Conservative Management of Large Post-Intubation Tracheal Laceration.

ABSTRACT: Tracheal rupture is a very rare but life-threatening complication of endotracheal intubation. It is more common in women and patients older than 50 years old. Overinflation of endotracheal tube cuff and tracheal wall weakening are the most important pathogenetic mechanisms. Laceration sites are located in the posterior membranous wall in most cases. Subcutaneous and mediastinal emphysema and respiratory distress are the most common manifestations. A 55-year-old female presented with postoperative subcutaneous and mediastinal emphysema without dyspnea because of a tear in the posterior tracheal wall. The diagnosis was based on clinical manifestation, chest computer tomography scans (CT), and endoscopic findings. A conservative approach by broad-spectrum antibiotic therapy was decided because of patients' vital signs stability and the absence of esophageal injury. The follow-up showed that there was no lesion in the posterior tracheal wall. Our case showed that in clinically stable patients without mediastinitis and with spontaneous breathing, conservative management of tracheal tears is a safe procedure.

Fate of the moderately diseased aorta: a single-center experience.

Introduction: The fate of the aorta after tube graft replacement remains unclear. Aim: We investigated the evolution of aortic dilatation after non-aortic cardiac operations and the dimensions of the root and arch after ascending aorta replacement. Material and methods: From 252 patients with aortic dilatation operated on between January 2010 and June 2019, 160 were followed with CT angiography. Two groups were formed according to the initial operation. Group I (n = 36) included patients with a dilated aorta, unreplaced during different indication cardiac surgery. Group II (n = 124) included patients receiving tube graft aorta replacement with or without aortic valve replacement. Mean preoperative and follow-up diameters of the different aortic segments were compared in both groups using the two-sided paired t-test for repeated measurements. Results: Eighteen patients died during follow-up, with one death occurring during reoperation for a false aneurysm of the distal anastomosis on the aortic arch. There was no other re-operation for aortic aneurysm, rupture or dissection. In group I the aortic arch diameter increased slightly, while the rest of the aortic segments remained stable. In group II the aortic root diameter decreased slightly while the aortic arch remained stable. Conclusions: Ascending aorta replacement with a tube graft remodeled the aortic root and did not allow progressive dilatation of the aortic arch. In patients with moderate ascending aorta dilatation, the unreplaced ascending aorta and aortic root remained relatively stable but the aortic arch increased slightly during follow-up.

Smoking behavior after coronary artery bypass surgery: Quit, relapse, continuing.

Objective: Tobacco smoking represents a major risk factor for coronary artery disease. Our study aimed to investigate whether Coronary Artery Bypass Graft (CABG) surgery could act as a motivating factor to enforce smoking cessation. Specifically, we observed the success rate in individuals who quitted smoking, along with the number and reasons of relapse(s) at least one year after the operation. Methods: The pre-operative characteristics, pre-operative tobacco exposure, socioeconomic factors and perioperative complications in patients who underwent isolated Coronary Artery Bypass Graft surgery in our Department from June 2012 to September 2016 were reviewed. Our survey was conducted via phone interview and using a standardized questionnaire. Only patients who were current smokers at the time of surgery were interviewed. Results: Our study group consisted of a total of 120 patients, 91 (75.8') reported initially quitting tobacco smoking. Because of relapse(s), one year after the procedure the number of patients who were still non-smokers dropped to 69 (57.5'). Smoking cessation attempts were not supported by professional assistance. Conclusions: Our findings demonstrate that there is a desire from CABG patients to quit smoking, as indicated by the high percentage of initial attempts in early postoperative period. However, a year after the procedure, only 57.5' of CABG patients were able to achieve or maintain smoking cessation. Patients who were retired or who were unemployed at the time of the surgery, found it easier to stop smoking than patients who were active employees. Patients who lived alone at the time of surgery also found it harder to stop smoking. Finally, patients with COPD also found quitting smoking harder in the post-operative period.

Integrating continuous monitoring and evaluation of risk-adjusted outcomes in a cardiac surgical program.

BACKGROUND: The variable life-adjusted display (VLAD) method shows the difference between predicted and observed outcomes over time. Our study aims to implement routine in-house monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery. METHODS: The Society of Thoracic Surgeons (STS) risk score was calculated for 249 isolated and combined coronary and aortic or mitral valve cases performed during a 6-month period. The nine predicted STS variables were operative mortality, permanent stroke, renal failure (RF), prolonged ventilation, deep sternal wound (DSW) infection, reoperation for any reason, short and long length of stay (LOS), and major morbidity or operative mortality. EuroSCORE II was also calculated for the study population. VLAD plots were generated for each variable indicating whether performance is better or worse than expected on the basis of predicted risk of failure. RESULTS: The mortality plot was fluctuating close to baseline risk. The prolonged ventilation, RF, reoperation, morbidity/mortality, and LOS plots were consistently positive, indicating favorable results. The stroke chart showed an upward trend for most of the period until two incidents toward last month led to a steep descent. The DSW infections plot though, indicated a worse-than-expected performance. The VLAD charts were shared in multidisciplinary meetings and clinicians were able to confront the performance with the population-specific expectancies and respond to adverse trends with further actions. CONCLUSION: Graphical tool monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery is feasible and allows detection of underperformance and implementation of changes in clinical practice.

The Role of Blood Transfusion in the Development of Atrial Fibrillation after Coronary Artery Bypass Grafting.

Objectives Atrial fibrillation (AF) is the most common complication after coronary artery bypass grafting (CABG). It is associated with prolonged hospital stay and increased cost. The aim of this study is to investigate the relationship between transfusion of blood derivatives and occurrence of postoperative paroxysmal AF. Materials and Methods From June 2012 to February 2014, 446 patients undergoing CABG with cardiopulmonary bypass (CPB) were prospectively evaluated for occurrence of postoperative AF. Patients and procedural variables were recorded and were associated with the development of new-onset AF with logistic regression analysis. Results AF developed in 111 patients (24.9%). Preoperative factors associated with the development of new-onset AF included age (p < 0.05), higher EuroSCORE II (p < 0.05), carotid disease (p = 0.01), peripheral vascular disease (p = 0.02), chronic obstructive pulmonary disease (p = 0.03), renal failure (p = 0.05), and cardiac failure (p = 0.01). Intraoperative and postoperative parameters included duration of CPB (p < 0.05), number of grafts (p = 0.009), intubation time (p = 0.001), occurrence of postoperative stroke (p = 0.01), transient ischemic attack (p = 0.02), need for prolonged ventilation (p = 0.002), development of respiratory tract infection (p = 0.02), need for noninvasive ventilation (p = 0.001), reintubation (p = 0.02), development of postoperative acute kidney injury (p = 0.002), and postoperative neurocognitive dysfunction (p = 0.002). The number of red blood cell (RBC) units transfused during surgery (p = 0.7) and the total number of RBC units transfused (p = 0.2) as well as units of fresh frozen plasma (p = 0. 7) and platelets units transfused in total (p = 0.3) were not found to increase the risk of postoperative AF. Conclusion Intraoperative and postoperative blood products transfusion in patients operated for CABG is not associated with increased risk of developing postoperative AF.