Improved neurologic outcome after implementing evidence-based guidelines for cardiac surgery.

OBJECTIVE: A high incidence of neurologic complications was observed in the year 2001 in cardiac surgical patients in this department. This article attempts to show the impact of changing and optimizing management protocols on the incidence of neurologic morbidity after cardiac surgery. DESIGN: An observational study of cardiac surgical patients. SETTING: University hospital. PARTICIPANTS: All cardiac surgical patients treated postoperatively in the cardiac surgical ICU in 2001 (n = 1,165, control group) and in 2003 (n = 1,222, intervention group) were evaluated. INTERVENTIONS: A quality improvement program started at the beginning of 2002, based on the Task Force Committee Guidelines, included surgical and cardiopulmonary bypass recommendations as well as peri- and postoperative care (eg, use of epiaortic echo and strict perfusion protocol, avoidance of hyperthermia and hyperglycemia, and minimization of cerebral edema). RESULTS: The number of neurologic complications decreased from 78 (6.7%) in 2001 to 33 (2.7%) in 2003 (p < 0.01), and corresponding numbers for ICU mortality were 44 (3.8%) and 24 (2.0%) (p < 0.01). The length of ICU stay also decreased (3.2 +/- 4.5 days in 2001 v 2.9 +/- 5.5 days in 2003, p < 0.001). In 2001, patients with neurologic complications consumed 853 ICU patient days (23% of all ICU patient days) and, in 2003, 549 (15% of all ICU patient days). According to logistic regression analysis that included 11 independent variables (treatment year, EuroSCORE, diabetes mellitus, history of stroke, and 7 different types of surgery), treatment in 2003 was independently associated with decreased risk for neurologic complications (odds ratio 0.30, 95% confidence intervals 0.19-0.47, p < 0.001). CONCLUSIONS: The occurrences of neurologic complications, mortality, and ICU resource consumption by this patient group decreased after implementation of an optimized management protocol and evidence-based guidelines.

Risk evaluation of cardiac surgery in octogenarians.

OBJECTIVE: To assess the predictive value of risk factors in the European System for Cardiac Operative Risk Evaluation (EuroSCORE) for cardiac surgery on octogenarians. DESIGN: An observational study of octogenarians undergoing cardiac surgery and average-aged controls matched according to the cardiac surgical procedure. SETTING: A university hospital. PARTICIPANTS: One hundred sixty-two consecutive patients 80 years or older who underwent cardiac surgery between January 1, 2001, and June 30, 2003, and 162 average-aged controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Risk factors according to the EuroSCORE (The European System for Cardiac Risk Evaluation) model and EuroScore algorithm without an age component (EuroSCOREex) were evaluated. The EuroSCORE model and EuroSCOREex predicted mortality (odds ratio 1.4) and morbidity (odds ratio 1.2 and 1.3, respectively) equally well in both age groups. Adding age group information into the EuroSCOREex model in combined data, the odds ratio estimate was 3.5 for age group. The 30-day mortality of octogenarians was 8.6% versus 1.9% in controls (p < 0.01). Incidences of organ-related complications were comparable. Octogenarians spent more days in the hospital's intensive care unit and surgical ward than did controls (3.4 +/- 3.3 days v 2.7 +/- 3.1 days, p < 0.01; 9.9 +/- 5.8 days v 8.6 +/- 3.8 days, p = 0.02). Only 31 (19.1%) octogenarians were discharged home, whereas the corresponding number was 66 (40.7%) in controls (p < 0.01). CONCLUSIONS: Risk factors other than age were not higher in octogenarians, and the EuroSCORE model predicted mortality and morbidity. Age was an important single risk factor predicting mortality.