Postoperative Complications and Outcomes Associated With a Transition to 24/7 Intensivist Management of Cardiac Surgery Patients.

OBJECTIVES: Nighttime intensivist staffing does not improve patient outcomes in general ICUs. Few studies have examined the association between dedicated in-house 24/7 intensivist coverage on outcomes in specialized cardiac surgical ICUs. We sought to evaluate the association between 24/7 in-house intensivist-only management of cardiac surgical patients on postoperative complications and health resource utilization. DESIGN: Before-and-after propensity matched cohort study. SETTING: Tertiary care cardiac surgical ICU. PATIENTS: Patients greater than 18 years old who underwent cardiac surgery between January 1, 2006, and April 30, 2013 (nighttime resident model), were propensity-matched (1:1) to patients from August 1, 2013, to December 31, 2014 (24/7 in-house intensivist model). INTERVENTIONS: Cardiac surgical ICU coverage change from a nighttime resident physician coverage model to a 24/7 in-house intensivist staffing model. MEASUREMENTS AND MAIN RESULTS: The primary outcome of interest was a composite of postoperative major complications. Secondary outcomes included duration of mechanical ventilation, all-cause cardiac surgical ICU readmissions, and surgical postponements attributed to lack of cardiac surgical ICU bed availability. A total of 1,509 patients during the nighttime resident model were matched to 1,509 patients during the intensivist model. The adjusted risk of major complications (26.3% vs 19.3%; odds ratio, 0.73; 95% CI, 0.36-0.85; p < 0.01), mean mechanical ventilation time (25.2 vs 19.4 hr; p < 0.01), cardiac surgical ICU readmissions (5.3% vs 1.6%; odds ratio, 0.31; 95% CI, 0.19-0.48; p < 0.01), and surgical postponements (3.4 vs 0.3 per mo; p < 0.01) were lower with the intensivist model. CONCLUSIONS: A transition to a 24/7 in-house intensivist care model was associated with a reduction in postoperative major complications, duration of mechanical ventilation, cardiac surgical ICU readmissions, and surgical postponements. These findings suggest that 24/7 intensivist physician care models may improve patient outcomes and health resource utilization in specialized cardiac surgical ICUs.

A case of acute respiratory distress syndrome responsive to methylene blue during a carcinoid crisis.

PURPOSE: In a carcinoid crisis, numerous vasoactive agents, such as bradykinin precursors, serotonin, and histamine, are secreted by tumour cells. Bradykinin has been shown to increase pulmonary vascular permeability and hypotension in animal models; however, little is known about its in vivo effects or targeted pharmacotherapy in a carcinoid crisis. We describe a case of acute respiratory distress syndrome (ARDS) in a carcinoid crisis refractory to conventional antiserotonin and antihistamine therapies. CLINICAL FEATURES: A 56-yr-old male with known liver metastases and previous resection of a small intestinal carcinoid tumour in 1991 underwent successful tricuspid and pulmonary valve replacements. On postoperative day 10, he developed hypotension, a fever, leukocytosis, and flushing. His hypotension was treated with a 200 µg octreotide iv bolus followed by a 150 µg·hr(-1) infusion, vasopressin, norepinephrine, and hydrocortisone. He also required tracheal intubation for ARDS (Pa02:FI02 ratio 96). After 72 hr of broad spectrum antibiotics and no clinical improvement, antiserotonin and antihistamine therapies were augmented with cyproheptadine, ranitidine, and serial octreotide boluses with an infusion of 1,500 µg·hr(-1). These interventions improved his oxygenation (Pa02:F i 02 ratio 162) and reduced his norepinephrine requirements. Following a methylene blue bolus (1 mg·kg(-1)) and 12-hr infusion (0.5 mg·kg(-1)·hr(-1)), all vasopressors were discontinued and his oxygenation improved (Pa02:F i 02 ratio 297). CONCLUSION: In a patient with a carcinoid crisis and ARDS refractory to conventional therapies, substantial hemodynamic and oxygenation improvements were observed following methylene blue administration. This case highlights the potential pathophysiologic role of bradykinin and methylene blue as an adjunct therapeutic option in carcinoid crises.

Association between preoperative frailty and outcomes among adults undergoing cardiac surgery: a prospective cohort study.

BACKGROUND: The identification of frailty before complex and invasive procedures may have relevance for prognostic and recovery purposes, to optimally inform patients, caregivers and clinicians about perioperative risk and postoperative care needs. The aim of this study was to estimate the prevalence of frailty and describe the associated clinical course and outcomes of patients referred for nonemergent cardiac surgery. METHODS: A prospective cohort of patients aged 50 years and older referred for nonemergent cardiac surgery in Alberta, Canada, from November 2011 to March 2014 were screened preoperatively for frailty, defined as a Clinical Frailty Scale (CFS) score of 5 or greater. Postoperatively, patients were followed by telephone to assess CFS score, health services use and vital status. The primary outcome was all-cause hospital mortality. Secondary outcomes included health services use, hospital discharge disposition, 1-year health-related quality of life and all-cause 5-year mortality. RESULTS: The cohort (n = 529) had a mean age of 67 (standard deviation [SD] 9) years; 25.9% were female, and the prevalence of frailty was 9.6% (n = 51; 95% confidence interval [CI] 7.3%-12.5%). Frail patients were older (median age 75, interquartile range [IQR] 65-80 v. 67, IQR 60-73, yr; p < 0.001), were more likely to be female (51.0% v. 23.2%; p < 0.001), had a higher mean EuroSCORE II (8, SD 3 v. 5, SD 3; p < 0.001) and received combined coronary artery bypass grafting and valve procedures more frequently (29.4% v. 15.9%; p = 0.02) than nonfrail patients. Postoperatively, frail patients had a longer median duration of stay in the cardiovascular intensive care unit (median difference 2.2, 95% CI 1.60-2.79) and hospital (median difference 9.3, 95% CI 8.2-10.3). Hospital mortality was 9.8% among frail patients and 1.0% among nonfrail patients (adjusted hazard ratio 3.84, 95% CI 0.90-16.34). INTERPRETATION: Preoperative frailty was present in 10% of patients and was associated with a higher risk of morbidity and greater health services use. Preoperative frailty has important implications for the postoperative clinical course and resource utilization of patients undergoing cardiac surgery.

The Impact of Preoperative Frailty on the Clinical and Cost Outcomes of Adult Cardiac Surgery in Alberta, Canada: A Cohort Study.

BACKGROUND: There is limited information about the impact of frailty on public payer costs in cardiac surgery. This study aimed to determine quality-adjusted life-years (QALYs) and costs associated with preoperative frailty in patients referred for cardiac surgery. METHODS: We retrospectively compared costs of frailty in a cohort of 529 patients aged ≥ 50 years who were referred for nonemergent cardiac surgery in Alberta. Patients were screened preoperatively for frailty, defined as a score of 5 or greater on the Clinical Frailty Scale. The primary outcome measure was public payer costs attributable to frailty, calculated in a difference-in-difference (DID) model. RESULTS: The prevalence of frailty was 10% (n = 51; 95% confidence interval [CI], 7%-12%). Median (interquartile range) costs for frail patients were higher in the first year postsurgery ($200,709 [$146,177-$486,852] vs $147,730 [$100,674-$177,025]; P < 0.001) compared to nonfrail; the difference-in-difference attributable cost of frailty was $57,836 (95% CI, $-28,608-$144,280). At 1 year, frail patients had fewer QALYs realized compared to nonfrail patients (0.71 [0.57-0.77] vs 0.82 [0.75-0.86], P < 0.001), whereas QALYs gained were similar (0.02 [-0.02-0.05] vs 0.02 [0.00-0.04], P = 0.58, median difference 0.003 [95% CI, -0.01-0.02]) in frail and nonfrail patients. CONCLUSIONS: Frailty screening identified a population with greater impairment in quality-of-life and greater healthcare costs. Costs attributable to frailty represent opportunity costs that should be considered in future cardiac surgical services planning in the context of our aging population and the growing prevalence of frailty.

CONTEXTE: Il existe peu de renseignements concernant les répercussions de la fragilité sur les coûts pour les payeurs publics en chirurgie cardiaque. Cette étude visait à déterminer les années de vie pondérées par la qualité (QALY, pour Quality-Adjusted Life-Years) et les coûts associés à la fragilité préopératoire chez les patients dirigés vers un service de chirurgie cardiaque. MÉTHODOLOGIE: Nous avons comparé de façon rétrospective les coûts de la fragilité dans une cohorte de 529 patients âgés de 50 ans ou plus qui ont été dirigés vers un service de chirurgie cardiaque pour une intervention non urgente en Alberta. Un dépistage de la fragilité, définie comme un score de 5 ou plus à l'échelle CFS (Clinical Frailty Scale), a été effectué avant l'intervention. Le principal critère d'évaluation était le coût attribuable à la fragilité pour les payeurs publics, calculé selon un modèle d'écart des différences. RÉSULTATS: La prévalence de la fragilité a été de 10 % (n = 51; intervalle de confiance [IC] à 95 % : 7 à 12 %). Les coûts médians (écart interquartile) dans la première année suivant l'intervention chirurgicale ont été plus élevés chez les patients fragiles que chez les patients non fragiles (200 709 $ [146 177 $ à 486 852 $] contre 147 730 $ [100 674 $ à 177 025 $]; p < 0,001); le coût attribuable de la fragilité selon le modèle d'écart des différences a été de 57 836 $ (IC à 95 % : −28 608 $ à 144 280 $). À 1 an, les patients fragiles avaient moins de QALY réalisées que les patients non fragiles (0,71 [0,57 à 0,77] contre 0,82 [0,75 à 0,86]; p < 0,001), alors que le nombre de QALY gagnées était similaire (0,02 [−0,02 à 0,05] contre 0,02 [0,00 à 0,04]; p = 0,58; différence médiane : 0,003 [IC à 95 % : −0,01 à 0,02]) chez les patients fragiles et non fragiles. CONCLUSIONS: Le dépistage de la fragilité a permis de repérer une population associée à une perte plus importante de qualité de vie et à des coûts plus élevés en soins de santé. Les coûts attribuables à la fragilité représentent des coûts de renonciation qui doivent être considérés dans la planification future des services de chirurgie cardiaque, dans le contexte du vieillissement de notre population et de la prévalence croissante de fragilité.

Association between older age and outcome after cardiac surgery: a population-based cohort study.

OBJECTIVE: Octogenarians (aged ≥ 80 years) are increasingly being referred for cardiac surgery. We aimed to describe the morbidity, mortality, and health services utilization of octogenarians undergoing elective cardiac surgery. METHODS: Retrospective population-based cohort study of adult patients receiving elective cardiac surgery between January 1 2004 and December 31 2009. Primary exposure was age ≥80 years. Outcomes were 30-day, 1- and 5-year mortality, post-operative complications, and ICU/hospital lengths of stay. Multi-variable logistic and Cox regression analyses were used to explore the association between older age and outcome. RESULTS: Of 6,843 patients receiving cardiac surgery, 544 (7.9%) were octogenarians. There was an increasing trend in the proportion of octogenarians undergoing surgery during the study period (0.3% per year, P = 0.073). Octogenarians were more likely to have combined procedures (valve plus coronary artery bypass or multiple valves) compared with younger strata (p < 0.001). Crude 30-day, 1-year and 5-year mortality for octogenarians were 3.7%, 10.8% and 29.0%, respectively. Compared to younger strata, octogenarians had higher adjusted 30-day (OR 4.83, 95%CI 1.30-17.92; P = 0.018) and 1-year mortality (OR 4.92; 95% CI, 2.32-10.46. P<0.001). Post-operative complications were more likely among octogenarians. Octogenarians had longer post-operative stays in ICU and hospital, and higher rates of ICU readmission (P < 0.001 for all). After multi-variable adjustment, age ≧ 80 years was an independent predictor of death at 30-days and 1 year. CONCLUSIONS: Octogenarians are increasingly referred for elective cardiac surgery with more combined procedures. Compared to younger patients, octogenarians have a higher risk of post-operative complications, consume greater resources, and have worse but acceptable short and long-term survival.

Difference between pre-operative and cardiopulmonary bypass mean arterial pressure is independently associated with early cardiac surgery-associated acute kidney injury.

BACKGROUND: Cardiac surgery-associated acute kidney injury (CSA-AKI) contributes to increased morbidity and mortality. However, its pathophysiology remains incompletely understood. We hypothesized that intra-operative mean arterial pressure (MAP) relative to pre-operative MAP would be an important predisposing factor for CSA-AKI. METHODS: We performed a prospective observational study of 157 consecutive high-risk patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The primary exposure was delta MAP, defined as the pre-operative MAP minus average MAP during CPB. Secondary exposure was CPB flow. The primary outcome was early CSA-AKI, defined by a minimum RIFLE class - RISK. Univariate and multivariate logistic regression were performed to explore for association between delta MAP and CSA-AKI. RESULTS: Mean (± SD) age was 65.9 ± 14.7 years, 70.1% were male, 47.8% had isolated coronary bypass graft (CABG) surgery, 24.2% had isolated valve surgery and 16.6% had combined procedures. Mean (± SD) pre-operative, intra-operative and delta MAP were 86.6 ± 13.2, 57.4 ± 5.0 and 29.4 ± 13.5 mmHg, respectively. Sixty-five patients (41%) developed CSA-AKI within in the first 24 hours post surgery. By multivariate logistic regression, a delta MAP≥26 mmHg (odds ratio [OR], 2.8; 95%CI, 1.3-6.1, p = 0.009) and CPB flow rate ≥54 mL/kg/min (OR, 0.2, 0.1-0.5, p < 0.001) were independently associated with CSA-AKI. Additional variables associated with CSA-AKI included use of a side-biting aortic clamp (OR, 3.0; 1.3-7.1, p = 0.012), and body mass index ≥25 (OR, 4.2; 1.6-11.2, p = 0.004). CONCLUSION: A large delta MAP and lower CPB flow during cardiac surgery are independently associated with early post-operative CSA-AKI in high-risk patients. Delta MAP represents a potentially modifiable intra-operative factor for development of CSA-AKI that necessitates further inquiry.