Comparison of Mask Oxygen Therapy and High-Flow Oxygen Therapy after Cardiopulmonary Bypass in Obese Patients.

Background: To clarify the efficiency of mask O2 and high-flow O2 (HFO) treatments following cardiopulmonary bypass (CPB) in obese patients. Methods: During follow-up, oxygenization parameters including arterial pressure of oxygen (PaO2), peripheral oxygen saturation (SpO2), and arterial partial pressure of carbon dioxide (PaCO2) and physical examination parameters including respiratory rate, heart rate, and arterial pressure were recorded respectively. Presence of atelectasia and dyspnea was noted. Also, comfort scores of patients were evaluated. Results: Mean duration of hospital stay was 6.9 ± 1.1 days in the mask O2 group, whereas the duration was significantly shorter (6.5 ± 0.7 days) in the HFO group (p=0.034). The PaO2 values and SpO2 values were significantly higher, and PaCO2 values were significantly lower in patients who received HFO after 4th, 12th, 24th, 36th, and 48th hours. In postoperative course, HFO leads patients to achieve better postoperative FVC (p < 0.001). Also, dyspnea scores and comfort scores were significantly better in patients who received HFO in both postoperative day 1 and day 2 (p < 0.001, p < 0.001 and p=0.002, p=0.001, resp.). Conclusion: Our study demonstrated that HFO following CPB in obese patients improved postoperative PaO2, SpO2, and PaCO2 values and decreased the atelectasis score, reintubation, and mortality rates when compared with mask O2.

Pulmonary vascular resistance index during coronary artery bypass surgery with aprotinin.

Low pulmonary vascular resistance index (PVRI) reflects favorable redundant pulmonary circulation following coronary artery bypass grafting with cardiopulmonary bypass surgery (CPB). This randomized study investigated whether aprotinin given in different modalities impacts PVRI after coronary artery bypass grafting. A total of 40 patients undergoing coronary artery bypass grafting were randomized to four groups according to aprotinin dose: (1) high dose, (2) early low dose, (3) late low dose, and (4) without aprotinin. Oxygenation index, pulmonary shunt, alveolar-arterial oxygen gradient and PVRI were determined. PVRI was calculated as the transpulmonary pressure gradient divided by cardiac index multiplied by 80. The results showed that PVRI remained relative low in all patients provided aprotinin regardless of treatment dosage; PVRI increased at 4 h after restarting ventilation after CPB in patients without aprotinin as compared with aprotinin (266 ± 137, 266 ± 115, 244 ± 86 vs. 386 ± 121, dynes-s-cm-5, respectively, p = .047). Elevated postoperative PVRI was predictive for patients without aprotinin (AUC 0.668; SE 0.40; p < .0001; CI 0.590-0.746). There were no statistical differences in oxygenation index, pulmonary shunt or alveolar-arterial oxygen gradient between the groups. In conclusion, aprotinin maintains a low PVRI in elective patients with healthy lungs during CPB. We suggest that aprotinin maintains pulmonary arterial endothelial integrity.

Patterns and determinants of functional and absolute iron deficiency in patients undergoing cardiac rehabilitation following heart surgery.

Background Anaemia and iron deficiency are frequent following major surgery. The present study aims to identify the iron deficiency patterns in cardiac surgery patients at their admission to a cardiac rehabilitation programme, and to determine which perioperative risk factor(s) may be associated with functional and absolute iron deficiency. Design This was a retrospective study on prospectively collected data. Methods The patient population included 339 patients. Functional iron deficiency was defined in the presence of transferrin saturation <20% and serum ferritin ≥100 µg/l. Absolute iron deficiency was defined in the presence of serum ferritin values <100 µg/l. Results Functional iron deficiency was found in 62.9% of patients and absolute iron deficiency in 10% of the patients. At a multivariable analysis, absolute iron deficiency was significantly ( p = 0.001) associated with mechanical prosthesis mitral valve replacement (odds ratio 5.4, 95% confidence interval 1.9-15) and tissue valve aortic valve replacement (odds ratio 4.5, 95% confidence interval 1.9-11). In mitral valve surgery, mitral repair carried a significant ( p = 0.013) lower risk of absolute iron deficiency (4.4%) than mitral valve replacement with tissue valves (8.3%) or mechanical prostheses (22.5%). Postoperative outcome did not differ between patients with functional iron deficiency and patients without iron deficiency; patients with absolute iron deficiency had a significantly ( p = 0.017) longer postoperative hospital stay (median 11 days) than patients without iron deficiency (median nine days) or with functional iron deficiency (median eight days). Conclusions Absolute iron deficiency following cardiac surgery is more frequent in heart valve surgery and is associated with a prolonged hospital stay. Routine screening for iron deficiency at admission in the cardiac rehabilitation unit is suggested.

Clopidogrel use After Myocardial Revascularization: Prevalence, Predictors, and One-Year Survival Rate.

INTRODUCTION: Antiplatelet therapy after coronary artery bypass graft (CABG) has been used. Little is known about the predictors and efficacy of clopidogrel in this scenario. OBJECTIVE: Identify predictors of clopidogrel following CABG. METHODS: We evaluated 5404 patients who underwent CABG between 2000 and 2009 at Duke University Medical Center. We excluded patients undergoing concomitant valve surgery, those who had postoperative bleeding or death before discharge. Postoperative clopidogrel was left to the discretion of the attending physician. Adjusted risk for 1-year mortality was compared between patients receiving and not receiving clopidogrel during hospitalization after undergoing CABG. RESULTS: At hospital discharge, 931 (17.2%) patients were receiving clopidogrel. Comparing patients not receiving clopidogrel at discharge, users had more comorbidities, including hyperlipidemia, hypertension, heart failure, peripheral arterial disease and cerebrovascular disease. Patients who received aspirin during hospitalization were less likely to receive clopidogrel at discharge (P≤0.0001). Clopidogrel was associated with similar 1-year mortality compared with those who did not use clopidogrel (4.4% vs. 4.5%, P=0.72). There was, however, an interaction between the use of cardiopulmonary bypass and clopidogrel, with lower 1-year mortality in patients undergoing off-pump CABG who received clopidogrel, but not those undergoing conventional CABG (2.6% vs 5.6%, P Interaction = 0.032). CONCLUSION: Clopidogrel was used in nearly one-fifth of patients after CABG. Its use was not associated with lower mortality after 1 year in general, but lower mortality rate in those undergoing off-pump CABG. Randomized clinical trials are needed to determine the benefit of routine use of clopidogrel in CABG.

Clopidogrel use after myocardial revascularization: prevalence, predictors, and one-year survival rate

Abstract Introduction: Antiplatelet therapy after coronary artery bypass graft (CABG) has been used. Little is known about the predictors and efficacy of clopidogrel in this scenario. Objective: Identify predictors of clopidogrel following CABG. Methods: We evaluated 5404 patients who underwent CABG between 2000 and 2009 at Duke University Medical Center. We excluded patients undergoing concomitant valve surgery, those who had postoperative bleeding or death before discharge. Postoperative clopidogrel was left to the discretion of the attending physician. Adjusted risk for 1-year mortality was compared between patients receiving and not receiving clopidogrel during hospitalization after undergoing CABG. Results: At hospital discharge, 931 (17.2%) patients were receiving clopidogrel. Comparing patients not receiving clopidogrel at discharge, users had more comorbidities, including hyperlipidemia, hypertension, heart failure, peripheral arterial disease and cerebrovascular disease. Patients who received aspirin during hospitalization were less likely to receive clopidogrel at discharge (P≤0.0001). Clopidogrel was associated with similar 1-year mortality compared with those who did not use clopidogrel (4.4% vs. 4.5%, P=0.72). There was, however, an interaction between the use of cardiopulmonary bypass and clopidogrel, with lower 1-year mortality in patients undergoing off-pump CABG who received clopidogrel, but not those undergoing conventional CABG (2.6% vs 5.6%, P Interaction = 0.032). Conclusion: Clopidogrel was used in nearly one-fifth of patients after CABG. Its use was not associated with lower mortality after 1 year in general, but lower mortality rate in those undergoing off-pump CABG. Randomized clinical trials are needed to determine the benefit of routine use of clopidogrel in CABG.

Factors Associated with Intubation Time and ICU Stay After CABG

ABSTRACT OBJECTIVE: The aim of this study was to identify factors associated with intubation time and intensive care unit stay after coronary artery bypass grafting with cardiopulmonary bypass. METHODS: This was a retrospective study, whose data collection was performed in the hospital charts of 160 patients over 18 years, who underwent surgery from September 2009 to July of 2013 in a hospital in the state of Espirito Santo, Brazil. RESULTS: The mean age of the subjects was 61.44±8.93 years old and 68.8% were male. Subjects had a mean of 5.17±8.42 days of intensive care unit stay and mean intubation time of 10.99±8.41 hours. We observed statistically significant positive correlation between the following variables: patients' age and intubation time; patients' age and intensive care unit stay; intubation time and intensive care unit stay. CONCLUSION: In conclusion, the study showed that older patients had longer intubation time and increased intensive care unit stay. Furthermore, patients with longer intubation time had increased intensive care unit stay.

Repercusión del cebado con coloides y la ultrafiltración sobre el sangrado posoperatorio y la transfusión sanguínea en cirugía cardiaca. Ensayo clínico aleatorizado / Effect of priming solution and ultrafiltration on post-operative bleeding and blood transfusion in cardiac surgery. Randomized controlled trial

Objetivo. Valorar la eficacia del cebado del sistema de circulación extracorpórea con albúmina-manitol asociado a ultrafiltración para reducir el sangrado posoperatorio y las necesidades transfusionales en cirugía cardiaca, así como su repercusión sobre los balances hídricos, los parámetros de coagulación y hematimetría, la reintervención por sangrado y la estancia en UCI y hospitalaria. Material y métodos. Ciento treinta y cuatro pacientes programados en cirugía cardiaca fueron aleatorizados para recibir en el cebado Ringer lactato 1.500 mL (grupo C), o 250 mL de manitol 20%, 150 mL de albúmina 20% y 1.100 mL de Ringer lactato asociado a ultrafiltración (grupo T). Se determinaron el volumen de sangrado, las transfusiones, los balances hídricos, los parámetros de coagulación y la hematimetría hasta las 48 h del posoperatorio. Resultados. Encontramos una reducción en el grupo T del sangrado posoperatorio, 1.165 ± 789 mL frente a 992 ± 662 mL (p = 0,17), y de la transfusión de hematíes, 694 ± 843 mL frente a 413 ± 605 mL (p = 0,03). El balance hídrico intraoperatorio y posoperatorio fue significativamente menos positivo en el grupo T, con un balance global de 2.292 ± 2.152 mL frente a 5.388 ± 2.834 mL (p < 0,001). Hubo valores superiores de hemoglobina y hematocrito intraoperatorio (p < 0,001), al ingreso en UCI (p = 0,001) y a las 6 h (p = 0,05) en el grupo T, e inferiores de INR a las 6 h (p = 0,01) y 24 h (p = 0,02). Las tasas de reintervención y estancia en UCI fueron superiores en el grupo C, pero no significativas. Conclusiones. El cebado del sistema de circulación extracorpórea con manitol, albúmina y Ringer lactato, asociado a ultrafiltración, mejora significativamente los balances hídricos intraoperatorio y posoperatorio y reduce el volumen de transfusión de sangre, con una repercusión no significativa sobre el sangrado posoperatorio, reintervenciones por sangrado y estancia en UCI (AU)

Objective. Assess the effectiveness of priming the extracorporeal circulation system with albumin-mannitol combined with ultrafiltration during extracorporeal circulation to reduce post-operative bleeding and transfusion requirements in heart surgery, as well as its impact on the fluid balance, coagulation and hematocrit parameters, re-operation for bleeding, ICU, and hospital length of stay. Material and methods. A total of 134 patients scheduled for heart surgery were randomized to receive Ringer's lactate 1,500 mL in the priming reservoir (group C), or mannitol 20% 250 mL, albumin 20% 150 mL and Ringer's lactate 1,100 mL combined with ultrafiltration (group T). Bleeding volume, transfusions, fluid balance, coagulation, and hematology parameters were determined until 48 h in the post-operative period. Results. There was a reduction of postoperative bleeding in group T, 1,165 ± 789 mL vs 992 ± 662 mL (P = .17), and red blood cell concentrate transfusions, 694 ± 843 mL vs 413 ± 605 mL (P = .03). Intra-operative and post-operative fluid balance was significantly less positive in group T, with an overall balance of 2,292 ± 2,152 mL vs 5,388 ± 2,834 mL (P < .001). There were higher values of hemoglobin and hematocrit, intraoperative (P < .001), on admission to ICU (P = .001), and at 6 h (P = .05) in group T, and lower INR at 6 h (P = .01) and 24 h (P = .02). Re-operation rate and length of stay in ICU were higher in group C, but not statiscally significant. Conclusions. The priming of extracorporeal reservoir with mannitol, albumin, and Ringer's lactate, combined with ultrafiltration, significantly improves intra- and post-operative fluid balance, resulting in a reduction in blood transfusions, with no significant decrease in post-operative bleeding, re-operation bleeding rate, and length of stay in the ICU (AU)

Factors Associated with Intubation Time and ICU Stay After CABG.

OBJECTIVE: The aim of this study was to identify factors associated with intubation time and intensive care unit stay after coronary artery bypass grafting with cardiopulmonary bypass. METHODS: This was a retrospective study, whose data collection was performed in the hospital charts of 160 patients over 18 years, who underwent surgery from September 2009 to July of 2013 in a hospital in the state of Espirito Santo, Brazil. RESULTS: The mean age of the subjects was 61.44±8.93 years old and 68.8% were male. Subjects had a mean of 5.17±8.42 days of intensive care unit stay and mean intubation time of 10.99±8.41 hours. We observed statistically significant positive correlation between the following variables: patients' age and intubation time; patients' age and intensive care unit stay; intubation time and intensive care unit stay. CONCLUSION: In conclusion, the study showed that older patients had longer intubation time and increased intensive care unit stay. Furthermore, patients with longer intubation time had increased intensive care unit stay.

Recovery of linear and nonlinear heart rate dynamics after coronary artery bypass grafting surgery.

BACKGROUND: Conventional coronary artery bypass grafting (C-CABG) and off-pump CABG (OPCAB) surgery may produce different patients' outcomes, including the extent of cardiac autonomic (CA) imbalance. The beneficial effects of an exercise-based inpatient programme on heart rate variability (HRV) for C-CABG patients have already been demonstrated by our group. However, there are no studies about the impact of a cardiac rehabilitation (CR) on HRV behaviour after OPCAB. The aim of this study is to compare the influence of both operative techniques on HRV pattern following CR in the postoperative (PO) period. METHODS: Cardiac autonomic function was evaluated by HRV indices pre- and post-CR in patients undergoing C-CABG (n = 15) and OPCAB (n = 13). All patients participated in a short-term (approximately 5 days) supervised CR programme of early mobilization, consisting of progressive exercises, from active-assistive movements at PO day 1 to climbing flights of stairs at PO day 5. RESULTS: Both groups demonstrated a reduction in HRV following surgery. The CR programme promoted improvements in HRV indices at discharge for both groups. The OPCAB group presented with higher HRV values at discharge, compared to the C-CABG group, indicating a better recovery of CA function. CONCLUSION: Our data suggest that patients submitted to OPCAB and an inpatient CR programme present with greater improvement in CA function compared to C-CABG.

Change in behavioral functional capacity is associated with preexisting cognitive function rather than with cognitive decline in patients 1 year after cardiac surgery.

OBJECTIVE: The objective was to examine whether preexisting cognitive function rather than cognitive decline associated with intraoperative procedures may predict change in behavioral functional capacity in patients 1 year after cardiac surgery. METHOD: Forty-five patients completed a cognitive evaluation, including the Trail Making Test part B (TMT-B) for attention and psychomotor speed, the Memory with 10-s interference for working memory, the Digit Span test for short-term memory and the Instrumental Activities of Daily Living (IADLs) questionnaire for behavioral functional capacity, before surgery and 1 year after cardiac surgery. RESULTS: Sixteen patients (36%) exhibited cognitive decline after cardiac surgery. Preoperative scores on TMT-B significantly predicted change in behavioral functional capacity as measured by IADLs (beta = 0.371, P < .05), whereas the postoperative cognitive decline and intraoperative variables were unrelated to residualized change scores in IADLs (all Ps > .08). CONCLUSIONS: Preexisting cognitive dysfunctions as assessed by TMT-B can be a marker of preoperative brain dysfunction, which, in turn, in addition to brain damage caused by cardiac surgery procedures, may further predispose patients to poor behavioral functional capacity and outcome 1 year after surgery. Impaired cognitive functions before surgery should be considered when evaluating the effects of cardiac surgery procedures on long-term behavioral functional status of patients.

Effects of testosterone supplementation on clinical and rehabilitative outcomes in older men undergoing on-pump CABG.

Testosterone levels decrease with age. This decline is steeper during "critical illnesses". Cardiac surgery is a particular representative model of major clinical condition producing stress responses similar to those observed during severe nonsurgical illness. Cardiac revascularization with extracorporeal circulation is characterized by marked postoperative complications such as insulin resistance, a pro-inflammatory state, acute anemia and renal dysfunction. These phenomena are more evident in older subjects, who are particularly vulnerable in the post-operative state, a condition that has been recently termed as "acute postoperative frailty". We recently showed that in older men with low ejection fraction undergoing cardiac revascularization with extracorporeal circulation, there is a profound decline in anabolic hormones, including testosterone. After surgery testosterone concentration frequently declines to less than 200 ng/dl, a situation suggestive of overt hypogonadism. Since men with low testosterone levels have a high probability of developing mobility limitations, we considered this a rationale for the perioperative use of testosterone treatment in older men undergoing cardiac revasularization surgery. We hypothesized that testosterone supplementation at this time might attenuate the impressive post-surgical catabolic hormonal milieu. The aim of this manuscript is to elucidate an ongoing randomized clinical trial in older men (70+ years old) undergoing elective cardiovascular revascularization with extracorporeal circulation. This randomized clinical trial will evaluate the effects of intramuscular testosterone administration on clinical and functional outcomes in this population. The study will also address potential mechanisms underlying the expected beneficial effects of testosterone supplementation including improvement of insulin sensitivity, markers of inflammatory status and improved hemoglobin levels.

Adolescents with d-transposition of the great arteries corrected with the arterial switch procedure: neuropsychological assessment and structural brain imaging.

BACKGROUND: We report neuropsychological and structural brain imaging assessments in children 16 years of age with d-transposition of the great arteries who underwent the arterial switch operation as infants. Children were randomly assigned to a vital organ support method, deep hypothermia with either total circulatory arrest or continuous low-flow cardiopulmonary bypass. METHODS AND RESULTS: Of 159 eligible adolescents, 139 (87%) participated. Academic achievement, memory, executive functions, visual-spatial skills, attention, and social cognition were assessed. Few significant treatment group differences were found. The occurrence of seizures in the postoperative period was the medical variable most consistently related to worse outcomes. The scores of both treatment groups tended to be lower than those of the test normative populations, with substantial proportions scoring ≥1 SDs below the expected mean. Although the test scores of most adolescents in this trial cohort are in the average range, a substantial proportion have received remedial academic or behavioral services (65%). Magnetic resonance imaging abnormalities were more frequent in the d-transposition of the great arteries group (33%) than in a referent group (4%). CONCLUSIONS: Adolescents with d-transposition of the great arteries who have undergone the arterial switch operation are at increased neurodevelopmental risk. These data suggest that children with congenital heart disease may benefit from ongoing surveillance to identify emerging difficulties. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000470.

Surgical treatment for pulmonary artery sarcoma.

OBJECTIVE: Pulmonary artery sarcomas are exceedingly rare and the prognosis for patients with pulmonary artery sarcoma is very poor. We retrospectively reviewed the early and late outcomes after treatment for pulmonary artery sarcoma, and the purpose of this study is to report our surgical experience with this fatal disease. METHODS: Between 1999 and 2007, a total of nine patients (mean age, 47.4 years; M:F = 4:5) underwent operations for pulmonary artery sarcoma at our institution. The tumor was radically resected and every effort was made to remove the tumor as completely as possible. Seven patients underwent surgical resection with the aid of hypothermic cardiopulmonary bypass. The completeness of resection was determined intraoperatively by frozen section biopsy of the resection margin. RESULTS: There was no in-hospital mortality. No patients suffered from significant complications related to the operation. Follow-up was completed for all the patients with a mean duration of 19.2 months. During follow-up, six patients died with a median survival time of 17.6 months. The cause of death was related to the recurrence of pulmonary artery sarcoma in all cases. The pattern of recurrence was local recurrence and distant metastasis in three and four patients, respectively. CONCLUSIONS: The early outcomes after surgical treatment for pulmonary artery sarcoma were excellent, and the late outcomes in this series were no worse than those in the previous reports. We suggest that the use of cardiopulmonary bypass is important to obtain a complete resection and the completeness of the resection should be confirmed intraoperatively by frozen section biopsy of the resection margin.

Effect of different ventilation modes with FC-77 on pulmonary inflammatory reaction in piglets after cardiopulmonary bypass.

RATIONALE: Cardiopulmonary bypass (CPB) causes pulmonary inflammatory reaction. Liquid ventilation with perfluorocarbon has shown an anti-inflammatory effect on severely injured lungs. The aim of this study is to investigate the treatment effect of different ventilation modes with perfluorocarbon on pulmonary inflammatory reaction in piglets after CPB. METHODS: After receiving CPB and subsequent infusion of lipopolysaccharide (1 microg/kg), 18 piglets were randomly treated with conventional gas ventilation, total liquid ventilation (TLV), or partial liquid ventilation (PLV) for 240 min. The lung tissue and blood samples were collected at the end of observation period. The pulmonary mRNA expressions and plasmatic concentrations of interleukin-6 (IL-6) and interleukin-8 (IL-8) were measured. Histological neutrophil count in lung parenchyma was performed. RESULTS: Hemodynamics, PaCO2 and PH did not differ among groups during the observation period. Both TLV and PLV showed significantly improved oxygenation, reduced pulmonary mRNA expressions and plasmatic levels of IL-6 and IL-8, and decreased total neutrophil count in lung parenchyma when compared with conventional gas ventilation. Furthermore, TLV resulted in significantly better oxygenation, lower pulmonary mRNA expressions of IL-6 and IL-8, and less total neutrophil count when compared with PLV. CONCLUSION: Both TLV and PLV improved oxygenation and reduced pulmonary inflammatory reaction in piglets after CPB, whereas TLV is more effective than PLV.

Pulse contour analysis after normothermic cardiopulmonary bypass in cardiac surgery patients.

INTRODUCTION: Monitoring of the cardiac output by continuous arterial pulse contour (COPiCCOpulse) analysis is a clinically validated procedure proved to be an alternative to the pulmonary artery catheter thermodilution cardiac output (COPACtherm) in cardiac surgical patients. There is ongoing debate, however, of whether the COPiCCOpulse is accurate after profound hemodynamic changes. The aim of this study was therefore to compare the COPiCCOpulse after cardiopulmonary bypass (CPB) with a simultaneous measurement of the COPACtherm. METHODS: After ethical approval and written informed consent, data of 45 patients were analyzed during this prospective study. During coronary artery bypass graft surgery, the aortic transpulmonary thermodilution cardiac output (COPiCCOtherm) and the COPACtherm were determined in all patients. Prior to surgery, the COPiCCOpulse was calibrated by triple transpulmonary thermodilution measurement of the COPiCCOtherm. After termination of CPB, the COPiCCOpulse was documented. Both COPACtherm and COPiCCOtherm were also simultaneously determined and documented. RESULTS: Regression analysis between COPACtherm and COPiCCOtherm prior to CPB showed a correlation coefficient of 0.95 (P < 0.001), and after CPB showed a correlation coefficient of 0.82 (P < 0.001). Bland-Altman analysis showed a mean bias and limits of agreement of 0.0 l/minute and -1.4 to +1.4 l/minute prior to CPB and of 0.3 l/minute and -1.9 to +2.5 l/minute after CPB, respectively. Regression analysis of COPiCCOpulse versus COPiCCOtherm and of COPiCCOpulse versus COPACtherm after CPB showed a correlation coefficient of 0.67 (P < 0.001) and 0.63 (P < 0.001), respectively. Bland-Altman analysis showed a mean bias and limits of agreement of -1.1 l/minute and -1.9 to +4.1 l/minute versus -1.4 l/minute and -4.8 to +2.0 l/minute, respectively. CONCLUSION: We observed an excellent correlation of COPiCCOtherm and COPACtherm measurement prior to CPB. Pulse contour analysis did not yield reliable results with acceptable accuracy and limits of agreement under difficult conditions after weaning from CPB in cardiac surgical patients. The pulse contour analysis thus should be re-calibrated as soon as possible, to prevent false therapeutic consequences.

Physiotherapy following cardiac surgery: is it necessary during the intubation period?

This randomised controlled clinical trial investigated whether physiotherapy during the period of mechanical ventilation following cardiac surgery influenced subject outcomes. Two hundred and thirty-six subjects admitted to the intensive care unit (ICU) following elective or semi-urgent cardiac surgery were randomised to either a treatment group, which received physiotherapy during the intubated phase, or a control group where physiotherapy was commenced only once the subject was extubated. No significant differences between the two groups were detected for length of intubation period, length of ICU stay, length of hospital stay, maximal daily incentive spirometry values or the incidence of post-operative pulmonary complications. For individuals following routine uncomplicated cardiac surgery, the provision of physiotherapy interventions during the post-operative intubation period does not improve outcomes.

Rapid recovery protocol applied to 5,658 consecutive "on-pump" coronary bypass patients.

BACKGROUND: Increasing hospital costs, restricted resources, and new surgical strategies have stimulated effectiveness of all routines in cardiac surgery. Over a 10-year period, 5,658 consecutive patients undergoing coronary artery bypass grafting followed a protocol aiming at short postoperative intubation times and rapid physical rehabilitation. METHODS: The patients were prepared for rapid recovery, emphasizing (1) preoperative education and respiratory training, (2) low-dose fentanyl anesthesia, (3) limited ischemic times and pump times, (4) mild hypothermia and rewarming to a rectal temperature of 36 degrees C, (5) restricted use of extended monitoring, (6) autologous blood salvage to avoid allogeneic blood transfusions, and (7) active physical training from postoperative day 1. All in-hospital data relevant to these steps were prospectively stored in a database. RESULTS: The median extubation time after arrival in the intensive care unit was 1.5 hours (0 to 320 hours). More than 99% of the patients were extubated within 5 hours. Sixty-two patients (1.1%) were reintubated and ventilated for a median of 24 hours (1 to 430 hours), mostly due to resternotomy for bleeding or cardiopulmonary decompensation. In total, 5,594 patients (98.9%) were able to sit in a chair the first postoperative day. Within the fourth postoperative day, 82.5% were able to move freely in the hospital area and were in fact physically fit for hospital discharge. Allogeneic blood products were given to 3.9% of the patients. Twenty-three patients (0.41%) died in-hospital. CONCLUSIONS: With the application of a protocol for rapid physical recovery in patients undergoing "on-pump" coronary artery bypass grafting, extubation within 1 to 2 hours was safe and feasible in most patients. After 5 hours, 99.3% of the patients were extubated, with a reintubation rate of 1.1%. More than 80% of the patients were fully physically mobile within 4 days after the operation.