The impact of an algorithm on the optimization of beta-blockers after cardiac surgery.

OBJECTIVE: To evaluate the impact of a simple written algorithm of early postoperative beta-blocker administration on daily practices. DESIGN: A prospective, single center observational study. SETTING: A 16-bed cardiac surgical intensive care unit in a university teaching hospital. PATIENTS: One hundred twenty-five consecutive adult patients chronically treated with beta-blockers and scheduled for conventional cardiac surgery. INTERVENTIONS: Two successive 4-month phases: Phase 1 = uncontrolled early postoperative beta-blocker administration (n = 73) and phase 2 = beta-blocker administration by an institutional written algorithm using incremental doses of bisoprolol and/or esmolol (n = 52). MEASUREMENTS AND MAIN RESULTS: The main endpoint was the number of patients receiving beta-blockers on the morning of postoperative day 1. Secondary endpoints were the number of patients receiving beta-blockers on the morning of postoperative day 1 and reaching the targeted therapeutic goal and the incidence of postoperative atrial fibrillation in the intensive care unit. A 79% increase in the number of patients receiving beta-blockers on the morning of postoperative day 1 (42% v 75%, p<0.001) was observed during the second phase of the study. The number of patients receiving beta-blockers on the morning of postoperative day 1 and reaching the targeted therapeutic goal was increased significantly by 127% (33% v 75%, p<0.001). The incidence of atrial fibrillation was similar between both phases of the study: 37% versus 31%, p = 0.567. CONCLUSIONS: A simple written algorithm markedly improved early postoperative continuation of beta-blockers in chronically treated patients undergoing conventional cardiac surgery.

Prediction of responsiveness to an intravenous fluid challenge in patients after cardiac surgery with cardiopulmonary bypass: a comparison between arterial pulse pressure variation and digital plethysmographic variability index.

OBJECTIVES: Arterial pulse pressure variation (PPV) and digital plethysmographic variability index (PVI) have been proposed to predict fluid responsiveness during anesthesia and in critically ill patients. The present study aimed to compare the clinical utility of PPV and PVI in predicting fluid responsiveness after elective cardiac surgery. DESIGN: A prospective observational study. SETTING: A university hospital. PARTICIPANTS: Eighty-seven adult patients. INTERVENTIONS: Admission to the intensive care unit after cardiac surgery. Investigation before and after fluid challenge. MEASUREMENTS AND MAIN RESULTS: The discrimination of both PPV and PVI in predicting fluid responsiveness was compared by using areas under the receiver operating characteristics curves (ROCAUC). Sensibility analyses were conducted after exclusion of patients with a low perfusion index, patients receiving norepinephrine, and patients with right ventricular dysfunction. Fifty-seven (71%) patients were responders and twenty-three (29%) were nonresponders. ROCAUC were 0.73 [95% CI: 0.63-0.83] versus 0.60 [95% CI: 0.48-0.71] for PPV and PVI in the whole cohort of patients, respectively (p = 0.020). The inconclusive class of responses included 47 (59%) and 62 (77%) patients, respectively (p = 0.010); whereas the discrimination of PVI remained low whatever the subgroup of patients, the discrimination of PPV markedly increased in patients without perfusion index ≤ 1.3 (ROCAUC = 0.83 [95% CI: 0.68-0.93]) and in patients without right ventricular dysfunction (ROCAUC = 0.85 [95% CI: 0.67-0.95]). CONCLUSIONS: PVI is not discriminant and probably inaccurate to predict fluid responsiveness after elective cardiac surgery. PPV could be of potential interest after exclusion of patients with a low perfusion index and right ventricular dysfunction.