Effect of methylprednisolone on acute kidney injury in patients undergoing cardiac surgery with a cardiopulmonary bypass pump: a randomized controlled trial.

BACKGROUND: Perioperative corticosteroid use may reduce acute kidney injury. We sought to test whether methylprednisolone reduces the risk of acute kidney injury after cardiac surgery. METHODS: We conducted a prespecified substudy of a randomized controlled trial involving patients undergoing cardiac surgery with cardiopulmonary bypass (2007-2014); patients were recruited from 79 centres in 18 countries. Eligibility criteria included a moderate-to-high risk of perioperative death based on a preoperative score of 6 or greater on the European System for Cardiac Operative Risk Evaluation I. Patients (n = 7286) were randomly assigned (1:1) to receive intravenous methylprednisolone (250 mg at anesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients, caregivers, data collectors and outcome adjudicators were unaware of the assigned intervention. The primary outcome was postoperative acute kidney injury, defined as an increase in the serum creatinine concentration (from the preoperative value) of 0.3 mg/dL or greater (≥ 26.5 µmol/L) or 50% or greater in the 14-day period after surgery, or use of dialysis within 30 days after surgery. RESULTS: Acute kidney injury occurred in 1479/3647 patients (40.6%) in the methylprednisolone group and in 1426/3639 patients (39.2%) in the placebo group (adjusted relative risk 1.04, 95% confidence interval 0.96 to 1.11). Results were consistent across several definitions of acute kidney injury and in patients with preoperative chronic kidney disease. INTERPRETATION: Intraoperative corticosteroid use did not reduce the risk of acute kidney injury in patients with a moderate-to-high risk of perioperative death who had cardiac surgery with cardiopulmonary bypass. Our results do not support the prophylactic use of steroids during cardiopulmonary bypass surgery. Trial registration: ClinicalTrials.gov, no. NCT00427388.

Perioperative Management of the Lung Graft Following Lung Transplantation.

Perioperative management of patients undergoing lung transplantation is one of the most complex in cardiothoracic surgery. Certain perioperative interventions, such as mechanical ventilation, fluid management and blood transfusions, use of extracorporeal mechanical support, and pain management, may have significant impact on the lung graft function and clinical outcome. This article provides a review of perioperative interventions that have been shown to impact the perioperative course after lung transplantation.

Methylprednisolone Does Not Reduce Persistent Pain after Cardiac Surgery.

BACKGROUND: Persistent incisional pain is common after cardiac surgery and is believed to be in part related to inflammation and poorly controlled acute pain. Methylprednisolone is a corticosteroid with substantial antiinflammatory and analgesic properties and is thus likely to ameliorate persistent surgical pain. Therefore, the authors tested the primary hypothesis that patients randomized to methylprednisolone have less persistent incisional pain than those given placebo. METHODS: One thousand forty-three patients having cardiopulmonary bypass for cardiac surgery via a median sternotomy were included in this substudy of Steroids in Cardiac Surgery (SIRS) trial. Patients were randomized to 500 mg intraoperative methylprednisolone or placebo. Incisional pain was assessed at 30 days and 6 months after surgery, and the potential risk factors were also evaluated. RESULTS: Methylprednisolone administration did not reduce pain at 30 days or persistent incisional pain at 6 months, which occurred in 78 of 520 patients (15.7%) in the methylprednisolone group and in 88 of 523 patients (17.8%) in the placebo group. The odds ratio for methylprednisolone was 0.93 (95% CI, 0.79 to 1.09, P = 0.37). Furthermore, there was no difference in worst pain and average pain in the last 24 h, pain interference with daily life, or use of pain medicine at 6 months. Younger age, female sex, and surgical infections were associated with the development of persistent incisional pain. CONCLUSIONS: Intraoperative methylprednisolone administration does not reduce persistent incisional pain at 6 months in patients recovering from cardiac surgery.

Intraoperative tight glucose control using hyperinsulinemic normoglycemia increases delirium after cardiac surgery.

BACKGROUND: Postoperative delirium is common in patients recovering from cardiac surgery. Tight glucose control has been shown to reduce mortality and morbidity. Therefore, the authors sought to determine the effect of tight intraoperative glucose control using a hyperinsulinemic-normoglycemic clamp approach on postoperative delirium in patients undergoing cardiac surgery. METHODS: The authors enrolled 198 adult patients having cardiac surgery in this randomized, double-blind, single-center trial. Patients were randomly assigned to either tight intraoperative glucose control with a hyperinsulinemic-normoglycemic clamp (target blood glucose, 80 to 110 mg/dl) or standard therapy (conventional insulin administration with blood glucose target, <150 mg/dl). Delirium was assessed using a comprehensive delirium battery. The authors considered patients to have experienced postoperative delirium when Confusion Assessment Method testing was positive at any assessment. A positive Confusion Assessment Method was defined by the presence of features 1 (acute onset and fluctuating course) and 2 (inattention) and either 3 (disorganized thinking) or 4 (altered consciousness). RESULTS: Patients randomized to tight glucose control were more likely to be diagnosed as being delirious than those assigned to routine glucose control (26 of 93 vs. 15 of 105; relative risk, 1.89; 95% CI, 1.06 to 3.37; P = 0.03), after adjusting for preoperative usage of calcium channel blocker and American Society of Anesthesiologist physical status. Delirium severity, among patients with delirium, was comparable with each glucose management strategy. CONCLUSION: Intraoperative hyperinsulinemic-normoglycemia augments the risk of delirium after cardiac surgery, but not its severity.

Rationale and design of the steroids in cardiac surgery trial.

BACKGROUND: Steroids may improve outcomes in high-risk patients undergoing cardiac surgery with the use of cardiopulmonary bypass (CBP). There is a need\ for a large randomized controlled trial to clarify the effect of steroids in such patients. METHODS: We plan to randomize 7,500 patients with elevated European System for Cardiac Operative Risk Evaluation who are undergoing cardiac surgery with the use of CBP to methylprednisolone or placebo. The first coprimary outcome is 30-day all-cause mortality, and the most second coprimary outcome is a composite of death, MI, stroke, renal failure, or respiratory failure within 30 days. Other outcomes include a composite of MI or mortality at 30 days, new onset atrial fibrillation, bleeding and transfusion requirements, length of intensive care unit stay and hospital stay, infection, stroke, wound complications, gastrointestinal complications, delirium, postoperative insulin use and peak blood glucose, and all-cause mortality at 6 months. RESULTS: As of October 22, 2013, 7,034 patients have been recruited into SIRS in 82 centers from 18 countries. Patient's mean age is 67.3 years, and 60.4% are male. The average European System for Cardiac Operative Risk Evaluation is 7.0 with 22.1% having an isolated coronary artery bypass graft procedure, and 66.1% having a valve procedure. CONCLUSIONS: SIRS will lead to a better understanding of the safety and efficacy of prophylactic steroids for cardiac surgery requiring CBP.

Steroids In caRdiac Surgery (SIRS) trial: acute kidney injury substudy protocol of an international randomised controlled trial.

INTRODUCTION: Steroids In caRdiac Surgery trial (SIRS) is a large international randomised controlled trial of methylprednisolone or placebo in patients undergoing cardiac surgery with the use of a cardiopulmonary bypass pump. At the time of surgery, compared with placebo, methylprednisolone divided into two intravenous doses of 250 mg each may reduce the risk of postoperative acute kidney injury (AKI). METHODS AND ANALYSIS: With respect to the study schedule, over 7000 substudy eligible patients from 81 centres in 18 countries were randomised in December 2013. The authors will use a logistic regression to estimate the adjusted OR of methylprednisolone versus placebo on the primary outcome of AKI in the 14 days following surgery (a postoperative increase in serum creatinine of ≥50%, or ≥26.5 µmol/L, from the preoperative value). The stage of AKI will also be considered, as will the outcome of AKI in those with and without preoperative chronic kidney disease. After receipt of grant funding, the authors began to record additional perioperative serum creatinine measurements in consecutive patients enrolled at substudy participating centres, and patients were invited to enroll in a 6-month serum creatinine collection. In these trial subpopulations, the authors will consider the outcome of AKI defined in alternate ways, and the outcome of a 6-month change in kidney function from the preoperative value. ETHICS AND DISSEMINATION: The authors were competitively awarded a grant from the Canadian Institutes of Health Research for this SIRS AKI substudy. Ethics approval was obtained for additional serum creatinine recordings in consecutive patients enrolled at participating centres. The additional kidney data collection first began for patients enrolled after 1 March 2012. In patients who provided consent, the last 6-month kidney outcome data will be collected in 2014. The results will be reported no later than 2015. CLINICAL TRIAL REGISTRATION: Number NCT00427388.

Rationale and design of the steroids in cardiac surgery trial

Background Steroids may improve outcomes in high-risk patients undergoing cardiac surgery with the use of cardiopulmonarybypass (CBP). There is a need for a large randomized controlled trial to clarify the effect of steroids in such patients.Methods We plan to randomize 7,500 patients with elevated European System for Cardiac Operative Risk Evaluation whoare undergoing cardiac surgery with the use of CBP to methylprednisolone or placebo. The first coprimary outcome is 30-day allcausemortality, and the most second coprimary outcome is a composite of death, MI, stroke, renal failure, or respiratory failurewithin 30 days. Other outcomes include a composite of MI or mortality at 30 days, new onset atrial fibrillation, bleeding andtransfusion requirements, length of intensive care unit stay and hospital stay, infection, stroke, wound complications,gastrointestinal complications, delirium, postoperative insulin use and peak blood glucose, and all-cause mortality at 6 months.Results As of October 22, 2013, 7,034 patients have been recruited into SIRS in 82 centers from 18 countries. Patient’smean age is 67.3 years, and 60.4% are male. The average European System for Cardiac Operative Risk Evaluation is 7.0with 22.1% having an isolated coronary artery bypass graft procedure, and 66.1% having a valve procedure.Conclusions SIRS will lead to a better understanding of the safety and efficacy of prophylactic steroids for cardiacsurgery requiring CBP. (Am Heart J 2014;167:660-5.)BackgroundWorldwide, N2 million patients undergo cardiacsurgery annually. Most cardiac surgeries use cardiopulmonarybypass (CPB). Although CPB serves an importantrole, it.

Perioperative risk and management in patients with pulmonary hypertension.

Pulmonary hypertension (PH) is a known risk factor for perioperative complications. Unlike in the case of cardiac surgery, PH is currently not listed as an independent risk factor for postoperative complications in guidelines for the management of noncardiac surgery. Despite the paucity of data, though, patients with PH are often counseled against having elective procedures because early and sudden postoperative deaths have been reported. Patients with PH are unable to accommodate alterations in right ventricular (RV) preload or afterload induced by fluid shifts, medications, or changes in the autonomic nervous system precipitated by hypoxia or hypercapnia. These factors become magnified in situations of added stress such as surgical intervention. Systemic hypotension and arrhythmias may precipitate RV ischemia, further worsening RV function. Patient and surgical characteristics and choice of anesthetic technique are crucial factors in perioperative management. The two main principles of perioperative management are the prevention of systemic hypotension (risk of RV ischemia) and the prevention of acute elevations in pulmonary arterial pressure (risk of RV failure). Close monitoring, optimization of systemic BP, pain control, oxygenation and ventilation, avoidance of exacerbating factors, and use of vasopressors and pulmonary vasodilators as necessary are essential elements of management. Understanding the pathophysiology, cause, and severity of PH in the individual perioperative patient allows accurate risk assessment, optimization of PH and RV function prior to surgery, and appropriate intraoperative and postoperative management.

Glycemic control with use of insulin glargine after cardiothoracic surgery: a retrospective study.

OBJECTIVE: Perioperative glycemic control in critically ill cardiothoracic surgery patients may improve postsurgical outcomes. The objective of the study was to compare outcomes before and after the implementation of a protocol using subcutaneous (SC) glargine at transition from intravenous insulin infusion (IVII). METHODS: In August 2006, the Cleveland Clinic began using glargine and supplemental rapid-acting sliding scale insulin (SSI) at transition from IVII (glargine-SSI group). Before August 2006, only supplemental insulin was used (SSI-only group). The primary outcome was first blood glucose (BG1) after discontinuation of IVII. Secondary outcomes included the absolute difference between the last glucose before discontinuation of IVII (BG0) and BG1, mean glucose in the first 24 hours after discontinuation of IVII (BG24), need for SSI, and hypoglycemia. RESULTS: Mean BG0, BG1, and BG24, and the difference between BG1 and BG0 and between BG24 and BG0 were not significantly different between groups. Diabetes mellitus (DM) patients who had received glargine had a lower mean difference between BG1 and BG0 and a lower mean BG24 than those who had not received glargine (14.6 mg/dL vs. 33.1 mg/dL; P = .20, and 163.8 mg/dL vs. 177.9 mg/dL; P = .29, respectively). A higher proportion of DM patients needed SSI than did non-DM patients (82% vs. 36%; P<.001). CONCLUSION: Glargine administered at the cessation of IVII enabled less SSI coverage in diabetic patients subsequent to transition from IVII. However, there was no significant difference in BG control between the glargine-SSI and SSI-only groups. Prospective studies involving more patients are needed to show possible clinically significant benefits of this intervention.

Perioperative glycemic management in insulin pump patients undergoing noncardiac surgery.

Increasingly more Americans are being diagnosed with diabetes mellitus, and the number of those using the continuous subcutaneous insulin infusion pump (CSII), commonly known as the insulin pump, is on the rise. Although evidence is lacking on how best to manage insulin pump patients perioperatively, several individual or institutional approaches have been developed. Here we propose a comprehensive algorithm for perioperative glycemic management in insulin pump patients undergoing noncardiac surgery. Where applicable, we discuss the rationale behind the algorithm.

Predictive models for acute kidney injury following cardiac surgery.

BACKGROUND: Accurate prediction of cardiac surgery-associated acute kidney injury (AKI) would improve clinical decision making and facilitate timely diagnosis and treatment. The aim of the study was to develop predictive models for cardiac surgery-associated AKI using presurgical and combined pre- and intrasurgical variables. STUDY DESIGN: Prospective observational cohort. SETTINGS & PARTICIPANTS: 25,898 patients who underwent cardiac surgery at Cleveland Clinic in 2000-2008. PREDICTOR: Presurgical and combined pre- and intrasurgical variables were used to develop predictive models. OUTCOMES: Dialysis therapy and a composite of doubling of serum creatinine level or dialysis therapy within 2 weeks (or discharge if sooner) after cardiac surgery. RESULTS: Incidences of dialysis therapy and the composite of doubling of serum creatinine level or dialysis therapy were 1.7% and 4.3%, respectively. Kidney function parameters were strong independent predictors in all 4 models. Surgical complexity reflected by type and history of previous cardiac surgery were robust predictors in models based on presurgical variables. However, the inclusion of intrasurgical variables accounted for all explained variance by procedure-related information. Models predictive of dialysis therapy showed good calibration and superb discrimination; a combined (pre- and intrasurgical) model performed better than the presurgical model alone (C statistics, 0.910 and 0.875, respectively). Models predictive of the composite end point also had excellent discrimination with both presurgical and combined (pre- and intrasurgical) variables (C statistics, 0.797 and 0.825, respectively). However, the presurgical model predictive of the composite end point showed suboptimal calibration (P < 0.001). LIMITATIONS: External validation of these predictive models in other cohorts is required before wide-scale application. CONCLUSIONS: We developed and internally validated 4 new models that accurately predict cardiac surgery-associated AKI. These models are based on readily available clinical information and can be used for patient counseling, clinical management, risk adjustment, and enrichment of clinical trials with high-risk participants.

The association between alcohol consumption and morbidity and mortality in patients undergoing coronary artery bypass surgery.

OBJECTIVE: Moderate alcohol consumption appears protective against cardiovascular events and mortality in community-based epidemiologic studies, but whether its consumption affects perioperative outcomes remains unknown. Therefore, the authors tested the hypothesis that alcohol consumption of 3 or more drinks per week improves postoperative outcomes in patients undergoing coronary artery bypass graft (CABG) surgery. DESIGN: A propensity-matched retrospective cohort study. SETTING: A major cardiovascular surgical institute, tertiary care teaching hospital. PARTICIPANTS: Data from 13,065 patients undergoing elective CABG surgery at the Cleveland Clinic were analyzed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Propensity scores were used to match alcohol users with infrequent/nonusers. From the matched subset, the relationship between alcohol use and the composite outcome (any major cardiac, renal, respiratory, infectious, or neurologic morbidity and mortality) was determined univariably with the Pearson chi-square test and multivariably using stepwise logistic regression. Estimation of the relationship between such alcohol use and hospital length of stay was of secondary interest. Patients who reported consuming at least 3 drinks per week experienced similar odds of the composite outcome (adjusted odds ratio [95% confidence interval] of 1.13 [0.96-1.34], p = 0.14) to infrequent or nonusers. In a secondary analysis, the hospital length of stay was unrelated to alcohol use (adjusted hazard ratio [95% CI] of 1.03 [0.97-1.09], p = 0.28). CONCLUSION: The present results showed that alcohol consumption was not associated with the risk for postoperative complications in patients undergoing CABG surgery. Alcohol abusers could not be separated in this study, and, based on previous literature, this result might not be applied to them.

Cleveland Clinic cardiovascular intensive care unit insulin conversion protocol.

BACKGROUND: The importance of near-normal blood glucose in the immediate postoperative period is generally accepted and is best achieved in the perioperative period with a constant intravenous (IV) infusion of insulin. This requires intensive nursing only achievable in an intensive care unit (ICU) setting. Glucose management after transfer to a regular nursing floor (RNF) has not been studied systematically. In August 2006, the Cleveland Clinic began using long-acting insulin glargine as the insulin infusion was terminated in the ICU. METHODS: This prospective analysis examined all patients receiving IV insulin infusion after cardiothoracic surgery in a 1 month period. The analyses evaluated the safety and efficacy of a protocol using a transition to subcutaneous insulin glargine of 50% of the calculated 24 h requirement at the end of the ICU insulin infusion protocol in preparation for transfer to the RNF. RESULTS: Only 1 patient in 99 developed hypoglycemia, and no patient suffered severe hypoglycemia (glucose < 40 mg/dl), while the majority (70%) had euglycemia (glucose between 70 and 150 mg/dl). CONCLUSIONS: This approach was both safe-as there was very little hypoglycemia (1 patient in 99)-and effective, as blood sugar was well controlled in most subjects. Efficacy for achieving euglycemia was 70%. Efficacy was likely reduced because of the upper limit of insulin glargine dosage imposed by some providers as a safety consideration. Although there was a physician option to override, the maximum protocol dose of 30 U was rarely exceeded, leading to inadequate dosing in some subjects who required high insulin infusion rates in the ICU.

Improved survival in acute kidney injury after cardiac surgery.

BACKGROUND: The overall incidence of acute kidney injury (AKI) or mortality after cardiac surgery is low, but mortality in patients with AKI remains high. Effects of factors such as change in comorbid disease burden, intraoperative factors, or postoperative complications on trends in the incidence of AKI and associated mortality after cardiac surgery were not examined. STUDY DESIGN: Observational cohort study. SETTING & PARTICIPANTS: 34,562 cardiac surgeries were performed from 1993 to 2002; only the first surgical procedure was considered (N = 33,217). PREDICTOR, OUTCOMES, & MEASUREMENTS: AKI was defined as a composite outcome of a 50% or greater decrease in postoperative glomerular filtration rate or requirement of dialysis (AKI-D). Mortality was defined as postoperative hospital mortality. We examined effects of the predictors AKI and year of surgery on mortality after accounting for preoperative risk factors and serious postoperative complications. RESULTS: Between the first and second halves of the study period (1993 to 2002), the incidence of AKI increased from 5.1% to 6.6%, but the associated mortality rate decreased from 32% to 23% (P < 0.0001). Similarly, the incidence of AKI-D also increased from 1.5% to 2.0%, with a decrease in associated mortality from 61% to 49% (P < 0.01). In a risk-adjusted model, mortality in patients with AKI significantly decreased over time. Patients with AKI-D and with other organ system failures did not show improvement in survival over time. A preoperative history of congestive heart failure was associated significantly with a decrease in mortality risk over time, particularly in patients requiring dialysis. LIMITATIONS: Single-center, retrospective, observational cohort design. CONCLUSION: The incidence of AKI after cardiac surgery has increased over time. Although the adjusted risk of mortality decreased in patients with AKI without other postoperative complications, it is unchanged in those with multiorgan system failure.

Ventilatory dependency after cardiovascular surgery.

OBJECTIVES: Ventilatory dependency is a widely recognized complication of cardiovascular surgery, often leading to tracheostomy. Some risk factors for its occurrence have been documented. Less well characterized are short- and long-term outcomes. Therefore, objectives were to identify risk factors for ventilatory dependency, assess its short- and long-term outcomes, and determine impact of tracheostomy. METHODS: From January 1998 to September 2001, 12,777 patients underwent cardiovascular surgery and survived at least 72 hours. Of these patients, 704 (5.5%) developed ventilatory dependency (cumulative intubation >72 hours); 185 (26%) underwent tracheostomy. Preoperative, intraoperative, and intensive care unit admission data were used sequentially to understand predictors of ventilatory dependency. Outcomes were analyzed by time-related methods, and impact of tracheostomy was assessed using competing-risks analysis. RESULTS: Hemodynamic status on intensive care unit admission (low cardiac output, vasopressor use, pulmonary hypertension; P < .0001) and early postoperative events (stroke, bacteremia; P < .0001) were more important than preoperative and intraoperative variables in predicting ventilatory dependency. Survival at 30 days, 1 year, and 5 years thereafter was 76%, 49%, and 33% and was strongly associated with favorable hemodynamic status. By 28 days, 24% of patients received tracheostomy; survival at 30 days and 2 years thereafter was 74% and 26%, considerably below anticipated survivals of 84% and 58%. CONCLUSIONS: Improved operative and postoperative strategies to preserve myocardial function and restore hemodynamics should decrease the prevalence of ventilatory dependency. Unfortunately, preoperative models of ventilatory dependency are too insensitive for clinical use. Tracheostomy and its outcome are also poorly predicted, highlighting the complex interaction of events altering patients' conditions before and after tracheostomy.

Management of pulmonary hypertension in the operating room.

Pulmonary artery hypertension is defined as persistent elevation of mean pulmonary artery pressure > 25 mm Hg with pulmonary capillary wedge pressure < 15 mm Hg or elevation of exercise mean pulmonary artery pressure > 35 mm Hg. Although mild pulmonary hypertension rarely impacts anesthetic management, severe pulmonary hypertension and exacerbation of moderate hypertension can lead to acute right ventricular failure and cardiogenic shock. Knowledge of anesthetic drug effects on the pulmonary circulation is essential for anesthesiologists. Intraoperative management should include prevention of exacerbating factors such as hypoxemia, hypercarbia, acidosis, hypothermia, hypervolemia, and increased intrathoracic pressure; monitoring and optimizing right ventricular function; and treatment with selective pulmonary vasodilators. Recent advances in pharmacology provide anesthesiologists with a wide variety of options for selective pulmonary vasodilatation. Pulmonary hypertension is a major determinant of perioperative morbidity and mortality in special situations such as heart and lung transplantation, pneumonectomy, and ventricular assist device placement.

Effect of dexamethasone on atrial fibrillation after cardiac surgery: prospective, randomized, double-blind, placebo-controlled trial.

OBJECTIVE: The purpose of this study was to assess the effect of preoperative dexamethasone (DEX) on the occurrence of postoperative atrial fibrillation (AF). DESIGN: Prospective, randomized, double-blind, placebo-controlled clinical trial. SETTING: Tertiary referral center. PARTICIPANTS: Seventy-eight adult patients undergoing combined valve and coronary artery bypass graft (CABG) surgery were randomized to receive either DEX or placebo. INTERVENTIONS: The DEX group received dexamethasone, 0.6 mg/kg, after induction of anesthesia, and the placebo group received an equal volume of normal saline. Interleukin (IL)-6, -8, and -10; tumor necrosis factor alpha; and endothelin (ET)-1 were measured preoperatively and on postoperative days (POD) 1, 2, and 3. Complement (C-4) and C-reactive protein (CRP) were measured preoperatively and on POD 2. Exhaled nitric oxide (NO) was measured preoperatively, 15 minutes after aortic unclamping, and 1 hour after intensive care unit admission. MEASUREMENTS AND MAIN RESULTS: No significant difference in the incidence of AF was found between the placebo (41%) and DEX groups (30%) (95% confidence interval [-11%, 34%); p = 0.31). DEX significantly reduced at least 1 postoperative level of IL-6, IL-8, IL-10, CRP, and exhaled NO. DEX did not affect ET-1 or C-4 levels. IL-10 on POD 3 was positively correlated with postoperative hospital length of stay (r = 0.30, p = 0.01). Increased levels of IL-8 and IL-10 on POD 1 were positively correlated with the intubation time (r = 0.31, p = 0.01; r = 0.30, p = 0.01, respectively). Conversely, C-4 on POD 2 was negatively correlated with the intubation time and intensive care unit length of stay (r = -0.32, p = 0.006; r = -0.30, p = 0.01, respectively). CONCLUSIONS: DEX did not affect the incidence of AF in patients undergoing combined CABG and valve surgery. However, it did modulate the release of several inflammatory and acute-phase response mediators that are associated with adverse outcomes.

Effect of off-pump coronary artery bypass graft surgery on postoperative acute kidney injury and mortality.

OBJECTIVE: Risk of mortality after cardiac surgery is associated with severity of acute kidney injury. The aim of this study is to examine the effect of off-pump coronary artery bypass surgery on the risk of postoperative acute kidney injury and its association with mortality. DESIGN: Observational cohort study. SETTING: Tertiary care center. PATIENTS: Some 10,061 patients underwent coronary artery bypass surgery (1998-2002), of which 1,365 patients underwent off-pump surgery. INTERVENTIONS: Acute kidney injury was defined as either requirement of dialysis or >/=50% decline in postoperative glomerular filtration rate but not requiring dialysis. We compared on- and off-pump surgeries and used propensity score matching to examine the effect of off-pump surgery on acute kidney injury and mortality. MEASUREMENTS AND MAIN RESULTS: We found that 2.6% on-pump and 1.2% off-pump patients developed acute kidney injury requiring dialysis among the 2,370 matched subjects (relative risk, 2.06; 95% confidence interval [CI], 1.36-3.36); 5.0% of on-pump patients suffered a >/=50% decline in glomerular filtration rate compared with 2.5% in off-pump group (relative risk, 2.00; 95% CI, 1.48-2.82). The mortality rate in the matched cohort was 2.3% for on-pump group vs. 0.6% in off-pump group (relative risk, 3.88; 95% CI, 2.29-9.50). Among matched patients with acute kidney injury, the risk of mortality was 13.14 (95% CI, 8.43-30.50) in patients requiring dialysis and 9.33 (95% CI, 4.83-19.00) in those with >/=50% decline in glomerular filtration rate but not requiring dialysis. CONCLUSIONS: Off-pump surgery is associated with a lower risk of developing acute kidney injury (regardless of its definition). The risk of mortality is incremental with worsening degrees of acute kidney injury. Lower risk of acute kidney injury may be one of the factors that offer a survival advantage after off-pump surgery.

Tracheostomy after cardiovascular surgery: an assessment of long-term outcome.

OBJECTIVE: To ascertain long-term survival, identify risk factors for death, and document complications of tracheostomy after cardiovascular surgery. METHODS: Between January 1, 1998, and September 1, 2001, 188 (1.4%) of 13,191 patients undergoing cardiovascular surgery had tracheostomy for respiratory failure 5 to 79 days (median, 14 days) after surgery. Factors associated with mortality were identified in the hazard function domain, and mode of death and complications of tracheostomy were determined by follow-up. RESULTS: Survival was 75%, 50%, and 31% at 30 days, 3 months, and 2 years, respectively. The most important risk factors for death were older age (P = .004) and variables representing deteriorating hemodynamic (P < .0001), respiratory (P < .0001), and renal (P = .0001) function between the index cardiovascular operation and tracheostomy. The mode of death was isolated respiratory failure in only 21 (16%) of 130 patients, but multisystem organ failure in 71 (55%). Follow-up of 58 survivors identified voice complaints in 13 (24%), tracheal stenosis in 5 (9.2%), and permanent tracheostomy in 3 (6%). CONCLUSIONS: Only one third of patients undergoing tracheostomy after cardiovascular surgery survive, because it is used primarily in those with deteriorating function of multiple organ systems. Although tracheostomy may enhance patient comfort and simplify nursing care, selection algorithms need to be developed if survival is the goal of the intervention.