The rare case of double valve surgery in a patient with factor VII deficiency.

Performing cardiac surgery on patients with bleeding diatheses poses significant challenges since these patients are at an increased risk for complications secondary to excessive bleeding. Despite its rarity, patients with factor VII (FVII) deficiency may require invasive procedures such as cardiac surgery. However, we lack guidelines on their pre-, peri-, and post-operative management. As FVII deficiency is rare, it seems unlikely to design and learn from large clinical studies. Instead, we need to base our clinical decision-making on single reported cases and registry data. Herein, we present the rare case of a patient with FVII deficiency who underwent double valve surgery. Pre-operatively, activated recombinant FVII (rFVIIa) was administered to reduce the risk of bleeding. Nevertheless, the patient experienced major bleeding. This case highlights the significance of FVII deficiency in patients undergoing cardiac surgery and emphasizes the importance of adequate and appropriate transfusion of blood products for these patients.

Ventricular-arterial decoupling is associated with in-hospital adverse events in normotensive pulmonary embolism.

During acute pulmonary embolism (PE) a compensatory increase in right ventricular (RV) contractility is required to match increased afterload to maintain right ventricular-pulmonary arterial (RV-PA) coupling. The aim of this study was to assess the prognostic utility of RV-PA decoupling in acute PE. We assessed the association between measures of transthoracic echocardiography (TTE)-derived RV-PA coupling including tricuspid annular plane systolic excursion (TAPSE)/right ventricular systolic pressure (RVSP) and right ventricular fractional area change (FAC)/RVSP as well as stroke volume index (SVI)/RVSP (a measure of pulmonary artery capacitance) with adverse PE-related events (in-hospital PE-related mortality or cardiopulmonary decompensation) using logistic regression analysis. In 820 normotensive patients TTE-derived markers of RV-PA coupling were associated with PE-related adverse events. For each 0.1 mm/mmHg decrease in TAPSE/RVSP the odds of an adverse event increased by 2.5-fold [adjusted OR (aOR) 2.49, 95% confidence interval (CI) 1.46-4.24, p = 0.001], for every 0.1%/mmHg decrease in FAC/RVSP the odds of an adverse event increased by 1.4-fold (aOR 1.42, CI 1.09-1.86, p = 0.010), and for every 0.1 mL/mmHg m2 decrease in SVI/RVSP the odds of an event increased by 2.75-fold (aOR 2.78, CI 1.72-4.50, p < 0.001). In multivariable analysis, TAPSE/RVSP and SVI/RVSP were independent of other risk stratification methods including computed tomography-derived right ventricular dysfunction (RVD), the Bova score, and subjective assessment of TTE-derived RVD. In patients with normotensive acute PE, TTE-derived measures of RV-PA coupling are associated with adverse in-hospital PE-related events and provide incremental value in the risk assessment beyond computed tomography-derived RVD, the Bova score, or subjective TTE-derived RVD.

Adverse events associated with administration of vasopressor medications through a peripheral intravenous catheter: a systematic review and meta-analysis.

BACKGROUND: It is unclear whether vasopressors can be safely administered through a peripheral intravenous (PIV). Systematic review and meta-analysis methodology was used to examine the incidence of local anatomic adverse events associated with PIV vasopressor administration in patients of any age cared for in any acute care environment. METHODS: MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials, and the Database of Abstracts of Reviews of Effects were searched without restriction from inception to October 2019. References of included studies and related reviews, as well as relevant conference proceedings were also searched. Studies were included if they were: (1) cohort, quasi-experimental, or randomized controlled trial study design; (2) conducted in humans of any age or clinical setting; and (3) reported on local anatomic adverse events associated with PIV vasopressor administration. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials or the Joanna Briggs Institute checklist for prevalence studies where appropriate. Incidence estimates were pooled using random effects meta-analysis. Subgroup analyses were used to explore sources of heterogeneity. RESULTS: Twenty-three studies were included in the systematic review, of which 16 and 7 described adults and children, respectively. Meta-analysis from 11 adult studies including 16,055 patients demonstrated a pooled incidence proportion of adverse events associated with PIV vasopressor administration as 1.8% (95% CI 0.1-4.8%, I2 = 93.7%). In children, meta-analysis from four studies and 388 patients demonstrated a pooled incidence proportion of adverse events as 3.3% (95% CI 0.0-10.1%, I2 = 82.4%). Subgroup analyses did not detect any statistically significant effects associated with stratification based on differences in clinical location, risk of bias or design between studies, PIV location and size, or vasopressor type or duration. Most studies had high or some concern for risk of bias. CONCLUSION: The incidence of adverse events associated with PIV vasopressor administration is low. Additional research is required to examine the effects of PIV location and size, vasopressor type and dose, and patient characteristics on the safety of PIV vasopressor administration.

Rapid prediction of adverse outcomes for acute normotensive pulmonary embolism: derivation of the Calgary Acute Pulmonary Embolism score.

BACKGROUND: Acute pulmonary embolism (PE) has a wide spectrum of outcomes, but the best method to risk-stratify normotensive patients for adverse outcomes remains unclear. METHODS: A multicentre retrospective cohort study of acute PE patients admitted from emergency departments in Calgary, Canada, between 2012 and 2017 was used to develop a refined acute PE risk score. The composite primary outcome of in-hospital PE-related death or haemodynamic decompensation. The model was internally validated using bootstrapping and the prognostic value of the derived risk score was compared to the Bova score. RESULTS: Of 2067 patients with normotensive acute PE, the primary outcome (haemodynamic decompensation or PE-related death) occurred in 32 (1.5%) patients. In simplified Pulmonary Embolism Severity Index high-risk patients (n=1498, 78%), a multivariable model used to predict the primary outcome retained computed tomography (CT) right-left ventricular diameter ratio ≥1.5, systolic blood pressure 90-100 mmHg, central pulmonary artery clot and heart rate ≥100 beats·min-1 with a C-statistic of 0.89 (95% CI 0.82-0.93). Three risk groups were derived using a weighted score (score, prevalence, primary outcome event rate): group 1 (0-3, 73.8%, 0.34%), group 2 (4-6, 17.6%, 5.8%), group 3 (7-9, 8.7%, 12.8%) with a C-statistic 0.85 (95% CI 0.78-0.91). In comparison the prevalence (primary outcome) by Bova risk stages (n=1179) were stage I 49.8% (0.2%); stage II 31.9% (2.7%); and stage III 18.4% (7.8%) with a C-statistic 0.80 (95% CI 0.74-0.86). CONCLUSIONS: A simple four-variable risk score using clinical data immediately available after CT diagnosis of acute PE predicts in-hospital adverse outcomes. External validation of the Calgary Acute Pulmonary Embolism score is required.

Echocardiography-Derived Stroke Volume Index Is Associated With Adverse In-Hospital Outcomes in Intermediate-Risk Acute Pulmonary Embolism: A Retrospective Cohort Study.

BACKGROUND: There remains uncertainty in the optimal prognostication and management of patients with intermediate-risk pulmonary embolism (PE). Transthoracic echocardiography can identify right ventricular dysfunction to recognize intermediate-high-risk patients. RESEARCH QUESTION: Is echocardiographic-derived stroke volume index (SVI) associated with death or cardiopulmonary decompensation in intermediate-risk patients with PE? STUDY DESIGN AND METHODS: and Methods: We retrospectively evaluated echocardiographic-derived variables that included SVI in normotensive patients with acute PE who were admitted between January 2012 and March 2017. SVI was determined with the use of the Doppler velocity-time integral in the left or right ventricular outflow tract. The primary outcome was in-hospital PE-related death or cardiopulmonary decompensation. We used logistic regression to determine the association between SVI and outcomes and receiver operating characteristic analysis to compare the performance of SVI and other echocardiographic measures. RESULTS: The primary outcome occurred in 26 of the 665 intermediate-risk patients (3.9%) with PE. Univariate logistic regression showed an OR of 1.37 (95% CI, 1.23-1.52; P < .001) per 1-mL/m2 decrease in SVI for the primary outcome. Bivariate logistic regression showed that SVI was independent of age, sex, heart rate, tricuspid regurgitation velocity, tricuspid annular plane systolic excursion, troponin, and Bova score. SVI had the highest C-statistic of 0.88 (95% CI, 0.81-0.96) of all echocardiographic variables with a Youden's J-statistic that identifies an optimal cut-point of 20.0 mL/m2, which corresponds to positive and negative likelihood ratios of 6.5 (95% CI, 5.0-8.6) and 0.2 (95% CI, 0.1-0.5) for the primary outcomes, respectively. INTERPRETATION: Low SVI was associated with in-hospital death or cardiopulmonary decompensation in acute PE. SVI had excellent performance compared with other clinical and echocardiographic variables.

Another Whipple's triad? Pericardial, myocardial and valvular disease in an unusual case presentation from a Canadian perspective.

BACKGROUND: Whipple's disease is a clinically relevant multi-system disorder that is often undiagnosed given its elusive nature. We present an atypical case of Whipple's disease involving pan-valvular endocarditis and constrictive pericarditis, requiring cardiac intervention. A literature review was also performed assessing the prevalence of atypical cases of Whipple's disease. CASE PRESENTATION: A previously healthy 56-year-old male presented with a four-year history of congestive heart failure with weight loss and fatigue. Notably, he had absent gastrointestinal symptoms. He went on to develop pan-valvular endocarditis and constrictive pericarditis requiring urgent cardiac surgery. A clinical diagnosis of Whipple's disease was suspected, prompting duodenal biopsy sampling which was unremarkable, Subsequently, Tropheryma whipplei was identified by 16S rDNA PCR on the cardiac valvular tissue. He underwent prolonged antibiotic therapy with recovery of symptoms. CONCLUSIONS: Our study reports the first known case of Whipple's disease involving pan-valvular endocarditis and constrictive pericarditis. A literature review also highlights this presentation of atypical Whipple's with limited gastrointestinal manifestations. Duodenal involvement was limited and the gold standard of biopsy was not contributory. We also highlight the Canadian epidemiology of the disease from 2012 to 2016 with an approximate 4% prevalence rate amongst submitted samples. Routine investigations for Whipple's disease, including duodenal biopsy, in this case may have missed the diagnosis. A high degree of suspicion was critical for diagnosis of unusual manifestations of Whipple's disease.

Epidemiology, Mechanical Power, and 3-Year Outcomes in Acute Respiratory Distress Syndrome Patients Using Standardized Screening. An Observational Cohort Study.

Rationale: Limited data on the epidemiology of acute respiratory distress syndrome (ARDS) using a standardized screening program exist.Objectives: To describe the population-based incidence of hypoxemic respiratory failure and ARDS using a prospective standardized screening protocol; and to describe the mechanical ventilation practice and the mechanical power and examine their association with 28-day and 3-year survival outcomes.Methods: A prospective standardized screening program for ARDS, as a quality improvement initiative, was initiated at four adult intensive care units over a 27-month period. An ancillary analysis of this observational cohort was performed. Patients requiring mechanical ventilation for ≥24 hours underwent prospective and consecutive screening using standardized ventilator settings. Patient physiological data and outcomes were collected prospectively through an electronic clinical-information system and retrospectively analyzed to apply Berlin criteria.Results: Screened were 7,944 patients, among which 986 (12.4%) had hypoxemic respiratory failure (arterial oxygen tension to inspired fraction of oxygen ratio ≤300), and 731 (9.2%) met criteria for ARDS. Age-adjusted incidence of hypoxemic respiratory failure and ARDS were 37.7 and 27.6 cases per 100,000 person-years, respectively. Patients sustaining the diagnosis of ARDS had a hospital mortality of 26.5% for mild, 31.8% for moderate, and 60.0% for severe ARDS and a 3-year mortality of 43.5% for mild, 46.9% for moderate, and 71.1% for severe ARDS. Mechanical power >22 J/min was associated with increased 28-day hospital and 3-year mortality. Determinants of mechanical power associated with lower 28-day hospital and 3-year survival included plateau pressure >30 cm H2O and driving pressure >15 cm H2O, but not tidal volumes >8 ml/kg of predicted body weight.Conclusions: Using standardized screening, a large proportion of patients with hypoxemic respiratory failure met criteria for ARDS. Increasing ARDS severity was associated with increased 28-day hospital and 3-year mortality. Increased mechanical power was associated with increased mortality. Potentially modifiable determinants of mechanical power associated with lower survival included plateau pressure and driving pressure.

Derivation of a PIRO Score for Prediction of Mortality in Surgical Patients With Intra-Abdominal Sepsis.

BACKGROUND: Mortality in patients with intra-abdominal sepsis remains high. Recognition and classification of patients with sepsis are challenging; about 70% of critical care specialists find the existing definitions confusing and not clinically useful. OBJECTIVE: To assess the usefulness of the predisposition, infection/injury, response, organ dysfunction (PIRO) concept in surgical intensive care patients with severe sepsis or septic shock due to an intra-abdominal source. METHODS: Data from 2005 through 2010 of a prospective observational cohort were reviewed retrospectively. RESULTS: Among 905 patients, overall mortality was 21.3%, but patients with septic shock had a mortality of 40.6%. The variables in each PIRO subset with P ≤ .10 were entered into a stepwise backward elimination logistic regression. A PIRO score was developed that included the following variables: age greater than 65 years; comorbid conditions; leukopenia; hypothermia; and cardiovascular, renal, respiratory, and central nervous system failure. One point was given for each feature detected. The mean score was significantly higher (P < .001) in non-survivors (3.9) than in survivors (2.3). When the data were distributed according to PIRO scores, mortality rate increased (P < .001). The area under the receiver operating characteristic curve indicated consistent mortality discrimination by PIRO scores (0.80; 95% CI, 0.79-0.83), outperforming the Acute Physiology and Chronic Health Evaluation II (0.72; 95% CI, 0.68-0.75) and the Sequential Organ Failure Assessment (0.72; 95% CI, 0.68-0.76) (P < .001). CONCLUSION: The PIRO score is useful for predicting mortality in patients with surgically related intra-abdominal sepsis.

Focused Critical Care Echocardiography: Development and Evaluation of an Image Acquisition Assessment Tool.

OBJECTIVES: Little attention has been placed on assessment tools to evaluate image acquisition quality for focused critical care echocardiography. We designed a novel assessment tool to objectively evaluate the image acquisition skills of critical care trainees learning focused critical care echocardiography and examined the tool for evidence of validity. DESIGN: Prospective observational study. SETTING: Medical-surgical ICUs at a tertiary care teaching hospital. SUBJECTS: Trainees in our critical care medicine fellowship program. INTERVENTIONS: Six trainees completed a focused critical care echocardiography training curriculum followed by performing 20 transthoracic echocardiograms on patients receiving invasive mechanical ventilation. At three assessment intervals (the 1st and 2nd examinations, 10th and 11th examinations, and 19th and 20th examinations), echocardiograms performed by trainees were compared with those of critical care physicians certified in echocardiography and scored according to the focused critical care echocardiography assessment tool. The primary outcome was an efficiency score (overall assessment tool score divided by examination time). Differences in mean efficiency scores between echocardiographers of differing skill levels and changes in trainees' mean efficiency scores with increasing focused critical care echocardiography experience were compared by using t tests. MEASUREMENTS AND MAIN RESULTS: On the initial assessment, mean efficiency scores (SD) for trainees and experienced physicians were 1.55 (0.95) versus 2.78 (1.38), respectively (p = 0.02), and for the second and third assessments, the corresponding efficiency ratings for trainees and experienced physicians were 2.48 (0.97) versus 4.55 (1.32) (p < 0.01) and 2.61 (1.37) versus 4.17 (2.12) (p = 0.04), respectively. CONCLUSIONS: Trainees' efficiency in focused critical care echocardiography image acquisition improved quickly in the first 10 studies, yet, it could not match with the performance of experienced physicians after 20 focused critical care echocardiography studies. The focused critical care echocardiography assessment tool demonstrated evidence of validity and could discern changes in trainees' image acquisition performance with increasing experience.

Cricoid pressure provides incomplete esophageal occlusion associated with lateral deviation: a magnetic resonance imaging study.

BACKGROUND: Cricoid pressure is a routine component of rapid sequence induction and is designed to reduce the risk of reflux and its associated morbidity. Recent studies have raised questions regarding the efficacy of cricoid pressure in terms of changes in the pharyngeal and esophageal anatomy. OBJECTIVE: This current descriptive study was designed to observe the anatomical effect of cricoid pressure on the occlusion of esophageal lumen in conscious volunteers using magnetic resonance imaging (MRI). METHODS: We quantitatively assessed esophageal patency before and during application of cricoid pressure in 20 awake volunteers utilizing MRI. RESULTS: Target cricoid pressure was achieved in 16 of 20 individuals, corresponding to a mean percentage reduction in cricovertebral distance of 43% (range 25-80%). Cricoid pressure was applied incorrectly in 4 (20%) individuals as evidenced by no change in the cricovertebral distance. Incomplete esophageal occlusion was seen in 10 of 16, or 62.5% (95% confidence interval 35-85%) of individuals when appropriate cricoid pressure was applied. Incomplete esophageal occlusion was always associated with a lateral deviation of the esophagus. None of the 6 subjects with complete occlusion had esophageal deviation during the appropriate application of cricoid pressure. CONCLUSION: Effective application of cricoid pressure by an experienced operator frequently resulted in lateral deviation of the esophagus and incomplete occlusion of esophageal lumen. Reliance on cricoid pressure for esophageal occlusion requires further evaluation utilizing functional studies.

The quality of reports of critical care meta-analyses in the Cochrane Database of Systematic Reviews: an independent appraisal.

OBJECTIVE: To independently appraise the methodological quality of a sample of reports of meta-analyses that address critical care topics in the Cochrane Database of Systematic Reviews compared with the quality of reports published in regular journals, using a validated assessment instrument, the Overview Quality Assessment Questionnaire (OQAQ). DATA SOURCE: Studies were selected from a search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews from 1994 to 2003, using multiple search terms for critical care and sensitive filters to identify meta-analyses. STUDY SELECTION: Two authors independently selected meta-analyses that addressed topics pertinent to critical care medicine. DATA EXTRACTION: Two authors independently extracted the data. The proportion of reports that met each component of the OQAQ was determined, as was the overall quality score. Meta-analyses published in the Cochrane Database of Systematic Reviews were compared with those published in regular journals. DATA SYNTHESIS: There were 36 reports of meta-analyses in the Cochrane Database of Systematic Reviews and 103 reports of meta-analyses published in regular journals; 11 of these were reports of Cochrane reviews. The meta-analyses published in the Cochrane Database of Systematic Reviews were more likely to fulfill most components of the OQAQ. The median overall OQAQ scores indicated significant methodological problems in the reports regardless of the source of publication, although the reports in the Cochrane database scored higher than those in regular journals (five compared with two, p<.001). Major methodological flaws, notably failure to appropriately refer to the validity of included studies, were found in meta-analyses in both the Cochrane Database of Systematic Reviews and regular journals (44.4% and 79.3%, respectively). CONCLUSIONS: Although the quality of reports of meta-analyses published in the Cochrane Database of Systematic Reviews is superior to the quality of reports of meta-analyses published in regular journals, there is significant room for improvement. Clinicians should critically appraise all reports of meta-analyses before considering the results, regardless of the source of publication.

Prophylactic Oral Amiodarone for the Prevention of Arrhythmias that Begin Early After Revascularization, Valve Replacement, or Repair: PAPABEAR: a randomized controlled trial.

CONTEXT: Atrial tachyarrhythmias after cardiac surgery are associated with adverse outcomes and increased costs. Previous trials of amiodarone prophylaxis, while promising, were relatively small and yielded conflicting results. OBJECTIVE: To determine whether a brief perioperative course of oral amiodarone is an effective and safe prophylaxis for atrial tachyarrhythmias after cardiac surgery overall and in important subgroups. DESIGN, SETTING, AND PATIENTS: Double-blind randomized controlled trial of 601 patients listed for nonemergent coronary artery bypass graft (CABG) surgery and/or valve replacement/repair surgery between February 1, 1999, and September 26, 2003, at a tertiary care hospital. The patients were followed up for 1 year. INTERVENTION: Oral amiodarone (10 mg/kg daily) or placebo administered 6 days prior to surgery through 6 days after surgery (13 days). Randomization was stratified for subgroups defined by age, type of surgery, and use of preoperative beta-blockers. MAIN OUTCOME MEASURE: Incidence of atrial tachyarrhythmias lasting 5 minutes or longer that prompted therapy by the sixth postoperative day. RESULTS: Atrial tachyarrhythmias occurred in fewer amiodarone patients (48/299; 16.1%) than in placebo patients (89/302; 29.5%) overall (hazard ratio [HR], 0.52; 95% confidence interval [CI], 0.34-0.69; P<.001); in patients younger than 65 years (19 [11.2%] vs 36 [21.1%]; HR, 0.51 [95% CI, 0.28-0.94]; P = .02); in patients aged 65 years or older (28 [21.7%] vs 54 [41.2%]; HR, 0.45 [95% CI, 0.27-0.75]; P<.001); in patients who had CABG surgery only (22 [11.3%] vs 46 [23.6%]; HR, 0.45 [95% CI, 0.26-0.79]; P = .002); in patients who had valve replacement/repair surgery with or without CABG surgery (25 [23.8%] vs 44 [44.1%]; HR, 0.51 [95% CI, 0.31-0.84; P = .008); in patients who received preoperative beta-blocker therapy (27 [15.3%] vs 42 [25.0%]; HR, 0.58 [95% CI, 0.34-0.99]; P = .03); and in patients who did not receive preoperative beta-blocker therapy (20 [16.3%] vs 48 [35.8%]; HR, 0.40 [95% CI, 0.22-0.71]; P<.001), respectively. Postoperative sustained ventricular tachyarrhythmias occurred less frequently in amiodarone patients (1/299; 0.3%) than in placebo patients (8/302; 2.6%) (P = .04). Dosage reductions of blinded therapy were more common in amiodarone patients (34/299; 11.4%) than in placebo patients (16/302; 5.3%) (P = .008). There were no differences in serious postoperative complications, in-hospital mortality, or readmission to the hospital within 6 months of discharge or in 1-year mortality. CONCLUSION: Oral amiodarone prophylaxis of atrial tachyarrhythmias after cardiac surgery is effective and may be safe overall and in important patient subgroups. Clinical Trials Registration ClinicalTrials.gov Identifier: NCT00251706.

A systematic evaluation of the quality of meta-analyses in the critical care literature.

INTRODUCTION: Meta-analyses have been suggested to be the highest form of evidence available to clinicians to guide clinical practice in critical care. The purpose of this study was to systematically evaluate the quality of meta-analyses that address topics pertinent to critical care. METHODS: To identify potentially eligible meta-analyses for inclusion, a systematic search of Medline, EMBASE and the Cochrane Database of Systematic Reviews was undertaken, using broad search terms relevant to intensive care, including: intensive care, critical care, shock, resuscitation, inotropes and mechanical ventilation. Predetermined inclusion criteria were applied to each identified meta-analysis independently by two authors. To assess report quality, the included meta-analyses were assessed using the component and overall scores from the Overview Quality Assessment Questionnaire (OQAQ). The quality of reports published before and after the publication of the QUOROM statement was compared. RESULTS: A total of 139 reports of meta-analyses were included (kappa = 0.93). The overall quality of reports of meta-analyses was found to be poor, with an estimated mean overall OQAQ score of 3.3 (95% CI; 3.0-3.6). Only 43 (30.9%) were scored as having minimal or minor flaws (>5). We noted problems with the reporting of key characteristics of meta-analyses, such as performing a thorough literature search, avoidance of bias in the inclusion of studies and appropriately referring to the validity of the included studies. After the release of the QUOROM statement, however, an improvement in the overall quality of published meta-analyses was noted. CONCLUSION: The overall quality of the reports of meta-analyses available to critical care physicians is poor. Physicians should critically evaluate these studies prior to considering applying the results of these studies in their clinical practice.

Pulse pressure variation predicts fluid responsiveness following coronary artery bypass surgery.

STUDY OBJECTIVE: To determine whether the degree of pulse pressure variation (PPV) and systolic pressure variation (SPV) predict an increase in cardiac output (CO) in response to volume challenge in postoperative patients who have undergone coronary artery bypass grafting (CABG), and to determine whether PPV is superior to SPV in this setting. DESIGN AND SETTING: This was a prospective clinical study conducted in the cardiovascular ICU of a university hospital. PATIENTS: Twenty-one patients were studied immediately after arrival in the ICU following CABG. INTERVENTION: A fluid bolus was administered to all patients. MEASUREMENTS: Hemodynamic measurements, including central venous pressure (CVP), pulmonary artery occlusion pressure (PAOP), CO (thermodilution), percentage of SPV (%SPV), and percentage of PPV (%PPV), were performed shortly after patient arrival in the ICU. Patients were given a rapid 500-mL fluid challenge, after which hemodynamic measurements were repeated. Patients whose CO increased by >/= 12% were considered to be fluid responders. The ability of different parameters to distinguish between responders and nonresponders was compared. RESULTS: In response to the volume challenge, 6 patients were responders and 15 were nonresponders. Baseline CVP and PAOP were no different between these two groups. In contrast, the %SPV and the %PPV were significantly higher in responders than in nonresponders. Receiver operating characteristic curve analysis suggested that the %PPV was the best predictor of fluid responsiveness. The ideal %PPV threshold for distinguishing responders from nonresponders was found to be 11. A PPV value of >/= 11% predicted an increase in CO with 100% sensitivity and 93% specificity. CONCLUSION: PPV and SPV can be used to predict whether or not volume expansion will increase CO in postoperative CABG patients. PPV was superior to SPV at predicting fluid responsiveness. Both of these measures were far superior to CVP and PAOP.

Development of a perioperative medicine research agenda: a cross sectional survey.

BACKGROUND: Post-operative complications are a significant source of morbidity and mortality for patients undergoing surgery. However, there is little research in the emerging field of perioperative medicine beyond cardiac risk stratification. We sought to determine the research priorities for perioperative medicine using a cross sectional survey of Canadian and American general internists. METHODS: Surveys were electronically sent to 312 general internists from the Canadian Society of Internal Medicine and 130 internists from the perioperative medicine research interest group within the US based Society of General Internal Medicine. The questionnaire contained thirty research questions and respondents were asked to rate the priority of these questions for future study. RESULTS: The research topics with the highest ratings included: the need for tight control of diabetes mellitus postoperatively and the value of starting aspirin on patients at increased risk for postoperative cardiac events. Research questions evaluating the efficacy and safety of perioperative interventions had higher ratings than questions relating to the prediction of postoperative risk. Questions relating to the yield of preoperative diagnostic tests had the lowest ratings (p < 0.001 for differences across these categories). CONCLUSION: The results of this survey suggest that practicing general internists believe that interventions studies are a priority within perioperative medicine. These findings should help prioritize research in this emerging field.