Perioperative Risk Factors for Intensive Care Unit Readmissions and Mortality After Cardiac Surgery.

OBJECTIVE: The aim of this study was to identify perioperative risk factors associated with intensive care unit readmission and in-hospital death after cardiac surgery. DESIGN: Retrospective analysis using a multivariate regression model to identify independent risk factors for intensive care unit [ICU] readmission and in-hospital mortality. SETTING: The study was carried out in a single tertiary-care hospital. PARTICIPANTS: This was an analysis of 2,789 adult patients. INTERVENTIONS: All patients underwent cardiac surgery and were admitted to the intensive care unit perioperatively at the General Hospital Vienna. MEASUREMENTS AND MAIN RESULTS: Among the 2,789 patients included in the analysis, 167 (6%) were readmitted to the intensive care unit during the same hospital stay. Preoperative risk factors associated with ICU readmission included end-stage renal failure (odds ratio [OR] 2.80, 95% CI: 1.126-6.964), arrhythmia (OR 1.59, 95% CI: 1.019-2.480), chronic obstructive pulmonary disease (OR 1.51, 95% CI: 1.018-2.237), age >80 (OR 2.55, 95% CI: 1.189-5.466), and European System for Cardiac Operative Risk Evaluation II >8 (OR 1.40, 95% CI: 1.013-1.940). Readmitted patients were more likely to die than nonreadmitted patients (OR 5.3, 95% CI: 3.284-8.558). In-hospital mortality in readmitted patients was 19.2%, whereas that in the nonreadmitted study population was 5.1%. CONCLUSION: Preoperative risk assessment is crucial for identifying cardiac surgery patients at risk of ICU readmission and in-hospital death. The potentially modifiable risk factors pinpointed by this study call for the optimization of care before surgery and after ICU discharge.

Earplugs during the first night after cardiothoracic surgery may improve a fast-track protocol.

BACKGROUND: Sleep deprivation after major surgery is common and associated with worse outcome. Noise is one important reason for sleep fragmentation, which contributes to enhanced morbidity. The purpose of this work was to evaluate the impact of earplugs on patients' sleep quality during their first night after cardiothoracic surgery to eventually improve an existing fast-track concept. METHODS: Sixty-three patients undergoing cardiothoracic surgery eligible for a postoperative fast-track regimen on our cardiothoracic post anesthesia care unit (C-PACU) were prospectively included. They were randomized to either sleep with or without earplugs. Quality of sleep was measured using questionnaires for patients and nurses. Required pain medications, pain intensity, and length of hospital stay were secondary outcome variables. RESULTS: Twenty-seven patients were randomized to the intervention group (earplugs) and 36 to the control group. Mean (SD) age was 61 (12) years. Self-reported quality of sleep was better in the intervention group (median, IQR [range]: 3, 2-4 [1-5] vs. 4, 3-5 [1-5]; scale: 1, "excellent," to 5, "very poor"; P=0.025). Patients of the intervention group also experienced less severe pain (P=0.047) despite similar dosages of administered analgesics and expressed improved satisfaction regarding their C-PACU stay (P=0.032). CONCLUSIONS: Implementation of the use of earplugs in a fast-track concept following cardiothoracic surgery is efficient and easy. Earplugs improved the quality of sleep as well as patient satisfaction and attenuated pain intensity. They may thereby contribute to a faster recovery, less morbidity, and reduced costs.

Position dependent right ventricular dysfunction caused by a giant right coronary artery aneurysm.

We describe an instructive case of a 79-year-old patient with a giant coronary aneurysm and a second smaller aneurysm with an uncommon symptomatology. Giant coronary artery aneurysms (>2 cm diameter) are rare pathologic entities with a prevalence of 0.02%. They either can be congenital malformations or are atherosclerotic in origin. Although spontaneous rupture of giant coronary artery aneurysms has been reported, they generally remain silent or induce myocardial ischemia. Our patient, however, showed no signs of myocardial malperfusion but transient position-dependent pre-syncope. The cardiologic work-up and the intraoperative considerations regarding patient management are described. During surgery, manipulation of the giant coronary artery aneurysm caused impairment of right ventricular function and regional wall hypokinesia, as assessed by transesophageal echocardiography. Venous cannulation of the right atrium was thus abandoned and extracorporeal circulation was established via the femoral vein. Subsequent dissection and surgical repair were uneventful and further recovery of the elderly patient was uncomplicated. This case underlines that once the diagnosis is established, proper perioperative management enables successful surgical treatment even of patients of advanced age.

Onset time, quality of blockade, and duration of three-in-one blocks with levobupivacaine and bupivacaine.

Levobupivacaine is the isolated S(-)-stereoisomer of racemic bupivacaine. Important pharmacodynamic properties of levobupivacaine have not been determined for the femoral three-in-one block. In this randomized, controlled, double-blinded trial, we studied 60 ASA physical status I-III patients scheduled for surgery of the lower limb. A nerve-stimulator-guided three-in-one block was performed as supplemental analgesic therapy with 20 mL of bupivacaine 0.5% (n = 20), levobupivacaine 0.5% (n = 20), or levobupivacaine 0.25% (n = 20). Sensory onset time, quality of blockade, and duration of blockade were assessed by pinprick test in the central sensory innervation region of the femoral nerve (distribution of the anterior femoral cutaneous nerve). A rating scale from 100% (normal sensation) to 0% (no sensation at all) as compared with the contralateral leg was used. No significant difference in sensory onset time among the three local anesthetic solutions was observed (mean [95% confidence interval]): bupivacaine 0.5%, 27 min (20-33 min); levobupivacaine 0.5%, 24 min (18-30 min); and levobupivacaine 0.25%, 30 min (23-36 min) (P = 0.49). The analgesic quality of the blockade was also not significantly different among the three groups, whereas a complete sensory block was achieved in significantly fewer patients in the levobupivacaine 0.25% group (P = 0.02). The duration of blockade was significantly shorter with levobupivacaine 0.25% compared with the other groups: bupivacaine 0.5%, 1053 min (802-1304 min); levobupivacaine 0.5%, 1001 min (844-1158 min); and levobupivacaine 0.25%, 707 min (551-863 min) (P = 0.01). Levobupivacaine 0.5% is recommended instead of bupivacaine 0.5% for the three-in-one block.