Cardiac variables as main predictors of endotracheal reintubation rate after cardiac surgery

Reintubation in patients after cardiac surgery is associatedwith undesirable consequences. The purpose of the present study was to identify variables that could predict reintubation necessity in this group of patients. We performed a prospective study in 1000 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass. The patients who required reintubation after extubation were compared with patients not requiring reintubation regarding demographic and preoperative clinical variables, including postoperative complications and in-hospital mortality. Postoperatively, 26 [2.6%] of the 1000 patients studied required reintubation due to respiratory, cardiac, or neurological reasons. Advanced age and mainly cardiac variables were determined as univariate infra- and postoperative predictors of reintubation [all p values < 0.05]. Multiple logistic regression analysis revealed lower preoperative [p = 0.014; OR = 3.00, 95% CI: 1.25 - 7.21], and postoperative ejection fraction [p = 0.001; OR = 11.10, 95% CI: 3.88 - 31.79], valvular disease [p = 0.043; OR = 1.84, 95%CI: 1.05 - 3.96], arrhythmia [p = 0.006; OR = 3.84, 95%CI: 1.47 - 10.03], and postoperative infra-aortic balloon pump requirement [p = 0.019; OR = 4.20, 95%CI: 1.26 - 14.00] as the independent predictors of reintubation. These findings reveal that cardiac variables are more common and significant predictors of reintubation after cardiac surgery in adult patients than are respiratory variables. The incidence of this complication, reintubation, is low, although it could result in significant postoperative morbidity and mortality

Relationship between gender and in-hospital morbidity and mortality after coronary artery bypass grafting surgery in an Iranian population

Many previous studies have investigated the influence of gender on coronary artery bypass grafting surgery [CABG] outcomes. Despite the great volume of reports on this issue, it is still not clear whether it is the gender of the patient or pre-existing comorbid conditions that is the best predictor for the different outcomes seen between men and women. Multiple studies have shown that women are at higher risk of postoperative complications than men, particularly in the perioperative period. The goal of this study was to determine whether sex differences exist in preoperative variables between men and women, and to evaluate the effect of gender on short-term mortality and morbidity after CABG in an Iranian population. Data were collected prospectively from 690 consecutive patients [495 men and 195 women] who underwent isolated CABG. Preoperative, intraoperative, and postoperative variables, major complications and death were compared between the male and female patients until hospital discharge using multivariate analysis. Women were older [P = 0.020], had more diabetes [P = 0.0001], more obesity [P = 0.010], a higher New York Heart Association functional class [P = 0.030], and there was less use of arterial grafts [P = 0.016]. Men had more tobacco smokers [P = 0.0001] and lower preoperative ejection fractions [EF] [P = 0.030]. After surgery, women had a higher incidence of respiratory complications [P = 0.003], higher creatine kinase [CK] - MB levels [P = 0.0001], and higher inotropic support requirements [P = 0.030]. They also had a higher incidence of decreased postoperative EF versus preoperative values [P = 0.020]. The length of ICU stay, incidence of return to ICU and postoperative death, were similar between men and women. Nevertheless, after adjusting for age and diabetes, female gender was still independently associated with higher morbidity in patients over 50 years of age. Women had more risk factors, comorbidities, and postoperative complications. Women older than 50 years of age were at a higher risk of postoperative complications than men. This difference decreased with younger age. In-hospital mortality rates were not influenced by sex, as there was no difference found between the two groups [2.5% women vs. 2.2% men; P > 0.05]

Perioperative risk factors for prolonged mechanical ventilation and tracheostomy in women undergoing coronary artery bypass graft with cardiopulmonary bypass

Prolonged mechanical ventilation is an important recognized complication occurring during cardiovascular surgery procedures. This study was done to assess the perioperative risk factors related to postoperative pulmonary complications and tracheostomy in women undergoing coronary artery bypass graft with cardiopulmonary bypass. It was a retrospective study on 5,497 patients, including 31 patients with prolonged ventilatory support and 5,466 patients without it; from the latter group, 350 patients with normal condition [extubated in 6-8 hours without any complication] were selected randomly. Possible perioperative risk factors were compared between the two groups using a binary logistic regression model. Among the 5,497 women undergoing coronary artery bypass graft [CABG], 31 women needed prolonged mechanical ventilation [PMV], and 15 underwent tracheostomy. After logistic regression, 7 factors were determined as being independent perioperative risk factors for PMV. Age >/-70 years old, left ventricular ejection fraction [LVEF]

effect of primary bolus dose of pancuronium versus cisatracurium without maintenance dose on extubation time in adult coronary artery bypass crafting

Given the importance of the effect of muscle relaxants on the extubation time in coronary artery bypass grafting [CABG] patients, we sought to assess the difference in "time to extubation" and "intensive care unit [ICU] length of stay" between the primary bolus doses of Pancuroniuni and Cisatracurium without using the maintenance dose of them during surgery. This double blind clinical trial divided 110 patients into two equal groups receiving either Cisatracurium or Pancuronium. The patients' surgical and cardiopulmonary bypass variables were evaluated, and the extubation time and ICU length of stay were compared between the two groups. There was no difference between the two groups regarding the depth of anesthesia, train-of-four [TOF] scores at the beginning of anesthesia, and the surgical and cardiopulmonary bypass variables. However, the Cisatracurium patients were extubated earlier and had a shorter ICU length of stay than the Pancuronium patients. An appropriate depth of anesthesia facilitates the administration of the niduction dose of Cisatracurium, which confers earlier extubation and shorter ICU length of stay by comparison with Pancuronium

Cardiovascular responses to orotracheal intubation in patients undergoing coronary artery bypass grafting surgery. Comparing fiberoptic bronchoscopy with direct laryngoscopy

The intubation by using fiberoptic brochoscop [FOB] can avoid the mechanical stimulus to oropharyngolaryngeal structures thereby it is likely to attenuate hemodynamic response during orotracheal intubation. Based on this hypothesis, we compared the hemodynamic responses to orotracheal intubation using an FOB and direct laryngoscope [DLS] in patients undergoing general anesthesia for coronary artery bypass grafting [CABG] surgery. Fifty patients with ASA physical status II and Mallampati score I and II were scheduled for elective CABG surgery under general anesthesia requiring orotracheal intubation were randomly allocated to either DLS group [n = 25] or FOB group [n = 25]. The same protocol of anesthetic medications was used. Invasive systolic and diastolic blood pressure [SBP and DBP] and heart rate [HR] were recorded before and after anesthesia induction, during intubation and in the first and second minutes after intubation. The differences among the hemodynamic variables recorded over time and differences in the circulatory variables between the two study groups were compared. Duration of intubation was shorter in DLS group [19.3 +/- 4.7 sec] compared with FOB group [34.9 +/- 9.8 sec; p = 0.0001]. In both study groups basic SBP and DBP and HR were not significantly different [P >0.05]. During the observation, there were no significant differences between the two groups in BP or HR at any time points or in their maximal values [all p values >0.05]. We conclude that the FOB had no advantage in attenuating the hemodynamic responses to orotracheal intubation in patients undergoing CABG surgery

Acute respiratory distress syndrome: rapid and significant response to volume-controlled inverse ratio ventilation

Pulmonary complications following cardiopulmonary bypass [CPB] are relatively common, with up to 12% of patients experiencing acute long injury [ALI]. The treatment for ALI or acute respiratory distress syndrome [ARDS] is primarily supportive with specific modes of mechanical ventilation. We report a 46-year-old man with ARDS after cardiac surgery whose arterial oxygenation was surprisingly improved 1 hour after using volume-controlled inverse ratio ventilation [VC-IRV]

Impact of body mass index on in-hospital mortality and morbidity after coronary artery bypass grafting surgery

Obesity is a common risk factor for morbidity and mortality after cardiac surgery. However, the relationship between obesity and postoperative risk has not been fully defined. A prospective study of 1015 consecutive patients undergoing isolated coronary artery bypass grafting [CABG] was carried out. Body mass index [BMI] was used as the measure of obesity and was categorized as normal weight [BMI=20-25] and obese [BMI > 25 and < 35]. The preoperative, operative, and postoperative risk factors as well as the complication and in-hospital death rates were compared between the two groups. Of the 1015 patients, 40% had a normal weight and 49% were obese. Compared with the normal-weight group, the obese group had a significantly higher incidence of diabetes mellitus [P=0.007] and lower arterial partial pressure of oxygen [PaO2] [P=0.03]. The normal-weight patients had a higher New York Heart Association [NYHA] Functional Class [P=0.03] and were at a higher risk for emergent surgery [P=0.003] or reoperation [P=0.002]. Among the postoperative complications, respiratory complications [P=0.027] were more frequent in the obese patients. The duration of mechanical ventilation [P=0.001], the incidence of arrhythmia [P=0.011], low cardiac output syndrome [P=0.001], reintubation [P=0.001], and neurological complications [P=0.003] were significantly higher in the normal-weight patients. Obesity was associated with a lower risk of reoperation for bleeding [P=0.032]. There were no significant differences in infective complications, length of intensive care unit [ICU] stay, total length of stay in hospital, and operative mortality between the groups. In the patients undergoing isolated CABG procedures, obesity did not increase the risk of operative mortality and morbidity with the exception of respiratory complications. The normal body weight patients were at a higher risk for complications than were the obese patients. Therefore, obese patients may safely undergo CABG without previous weight reduction if due attention is paid to minimize respiratory complications