86 pg/ml, dilutional, and 6.44 +/- 1.82 pg/ml, modified ultrafiltrate). Endothelin-1 and the pulmonary/systemic pressure ratio were significantly lower in experimental compared with control patients. Nitric oxide metabolites and cyclic guanosine monophosphate increased similarly in both groups for 12 hours after the operation (p = not significant). Three of 12 control patients (25%) but no experimental patients had pulmonary hypertensive crises (p = 0.07). The experimental patients required significantly less ventilatory support (67 +/- 47 hours vs 178 +/- 139 hours for control patients, p = 0.048). CONCLUSIONS: Dilutional and modified ultrafiltration reduce endothelin-1 and the pulmonary/systemic pressure ratio postoperatively and may become an important adjunct for preventing pulmonary hypertension after operations for congenital heart disease in high-risk patients.     

Efficacy of epidural analgesia in minimally invasive direct coronary artery bypass surgery

Minimally invasive direct coronary artery bypass surgery (MIDCAB), coronary bypass grafting with small thoracotomy using no cardiopulmonary bypass (CPB), became popular recently. To attenuate perioperative stress-response, we used epidural analgesia (EPI) with general anesthesia for MIDCAB operation. In this study, we compared retrospectively 11 cases of MIDCAB managed with EPI [ED (+)], and 14 cases of MIDCAB anesthetized without using EPI [ED (-)], concerning extubation time, ICU stay, hospital stay and perioperative complications. The mean time from cessation of general anesthesia to extubation was significantly shorter in ED (+) patients (0.5 hours) when compared to ED (-) patients (18.2 hours). Mean periods of ICU stay and hospital stay were, also, shorter in ED (+) patients (2.1 days, 30.5 days, respectively) when compared to ED (-) (4.3 days, 45.1 days, respectively) patients. We experienced ventricular tachycardia in three patients of ED (-). No major complication occurred in ED (+) patients. These results suggest that EPI shortened extubation time, ICU and hospital stay for MIDCAB patients.     

The need for inotropic support in a subgroup of infants with severe life-threatening respiratory syncytial viral infection

BACKGROUND: We experienced an unusual complication of life-threatening respiratory syncytial viral disease cardiovascular compromise. Life-threatening respiratory syncytial virus (RSV) infection has predominancy involved with ventilatory support for respiratory distress and/or failure. We performed a retrospective chart review of 20 consecutive infants admitted to the pediatric intensive care unit (PICU) for impending respiratory failure. METHODS: Seventeen required ventilatory support. As part of the infants' initial assessment, blood pressure, distal perfusion [capillary refill time (CRT) > or = 3 sec], decreased peripheral pulses, and peripheral mottling were used to determine cardiovascular compromise. These infants received volume resuscitation either at the referring facility or the PICU until euvolemia was obtained, as determined by central venous pressure (CVP) monitoring (between 3 to 7 cm H20). Nine of the 20 infants did not respond to volume resuscitation alone and required vasopressor support in the form of: Dopamine (7 patients, 5-10 micrograms/kg/min), Dobutamine (2 patients, 5-7 micrograms/kg/min), and one who expired required both Epinephrine (600 ng/kg/min) and Dopamine (10 micrograms/kg/min). The mean ages of these 9 patients were 6.2 +/- 3.4 weeks (range 3-12 weeks), the mean duration of ventilation was 7.2 +/- 4.1 days (range 4-12 days). The mean duration of pharmacologic support was 69.7 +/- 47 hours (range 14-168 hours). The mean ages of RSV+ infants not requiring inotropic support was 19.4 +/- 27.4 weeks (range 1-90 weeks), and mean duration of ventilation was 5.5 +/- 5.9 days (range 2-20 days). RESULTS: The inotrope treated patients were weaned from pharmacologic support prior to extubation, without any hemodynamic deficits. Our experience with this rather high incidence of hemodynamic complications during this RSV epidemic was unexpected. CONCLUSION: These results substantiate the fact that younger patients with RSV disease are at both greater risk for pulmonary complications and cardiovascular deterioration and may thus benefit from pharmacologic support.     

Doctoral education in nursing for practitioner knowledge and for academic knowledge: the University of Adelaide, Australia

A retrospective review was made of 49 survivors who were mechanically ventilated for more than 48 hours in the neurosurgical ICU. Thirty-two patients (Gp I) were successfully extubated, 9 patients (Gp II) underwent tracheostomy after one or more failed extubations, and 8 patients (Gp III) underwent elective tracheostomy. Glasgow Coma Scale (GCS) scores at extubation were 11.3 +/- 2.8 (mean (SD) for Gp I vs 7.8 +/- 2.7 for Gp II (P = n.s.) and at elective tracheostomy (Gp III) was 5.4 +/- 2.3. Incidence of ventilator-associated pneumonia were 35% in Gp I vs 100% of patients in Gp II and III (P < 0.05). Reasons for reintubation in 7 of 9 patients (Gp II) were upper airway obstruction and tenacious tracheal secretions while 14 of 17 patients were weaned off the ventilator within 48 hours of tracheostomy. The length of stay in ICU was 16.8 +/- 7.1 days in Gp II vs 11.7 +/- 2.9 days in Gp III (P < 0.05). In our study, elective tracheostomy for selected patients with poor GCS scores and nosocomial pneumonia has resulted in shortened ICU length of stay and rapid weaning from ventilatory support.     

The risk of coronary artery surgery in women: a matched comparison using preoperative severity of illness scoring

OBJECTIVE: To evaluate the effect of gender on outcomes of coronary artery bypass surgery using a weighted preoperative severity of illness scoring system. DESIGN: Retrospective database review. SETTING: Tertiary care teaching hospital. PARTICIPANTS: The patient population consisted of 2,800 consecutive coronary artery bypass graft (CABG) patients (658 women, 2,142 men), with or without concurrent procedures, operated on between January 1, 1993 and March 31, 1994. MEASUREMENTS AND MAIN RESULTS: Patients were stratified for severity of illness using a 13-element scoring system. The distribution of severity of illness scores and severity of illness-stratified morbidity, hospital mortality, and intensive care unit (ICU) length of stay were compared by chi-square and Fischer's exact test where appropriate. Median duration of intubation and median duration of ICU length of stay were examined by the median test. Female versus male unadjusted mortality (4.9% v 3.0%), total morbidity (15.0% v 9.2%), and average initial ICU length of stay (92.62% v 60.56 hours) were statistically different. Female patients also had significantly more of the following postoperative morbidities: central nervous system complications (focal neurologic deficits, patients > or = 65 years 3.20% v 1.54%; global neurologic deficits, patients > or = 65 years 2.75% v 1.25%), duration of perioperative ventilation that includes the intubation time in the operating room until extubation in the ICU (average = 77.36 hours v 49.20 hours; median = 21.87 v 20.26 hours), and average initial ICU length of stay (average = 92.62 hours v 60.56 hours; median = 42.33 hours v 27.91 hours). However, distribution of severity scores was also different. Women had significantly more preoperative risk factors (p < 0.05): age 65 to 74 years (45.1% v 36.6%), age > or = 75 years (21.3% v 11.9%), chronic obstructive pulmonary disease (10.8% v 6.4%), hematocrit less than 34% (21.9% v 5.5%), diabetes (34.8% v 21.8%), weight less than 65 kg (37.4% v 6.2%), and operative mitral valve insufficiency (9.6% v 6.0%). Stratified by severity, no statistically significant gender differences were found for mortality, morbidity, or ICU length of stay. CONCLUSIONS: Gender does not appear to be an independent risk factor for perioperative morbidity, mortality, or excessive ICU length of stay when patients are stratified by preoperative risk in this severity of illness scoring system.     

Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation

Patients requiring reintubation after failed extubation have a poor prognosis, with hospital mortality exceeding 30 to 40%, though the reason remains unclear. To examine the impact of etiology of extubation failure and time to reintubation on hospital outcome, we performed a post hoc analysis of prospectively gathered data on 74 MICU patients (47 men, 27 women), 64 +/- 2 yr of age who required reintubation within 72 h of extubation. Cause for reintubation was classified as airway (upper airway obstruction, 11; aspiration/excess pulmonary secretions, 12) or nonairway (respiratory failure, 21; congestive heart failure, 17; encephalopathy, 7; other, 6). The duration of mechanical ventilation prior to extubation was 139 +/- 19 h, and the median time to reintubation was 21 h. Thirty-one of 74 patients (42%) died, with mortality highest for patients failing from nonairway etiologies (27/51, 53% versus 4/23, 17%; p < 0.01). Patients failing from an airway cause tended to be reintubated earlier (21 +/- 4 versus 31 +/- 3 h, p = 0.07). Mortality increased with longer duration of time from extubation to reintubation (<= 12 h, 6/25 versus > 12 h, 25/49; p < 0.05). With multiple logistic regression, both cause for extubation failure and time to reintubation were independently associated with hospital mortality. In conclusion, etiology of extubation failure and time to reintubation are independent predictors of outcome in reintubated MICU patients. The high mortality for those reintubated for nonairway problems indicate that efforts should be preferentially focused on identifying these patients. The effect of time to reintubation suggests that identification of patients early after extubation and timely reinstitution of ventilatory support has the potential to reduce the increased mortality associated with extubation failure.     

Does modern cardiac surgery require conventional intensive care?

We considered that, with modern perfusion equipment and mildly hypothermic cardiopulmonary bypass, protracted post-operative ventilation in an intensive care unit (ITU) is no longer required after most cardiac operations. We used a three-bedded cardiac recovery area (CRA) within the operating suite for 1,000 patients between January 1990 and June 1991. Forty-five patients with special needs were managed in the ITU. The time to extubation (T50%; range) for coronary bypass, aortic valve, mitral valve, and double-valve patients was 2.0 (0-42), 2.5 (0-12), 3.0 (0-15), and 3.0 (1-36) hours, respectively. Recovery beds were re-used allowing 5-6 operations daily. The difference in nursing staff complement for a CRA versus ITU bed was 4.5/7.8. Patient management was by nurse specialists supported by cardiac surgeons. Intervention by cardiac anaesthetists or intensivists was limited to specific ventilatory problems or renal failure. The early extubation policy failed in ten patients (five coronary, three aortic, one mitral and one double-valve patient) through poor pre-operative respiratory function, left ventricular failure or intra-operative events. The overall mortality in CRA was 1.4%. The mean duration of post-operative stay was 7 days (range 5-12). We conclude that a CRA staffed by nurse practitioners provides a safe and effective alternative to the anaesthetist-managed ITU. A rapid turnover of CRA beds removes the constraints of ITU bed availability.     

Addition of a thiazide: an effective remedy for furosemide resistance after cardiac operations

BACKGROUND: The frequent use of diuretic drugs in cardiac surgical practice contrasts with the lack of documentation regarding diuretic treatment in this setting. The aims of this study were to delineate the need for diuretic drugs in adult cardiac surgical practice and to evaluate the impact of adding a combination of 50 mg hydrochlorothiazide and 5 mg amiloride orally to patients responding poorly to furosemide. METHODS: Two hundred ten consecutive patients, 159 undergoing coronary artery bypass grafting procedures and 51 having valve operations, were studied. RESULTS: Seventy-seven patients received large doses of furosemide (> or = 80 mg/24 h) at some time during the postoperative course, and of these 20 responded poorly to furosemide (weight loss 0.3 +/- 0.2 kg) despite considerable fluid retention. The addition of hydrochlorothiazide and amiloride provided a prompt and effective remedy to relative furosemide resistance. Average weight loss was 2.3 +/- 0.2 kg (p < 0.01 compared with response to furosemide) and average diuresis was 2,949 +/- 156 mL in the following 24 hours. CONCLUSIONS: Relative furosemide resistance is common after cardiac operations. Thiazides, although they are mild diuretic agents, may serve as useful adjuncts in this setting.     

Venovenous extracorporeal life support for patients after cardiotomy

Pulmonary edema and acute lung injury are common sequelae after cardiopulmonary bypass. Increased ventilatory support improves gas exchange, but may compromise ventricular function. From July 1994 to February 1997, nine patients were supported with veno-venous (V-V) extracorporeal life support (ECLS) for post cardiotomy respiratory failure. The mean age was 53 +/- 13 years (range: 37-80 years), and eight (89%) were men. Pre-operatively, five of nine (56%) were intubated, three (33%) were supported with an intra-aortic balloon pump, and five (56%) were on veno-arterial ECLS. Four patients were post left ventricular assist device (LVAD) implantation, one each after resection of an aortic aneurysm, mitral valve replacement and bypass grafting, aortic valve replacement, and pulmonary embolectomy and heart transplantation. Mean duration of support was 2 +/- 1 days (range: 1-4 days). Patients were intubated for a mean of 2 +/- 22 days (range: 4-71 days). One patient (11%) required mediastinal re-exploration secondary to bleeding, two patients underwent hemodialysis or ultrafiltration, and seven (77%) developed bacterial pneumonia. All patients were weaned from ECLS. Six patients (67%) survived to hospital discharge. Cause of death was multiple organ failure in two patients; one died from respiratory failure. V-V ECLS is a useful alternative to open sternotomy for ventilatory induced hemodynamic compromise post cardiotomy, especially in patients with LVADs.     

Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial

BACKGROUND: Economics has caused the trend of early tracheal extubation after cardiac surgery, yet no prospective randomized study has directly validated that early tracheal extubation anesthetic management decreases costs when compared with late extubation after cardiac surgery. METHODS: This prospective, randomized, controlled clinical trial was designed to evaluate the cost savings of early (1-6 h) versus late tracheal extubation (12-22 h) in patients after coronary artery bypass graft (CABG) surgery. The total cost for the services provided for each patient was determined for both the early and late groups from hospital admission to discharge home. All costs applicable to each of the services were classified into direct variables, direct fixed costs, and overhead (an indirect cost). Physician fees and heart catheterization costs were included. The total service cost was the sum of unit workload and overhead costs. RESULTS: One hundred patients having elective CABG who were younger than 75 yr were studied. Including all complications, early extubation (n = 50) significantly reduced cardiovascular intensive care unit (CVICU) costs by 53% (P < 0.026) and the total CABG surgery cost by 25% (P < 0.019) when compared with late extubation (n = 50). Forty-one patients (82%) in each group were tracheally extubated within the defined period. In the early extubation group, the actual departmental cost savings in CVICU nursing and supplies was 23% (P < 0.005), in ward nursing and supplies was 11% (P < 0.05), and in respiratory therapy was 12% (P < 0.05). The total cost savings per patient having CABG was 9% (P < 0.001). Further cost savings using discharge criteria were 51% for CVICU nursing and supplies (P < 0.001), 9% for ward nursing and supplies (P < 0.05), and 29% for respiratory therapy (P < 0.001), for a total cost savings per patient of 13% (P < 0.001). Early extubation also reduced elective case cancellations (P < 0.002) without any increase in the number of postoperative complications and readmissions. CONCLUSIONS: Early tracheal extubation anesthetic management reduces total costs per CABG surgery by 25%, predominantly in nursing and in CVICU costs. Early extubation reduces CVICU and hospital length of stay but does not increase the rate or costs of complications when compared with patients in the late extubation group. It shifts the high CVICU costs to the lower ward costs. Early extubation also improves resource use after cardiac surgery when compared with late extubation.     

Complement activation and cytokine generation after modified Fontan procedure

BACKGROUND: The modified Fontan procedure separates the systemic and pulmonary circulations in patients born with a functional single ventricle. Delayed recovery is frequently observed after this procedure. It was our hypothesis that complement activation or cytokine generation may contribute to the pathophysiology of this problem. METHODS: We measured activated complement C3, thromboxane B2, interleukin-6, and tumor necrosis factor-alpha levels by immunoassay in 16 patients undergoing Fontan procedure. Patient plasma samples were obtained preoperatively, on initiation of cardiopulmonary bypass, after administration of protamine, and 1, 4, 8, and 24 hours postoperatively. RESULTS: There was no early or late mortality in this cohort of patients. Low cardiac output developed in 3 of 16 patients, and pleural effusions developed in 5. The median length of hospital stay was 9 days. Activated complement C3 levels increased from a baseline of 1,486 +/- 564 to 4,600 +/- 454 ng/mL after cardiopulmonary bypass and administration of protamine, and returned to baseline by 24 hours. The level of interleukin-6 increased from 42 +/- 32 to 176 +/- 22 pg/mL and at 24 hours remained elevated at 71 +/- 15 pg/mL. Neither thromboxane B2 nor tumor necrosis factor-alpha levels increased significantly. CONCLUSIONS: The data demonstrate threefold to four-fold increases in activated complement C3 and interleukin-6, indicating that both humoral and cellular systems are affected. It is our conclusion that complement and cytokine activation may contribute to the delayed recovery observed after Fontan procedure.     

Propofol or midazolam for sedation and early extubation following cardiac surgery

PURPOSE: The purpose of this randomized, double-blind study was to evaluate the efficacy of midazolam and propofol for postoperative sedation and early extubation following cardiac surgery. METHODS: ASA physical status II-III patients scheduled to undergo elective first-time cardiac surgery with an ejection fraction > 45% were eligible. All patients received a standardized sufentanil/isoflurane anaesthesia. During cardiopulmonary bypass 100 micrograms.kg-1.min-1 propofol was substituted for isoflurane. Upon arrival in the Intensive Care Unit (ICU), patients were randomized to either 10 micrograms.kg-1.min-1 propofol (n = 21) or 0.25 microgram.kg-1.min-1 midazolam (n = 20). Infusion rates were adjusted to maintain sedation within a predetermined range (Ramsay 2-4). The infusion was terminated after four hours. Patients were weaned from mechanical ventilation and their tracheas extubated when Haemodynamic stability, haemostasis, normothermia and mental orientation were confirmed. Haemodynamic measurements, arterial blood gas tensions and pulmonary function tests were recorded at specified times. RESULTS: There were no differences between the two groups for the time spent at each level of sedation, number of infusion rate adjustments, amount of analgesic and vasoactive drugs, times to awakening and extubation. The costs of propofol were higher than those of midazolam. There were no differences in haemodynamic values, arterial blood gas tensions and pulmonary function. CONCLUSION: We conclude that midazolam and propofol are safe and effective sedative agents permitting early extubation in this selected cardiac patient population but propofol costs were higher.     

Early extubation following cardiac surgery in a veterans population

BACKGROUND: Early tracheal extubation is an important component of the "fast track" cardiac surgery pathway. Factors associated with time to extubation in the Department of Veterans Affairs (DVA) population are unknown. The authors determined associations of preoperative risk and intraoperative clinical process variables with time to extubation in this population. METHODS: Three hundred four consecutive patients undergoing coronary artery bypass graft, valve surgery, or both on a fast track clinical pathway between October 1, 1993 and September 30, 1995 at a university-affiliated DVA medical center were studied retrospectively. After univariate screening of a battery of preoperative risk and intraoperative clinical process variables, stepwise logistic regression was used to determine associations with tracheal extubation < or = 10 h (early) or > 10 h (late) after surgery. Postoperative lengths of stay, complications, and 30-day and 6-month mortality rates were compared between the two groups. RESULTS: One hundred forty-six patients (48.3%) were extubated early; one patient required emergent reintubation (0.7%). Of the preoperative risk variables considered, only age (odds ratio, 1.80 per 10-yr increment) and preoperative intraaortic balloon pump (odds ratio, 7.88) were multivariately associated with time to extubation (model R) ("late" association is indicated by an odds ratio >1.00; "early" association is indicated by an odds ratio <1.00). Entry of these risk variables into a second regression model, followed by univariately significant intraoperative clinical process variables, yielded the following associations (model R-P): age (odds ratio, 1.86 per 10-yr increment), sufentanil dose (odds ratio, 1.54 per 1-microg/kg increment), major inotrope use (odds ratio, 5.73), platelet transfusion (odds ratio, 10.03), use of an arterial graft (odds ratio, 0.32), and fentanyl dose (odds ratio, 1.45 per 10-microg/kg increment). Time of arrival in the intensive care unit after surgery was also significant (odds ratio, 1.42 per 1-h increment). Intraoperative clinical process variables added significantly to model performance (P < 0.001 by the likelihood ratio test). CONCLUSIONS: In this population, early tracheal extubation was accomplished in 48% of patients. Intraoperative clinical process variables are important factors to be considered in the timing of postoperative extubation after fast track cardiac surgery.     

Do shorter-acting neuromuscular blocking drugs or opioids associate with reduced intensive care unit or hospital lengths of stay after coronary artery bypass grafting? CABG Clinical Benchmarking Data Base Participants

BACKGROUND: The authors hypothesized that shorter-acting opioid and neuromuscular blocking drugs would be associated with reductions in duration of intubation, length of stay (LOS) in the intensive care unit (ICU) after tracheal extubation, or postoperative (exclusive of ICU) LOS, and that shorter durations of intubation would be associated with reduced ICU LOS after extubation and postoperative (exclusive of ICU) LOS. METHODS: One-thousand ninety-four patients undergoing primary coronary artery bypass graft surgery at 40 academic health centers were studied. Multiple patient-related factors were included in multivariate models for hypothesis testing. RESULTS: The duration of tracheal intubation, ICU LOS after extubation, and postoperative (exclusive of ICU) LOS all varied significantly by site. There was no difference between vecuronium and pancuronium in duration of intubation, ICU LOS after extubation, or postoperative (exclusive of ICU) LOS. Use of sufentanil rather than fentanyl was associated with a significant (P=0.045) reduction of 1.9 h (95% CI, 0.04 to 4.1 h) in duration of tracheal intubation but had no significant effect on ICU LOS after extubation, total ICU LOS, postoperative (exclusive of ICU) LOS, or total postoperative LOS. The authors' best model predicts a complex association between increasing duration of intubation and both ICU LOS after tracheal extubation and postoperative (exclusive of ICU) LOS, which was associated with an increase in those measures when duration of intubation exceeded 7.3 or 3 h, respectively. CONCLUSIONS: The LOS measures varied considerably among the institutions. Use of shorter-acting opioid and neuromuscular blocking drugs had no association with ICU LOS after tracheal extubation or with postoperative (exclusive of ICU) LOS. Only when the duration of intubation exceeded threshold values was it associated with increased LOS measures.     

Assessing outcomes, costs, and benefits of emerging technology for minimally invasive saphenous vein in situ distal arterial bypasses

BACKGROUND: Instrumentation for a minimally invasive angioscopic in situ peripheral arterial bypass (MIAB) with catheter-directed side-branch occlusion has recently been approved for use. Despite the attractiveness of this approach (2 short incisions), benefits such as lower morbidity and shorter hospitalizations remain undocumented. To justify wide acceptance, minimally invasive surgical techniques must match conventional procedures in durability and cost while enhancing patient comfort. Often such comparisons are difficult during the implementation phase of a new procedure. OBJECTIVE: To compare the outcomes of the MIAB procedures with a concurrent group of patients undergoing conventional in situ bypass procedures. DESIGN: Retrospective review. SETTING: University medical center. PATIENT: The first 20 consecutive MIAB procedures in 19 patients performed between August 1, 1995, and July 31, 1997, were compared with 19 contemporaneous consecutive conventional in situ bypass procedures performed at the same institution. MAIN OUTCOME MEASURES: Operative time, postoperative length of stay, hospital costs, complications, primary assisted and secondary patency, limb salvage, and survival. RESULTS: The patient groups were comparable with respect to age, sex, incidence of smoking, coronary artery disease, hypertension, diabetes, renal failure, cerebrovascular disease, indication, and distal anastomosis level. The median operative time was significantly greater for the MIAB group (6.6 hours vs 5.7 hours; P=.009), and intraoperative completion arteriography more frequently showed retained arteriovenous fistulas in the MIAB group (55% vs 21%; P=.05). The median postoperative length of stay and total cost were 6.5 days and $18,000 for the MIAB group and 8 days and $27,800 for the conventional group (P > or = .05). There were no significant differences in major complications (10% in the MIAB group vs 11% in the conventional group), wound complications (10% vs 11%, respectively), primary assisted patency at 1 year (68%+/-11% vs 78%+/-10%, respectively), secondary patency at 1 year (79%+/-10% vs 88%+/-8%, respectively), limb salvage at 1 year (85%+/-10% vs 94%+/-6%, respectively), or patient survival at 1 year (89%+/-8% vs 61%+/-13%, respectively). CONCLUSION: Patients undergoing the MIAB procedure avoided lengthy vein exposure incisions without sacrificing short-term results. There was a trend toward decreased hospital stay and cost, which may be further realized as the clinical experience broadens. Although longer follow-up and larger cohorts will always be required to define durability, immediate access to outcomes and costs on small numbers of patients facilitates the early assessment of emerging technology.     

Molecular analysis of the adaptive response of intestinal bile acid transport after ileal resection in the rat

OBJECTIVES: Major operative trauma like aorta-coronary bypass operation may lead to postoperative immunodisturbance, putting the patient at an increased risk for infection and sepsis. The monocyte/macrophage system and the endotoxin receptor CD14 are important in the early recognition and elimination of invading bacteria. The aim of this study was to analyze changes in membrane-associated CD14 and soluble CD14 during and after cardiac involving cardiopulmonary bypass. METHODS: We studied numbers of leukocytes, monocytes, and monocyte subpopulations, expression of monocyte membrane-associated CD14 and plasma levels of soluble CD14 in 10 patients (63 +/- 8 years of age), who underwent elective cardiopulmonary bypass. RESULTS: Cardiopulmonary bypass induced marked postoperative monocytosis, which was maximal 20 hours after the operation (485 +/- 242 cells/microl before, 1080 +/- 264 cells/microl 20 hours after surgery). Expression of membrane-associated CD14 on classical CD14++ monocytes decreased significantly by 40%, reaching a nadir 20 hours after surgery (p < 0.05). At the time of maximal membrane-associated CD14 suppression, the levels of soluble CD14 measured by enzyme-linked immunosorbent assay were clearly increased (3.2 +/- 1.0 microg/ml before versus 5.6 +/- 1.0 microg/ml 20 hours after, p < 0.001). No significant change of the percentage of small (alpha) and large (beta) forms of soluble CD14 was found. CONCLUSIONS: Cardiopulmonary bypass leads to reduced membrane-associated CD14 expression on peripheral blood monocytes and increased levels of soluble CD14 through shedding or secretion of membrane-associated CD14 from the cell surface. These findings indicate that bypass is associated with significant monocyte activation.