Prognostic value of daily cardiac surgery score (CASUS) and its derivatives in cardiac surgery patients.

BACKGROUND: We aimed to validate the usefulness of CASUS derivatives for cardiac surgery patients and their reliability for daily decision making. METHODS: We included, prospectively, the data of all adult cardiac surgery patients who had an ICU stay of at least 12 hours between 20 January 2003 and 14 October 2005 in the Department of Cardiothoracic Surgery of the University of Cologne, Germany. Data were collected until ICU discharge and included initial, maximum, mean, and total CASUS values. δ CASUS (difference from initial value) was calculated at 48 and 96 hours postoperatively. The predictive efficacy of the derivatives was tested with calibration and discrimination statistics. RESULTS: 2372 patients were included with a mean age of 66.2 ± 11.2 years. ICU mortality was 3.6 % (n =85). Mean ICU stay was 3.0 ± 6.1 days. The discrimination was very good for all derivatives (area under the curve ranged between 0.988 and 0.926). The calibration was also good except for the total CASUS, which showed a significant difference between the expected and observed mortality. Increased δ CASUS at 48 hours (1038 patients) and 96 hours (435 patients) correlated with an increase in mortality (23.1 % and 42.9 %, respectively), and conversely a decreased mortality rate was observed with decreasing values (1.9 % and 3.8 %, respectively). CONCLUSION: CASUS derivatives including δ CASUS have a good prognostic value for cardiac surgery patients with regard to the prediction of mortality and survival during ICU stay, with the exception of total CASUS which was not informative.

S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system.

Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery (Deutsche Gesellschaft für Thorax-, Herz- und Gefässchirurgie, DGTHG) and the German Society for Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin, DGAI) made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess the available monitoring methods with regard to indication, procedures, predication, limits, contraindications and risks for use. The differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilatators, inodilatators and calcium sensitizers and the use of intra-aortic balloon pumps will also be addressed. The guideline has been developed following the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).

Risk stratification models fail to predict hospital costs of cardiac surgery patients.

BACKGROUND: The aim of this prospective study was to determine if commonly used risk stratification models can predict total hospital costs in cardiac surgical patients. METHODS: Between October 1st and December 31st 2003, all consecutive adult patients undergoing cardiac surgery on CPB at our institution were classified using seven risk stratification scoring systems: EuroSCORE, Cleveland, Parsonnet, Ontario, French, Pons, and CABDEAL. Total hospital costs for each patient were calculated on a daily basis including preoperative diagnostic tests, operating room costs, disposable materials, drugs, blood components, costs for personnel, and hospital fixed-costs. Linear regression analysis was used to determine the correlation between costs and the seven risk stratifications models as well as length of stay (LOS) on ICU. The Spearman correlation coefficient was calculated from the regression line, and an analysis of residuals was performed to determine the quality of the regression. RESULTS: A total of 252 patients were operated for CABG (n=175), valve (n=39), CABG plus valve (n=21), thoracic aorta (n=13) and miscellaneous (2 myxoma, 1 ASD, 1 pulmonary embolism). Mean age of the patients was 66.0+/-11.4 years, 29.4% were female. LOS on ICU was 3.3+/-6.3 days and the 30-day mortality rate was 6.7%. Spearman correlation between the seven risk stratification models and hospital costs was below r=0.32 (p=0.0001), but was r=0.94 (p=0.0001) between ICU LOS and costs. CONCLUSIONS: Total hospital costs can be identified by length of ICU stay. None of the common risk stratification models accurately predicted total hospital costs in cardiac surgical patients.

The effect of preoperative antiplatelet therapy in coronary artery surgery: blood transfusion requirements for patients on cardiopulmonary bypass.

INTRODUCTION: Bleeding after heart operations remains a common complication and contributes to morbidity and death. Recent studies have suggested that antiplatelet therapy (APT) may not increase homologous blood requirements in coronary bypass surgery. The purpose of this study was to examine the influence of APT therapy on haemorrhage and transfusion requirements in patients undergoing coronary artery bypass (CABG) on cardiopulmonary bypass (CPB). MATERIALS AND METHODS: Records from 290 consecutive patients who underwent CABG with CPB were retrospectively reviewed, including 145 patients who received APT within 5 days prior to surgery and 145 control patients (CON). Blood loss was measured up to 24 h. Demographic and clinical patient data were collected until hospital discharge. RESULTS: Both groups were well matched with respect to demographic and intra-operative data. There was significantly (p < 0.0005) more mediastinal tube drainage at 24 h in the APT group (1123 mL +/- 537 mL) compared to CON patients (874 mL +/- 351 mL). In addition, the APT group received significantly more units of blood (APT: 2.6 +/- 2.5 vs CON: 1.6 +/- 1.8; p < 0.0005), platelet units (APT: 1.2 +/- 1.8 vs CON: 0.2 +/- 0.8; p < 0.0005), and fresh frozen plasma units (APT: 2.0 +/- 2.2 vs CON: 1.3 +/- 2.0; p = 0.01). CONCLUSION: This study suggests consideration should be given to delaying elective CABG for patients who have received APT treatment until APT is discontinued for at least 5 days.

Morphology and density of initial lymphatics in human myocardium determined by immunohistochemistry.

BACKGROUND: Myocardial edema is a common finding in congestive heart failure, transplant rejection, and cardiomyopathy. Although pathological alterations in the lymphatic morphology are part of the underlying disease, knowledge on these changes is limited. However, lymphatic morphology may be investigated by immunohistochemical staining for fms-like tyrosine 4 kinase (flt-4), which is specific for lymphatic endothelium in adult tissue. METHODS: We used myocardial tissue of ventricular out flow tract taken from five human semilunar valves harvested as allografts but unsuitable for implantation for analysis, performing immunohistochemical staining for flt-4 with a commercially available antibody. Lymphatic morphometry was completed according Gundersen method. RESULTS: Immunohistochemical staining for flt-4 resulted in successful labeling of lymph capillaries in adult human myocardium. Lymph capillary density was calculated as 50.7 +/- 12.5 per mm2 and average diameter was 3.7 +/- 0.7 microm. Conclusions. Lymph capillary morphology in human myocardium may be successfully determined by immunohistochemical staining for flt-4. Tissue samples as small as myocardial biopsies may be used for analysis. Using this method, morphological changes in myocardial lymphatics may be investigated in various cardiovascular diseases.

[Urinary infections following bladder catheterization]. / Infections urinaires après cystographie mictionnelle par sondage

The incidence and the prophylaxis of urinary tract infection following bladder catheterization have been studied in 142 patients admitted for voiding cystourethrography (VCU). 71 children received a prophylactic treatment of 2 mg/kg nitrofurantoin daily for 4 days, while 71 received no treatment following bladder catheterization. Bacteriologic examination of the urine 4-9 days after catheterization showed significant bacteriuria in 5 untreated children. The germs responsible were E. coli, Proteus, and Klebsiella. None of the treated patients presented with significant bacteriuria. It is concluded that the incidence of significant bacteriuria after a VCU is not inconsiderable, that this urinary tract infection is often asymptomatic, and that the prophylactic administration of a disinfectant is justified.