Multi-vessel coronary artery grafting: analyzing the minimally invasive approach and its safety.

Introduction: At our institution, we perform off-pump coronary artery bypass (OPCAB) as a standard procedure. Moreover, patients with favorable coronary anatomy and condition are selected for minimally invasive cardiac surgery (MICS)-OPCAB. We retrospectively compared early outcomes, focusing on safety, between MICS-OPCAB and conventional off-pump techniques for multivessel coronary artery bypass grafting (CABG). Methods: From August 2017 to September 2022, 1,220 patients underwent multivessel coronary artery grafting at our institution. They were divided into the MICS-OPCAB group (MICS group = 163 patients) and the conventional OPCAB group (MS group = 1057 patients). Propensity score matching (1 : 1 ratio) was applied to the MICS-OPCAB and MS groups (149 patients per group) based on 23 preoperative clinical characteristics. Results: After matching, there were no significant differences in preoperative characteristics between the groups. The MICS group had a lower total graft number (2.3 ± 0.6 vs. 2.9 ± 0.8, p < 0.001) and fewer distal anastomoses (2.7 ± 0.8 vs. 3.2 ± 0.9, p < 0.001). There were no significant differences in hospital stay, intensive care unit stay, postoperative complications, and 30-day mortality. The MICS group had less drain output (MICS 350 ml [250-500], MS 450 ml [300-550]; p = 0.013). Kaplan-Meier analysis revealed no significant differences in postoperative MACCE (major adverse cardiac or cerebrovascular events)-free and survival rates between the groups (MACCE-free rate p = 0.945, survival rate p = 0.374). Conclusion: With proper patient selection, MICS-OPCAB can provide good short to mid-term results, similar to those of conventional OPCAB.

Assessing the benefits of anaortic off-pump coronary artery bypass grafting.

Introduction: The procedure called the "aorta no-touch" (NT) or anaortic technique in off-pump coronary artery bypass grafting (OPCAB) is designed to reduce the perioperative risk of stroke. We have observed an increased frequency of anaortic OPCAB procedures at our institution. The main purpose of the present study is to investigate the effectiveness of anaortic OPCAB in reducing the perioperative risk of stroke. Methods: From April 2011 to July 2023, a total of 2,236 patients underwent isolated OPCAB at our single center. The patients were divided into the anaortic group (NT, n = 762) and the aortic group (A, n = 1,474). The NT group was propensity score-matched (PSM) with the A group at a 1:1 ratio (NT n = 640; A n = 640), and matching was performed based on 26 covariates with preoperative clinical characteristics. Results: In both the unmatched and matched cohorts of the NT and A groups, there were no significant differences observed in new stroke rates (NT vs. A; unmatched, 1.0% vs. 1.2%, p = 0.624; matched, 0.9% vs. 1.3%, p = 0.789). The univariable logistic analysis did not identify the anaortic technique as an independent factor negatively associated with new stroke events (OR = 0.81, 95% CI = 0.35-1.86, p = 0.624). Conclusion: The present study did not find the anaortic technique to reduce the perioperative risk of stroke in OPCAB. Hence, further large studies are needed to identify patient cohorts in which anaortic OPCAB is significantly beneficial.

The efficacy of prophylactic metoclopramide in preventing nausea and vomiting in patients with acute pain treated with intravenous tramadol: a randomized double-blinded, placebo-controlled trial.

OBJECTIVE: To examine the clinical efficacy of prophylactic metoclopramide in reducing the incidence of nausea and vomiting in emergency department (ED) patients with acute pain who were treated with intravenous tramadol. RESULTS: We conducted a single-center randomized, double-blinded, placebo-controlled trial. A total of 99 ED patients presented with acute pain were recruited. Sixty-four patients were randomized, 31 patients in the treatment arm and 33 in the control arm. Overall, there were no significant differences in baseline characteristics between treatment arm and control arm. Only one patient within each arm reported having nausea symptom. No patients reported vomiting episode. There was no statistically significant difference in the proportion of patients with nausea or vomiting symptoms between the two groups (3.2% in the treatment arm vs. 3.0% in the control arm, p = 1.000). The administration of prophylactic metoclopramide may not provide additional benefit in reducing the occurrence of nausea and/or vomiting episode in ED patients with acute pain treated with intravenous tramadol. Trial registration Randomized clinical trial TCTR20220525001; registration date: 21 October 2021. Retrospectively registered.

Accuracy of laboratory tests drawn by pull-push method from central venous catheterization after routine flushing with 10 ml normal saline in patients with sepsis at the emergency department.

Central venous catheterization (CVC) remains a common practice in the emergency setting. Routine flushing 10-20 ml of normal saline to maintain the patency of CVC could affect the accuracy of laboratory tests. Typically, physicians require peripheral vein phlebotomy when more blood sampling is needed. One alternative method, the Pull-push method, could avoid the trauma associated with venipuncture and unnecessary peripheral vein phlebotomy. However, there has been no recent study analyzing the accuracy of blood sampling using this technique. We evaluate laboratory tests' accuracy between blood samples drawn by the Pull-push method from CVC after routine flushing with 10 ml of normal saline versus control. We conducted a diagnostic accuracy study from May to September 2019. After exclusion, 72 patients were eligible for analysis. Promptly after central venous catheterization, we drew blood samples, stored them in blood collecting tubes, and labeled them for the gold standard group. We flushed with 10 ml of normal saline before blood sampling using the Pull-push method's completed three times; then, we drew blood samples again, labeled Pull-push group. We compared the laboratory results between two groups by paired t-test. The accuracies were analyzed based on an allowable error by Clinical Laboratory Improvement Amendments (CLIA) and presented by a modified Bland-Altman plot. The 72 patients were primarily male (n = 47, 65.3%), had a mean age 60.1 ± 14.0 years, and were diagnosed with sepsis (n = 4, 5.6%) or septic shock (n = 65, 90.3%). For almost all the laboratory values, including hemoglobin, hematocrit, white blood cell count, platelet count, blood urea nitrogen, creatinine, sodium, potassium, chloride, bicarbonate, prothrombin time, international normalized ratio, and blood sugar, the accuracy was more than 90% (92.8-98.6%), except aPTT (85.5%) and aPTT ratio (86.7%). Laboratory tests drawn by the Pull-push method could replace peripheral vein phlebotomy to avoid the trauma associated with venipuncture and infection risk.

Accuracy of laboratory tests collected at referring hospitals versus tertiary care hospitals for acute stroke patients.

BACKGROUND: The standard treatment of acute ischemic stroke patients is thrombolytic therapy within 60 minutes of a patient's arrival in stroke center hospitals. Based on the policy of the Lampang Referral System Committee, blood samples of suspected stroke patients need to be collected before transfer to the stroke center (Lampang Hospital). It was still questionable as to whether these blood samples are valid for clinical use and the present study aimed to confirm or deny their validity. METHODS: A diagnostic study was conducted from June 2015 to May 2016. After exclusion, 340 patients were deemed eligible for analysis. Blood samples were collected just before normal saline infusion at referring hospitals and stored in blood collecting tube boxes set during transportation. At the stroke center, informed consents was requested, blood samples were re-collected to serve as a 'gold standard'. Prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (aPTT), platelet count, hemoglobin (Hb), hematocrit (Hct), blood urea nitrogen (BUN), and creatinine (Cr) were compared using paired t-tests. Binary regression was used to analyze for accuracy (%) to adjust for extraneous influences and was presented by modified Bland-Altman plots. RESULTS: The laboratory results of referring hospitals vs. the stroke center were: PT, 12.4±3.2 vs. 12.5±3.0 sec; INR: 1.0±0.3 vs. 1.0±0.3; and platelet count: 239.8±77.1 vs. 239.8±74.8 (x103/µL). The adjusted accuracy of the PT, INR, and platelet counts were 96.8%, 96.8%, and 95.3% respectively. CONCLUSION: Laboratory tests from referring hospital were determined to be valid. Blood samples should thus be collected at referring hospitals in order to avoid unnecessary blood collection at the stroke center.

Prediction of Symptomatic Intracranial Hemorrhage after Intravenous Thrombolysis in Acute Ischemic Stroke: The Symptomatic Intracranial Hemorrhage Score.

BACKGROUND: Symptomatic intracranial hemorrhage (sICH) is common after intravenous thrombolysis in acute ischemic strokes (AISs). Available predictive scoring systems were derived mostly in the Western countries. METHODS: Retrospective data in 1 provincial and 4 regional hospitals in the northern part of Thailand were reviewed. Patients with AIS, to whom recombinant tissue plasminogen activator (rt-PA) had been prescribed, were classified into 3 groups: no intracranial hemorrhage (no ICH), asymptomatic intracranial hemorrhage (asICH) and sICH. Coefficients under the multilevel ordinal logistic model were transformed into item scores and sum scores. Measures of discrimination, calibration, and internal validation were analyzed. RESULTS: Among 1172 patients, there were 78.8% with no ICH (n = 923), 13.1% with asICH (n = 154), and 8.1% with sICH (n = 95). The final model was named "SICH score" and included 6 variables: valvular heart diseases, use of aspirin, systolic blood pressure prior to thrombolysis that is 140 mmHg or higher, National Institutes of Health Stroke Scale scores higher than 10 and 20, a platelet count lower than 250,000 cell/mm3, and use of intravenous antihypertensive drugs during thrombolysis, with an Area under Receiver Operating Characteristic of .75 (95% confidence interval, .71-.80). CONCLUSION: The SICH score could be an assisting tool to predict an individual risk of sICH after intravenous thrombolysis for AIS in Thai patients.

Prognostic Parameters for Symptomatic Intracranial Hemorrhage after Intravenous Thrombolysis in Acute Ischemic Stroke in an Asian Population.

BACKGROUND: Symptomatic intracranial hemorrhage (sICH) is a major complication after intravenous thrombolysis leading to severe disability and death. The incidence was higher in Asian than in western countries. Prognostic factors across ethnicities are presumably different. Studies in Asian populations are limited. METHOD: Clinical data from January 2008 to September 2016 in one provincial and four regional hospitals in the northern part of Thailand were retrospectively reviewed. Patients were those with acute ischemic stroke, to whom recombinant tissue plasminogen activator (rt-PA) had been prescribed. They were classified into 3 groups; no intracranial hemorrhage (no ICH), asymptomatic intracranial hemorrhage (asICH) and symptomatic intracranial hemorrhage (sICH), based on clinical and brain imaging (computed tomography or CT). Prognostic parameters were investigated using a multi-level, multivariable ordinal logistic model. RESULTS: After exclusion of ineligible patients, the remaining 1,172 patients were classified into no ICH (n=923, 78.8%), asICH (n=154, 13.1%) and sICH (n=95, 8.1%). Independent prognostic parameters for intracranial hemorrhage were the National Institutes of Health Stroke Scale (NIHSS) >20 (OR, 3.51; 95% CI, 2.18-5.65; p<0.001), NIHSS >10 (OR, 2.02; 95% CI, 1.42-2.87; p<0.001), use of nicardipine during rt-PA (OR, 1.61; 95% CI, 1.09-2.40; p=0.018), systolic blood pressure (SBP) prior to thrombolysis ≥ 140 mmHg (OR, 1.47; 95% CI, 1.06-2.04; p=0.021), and platelet count <250,000 cell/mm3 (OR, 1.45; 95% CI, 1.04-2.01; p=0.029). CONCLUSION: Patients with these parameters should be closely monitored. Information should be provided to the patients and their relatives.