Can timing of tracheal extubation predict improved outcomes after cardiac surgery?

INTRODUCTION: Early tracheal extubation is a common goal after cardiac surgery. Our study aims to examine whether timing of tracheal extubation predicts improved postoperative outcomes and late survival after cardiac surgery. We also evaluated the optimal timing of extubation and its association with better postoperative outcomes. METHODS: Between 2002 and 2006, 1164 patients underwent early tracheal extubation (<6 hours after surgery) and 1571 had conventional extubation (>6 hours after surgery). Propensity score adjustment and multivariable logistic regression analysis were used to adjust for imbalances in the patients' preoperative characteristics. Receiver operating characteristic curves (ROC) were used to identify the best timing of extubation and improved postoperative outcomes. Cox regression analysis was used to identify whether early extubation is a risk factor for decreased late mortality. RESULTS: Results - Early extubation was associated with lower propensity score-adjusted rate of operative mortality (Odds Ratio =0.55, 95% Confidence Intervals =0.31-0.98, p=0.043). Extubation within 9 hours emerged as the best predictor of improved postoperative morbidity and mortality (sensitivity =85.5%, specificity =52.7%, accuracy =64.5%). Early extubation also predicted decreased late mortality (Hazard Ratio =0.45, 95% Confidence Intervals 0.31-0.67, p<0.001). CONCLUSIONS: Early extubation may predict improved outcomes after cardiac surgery. Extubation within 9 hours after surgery was the best predictor of uncomplicated recovery after cardiac surgery. Those patients intubated longer than 16 hours have a poorer postoperative prognosis. Early extubation predicts prolonged survival up to 16 months after surgery.

From Hippocrates to Palmaz-Schatz, the history of carotid surgery.

The extracranial carotid artery is the most common site for peripheral vascular procedures. Although the association of carotid disease and neurologic dysfunction was understood by the ancient Greeks, over 1700 years would pass before the relevant anatomy was described. In the 16th and 17th centuries, attempts at treatment of carotid injury and aneurysm by ligation were met with extremely high rates of stroke and death. It is not until the mid 20th century, with the introduction of carotid angiography and improved vascular surgical techniques, that the era of reconstructive carotid surgery begins. We present a synopsis of the history of carotid surgery from ancient times to present day.

Patent foramen ovale and pulmonary embolism. An underestimated co-morbidity following cardiac surgery.

When pulmonary embolism occurs in the presence of a patent foramen ovale the sudden increase in the right heart pressure can open the defect and could cause right to left atrial shunting. This may further aggravate the already existing hypoxemia, and the direct communication between the venous and the arterial circulation increases the risk of paradoxical embolization. In this paper we present a case of postoperative pulmonary embolization in a patient with patent foramen ovale, and the effects of these co-existing conditions are reviewed. In the cardiac surgical literature such a complication has not yet been described.

Resection of a bronchogenic cyst involving the wall of the mainstem bronchus and repair utilizing a pedicled pericardial flap.

Symptomatic bronchogenic cysts should be completely resected because of uncertainties in diagnosis, to prevent recurrence, and to avoid late complications. Infrequently, these cysts may involve the proximal tracheobronchial tree. Often such cysts are incompletely excised with less than optimal results. A case of a patient with a bronchogenic cyst involving the wall of the right mainstem bronchus is presented. The cyst was completely excised and the bronchus repaired using a pedicled pericardial flap. The procedure may serve as the preferred method of reconstruction in such circumstances.

The use of maggots in wound debridement.

Since antiquity, clinicians have observed that maggots can provide debridement of necrotic wounds, but the therapeutic use has declined since the advent of aseptic wound management and antibiotics. In certain difficult wounds, the use of maggots for debridement may have a role. If so, the larvae must be prepared prospectively to control the bacterial population of the insect's intestinal tract and integument. The mechanism of wound debridement by maggots includes the secretion of proteolytic enzymes and antibacterial substances. A case of infestation of a necrotic wound in a patient with cancer of the head and neck is presented including the entomological identification and description of the maggots.