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1.
Anesthesiology ; 126(5): 799-809, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28207437

RESUMO

BACKGROUND: Statins may reduce the risk of pulmonary and neurologic complications after cardiac surgery. METHODS: The authors acquired data for adults who had coronary artery bypass graft, valve surgery, or combined procedures. The authors matched patients who took statins preoperatively to patients who did not. First, the authors assessed the association between preoperative statin use and the primary outcomes of prolonged ventilation (more than 24 h), pneumonia (positive cultures of sputum, transtracheal fluid, bronchial washings, and/or clinical findings consistent with the diagnosis of pneumonia), and in-hospital all-cause mortality, using logistic regressions. Second, the authors analyzed the collapsed composite of neurologic complications using logistic regression. Intensive care unit and hospital length of stay were evaluated with Cox proportional hazard models. RESULTS: Among 14,129 eligible patients, 6,642 patients were successfully matched. There was no significant association between preoperative statin use and prolonged ventilation (statin: 408/3,321 [12.3%] vs. nonstatin: 389/3,321 [11.7%]), pneumonia (44/3,321 [1.3%] vs. 54/3,321 [1.6%]), and in-hospital mortality (52/3,321 [1.6%] vs. 43/3,321 [1.3%]). The estimated odds ratio was 1.06 (98.3% CI, 0.88 to 1.27) for prolonged ventilation, 0.81 (0.50 to 1.32) for pneumonia, and 1.21 (0.74 to 1.99) for in-hospital mortality. Neurologic outcomes were not associated with preoperative statin use (53/3,321 [1.6%] vs. 56/3,321 [1.7%]), with an odds ratio of 0.95 (0.60 to 1.50). The length of intensive care unit and hospital stay was also not associated with preoperative statin use, with a hazard ratio of 1.04 (0.98 to 1.10) for length of hospital stay and 1.00 (0.94 to 1.06) for length of intensive care unit stay. CONCLUSIONS: Preoperative statin use did not reduce pulmonary or neurologic complications after cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Inibidores de Hidroximetilglutaril-CoA Redutases/farmacologia , Doenças do Sistema Nervoso/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Transtornos Respiratórios/prevenção & controle , Idoso , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial/estatística & dados numéricos , Fatores de Risco , Resultado do Tratamento
2.
Eur J Cardiothorac Surg ; 50(2): 344-9, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26825108

RESUMO

OBJECTIVES: This investigation was undertaken to analyse the association between body mass index (BMI) and morbidity after coronary artery bypass graft (CABG) operations. METHODS: The setting was a cardiovascular intensive care unit (ICU) of a tertiary medical referral centre. This was a retrospective review; patients were classified according to their BMI into five groups: underweight <18.5 kg/m(2); normal weight 18.5-24.9 kg/m(2); overweight 25-29.9 kg/m(2); Class I obesity 3034.9 kg/m(2); and Class II/III obesity >35 kg/m(2). We included patients who underwent isolated CABG between January 3, 2006 and March 8, 2011. After including only the initial operation or admission in patients with more than one operation or hospital admission and excluding patients with any missing variable, 3470 patients remained in the analyses. The primary outcomes analysed were hospital mortality and pulmonary and infection morbidities. We secondarily assessed the association between BMI category and each of the three outcomes. RESULTS: Respective mortality, and pulmonary and infection morbidity occurrence rates were: 8.7, 13.0 and 13.0% for the underweight; 2.4, 8.0 and 4.8% for the overweight; 1.8, 10.9 and 5.6% for the Class I obesity group; and 2.7, 11.1 and 5.7% for the Class II/III obesity group, vs 2.3, 7.0 and 6.2% for the normal weight group. Class I and II/III obesity patients were more likely to have pulmonary morbidity compared with the normal weight group, after adjusting for the potential confounding variables. CONCLUSIONS: Class I and Class II/III obesity (BMI ≥30 kg/m(2)) was associated with increased pulmonary morbidity after CABG operations. There was no difference in mortality or infection morbidity in any BMI group compared with the normal group.


Assuntos
Índice de Massa Corporal , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Obesidade/complicações , Complicações Pós-Operatórias/epidemiologia , Idoso , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Ohio/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
3.
J Cardiothorac Vasc Anesth ; 29(3): 611-6, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25847409

RESUMO

OBJECTIVE: To assess the association of preoperative brain natriuretic peptide with atrial arrhythmias and length of stay after cardiac surgery. DESIGN: A retrospective data analysis. SETTING: All data were collected from patients who underwent cardiac surgery at a single institution, an academic hospital, between 2005 and 2010. PARTICIPANTS: Patient data were collected from the authors' institution's Perioperative Health Documentation System of cardiac surgeries. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The major findings were that individuals with a 10-pg/mL increase in brain natriuretic peptide were 1.005 (95% CI: 1.002, 1.009) times more likely to have an atrial arrhythmia than those with no increase in brain natriuretic peptide. A brain natriuretic peptide value ≥306 pg/mL was calculated to best predict an atrial arrhythmia. Those above the threshold were 1.455 (95% CI: 1.087, 1.947) times more likely to have an atrial arrhythmia than those below the threshold. Individuals above the threshold had a median of 3 days in the intensive care unit compared to 1 day for those below the threshold, as well as median hospital stays of 11 days for those below the threshold. CONCLUSIONS: The results indicated that elevated brain natriuretic peptide was associated with increased risk of atrial arrhythmias and prolonged length of hospital stay after cardiac surgery. Identifying at-risk patients is important to guide preventative strategies for postoperative atrial arrhythmias.


Assuntos
Fibrilação Atrial/sangue , Ponte de Artéria Coronária/efeitos adversos , Peptídeo Natriurético Encefálico/sangue , Complicações Pós-Operatórias/sangue , Cuidados Pré-Operatórios , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/etiologia , Biomarcadores/sangue , Feminino , Humanos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Cuidados Pré-Operatórios/métodos , Estudos Retrospectivos
4.
J Intensive Care Med ; 30(6): 338-43, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24488037

RESUMO

PURPOSE: Postoperative positive end-expiratory pressure (PEEP) selection in patients who are mechanically ventilated after cardiac operations often seems random. The aim of this investigation was to compare the 2 most common postoperative initial PEEP settings at our institution, 8 and 5 cm H2O, on postoperative initial tracheal intubation time (primary outcome); cardiovascular intensive care unit (CVICU); hospital length of stay (LOS); occurrence of pneumonia; and hospital mortality (secondary outcomes). MATERIALS AND METHODS: The electronic medical records of patients who were mechanically ventilated after isolated coronary artery bypass grafting (CABG) or combined CABG and valve operations were reviewed. Propensity score matching was used to compare patients with an initial postoperative PEEP setting of 8 cm H2O (n = 4722 [25.9%]) with those who had PEEP of 5 cm H2O (n = 13 535 [74.1%]) on the primary and secondary outcomes listed earlier. RESULTS: There was no difference in initial postoperative intubation time between the PEEP of 8 cm H2O and the PEEP of 5 cm H2O patient groups (mean 11.9 vs 12.0 hours [median 8.2 vs 8.8 hours], P = .89). The groups did not differ on the occurrence of pneumonia (0.43% vs 0.60%, P = .25) nor on hospital mortality (0.47% vs 0.43%, P = .76). Aspiration pneumonia occurrence approached a significant difference (0.06% vs 0.21%, P value = .052), as did CVICU LOS (mean: 47.9 vs 49.8 hours [median: 28.5 vs 28.4 hours], P = .057), but were not statistically different. There was a slight but likely clinically unimportant difference in hospital LOS (7.7 vs 7.4 days, PEEP = 8 vs 5, P < .001). CONCLUSION: Patients being mechanically ventilated after cardiac operations with an initial postoperative PEEP setting of 8 versus 5 cm H2O differed significantly only on hospital LOS but the difference was likely clinically unimportant. Thus, use of 8 cm H2O PEEP in these patients without a clinical indication, although likely not harmful, does not seem beneficial.


Assuntos
Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Respiração com Pressão Positiva/métodos , Complicações Pós-Operatórias/epidemiologia , Respiração Artificial/métodos , Água/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Intubação Intratraqueal/estatística & dados numéricos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pneumonia Aspirativa/epidemiologia , Pneumonia Aspirativa/etiologia , Respiração com Pressão Positiva/efeitos adversos , Complicações Pós-Operatórias/etiologia , Pontuação de Propensão , Respiração Artificial/efeitos adversos , Fatores de Tempo , Adulto Jovem
5.
J Clin Anesth ; 26(8): 634-42, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25439402

RESUMO

STUDY OBJECTIVE: To determine whether postoperative cardiac surgery patients who are sedated with dexmedetomidine have fewer atrial arrhythmias, and whether dexmedetomidine is associated with fewer renal and more gastrointestinal (GI) complications. DESIGN: Retrospective study. SETTING: Urban academic hospital. MEASUREMENTS: The records of 765 postoperative cardiac surgery patients who were given dexmedetomidine for postoperative sedation in the intensive care unit (ICU) were studied. Data from the hospital's Cardiac Anesthesiology database between the years 2005 and 2010 were evaluated. Records of patients whose ASA physical status was > 4 or who were < 18 years of age were excluded from the study. Patients who were and were not given dexmedetomidine were compared for postoperative sedation within three days after cardiac surgery using multivariable logistic regression, adjusting for imbalanced covariables. MAIN RESULTS: The records of 17,776 patients, including 765 cardiac patients given dexmedetomidine for postoperative sedation in the ICU, were reviewed. Patients who received postoperative dexmedetomidine had a lower risk of having atrial arrhythmias: (OR 0.74 (95% CI: 0.60, 0.91; P = 0.004). Dexmedetomidine was not associated with 30-day mortality (1.10, 0.40 - 3.02; P = 0.86), or with any of the following 30-day outcomes: surgical infection (0.72, 0.36-1.42; P = 0.34), systemic infection (1.38, 0.93 - 2.05; P = 0.11), GI complications (1.34, 0.74 - 2.42; P = 0.33), or renal complications (1.23, 0.70 - 2.15; P = 0.48). CONCLUSIONS: Dexmedetomidine use after cardiac surgery was associated with a lower incidence of atrial arrhythmias.


Assuntos
Fibrilação Atrial/prevenção & controle , Flutter Atrial/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/métodos , Dexmedetomidina/administração & dosagem , Adulto , Idoso , Fibrilação Atrial/epidemiologia , Flutter Atrial/epidemiologia , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/farmacologia , Unidades de Terapia Intensiva , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos
6.
PLoS One ; 8(5): e63831, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23724006

RESUMO

OBJECTIVE: To determine the effect of vitamin D on postoperative outcomes in cardiac surgical patients. DESIGN: Retrospective study. SETTING: Single institution-teaching hospital. PARTICIPANTS: Adult cardiac surgical patients with perioperative 25-hydroxyvitamin D measurements. INTERVENTIONS: None. We gathered information from the Cardiac Anesthesiology Registry that was obtained at the time of the patients' visit/hospitalization. MEASUREMENTS AND MAIN RESULTS: We used data of 18,064 patients from the Cardiac Anesthesiology Registry; 426 patients with 25-hydroxyvitamin D measurements met our inclusion criteria. Association with Vitamin D concentration and composite of 11 cardiac morbidities was done by multivariate (i.e., multiple outcomes per subject) analysis. For other outcomes separate multivariable logistic regressions and adjusting for the potential confounders was used. The observed median vitamin D concentration was 19 [Q1-Q3∶12, 30] ng/mL. Vitamin D concentration was not associated with our primary composite of serious cardiac morbidities (odds ratio [OR], 0.96; 95% CI, 0.86-1.07). Vitamin D concentration was also not associated with any of the secondary outcomes: neurologic morbidity (P = 0.27), surgical (P = 0.26) or systemic infections (P = 0.58), 30-day mortality (P = 0.55), or length of initial intensive care unit (ICU) stay (P = 0.04). CONCLUSIONS: Our analysis suggests that perioperative vitamin D concentration is not associated with clinically important outcomes, likely because the outcomes are overwhelmingly determined by other baseline and surgical factors.


Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Morbidade , Vitamina D/análogos & derivados , Adulto , Humanos , Resultado do Tratamento , Vitamina D/sangue
7.
Ann Thorac Surg ; 95(2): 486-92, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-22959571

RESUMO

BACKGROUND: Early predictors of morbidity after cardiac operations are lacking. Elevated lactate concentrations in the immediate postoperative period reflect unmet metabolic demand and may be associated with outcome. This study examined the association between early plasma lactate concentrations and outcome after cardiac operations. METHODS: As a retrospective cohort investigation, patient information was obtained from the Cardiovascular Information and the Anesthesiology Institute's patient registries. Inclusion criteria were all adult cardiac surgical patients undergoing isolated coronary artery bypass grafting or valve procedures, or coronary artery bypass grafting with a valve procedure, from January 1, 2008, to August 7, 2008 (arterial lactate values were added to the patient registry beginning January 1, 2008). RESULTS: Lactate concentrations during the initial 12 postoperative hours of a patient's stay in the cardiovascular intensive care unit were averaged (mean lactate concentration), and linear regression concentrations over time were used to predict when the lactate concentration would reach 1.5 mmol/L in individual patients (predicted lactate clearance time). We also considered the product of the mean and clearance (product value). Predicted lactate clearance time, mean lactate concentration, and product value were associated with any type of reoperation, death, and a set of composite outcomes (p < 0.001 for each). The accuracy of these indices was moderate to good, with the highest C statistic (for product value) being 0.82. CONCLUSIONS: Predicted lactate clearance time, mean lactate concentration, and product value are each associated with death, any type of reoperation, and a set of composite outcomes in patients undergoing coronary artery bypass grafting or valve operations, or both. Product value provided the best early prognostic guidance in individual patients.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Ácido Láctico/sangue , Complicações Pós-Operatórias/epidemiologia , Adulto , Causas de Morte , Estudos de Coortes , Humanos , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Tempo
8.
J Am Coll Surg ; 214(6): 1008-16.e4, 2012 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22541987

RESUMO

BACKGROUND: The best time to perform a tracheostomy in cardiac surgery patients who require prolonged postoperative mechanical ventilation remains unknown. The primary aim of this investigation was to determine if tracheostomy performed before postoperative day 10 improves patient outcomes. STUDY DESIGN: We conducted a retrospective review of prospectively collected patient information obtained from the Anesthesiology Institute Patient Registry on adult patients recovering from coronary artery bypass grafting and/or valve surgery. Demographic and comorbidity patient variables were obtained. Patients were divided into 2 groups based on the timing of their tracheostomy: early (less than 10 days) and late (14 to 28 days). The 2 patient groups were matched using propensity scores and compared on morbidity and in-hospital mortality outcomes. The primary outcomes measures were length of stay, morbidity, and in-hospital mortality. RESULTS: After propensity matching (n = 114 patients/group), early tracheostomy was associated with decreased in-hospital mortality (21.1% vs 40.4%, p = 0.002) and cardiac morbidity (14.0% vs 33.3%, p < 0.001), along with decreased ICU (median difference 7.2 days, p < 0.001) and hospital (median difference 7.5 days, p = 0.010) durations. The occurrence of sternal wound infection (6.0% vs 19.5%, p = 0.009) was less in the early tracheostomy group, but mediastinitis did not differ significantly (3.5% vs 7.0%, p = 0.24). CONCLUSIONS: Tracheostomy within 10 postoperative days in cardiac surgery patients who require prolonged mechanical ventilation was associated with decreased length of stay, morbidity, and mortality.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/prevenção & controle , Respiração Artificial/métodos , Traqueostomia/métodos , Adulto , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Incidência , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Estados Unidos/epidemiologia
9.
J Card Surg ; 27(2): 246-52, 2012 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22372761

RESUMO

Extracorporeal membrane oxygenation (ECMO) technology has undergone several advancements over the last decade. We sought to compare current ECMO technology to older ones to determine how these technological improvements have impacted outcomes in patients suffering from postcardiotomy cardiogenic shock (PCS). Between 2005 and 2010, 49 patients received ECMO as support for PCS following elective cardiac surgery. Patients were divided into three groups. Group 1 (Gp 1, n = 11) patients received a Biomedicus pump with an Affinity oxygenator, Group 2 (Gp 2, n = 11) patients received a Biomedicus pump with a Quadrox D oxygenator, and Group 3 (Gp 3, n = 27) patients received a Rotaflow pump with a Quadrox D oxygenator. Groups were compared with regards to adverse events and ability to wean. Adverse event analysis showed no statistically significant difference between groups in incidence of stroke (p = 0.08), renal failure (p = 0.88), or bleeding requiring reexploration (p = 0.10). Changes in technology did little to improve weaning rates from ECMO (Gp 1 = 63.6%, Gp 2 = 45.5%, and Gp 3 = 55.6%). Similar trends were detected in hospital survival (Gp 1 = 27.3%, Gp 2 = 27.3%, and Gp 3 = 33.3%). Technology did impact oxygenator durability with Gp 1 requiring seven (63.6%) oxygenator exchanges compared to zero (0.0%) in Gp 2 and two (7.4%) in Gp 1. While advancements in ECMO technology have resulted in improved oxygenator durability, outcomes in patients requiring such support for PCS continue to be poor.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Procedimentos Cirúrgicos Eletivos , Oxigenação por Membrana Extracorpórea/instrumentação , Complicações Pós-Operatórias/terapia , Choque Cardiogênico/terapia , Idoso , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Choque Cardiogênico/etiologia , Choque Cardiogênico/mortalidade , Resultado do Tratamento
10.
Ann Thorac Surg ; 90(1): 109-15, 2010 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-20609758

RESUMO

BACKGROUND: Gastrointestinal (GI) complications after coronary artery bypass graft surgery (CABG) are uncommon but associated with a disproportionate share of mortality. We thus identified variables associated with GI complications and analyzed their effect on postoperative mortality in patients undergoing isolated CABG. METHODS: Information from patients who underwent isolated CABG at our institution during a 12-year period was obtained from the Anesthesiology Institute patient registry. Patients who experienced one or more postoperative GI complication(s) during their initial intensive care unit stay were identified. Multivariable logistic regression with backward variable selection was used to determine variables associated with GI complications and to evaluate their effect on mortality. RESULTS: Among 16,043 patients who underwent isolated CABG, 213 (1.43%) had one or more GI complication(s). The main patient variables associated with postoperative GI complications included preoperative (odds ratio, 2.43; 95% confidence interval [CI], 1.39 to 4.23; p < 0.001) and intraoperative (odds ratio, 5.07; 95% CI, 3.08 to 8.35; p < 0.001) intraaortic balloon pump insertion, patient age (odds ratio, 1.65; 95% CI, 1.41 to 1.94; p < 0.001), intraoperative fresh-frozen plasma transfusion (odds ratio, 3.38; 95% CI, 2.12 to 5.41; p < 0.001), and cardiogenic shock (odds ratio, 3.04; 95% CI, 1.12 to 8.24). No difference was detected in complication rates between off-pump and on-pump CABG procedures (1.50% versus 1.30%, respectively; p = 0.63). Postoperative GI complication(s) after CABG was associated with a 12.98 times increase in mortality (p < 0.001). CONCLUSIONS: This single-center cohort study indicates that GI complications after isolated CABG remain rare with an incidence 1.43%. However, GI complications portend a significant mortality. The implications of intraoperative administration of fresh-frozen plasma and insertion of an intraaortic balloon pump deserve further investigation as they are associated with GI complications.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Gastroenteropatias/mortalidade , Idoso , Estudos de Coortes , Ponte de Artéria Coronária/mortalidade , Feminino , Gastroenteropatias/etiologia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Fatores de Risco
11.
J Cardiothorac Vasc Anesth ; 24(6): 946-51, 2010 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-20599396

RESUMO

OBJECTIVE: The authors analyzed hospital mortality in adult cardiac surgery patients who required postoperative venoarterial extracorporeal membrane oxygenation (ECMO) support for circulatory failure and identified perioperative patient variables associated with hospital mortality in these patients. DESIGN: A retrospective study. SETTING: A single institution, tertiary academic center. PARTICIPANTS: Adult patients requiring venoarterial ECMO support after cardiac surgery from January 1995 to December 2005 were identified from the Anesthesiology Institute Patient Registry. Twenty-two preselected patient variables were entered into a logistic regression model of hospital death. INTERVENTIONS: None. RESULTS: Two hundred thirty-three of 40,116 (0.58%) adult cardiac surgery patients required postoperative venoarterial ECMO, and among these, 149 (64%) died in the hospital. In an unadjusted analysis, older age, higher preoperative albumin, diabetes history, coronary artery bypass graft surgery, and longer total cardiopulmonary bypass (CPB) time were associated with increased hospital mortality, and a history of cardiogenic shock was associated with decreased mortality. In an adjusted logistic regression analysis, a history of cardiogenic shock and younger age were associated with decreased hospital mortality. The overall use of postoperative venoarterial ECMO in this patient population decreased since its peak in 1996. CONCLUSION: Venoarterial ECMO support after cardiac surgery was required in a small fraction of patients and was associated with very high hospital mortality; but among those requiring ECMO, mortality in these patients was lower in younger, nondiabetic patients with cardiogenic shock who had shorter CPB times. The mortality associated patient variables identified are not easily modifiable and do not appear sufficiently robust to define which patients should be selected for this potentially life-saving therapy.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Oxigenação por Membrana Extracorpórea , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/epidemiologia , Adulto , Fatores Etários , Idoso , Cuidados Críticos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Análise de Sobrevida , Sobreviventes , Resultado do Tratamento , Adulto Jovem
12.
J Cardiothorac Vasc Anesth ; 24(3): 447-50, 2010 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-19800819

RESUMO

OBJECTIVE: The primary aim of this investigation was to compare the incidence of new-onset postoperative atrial arrhythmias (POAAs) in cardiac versus noncardiac thoracic surgery patients. A subgroup analysis also was performed in the cardiac surgery patients comparing POAAs in patients who underwent cardiac surgery on and off cardiopulmonary bypass (CPB). DESIGN: This was a retrospective study using the Department of Cardiothoracic Anesthesia patient registry. All patients (n = 33,500) undergoing cardiac (n = 29,057) and noncardiac thoracic (n = 4,443) surgeries between 1993 and 2004 were identified from the patient registry. Two propensity-matched comparisons for the incidence of POAAs were made: (1) in cardiac surgery patients versus noncardiac thoracic surgery patients and (2) in patients undergoing cardiac surgery with versus without CPB. SETTING: A large metropolitan multidisciplinary clinic. PARTICIPANTS: Patients. INTERVENTION: No interventions were done because this was a retrospective study. MEASUREMENTS AND MAIN RESULTS: The cardiac patients had a significantly higher incidence of POAAs when compared with noncardiac thoracic surgery patients (11.6% v 7.5%, p < 0.001). There was no significant difference in the incidence of POAAs between patients undergoing CPB versus off-pump CPB (13.3% v 12.3%, p = 0.3). CONCLUSION: The incidence of new-onset POAAs was higher in patients undergoing cardiac surgery than in patients undergoing noncardiac thoracic surgery in propensity-matched patient groups. CPB was not associated with new-onset POAAs.


Assuntos
Arritmias Cardíacas/epidemiologia , Procedimentos Cirúrgicos Cardíacos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Torácicos , Idoso , Ponte Cardiopulmonar , Ponte de Artéria Coronária sem Circulação Extracorpórea , Creatinina/sangue , Bases de Dados Factuais , Feminino , Átrios do Coração , Frequência Cardíaca/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tamanho da Amostra
13.
Anesthesiology ; 111(4): 785-9, 2009 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-20029251

RESUMO

BACKGROUND: Human factors such as fatigue, circadian rhythms, scheduling, and staffing may have an impact on patient care over the course of a day across all medical specialties. Research by the transportation industry concludes that human performance is degraded by shift work, circadian rhythm disturbances, and prolonged duty. This study investigated whether the timing of coronary artery bypass graft surgery affects outcomes. METHODS: The outcomes of coronary artery bypass graft surgery patients were analyzed according to the hour of the day, day of the workweek, month, and moon phase in which the surgery started. All patients who underwent isolated coronary artery bypass graft surgery between January 1, 1993 and July 1, 2006 were considered for the study.The primary outcome measurement was a compound morbidity outcome of six variables defined by the Society of Thoracic Surgeons. These outcomes included (1) in-hospital death, (2) acute postoperative myocardial infarction, (3) neurologic morbidity, including focal or global neurologic deficits or death without awakening, (4) serious infection morbidity consisting of sepsis syndrome or septic shock, (5) new-onset renal failure requiring dialysis, and (6) postoperative ventilatory support exceeding 72 h. RESULTS: The composite morbidity and in-hospital mortality rates were 4.8% and 1.4%, respectively. The number of cases each weekday, each month of the year, and during each phase of the moon were consistent. None of the time factors significantly affected the composite morbidity outcome. CONCLUSIONS: Elective coronary artery bypass graft surgery can be scheduled throughout the workday, any day of the work week and in any month of the year without compromising outcome.


Assuntos
Ponte de Artéria Coronária , Vasos Coronários/cirurgia , Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/mortalidade , Idoso , Ponte de Artéria Coronária/mortalidade , Procedimentos Cirúrgicos Eletivos , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Lua , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Doenças do Sistema Nervoso/epidemiologia , Doenças do Sistema Nervoso/etiologia , Assistência Perioperatória , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/mortalidade , Respiração Artificial/mortalidade , Medição de Risco , Estações do Ano , Fatores de Tempo , Resultado do Tratamento
14.
J Cardiothorac Vasc Anesth ; 23(4): 479-83, 2009 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-19285430

RESUMO

OBJECTIVES: The primary objective of this study was to analyze perioperative intra-aortic balloon pump (IABP) insertion in patients undergoing cardiac surgery in the authors' institution from 1995 to 2005 and to propose an explanation for changes in use over this period. A secondary objective was to assess patient variables associated with IABP use. DESIGN: This is a retrospective study including patients who underwent cardiac surgery between 1995 and 2005. SETTING: The Cardiothoracic Anesthesia Patient Registry of a single teaching institution was queried to obtain the required information. PARTICIPANTS: Thirty thousand two hundred sixty-nine cardiac surgery patients. INTERVENTIONS: Intra-aortic balloon pump insertion before surgery, after cardiopulmonary bypass, or in the cardiovascular intensive care unit was assessed in patients who underwent isolated coronary artery bypass graft surgery, valve surgery, or both. Select patient variables were analyzed for their association with IABP insertion. Transesophageal echocardiography (TEE) examinations, milrinone use, and mortality rates also were determined. MEASUREMENTS AND MAIN RESULTS: Among 30,269 cardiac surgery patients, 1,310 (4.32%) underwent IABP insertion. Combined preoperative, intraoperative, and postoperative IABP use decreased from 7.8% in 1995 to 3.0% in 2005. Simultaneously, the intraoperative use of milrinone increased from 4.8% to 8.8% and postoperative use increased from 5.2% to 7.8%. The number of intraoperative TEE examinations more than doubled from approximately 1,700 to 3,500. The overall mortality for patients with preoperative, intraoperative, and postoperative IABP insertion was 12.6%, 17.5%, and 47.7%, respectively. CONCLUSIONS: From 1995 to 2005, preoperative, intraoperative, and postoperative IABP use decreased by approximately 60% in cardiac surgery patients. Simultaneously, the use of TEE and milrinone each doubled. Although a cause-effect relationship cannot be established from the present study's observational data, the trends coincide and may be related.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Balão Intra-Aórtico , Idoso , Procedimentos Cirúrgicos Cardíacos/mortalidade , Ponte Cardiopulmonar , Ponte de Artéria Coronária , Ecocardiografia Transesofagiana , Feminino , Testes de Função Cardíaca , Humanos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/mortalidade , Período Intraoperatório/mortalidade , Modelos Logísticos , Masculino , Milrinona/uso terapêutico , Inibidores de Fosfodiesterase/uso terapêutico , Período Pós-Operatório , Estudos Retrospectivos , Fatores de Risco
15.
Pacing Clin Electrophysiol ; 31(11): 1371-82, 2008 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-18950293

RESUMO

BACKGROUND: Electrocardiographic (ECG) characteristics were analyzed in postoperative cardiac surgery patients in an attempt to predict development of new-onset postoperative atrial fibrillation (AF). METHODS: Nineteen ECG characteristics were analyzed using computer-based algorithms. The parameters were retrospectively analyzed from ECG signals recorded in postoperative cardiac surgery patients while they were in the cardiovascular intensive care unit (CVICU) at our institution. ECG data from 99 patients (of whom 43 developed postoperative AF) were analyzed. A bootstrap variable selection procedure was applied to select the most important ECG parameters, and a multivariable logistic regression model was developed to classify patients who did and did not develop AF. RESULTS: Premature atrial activity (PAC) was greater in AF patients (P < 0.01). Certain heart rate variability (HRV) and turbulence parameters also differed in patients who did and did not develop AF. In contrast, P-wave morphology was similar in patients with and without AF. Receiver operating curve (ROC) analysis applied to the model produced a C-statistic of 0.904. The model thus correctly classified AF patients with more than a 90% sensitivity and a 70% specificity. CONCLUSION: Among the 19 ECG parameters analyzed, PAC activity, frequency-domain HRV, and heart rate turbulence parameters were the best discriminators for postoperative AF.


Assuntos
Fibrilação Atrial/diagnóstico , Fibrilação Atrial/etiologia , Procedimentos Cirúrgicos Cardiovasculares/efeitos adversos , Eletrocardiografia/métodos , Medição de Risco/métodos , Adulto , Fibrilação Atrial/prevenção & controle , Feminino , Humanos , Masculino , Prognóstico , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Risco , Sensibilidade e Especificidade
17.
Ann Thorac Surg ; 85(6): 1974-9, 2008 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-18498805

RESUMO

BACKGROUND: By 2050, the number of people in the United States aged 85 years and older is expected to increase from 4.2 to 20.8 million. We therefore compared outcomes after isolated coronary artery bypass grafting (CABG) in patients aged 85 years and older with those 55 to 65 years old. METHODS: Propensity matching and multivariable analysis were used to compare morbidity and mortality outcomes in 132 patients aged 85 years and older and in 5243 patients aged 55 to 65 years who underwent CABG between 1993 and 2004. Variables of interest were compared using Student t, Wilcoxon rank sum, chi(2), or Fischer exact tests, as appropriate. RESULTS: After propensity matching, each group had 122 patients who were matched on all baseline and intraoperative variables except number of intraoperative red blood cell (RBC) transfusions, which was greater in the older group. Atrial arrhythmias occurred more frequently and intensive care unit (ICU) and hospital lengths of stay (LOS) were longer in the older group. Multiple logistic regression analysis demonstrated that atrial arrhythmias and catheter-related sepsis were more common in the older group. CONCLUSIONS: Older patients received more RBC transfusions, presumably reflecting a lower threshold to transfuse older patients. Atrial arrhythmias were more common in the older group, this can account for their longer ICU and hospital LOS, which can also explain their greater incidence of catheter sepsis. The two age groups had similar mortality and morbidity. Advanced age is not associated with substantively worse outcome after CABG compared with a propensity-matched younger age group.


Assuntos
Ponte de Artéria Coronária , Complicações Pós-Operatórias/etiologia , Centros Médicos Acadêmicos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/etiologia , Estudos Transversais , Transfusão de Eritrócitos , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação/estatística & dados numéricos , Masculino , Análise por Pareamento , Pessoa de Meia-Idade , Ohio , Complicações Pós-Operatórias/epidemiologia , Fatores de Risco , Sepse/epidemiologia , Sepse/etiologia
18.
Artigo em Inglês | MEDLINE | ID: mdl-17946200

RESUMO

A novel automatic QRS detection algorithm that is based on a wavelet pre-filter and an adaptive threshold technique is presented. The algorithm utilizes a bi-orthogonal wavelet filter to de-noise the ECG signal. The QRS complexes are then identified by computing the first derivative of the signal and applying a set of adaptive thresholds that are not limited to a strict range. QRS complexes are identified in multiple ECG channels of a 5-lead configuration and an inter-channel comparison is performed to verify QRS locations. The algorithm was initially developed using ECG signals from Physionet website, but was later refined using ECG data collected from post cardiac surgery patients in the intensive care units. The proposed algorithm was able to detect QRS complexes with high sensitivity (>99%) and specificity (>99%) when compared to the algorithm used in Physionet ECG database. Additionally, the new algorithm can be implemented in real-time and can successfully detect QRS complexes for a wide variety of ECG shapes and characteristics often encountered in cardiac patients.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Algoritmos , Automação , Eletrocardiografia , Frequência Cardíaca , Humanos , Unidades de Terapia Intensiva , Período Pós-Operatório , Sensibilidade e Especificidade , Processamento de Sinais Assistido por Computador
19.
Crit Care Med ; 33(6): 1327-32, 2005 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-15942351

RESUMO

OBJECTIVE: "Renal dose" dopamine (rDA; 1-3 microg/kg per min) is administered to patients after cardiac surgery to preserve or improve renal function. Many of these patients develop new-onset postoperative atrial fibrillation or atrial flutter (pAF) that could be related to rDA administration. The objective of this investigation was to determine whether there was an association between rDA and new-onset pAF in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass (CABG). SETTING: Research hospital. SUBJECTS: The study population consisted of 1,731 patients undergoing CABG. INTERVENTIONS: CABG with and without rDA. DESIGN: After approval by the institutional review board, a retrospective study using the Cardiothoracic Anesthesia Patient Registry was undertaken to determine the association between rDA and pAF in patients undergoing CABG. Patients with a documented history of atrial fibrillation, those who required inotrope use during or after surgery, and those having valve surgery were excluded. MEASUREMENTS AND MAIN RESULTS: One-thousand seven-hundred thirty-one patients undergoing CABG during the period of January 1, 2000, through June 30, 2002, were the study population; of these, 15.0% (260/1,731) developed pAF. The incidence of pAF was 23.3 % (41/176) among patients who received rDA and 14.1% (219/1,555) among those who did not receive rDA. In the multivariable logistic regression model, patient age, gender, chronic obstructive pulmonary disease or asthma, and rDA were associated with pAF (p < .01). Receipt of rDA increased the odds of developing pAF by 74%, independent of the effect of other variables. CONCLUSIONS: Renal-dose dopamine is associated with a 1.74 odds ratio of pAF developing after CABG.


Assuntos
Fibrilação Atrial/induzido quimicamente , Ponte de Artéria Coronária , Dopamina/efeitos adversos , Nefropatias/prevenção & controle , Complicações Pós-Operatórias/induzido quimicamente , Fibrilação Atrial/epidemiologia , Flutter Atrial/induzido quimicamente , Flutter Atrial/epidemiologia , Ponte Cardiopulmonar , Dopamina/administração & dosagem , Feminino , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Ohio/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Fatores de Risco
20.
Ann Thorac Surg ; 76(2): 605-7, 2003 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-12902115

RESUMO

First identified in the United States in 1999, West Nile virus caused approximately 3,500 infections in the late summer and fall of 2002. The virus is predominantly transmitted by mosquitoes, and the risk of infection through blood product transfusion is believed to be low. We present a case of West Nile virus encephalitis transmitted by red blood cell transfusion at the time of coronary artery bypass grafting that resulted in the patient's death. Individuals undergoing procedures with high blood product transfusion requirements, such as cardiac surgery or organ transplantation, may be at higher risk of this nosocomial infection during epidemics.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Transfusão de Eritrócitos/efeitos adversos , Meningoencefalite/virologia , Vírus do Nilo Ocidental/isolamento & purificação , Idoso , Ponte de Artéria Coronária/métodos , Doença das Coronárias/cirurgia , Evolução Fatal , Feminino , Humanos , Meningoencefalite/etiologia , Medição de Risco
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