Long-term outcome when major complications follow coronary artery bypass graft surgery. Recovery after complicated coronary artery bypass graft surgery.

OBJECTIVE: To determine whether information available 1 week after surgery correlates with long-term function in patients who suffer major complications after coronary artery bypass graft (CABG) surgery. DESIGN: An inception cohort study. SETTING: A 526-bed community teaching hospital. PATIENTS: All 67 patients who required at least 7 days of CT-ICU care following 2,751 consecutive CABG operations. MAIN OUTCOMES: Hospital survival, long-term survival, and functional ability at long-term follow-up. RESULTS: Forty-three patients survived hospitalization (64%), while 24 died 37 +/- 45 days (range, 7 to 190 days) after surgery. When 42 patients were surveyed 22 +/- 9 months after surgery, 21 of the survivors enjoyed excellent, independent function, 7 were moderately impaired but living at home, 6 were institutionalized with severe limitations, and 8 had died. Patients with very severe cardiac or neurologic dysfunction 1 week after surgery had an extremely poor outcome. When mechanical ventilation was required for causes other than primary failure of the respiratory system, long-term function and hospital survival were poor. Twelve of 14 patients with pulmonary complications survived hospitalization, and all 12 were alive at long-term follow-up. CONCLUSION: More than half of patients requiring 7 days or more of ICU treatment after CABG surgery survive, and many enjoy excellent long-term function. However, those with very severe cardiac or neurologic dysfunction 1 week after surgery have little chance for independent recovery.

Withdrawing care. Experience in a medical intensive care unit.

OBJECTIVE: To describe the process and outcomes of withdrawing life-sustaining interventions in a medical intensive care unit (MICU). DESIGN: Retrospective case series. SETTING: Medical intensive care unit in a community teaching hospital. PATIENTS: Consecutive series of 28 patients in whom mechanical ventilation, dialysis, and/or vasopressors were withdrawn. We distinguished physiological, neurological, and functional rationales for care withdrawal. MAIN OUTCOME MEASURES: Duration of discussions, MICU length of stay, and hospital survival. RESULTS: Mean +/- SD Acute Physiology and Chronic Health Evaluation (APACHE II) score was 27.1 +/- 7.3 on MICU admission, and average +/- SD predicted hospital mortality was 61% +/- 22%. Discussions leading to withdrawal of care occurred over an average +/- SD of 5.2 +/- 5.5 days, with decisions achieved soonest in cases with poor neurological prognosis. Average +/- SD MICU length of stay was 1.4 +/- 1.8 days following a decision to withdraw MICU care, and only four patients received more than 48 hours of additional MICU care. Four patients were discharged alive from the hospital. CONCLUSIONS: Patients and their surrogates willingly considered outcomes in addition to mortality when considering withdrawal of life-sustaining interventions. Finding an accommodation between physician judgments and patient preferences took time and effort but was an effective means of limiting ineffective life-sustaining efforts. Withdrawing futile or unwanted care was not always fatal.

Recurrent acoustic neuroma presenting as central alveolar hypoventilation.

Centrally mediated hypoventilation causes respiratory failure without respiratory distress. We present a case of recurrent acoustic neuroma at the cerebellopontine angle causing acute and chronic respiratory failure. Tumor resection eliminated recurrence of respiratory failure.

Respiratory failure in the elderly. Analysis of outcome after treatment with mechanical ventilation.

BACKGROUND: Concerns about rendering futile care, the financial costs of mechanical ventilation, and aging of the population make it important to analyze the benefit of aggressive therapy for respiratory failure in the elderly. METHODS: This study is a retrospective review of 1860 patients treated with mechanical ventilation in the medical intensive care unit for more than 3 hours between 1974 and 1985. Patients were assigned to one of nine diagnostic groups, and 10 premorbid chronic illnesses or organ system dysfunctions were recorded. Survival to discharge was determined for all patients, and the duration of survival after discharge was determined for patients aged 80 years and older. Two hundred eighty-two patients aged 80 years and older were compared with 1578 patients less than 80 years of age. RESULTS: Fifteen percent of patients treated with mechanical ventilation were 80 years of age or older. Forty-four percent of patients younger than 80 years, and 30.9% of patients aged 80 years and older survived to discharge. Patients aged 80 years or older with preexisting renal disease, liver disease, cancer, systemic illness, or chronic gastrointestinal disease with malnutrition had only a 7% survival compared with 29% for younger patients. For patients without these premorbid conditions (80% of both the younger and older groups) survival among the elderly was better, even though it was still poorer than for younger patients (38% vs 49%). Elderly patients requiring more than 15 days of mechanical ventilation had a 9% survival compared with 36% for younger patients. CONCLUSIONS: A subgroup of patients 80 years of age or older can be identified whose chance for survival from respiratory failure is so poor that withholding or withdrawing treatment with mechanical ventilation may be appropriate. For the majority of elderly patients, short-term survival is nearly as good as in younger patients. Further studies are needed that assess long-term survival and functional recovery after treatment for respiratory failure so that elderly patients and their physicians can better decide whether or not to choose treatment with mechanical ventilation.

Effect of age and preoperative airway obstruction on lung function after coronary artery bypass grafting.

To determine whether age or obstructive lung disease affects pulmonary function changes caused by uncomplicated coronary artery bypass grafting, we measured pulmonary function before operation and then 3 or 4 days, 7 days, and 17 +/- 2.2 weeks after operation in elderly patients (age, 74.8 +/- 3.3 years) and patients with obstructive lung disease (ratio of forced expiratory volume in 1 second to forced vital capacity, 0.60 +/- 8.8) and compared the results with those of a "normal" group. In all three groups a severe restrictive defect developed on day 3 (vital capacity, 61% +/- 20% of the preoperative value). Vital capacity recovered to 76.4% +/- 18.5% of the preoperative value on day 7. Three months after coronary artery bypass grafting, lung function had recovered to preoperative baseline (p > 0.2). The percent change from baseline in vital capacity, forced expiratory volume in 1 second, total lung capacity, and diffusing capacity for carbon monoxide was the same in all three groups throughout the study. A severe, reversible restrictive pulmonary function change follows coronary artery bypass grafting. This change is not affected by age or preexisting moderately severe obstructive lung disease.

Reinfusion of shed blood after coronary operation causes elevation of cardiac enzyme levels.

We studied the effect of reinfusing mediastinal and chest tube drainage (autotransfusion) after coronary artery bypass grafting on circulating levels of creatine kinase, lactate dehydrogenase, and serum glutamic-oxaloacetic transaminase in 20 patients. Reinfusion of 469 +/- 171 mL (mean +/- standard deviation) of drainage caused enzyme levels to rise to 372% (creatine kinase), 159% (serum glutamic-oxaloacetic transaminase), and 143% (lactate dehydrogenase) of their levels before autotransfusion. The MB fraction of the circulating creatine kinase was not elevated. Enzyme changes caused by autotransfusion can potentially mimic or mask the presence of perioperative myocardial infarction. Enzyme determinations after coronary artery bypass grafting must be carefully interpreted when reinfusion of shed blood is used as a blood salvage technique. Routine measurement of these enzymes after operation may not be warranted.

Acute cardiogenic pulmonary edema treated with mechanical ventilation. Factors determining in-hospital mortality.

We reviewed 88 episodes of cardiogenic pulmonary edema (CPE) treated with mechanical ventilation to define the clinical features that predict in-hospital mortality. Fifty-six patients survived to hospital discharge. APACHE II scores were not helpful in prediction. Multiple logistic regression models to predict outcome were developed using variables present at the time of intubation and 24 hours later. The model at the time of intubation indicated mortality was related to systolic blood pressure less than 130 mm Hg, the presence of anterior myocardial infarction, use of calcium channel blockers, age, and absence of prior hospitalization for CPE. A model using additional variables available 24 hours later showed that mortality was related only to the need for vasopressor medication at 24 hours, and systolic blood pressure at intubation less than 130 mm Hg. The predictive power of these models was confirmed by applying them to 46 additional patients. The variables contained in these models suggest that the prognosis of patients with CPE treated with mechanical ventilation depends primarily on the severity of acute left ventricular injury. Variables relating the degree of respiratory failure, however, were not predictive of mortality. These multiple logistic regression models provide a means to compare patients with CPE for quality assessment purposes and for studies of treatment regimens, and may also provide information useful to patient and family counseling regarding the value of continued aggressive intensive care.

APACHE II score and mortality in respiratory failure due to cardiogenic pulmonary edema.

We reviewed retrospectively 88 patients to assess whether the APACHE II severity of disease classification system can predict mortality in patients with respiratory failure due to cardiac pulmonary edema. Mean score for survivors was higher than for nonsurvivors (24.5 +/- 6.7 vs. 20.7 +/- 5.7, p less than .01), and increasing APACHE II scores were not associated with increasing mortality. Mortality was 54% for APACHE II scores less than or equal to 18, 43% for scores greater than 18 and less than or equal to 24, 22% for scores greater than 24 and less than or equal to 31, and 25% for scores between 32 and 40. The relationship of APACHE II scores to mortality did not improve when the 25 patients with ICU stays less than 48 h were analyzed; the mean score of survivors in this group was 24.3 +/- 5.2 vs. 18.8 +/- 4.6 for nonsurvivors, p less than .001. The presence of myocardial infarction (MI) was associated with a high mortality. Mortality in the 51 MI patients was 52.9% vs. 13.5% in the 37 patients without MI (p less than .001), but APACHE II scores were similar (22.6 +/- 6.6 and 23.7 +/- 6.4, respectively). The relationship between APACHE II scores and mortality did not improve if patients with and without MI are analyzed separately. For patients with MI, mortality was 78.6% for scores between 12 and 17, 56.2% for scores between 18 and 23, 33.3% for scores between 24 and 29, and 33.3% for scores greater than 29.(ABSTRACT TRUNCATED AT 250 WORDS)

Utility of fiberoptic bronchoscopy in patients with hemoptysis and a nonlocalizing chest roentgenogram.

The need for fiberoptic bronchoscopy in the patient with hemoptysis and a normal or nonlocalizing chest roentgenogram remains a subject of debate. Currently, diagnostic fiberoptic bronchoscopy is recommended as the investigative procedure of choice. To develop predictors that identify the patient in whom fiberoptic bronchoscopy is most likely to be diagnostic, we reviewed our community's experience with this population over a five-year period. We identified 196 patients with hemoptysis and a normal or nonlocalizing chest roentgenogram who underwent fiberoptic bronchoscopy. Three quarters were active or previous smokers. We examined the relationship of advancing age, sex, smoking, nonspecific roentgenographic findings and the amount, duration, and previous bouts of hemoptysis to the incidence of a diagnostic fiberoptic bronchoscopy. Twelve patients (6 percent) had bronchogenic carcinoma and 33 (17 percent) another specific cause for the hemoptysis identified by fiberoptic bronchoscopy. By univariate and discriminant analyses, we found that the three factors of age of 50 years or more, male sex, and smoking of 40 pack-years or more best predicted a diagnosis of malignancy. Bleeding in excess of 30 ml daily was associated with an increase in overall diagnostic yield. The presence of two of the three factors associated with malignancy or bleeding in excess of 30 ml daily (or both) identified 100 percent of the patients with bronchogenic carcinoma and 82 percent of all of the diagnostic fiberoptic bronchoscopic procedures. use of these criteria in selecting the patient for fiberoptic bronchoscopy could have reduced our use of the bronchoscope by 28 percent, with the remaining patients safely observed.

Comparison of noninvasive measurements of carbon dioxide tension during withdrawal from mechanical ventilation.

End tidal CO2 tension (PetCO2) and transcutaneous CO2 tension (PtcCO2) were compared with arterial CO2 (PaCO2) before and after withdrawal of mechanical ventilation in 20 patients predisposed to hypercarbia. With stable PaCO2 during mechanical ventilation, the correlation coefficient (r) between PaCO2 and PetCO2 was .9, and between PaCO2 and PtcCO2, .87. PtcCO2 considerably overestimated PaCO2 in three patients who were receiving dopamine. After withdrawal of mechanical ventilation, changes in PaCO2 were closely paralleled by changes in PetCO2 and PtcCO2 (r = .82 and .86, respectively). Nine of 20 patients had an increased PaCO2 of 10 torr or greater. In eight of these, PetCO2 and PtcCO2 rose by at least 5 torr, and in seven, the rise in PetCO2 and PtcCO2 was within 5 torr of the rise in PaCO2. During mechanical ventilation, PetCO2 and PtcCO2 estimated stable PaCO2 with sufficient accuracy for clinical use, except in patients with cutaneous vasoconstriction. After withdrawal of mechanical ventilation, changes in PetCO2 and PtcCO2 were predictive of important PaCO2 increases, warranting continued exploration and evaluation as to their use in monitoring patients predisposed to hypercarbia.

Histoplasmoma, pleural fibrosis, and slowly enlarging pleural effusion in an asymptomatic patient.

A slowly enlarging pleural effusion and significant pleural fibrosis occurred in an asymptomatic patient with a subpleural histoplasmoma. The pleural disease may be a reaction to antigen diffusing into the pleural space from the histoplasmoma. In selected patients, resection of the histoplasmoma may be necessary to prevent impairment of ventilation from pleural fibrosis.

Predictors of mortality in the immunocompromised patient with pulmonary infiltrates.

To determine predictors of mortality in immunocompromised patients with pulmonary infiltrates, we reviewed the records of all such patients admitted to two community teaching hospitals who underwent a lung biopsy over a ten-year period. We examined the consequences of advancing age, primary disease, fever, neutropenia, immunosuppressive corticosteroid therapy, previous lung radiation, roentgenographic pattern, result of lung biopsy, room air arterial oxygen pressure (Pao2), early mechanical ventilation, and the presence of a comorbid disease on eventual outcome. We identified 104 episodes in 99 patients. Sixty-seven (64%) survived and 37 died. By both discriminant analysis and logistic regression statistical methods, mechanical ventilation, the initial room air Pao2, and corticosteroid therapy were the dominant independent variables, in that order, to significantly predict mortality. No patient survived who simultaneously had a room air Pao2 less than or equal to 50 mm Hg, was on corticosteroids, and was mechanically ventilated. Eighty-three percent of survivors had either none or, at most, one of these three variables present. We conclude that hypoxia, immunosuppression by corticosteroids, and the necessity for mechanical ventilation within 72 hours of hospitalization indicate a poor prognosis in the immunocompromised patient with pulmonary infiltrates who has undergone a lung biopsy.