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2.
JTCVS Open ; 2022 May 13.
Artigo em Inglês | MEDLINE | ID: mdl-35664693

RESUMO

Objectives: The coronavirus disease 2019 (COVID-19) pandemic negatively impacted cardiothoracic (CT) surgery, with changes in clinical, academic, and personal responsibilities. We hypothesized that the pandemic may disproportionately impact female academic CT surgeons, accentuating preexisting sex disparities. This study assessed sex differences in authorship of 2 major CT surgery journals during the early part of the COVID-19 pandemic. Methods: All accepted submissions to The Annals of Thoracic Surgery and The Journal of Thoracic and Cardiovascular Surgery between April and August of 2019 and the same period in 2020 were reviewed. Article type and author characteristics were obtained from the journals. Author sex was predicted using a validated multinational database (Genderize.io) and verified with authors' institutional and public professional profiles. Results: In total, 1106 submissions were accepted during the 2019 period, whereas 900 articles (18.6% decrease) were accepted during the same period in 2020. Original research articles comprised 33.3% of the 2019 articles but only 4.9% of the 2020 articles. Female authors contributed to 39.3% (23.1% original research and 16.2% nonoriginal articles) and 29.4% (3.3% original research and 26.1% nonoriginal articles) of articles during the 2019 and 2020 periods, respectively. This represents a marked change in the type of articles that female authors contributed to. Conclusions: Early on during the COVID-19 pandemic, the type of articles accepted, and authorship demographic changed. There was a decrease in contribution of female-authored CT surgery articles submitted to both journals, especially for original research. Future research will elucidate the long-term impact of the pandemic on sex disparities in academic productivity.

3.
Artigo em Inglês | MEDLINE | ID: mdl-35695738

RESUMO

INTRODUCTION: Noninvasive neuromonitoring could be a valuable option for bedside assessment of cerebral dysfunction in patients with coronavirus disease-2019 (COVID-19) admitted to intensive care units (ICUs). This systematic review aims to investigate the use of noninvasive multimodal neuromonitoring in critically ill adult patients with COVID-19 infection. METHODS: MEDLINE/PubMed, Scopus, Cochrane, and EMBASE databases were searched for studies investigating noninvasive neuromonitoring in patients with COVID-19 admitted to ICUs. The monitoring included transcranial Doppler ultrasonography (TCD), the Brain4care Corp. cerebral compliance monitor (B4C), optic nerve sheath diameter (ONSD), near infrared spectroscopy, automated pupillometry, and electroencephalography (EEG). RESULTS: Thirty-two studies that investigated noninvasive neuromonitoring techniques in patients with COVID-19 in the ICU were identified from a systematic search of 7001 articles: 1 study investigating TCD, ONSD and pupillometry; 2 studies investigating the B4C device and TCD; 3 studies investigating near infrared spectroscopy and TCD; 4 studies investigating TCD; 1 case series investigating pupillometry, and 21 studies investigating EEG. One hundred and nineteen patients underwent TCD monitoring, 47 pupillometry, 49 ONSD assessment, 50 compliance monitoring with the B4C device, and 900 EEG monitoring. Alterations in cerebral hemodynamics, brain compliance, brain oxygenation, pupillary response, and brain electrophysiological activity were common in patients with COVID-19 admitted to the ICU; these abnormalities were not clearly associated with worse outcome or the development of new neurological complications. CONCLUSIONS: The use of noninvasive multimodal neuromonitoring in critically ill COVID-19 patients could be considered to facilitate the detection of neurological derangements. Determining whether such findings allow earlier detection of neurological complications or guide appropriate therapy requires additional studies.

4.
Intensive Care Med ; 2022 May 19.
Artigo em Inglês | MEDLINE | ID: mdl-35587274

RESUMO

PURPOSE: The aim of this Intensive Care Medicine Rapid Practice Guideline (ICM­RPG) was to formulate evidence­based guidance for the use of dexmedetomidine for sedation in invasively mechanically ventilated adults in the intensive care unit (ICU). METHODS: We adhered to the methodology for trustworthy clinical practice guidelines, including use of the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence, and the Evidence-to-Decision framework to generate recommendations. The guideline panel comprised 28 international panelists, including content experts, ICU clinicians, methodologists, and patient representatives. Through teleconferences and web­based discussions, the panel provided input on the balance and magnitude of the desirable and undesirable effects, the certainty of evidence, patients' values and preferences, costs and resources, feasibility, acceptability, and research priorities. RESULTS: The ICM­RPG panel issued one weak recommendation (suggestion) based on overall moderate certainty of evidence: "In invasively mechanically ventilated adult ICU patients, we suggest using dexmedetomidine over other sedative agents, if the desirable effects including a reduction in delirium are valued over the undesirable effects including an increase in hypotension and bradycardia". CONCLUSION: This ICM-RPG provides updated evidence-based guidance on the use of dexmedetomidine for sedation in mechanically ventilated adults, and outlines uncertainties and research priorities.

5.
Ann Thorac Surg ; 2022 May 18.
Artigo em Inglês | MEDLINE | ID: mdl-35595089

RESUMO

The coronavirus disease 2019 (COVID-19) pandemic continues to disrupt the provision of cardiac procedural services due to overwhelming interval surges in COVID-19 cases and the associated crisis of cardiac intervention deferment. Despite the availability of widespread testing, highly efficacious vaccines, and intensive public health efforts, the pandemic is entering its third year, where new severe acute respiratory syndrome-coronavirus-2 variants have increased the likelihood that patients scheduled for a cardiac intervention will contract COVID-19 in the perioperative period. The Society of Thoracic Surgeons (STS) Workforce on Critical Care, the STS Workforce on Adult Cardiac and Vascular Surgery, and the Canadian Society of Cardiac Surgeons have developed this document, endorsed by the STS and affirmed by the Society of Cardiovascular Angiography and Interventions and the Canadian Association of Interventional Cardiology, to provide guidance for cardiac procedure deferment and intervention timing for preoperative patients diagnosed with COVID-19. This document is intended for the perioperative cardiac surgical team and outlines the present state of the pandemic, the impact of COVID-19 on intervention outcome, and offers a recommended algorithm for individualized cardiac procedure triage and timing.

6.
Perioper Med (Lond) ; 11(1): 19, 2022 Apr 28.
Artigo em Inglês | MEDLINE | ID: mdl-35477446

RESUMO

Advances in cardiac surgical operative techniques and myocardial protection have dramatically improved outcomes in the past two decades. An unfortunate and unintended consequence is that 80% of the preventable morbidity and mortality following cardiac surgery now originates outside of the operating room. Our hope is that a renewed emphasis on evidence-based best practice and standardized perioperative care will reduce overall morbidity and mortality and improve patient-centric care. The Perioperative Quality Initiative (POQI) and Enhanced Recovery After Surgery-Cardiac Society (ERAS® Cardiac) have identified significant evidence gaps in perioperative medicine related to cardiac surgery, defined as areas in which there is significant controversy about how best to manage patients. These five areas of focus include patient blood management, goal-directed therapy, acute kidney injury, opioid analgesic reduction, and delirium.

7.
J Cardiothorac Surg ; 17(1): 69, 2022 Apr 06.
Artigo em Inglês | MEDLINE | ID: mdl-35382846

RESUMO

BACKGROUND: While fast track clinical pathways have been demonstrated to reduce resource utilization in patients undergoing cardiac surgery, it remains unclear as to whether they adversely affect post-operative outcomes. The purpose of this study was to determine the impact of fast tracking on post-operative outcomes following cardiac surgery. METHODS: In a retrospective study, all patients undergoing first-time, on-pump, non-emergent coronary artery bypass grafting, valve, or coronary artery bypass grafting + valve at a single centre between 2010 and 2017 were included. Patients were considered to have been fast tracked if they were extubated and transferred from intensive care to a step-down unit on the same day as their procedure. The risk-adjusted effect of fast tracking on a 30-day composite of all-cause mortality, stroke, renal failure, infection, atrial fibrillation, and readmission to hospital was determined. Furthermore, propensity score matching was used to match fasting track patients in a 1-to-1 manner with their nearest "neighbor" in the control group and subsequently compared in terms of 30-day post-operative outcomes. RESULTS: 3252 patients formed the final study population (fast track: n = 245; control: n = 3007). Patients who were fast tracked experienced reduced time to initial extubation (4.3 vs. 5.6 h, p < 0.0001) and lower median initial intensive care unit length of stay (7.8 vs. 20.4 h, p < 0.0001). Fast tracked patients experienced lower 30-day rates of the composite outcome (42.4% vs. 51.5%, p = 0.008). However, following propensity score matching, fast tracked patients experienced similar 30-day rates of the composite outcome as the control group (42.4% vs. 44.5%, p = 0.72). After risk adjustment using multivariable regression modeling, fast tracking was predictive of an improved 30-day composite outcome (OR 0.75, 95% CI 0.57-0.98, p = 0.03). CONCLUSION: Fast track clinical pathways was associated with reduced intensive care unit, overall length of stay and similar 30-day post-operative outcomes. These results suggest that fast tracking appropriate patients may reduce resource utilization, while maintaining patient safety.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Extubação , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte de Artéria Coronária , Humanos , Tempo de Internação , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos
8.
BMC Cardiovasc Disord ; 22(1): 123, 2022 03 23.
Artigo em Inglês | MEDLINE | ID: mdl-35321649

RESUMO

BACKGROUND: The influence of renin-angiotensin-aldosterone system (RAAS) inhibitors on the critically ill COVID-19 patients with pre-existing hypertension remains uncertain. This study examined the impact of previous use of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) on the critically ill COVID-19 patients. METHODS: Data from an international, prospective, observational cohort study involving 354 hospitals spanning 54 countries were included. A cohort of 737 COVID-19 patients with pre-existing hypertension admitted to intensive care units (ICUs) in 2020 were targeted. Multi-state survival analysis was performed to evaluate in-hospital mortality and hospital length of stay up to 90 days following ICU admission. RESULTS: A total of 737 patients were included-538 (73%) with pre-existing hypertension had received ACEi/ARBs before ICU admission, while 199 (27%) had not. Cox proportional hazards model showed that previous ACEi/ARB use was associated with a decreased hazard of in-hospital death (HR, 0.74, 95% CI 0.58-0.94). Sensitivity analysis adjusted for propensity scores showed similar results for hazards of death. The average length of hospital stay was longer in ACEi/ARB group with 21.2 days (95% CI 19.7-22.8 days) in ICU and 6.7 days (5.9-7.6 days) in general ward compared to non-ACEi/ARB group with 16.2 days (14.1-18.6 days) and 6.4 days (5.1-7.9 days), respectively. When analysed separately, results for ACEi or ARB patient groups were similar for both death and discharge. CONCLUSIONS: In critically ill COVID-19 patients with comorbid hypertension, use of ACEi/ARBs prior to ICU admission was associated with a reduced risk of in-hospital mortality following adjustment for baseline characteristics although patients with ACEi/ARB showed longer length of hospital stay. Clinical trial registration The registration number: ACTRN12620000421932; The date of registration: 30, March 2020; The URL of the registration: https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12620000421932 .


Assuntos
COVID-19 , Hipertensão , Antagonistas de Receptores de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Estudos de Coortes , Estado Terminal , Mortalidade Hospitalar , Humanos , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Estudos Prospectivos , Sistema Renina-Angiotensina , Estudos Retrospectivos
9.
Artigo em Inglês | MEDLINE | ID: mdl-35346489

RESUMO

OBJECTIVES: Long-term data on patient survivors after extracorporeal membrane oxygenation (ECMO) support remains limited. This study sought to examine the 5-year survival and health-related quality of life (HRQoL) of patients treated with venoarterial (VA)- or venovenous (VV)-ECMO. METHODS: A single-center retrospective chart review and survival analysis was conducted on all patients who required ECMO from December 2007 to June 2019. Cross-sectional HRQoL assessments were performed using 8 standardized questionnaires among survivors. RESULTS: Records for 370 ECMO patients (288 VA-ECMO, 82 VV-ECMO) were reviewed. Survival at 5 years was 33% (VA-ECMO) and 36% (VV-ECMO). Among patients that survived to 30 days, 5-year survival rates were 73% (VA-ECMO) and 71% (VV-ECMO). Sixty surviving patients (56%) had HRQoL assessments (48 VA-ECMO, 12 VV-ECMO). Median follow-up time was 4.2 (VA-ECMO) and 5.7 years (VV-ECMO). Fourteen (29%) VA-ECMO patients and 9 (75%) VV-ECMO patients reported difficulty with any activity of daily living whereas 13 (27%) VA-ECMO patients and 8 (67%) VV-ECMO patients reported difficulty with any instrumental activity of daily living. Eleven (23%) VA-ECMO patients and 7 (58%) VV-ECMO patients reported a high post-traumatic stress disorder score. Low decision regret scores in both cohorts indicated minimal regret that ECMO was initiated. CONCLUSIONS: Five-year clinical and patient-centered outcomes of patients requiring ECMO support is acceptable in those who survived the initial 30 days. Among ECMO survivors, persistent HRQoL concerns were apparent, highlighting the importance of longer-term postdischarge follow-up.

12.
BMC Geriatr ; 22(1): 13, 2022 01 03.
Artigo em Inglês | MEDLINE | ID: mdl-34979966

RESUMO

Healthcare systems need to adapt to better serve an aging population with complex presentations. Frailty assessments are a potential means to address this heterogeneity in aging to identify individuals at increased risk for adverse health outcomes. Furthermore, frailty assessments offer an opportunity to optimize patient care in various healthcare settings. While the vast number of frailty assessment tools available can be a source of confusion for clinicians, each tool has features adaptable to the constraints and goals of different healthcare settings. This review discusses and compares barriers, facilitators, and the application of frailty assessments in primary care, the emergency department/intensive care unit and surgical care to cover a breadth of settings with different frailty assessment considerations. The implementation of frailty-aware care across healthcare settings potentiates better healthcare outcomes for older adults.


Assuntos
Fragilidade , Idoso , Envelhecimento , Atenção à Saúde , Serviço Hospitalar de Emergência , Idoso Fragilizado , Fragilidade/diagnóstico , Fragilidade/epidemiologia , Avaliação Geriátrica , Humanos , Atenção Primária à Saúde
14.
J Thorac Cardiovasc Surg ; 163(2): 725-734, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-32859411

RESUMO

BACKGROUND: Delirium after cardiac surgery is associated with prolonged intensive care unit (ICU) and hospital length of stay and elevated rates of mortality. The Society of Thoracic Surgery National Database (STS-ND) includes delirium in routine data collection but restricts its definition to hyperactive symptoms. The objective is to determine whether the Confusion Assessment Method for ICU (CAM-ICU), which includes hypo- and hyperactive symptoms, is associated with improved prediction of poor 1-year functional survival following cardiac surgery. METHODS: Clinical and administrative databases were used to determine the influence of postoperative delirium on 1-year poor functional survival, defined as being institutionalized or deceased at 1 year. Patients experiencing postoperative delirium using the STS-ND definition (2007-2009) were compared with patients with delirium identified by the CAM-ICU (2010-2012). A propensity score match was undertaken, and multivariable Cox proportional hazards regression models were generated to determine risk of poor 1-year functional survival. RESULTS: There were 2756 and 2236 patients in the STS-ND and CAM-ICU cohorts, respectively. Propensity matching resulted in a cohort of 1835 patients (82.1% matched). The overall rate of delirium in the matched study population was 7.6% in the STS-ND cohort and 13.0% in the CAM-ICU cohort (P < .001). Delirium in the CAM-ICU cohort was independently associated with poor 1-year functional survival (hazard ratio, 2.58; 95% confidence interval, 1.20-5.54; P = .02); delirium in the STS-ND cohort was not associated with poor 1-year functional survival (hazard ratio, 0.92; 95% confidence interval, 0.49-1.71; P = .79). CONCLUSIONS: A systematic screening tool identifies postoperative delirium with improved prediction of poor 1-year functional survival following cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Delírio/diagnóstico , Indicadores Básicos de Saúde , Terminologia como Assunto , Idoso , Procedimentos Cirúrgicos Cardíacos/mortalidade , Lista de Checagem , Bases de Dados Factuais , Delírio/classificação , Delírio/mortalidade , Feminino , Estado Funcional , Humanos , Incidência , Tempo de Internação , Masculino , Manitoba/epidemiologia , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
15.
J Thorac Cardiovasc Surg ; 163(5): 1900-1901, 2022 05.
Artigo em Inglês | MEDLINE | ID: mdl-32896375
19.
J Thorac Cardiovasc Surg ; 163(1): 16-23.e7, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-32334886

RESUMO

OBJECTIVE: Spinal cord ischemia (SCI) is a devastating complication of thoracoabdominal aortic aneurysm repair. We aim to characterize current practices pertaining to SCI prevention and treatment across Canada. METHODS: Two questionnaires were developed by the Canadian Thoracic Aortic Collaborative and the Canadian Cardiovascular Critical Care Society targeting aortic surgeons and intensivists. A list of experts in the management of patients at risk of SCI was developed, with representation from each of the Canadian centers that perform complex aortic surgery. RESULTS: The response rate was 91% for both intensivists (21/23), and from cardiac and vascular surgeons (39/43). Most surgeons agreed that staging is important during endovascular repair of extent II thoracoabdominal aortic aneurysm (60%) but not for open repair (34%). All of the surgeons felt prophylactic lumbar drains were effective in reducing SCI, whereas only 66.7% of intensivists felt that lumbar drains were effective (P < .001). There was consensus among surgeons over when to employ lumbar drains. A majority of surgeons preferred to keep the hemoglobin over 100 g/L if the patient demonstrated loss of lower-extremity function, whereas most intensivists felt a target of 80 g/L was adequate (P < .001). Management of perioperative antihypertensives, use of intraoperative adjuncts, and management of venous thromboembolism prophylaxis in the presence of a lumbar drain, were highly variable. CONCLUSIONS: We observed some consensus but considerable variability in the approach to SCI prevention and management across Canada. Future studies focused on the areas of variability may lead to more consistent and improved care for this high-risk population.


Assuntos
Anti-Hipertensivos/uso terapêutico , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Drenagem/métodos , Procedimentos Endovasculares , Região Lombossacral , Complicações Pós-Operatórias , Isquemia do Cordão Espinal , Idoso , Atitude do Pessoal de Saúde , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Canadá/epidemiologia , Consenso , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Feminino , Hemoglobinas/análise , Humanos , Região Lombossacral/patologia , Região Lombossacral/cirurgia , Masculino , Paraparesia/diagnóstico , Paraparesia/etiologia , Paraparesia/prevenção & controle , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/terapia , Risco Ajustado/métodos , Isquemia do Cordão Espinal/sangue , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Isquemia do Cordão Espinal/prevenção & controle
20.
Front Neurol ; 13: 814405, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35493827

RESUMO

Introduction: Neurological complications are frequent in patients with coronavirus disease-2019 (COVID-19). The use of non-invasive neuromonitoring in subjects without primary brain injury but with potential neurological derangement is gaining attention outside the intensive care unit (ICU). This systematic review and meta-analysis investigates the use of non-invasive multimodal neuromonitoring of the brain in non-critically ill patients with COVID-19 outside the ICU and quantifies the prevalence of abnormal neuromonitoring findings in this population. Methods: A structured literature search was performed in MEDLINE/PubMed, Scopus, Cochrane, and EMBASE to investigate the use of non-invasive neuromonitoring tools, including transcranial doppler (TCD); optic nerve sheath diameter (ONSD); near-infrared spectroscopy (NIRS); pupillometry; and electroencephalography (EEG) inpatients with COVID-19 outside the ICU. The proportion of non-ICU patients with CVOID-19 and a particular neurological feature at neuromonitoring at the study time was defined as prevalence. Results: A total of 6,593 records were identified through literature searching. Twenty-one studies were finally selected, comprising 368 non-ICU patients, of whom 97 were considered for the prevalence of meta-analysis. The pooled prevalence of electroencephalographic seizures, periodic and rhythmic patterns, slow background abnormalities, and abnormal background on EEG was.17 (95% CI 0.04-0.29), 0.42 (95% CI 0.01-0.82), 0.92 (95% CI 0.83-1.01), and.95 (95% CI 0.088-1.09), respectively. No studies investigating NIRS and ONSD outside the ICU were found. The pooled prevalence for abnormal neuromonitoring findings detected using the TCD and pupillometry were incomputable due to insufficient data. Conclusions: Neuromonitoring tools are non-invasive, less expensive, safe, and bedside available tools with a great potential for both diagnosis and monitoring of patients with COVID-19 at risk of brain derangements. However, extensive literature searching reveals that they are rarely used outside critical care settings.Systematic Review Registration: www.crd.york.ac.uk/prospero/display_record.php?RecordID=265617, identifier: CRD42021265617.

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