Postoperative Weight Gain within Enhanced Recovery after Cardiac Surgery.

Optimal fluid therapy during perioperative care as part of enhanced recovery after cardiac surgery (ERACS) should improve the outcome. Our objective was finding out the effects of fluid overload on outcome and mortality within a well-established ERACS program. All consecutive patients undergoing cardiac surgery between January 2020 and December 2021 were enrolled. According to ROC curve analysis, a cut-off of ≥7 kg (group M, n = 1198) and <7 kg (group L, n = 1015) was defined. A moderate correlation was shown between weight gain and fluid balance r = 0.4, and a simple linear regression was significant p < 0.0001, R2 = 0.16. Propensity score matching showed that increased weight gain was associated with a longer hospital length of stay (LOS) (L 8 [3] d vs. M 9 [6] d, p < 0.0001), an increased number of patients who received pRBCs (L 311 (36%) vs. M 429 (50%), p < 0.0001), and a higher incidence of postoperative acute kidney injury (AKI) (L 84 (9.8%) vs. M 165 (19.2%), p < 0.0001). Weight gain can easily represent fluid overload. Fluid overload after cardiac surgery is common and is associated with prolonged hospital LOS and increases the incidence of AKI.

Is perioperative fast-track management the future of proximal aortic repair?

OBJECTIVES: The Bentall procedure is the gold standard for patients with combined aortic root dilation and valve dysfunction. Over the past decade, fast-track (FT) perioperative anaesthetic management protocols have progressively evolved. We reviewed our results for selected patients undergoing Bentall surgery under an FT protocol. METHODS: We retrospectively analysed a consecutive cohort of patients who underwent elective Bentall procedures at our institution between 2000 and 2018. Complex aortic root repair (i.e. David and Ross procedure, redo surgery, major concomitant procedures, emergency repair for acute dissections) was excluded. Patients who underwent conventional perioperative treatment and those treated according to our institutional FT concept were compared following 1:1 propensity score matching. RESULTS: Of 772 patients who fit the in- and exclusion criteria, 565 were treated conventionally post-surgery, while 207 were treated using the FT protocol. Propensity score matching resulted in 197 pairs, with no differences in baseline characteristics after matching. In-house mortality, 30-day mortality and overall all-cause long-term mortality were comparable between the FT and the conventionally treated cohort. Postoperative anaesthetic care unit/intensive care unit length-of-stay (6.2 vs 20.6 h, P = 0.03) and postoperative ventilation times (158.9 vs 465.5 min, P < 0.001) were significantly shorter in the FT cohort. There were no differences in rates of postoperative adverse events. CONCLUSIONS: In centres with experienced anaesthesiologists, perioperative FT management is non-inferior to conventionally treated patients undergoing elective Bentall procedures without compromising patient safety.

Interventions Triggered During Routine Use of NIRS Cerebral Oxygenation Monitoring in Cardiac Surgical Patients.

OBJECTIVE: The purpose of this study was to determine the incidence and types of interventions triggered during a drop of baseline near-infraredspectroscopy (NIRS) values in consecutive cardiac surgical patients. DESIGN: A single-center, retrospective observational study. SETTING: A university-affiliated tertiary care center. PARTICIPANTS: Three thousand three hundred two consecutive cardiac surgical patients from October 2016 to August 2017 Interventions: None. MEASUREMENTS AND MAIN RESULTS: Of the 1,972 patients who met the inclusion criteria, 576 (29.2%) patients showed NIRS deviation of -20% from baseline. Interventions performed during the drop of baseline NIRS values were documented in 285 (14.4%) patients, with a total of 391 interventions. Three hundred fifteen (80%) interventions were triggered by a deviation in NIRS and concomitant changes in standard monitoring parameters. Seventy-six (20%) interventions were triggered by NIRS deviation alone, with no concomitant pathologic deviation in standard monitoring. A total of 279 (71%) interventions were performed on patients who had no recommendation for NIRS monitoring by current national guidelines. Out of these, 30 (7.7%) interventions (1.3% of all patients) were performed based on NIRS monitoring alone. The higher risk deviation group had longer intensive care unit and hospital lengths of stays (one and 15 days) and postoperative delirium when compared with the no-deviation group (zero and 13 days) Conclusions: The authors' data suggested that most interventions triggered during the drop of baseline values during routine use of NIRS would have also been triggered by the concomitant changes in standard monitoring parameters. Routine use of NIRS for all cardiac surgical patients still is debatable and needs to be evaluated in a large prospective trial.

Persistent and acute postoperative pain after cardiac surgery with anterolateral thoracotomy or median sternotomy: A prospective observational study.

OBJECTIVE: The primary objective of this study was to compare the association between cardiac surgical approach (thoracotomy vs. sternotomy) and incidence of persistent postoperative pain at 3 months. Secondary objectives were the incidence and intensity of persistent pain at 6 and 12 months, acute postoperative pain, analgesic requirement and its side effects. DESIGN: Single-center, prospective, observational study. Recruitment between December 2017 and August 2018. SETTING: Perioperative care at university-affiliated tertiary care centre. PATIENTS: 202 adults scheduled for cardiac surgery. Patients with chronic pain or behavioural disorder were excluded. INTERVENTIONS: Thoracotomy (n = 106) and sternotomy (n = 96). MEASUREMENTS: Pain scores and pain medication requirements from extubation until hospital discharge. Persistent postoperative pain was assessed using a telephone questionnaire. MAIN RESULTS: Incidence and intensity of pain was not significantly different between thoracotomy or sternotomy either in the short- or in the long-term follow-up. Incidence of persistent postoperative pain showed no differences between groups (30.2 vs 22.9% at 3 months (p = 0.297), 10.4 vs 7.3% at 6 months (p = 0.364) and 7.5 vs 7.3% at 12 months (p = 0.518) in thoracotomy and sternotomy group). A significant decrease of pain incidence was observed between 3 and 6 months (p < 0.001) but not between 6 and 12 months (p = 0.259) in both groups. ANOVA of repeated measures adjusted for confounding variable showed a decrease of acute pain intensity over time (p = 0.001) with no difference between groups (p = 0.145). Acute pain medication requirements were not different between the groups (p = 0.237 for piritramide and p = 0.743 for oxycodone) with no difference in their side effects. CONCLUSIONS: Our study showed no difference in short- or long-term pain in patients undergoing anterolateral thoracotomy or median sternotomy. Both groups showed a decrease in persistent postoperative pain incidence between 3 and 6 months without any significant changes at 12 months.

A Comparison of Patients Undergoing On- vs. Off-Pump Coronary Artery Bypass Surgery Managed with a Fast-Track Protocol.

The purpose of this study was to compare patients who underwent on- vs. off-pump coronary artery bypass surgery managed with a fast-track protocol. Between September 2012 and December 2018, n = 3505 coronary artery bypass surgeries were managed with a fast-track protocol in our specialized post-anesthesia care unit. Propensity score matching was applied and resulted in two equal groups of n = 926. There was no significant difference in ventilation time (on-pump 75 (55-120) min vs. off-pump 80 (55-120) min, p = 0.973). We found no statistically significant difference in primary fast-track failure in on-pump (8.2% (76)) vs. off-pump (6% (56)) groups (p = 0.702). The secondary fast-track failure rate was comparable (on-pump 12.9% (110) vs. off-pump 12.3% (107), p = 0.702). There were no significant differences between groups in regard to the post-anesthesia care unit, the intermediate care unit, and the hospital length of stay. Postoperative outcome and complications were also comparable, except for a statistically significant difference in PACU postoperative blood loss in on-pump (234 mL) vs. off-pump (323 mL, p < 0.0001) and red blood cell transfusion (11%) and (5%, p < 0.001), respectively. Our results suggest that on- and off-pump coronary artery bypass surgery in fast-track settings are comparable in terms of ventilation time, fast-track failure rate, and postoperative complications rate.

Retrospective study of complete atrioventricular canal defects: Anesthetic and perioperative challenges.

OBJECTIVE: The objective of this study was to highlight anesthetic and perioperative management and the outcomes of infants with complete atrioventricular (AV) canal defects. DESIGN: This retrospective descriptive study included children who underwent staged and primary biventricular repair for complete AV canal defects from 1999 to 2013. SETTING: A single-center study at a university affiliated heart center. PARTICIPANTS: One hundred and fifty-seven patients with a mean age at surgery of 125 ± 56.9 days were included in the study. About 63.6% of them were diagnosed as Down syndrome. Mean body weight at surgery was 5.6 ± 6.3 kg. METHODS: Primary and staged biventricular repair of complete AV canal defects. MEASUREMENTS AND MAIN RESULTS: A predefined protocol including timing of surgery, management of induction and maintenance of anesthesia, cardiopulmonary bypass, and perioperative intensive care treatment was used throughout the study. Demographic data as well as intraoperative and perioperative Intensive Care Unit (ICU) data, such as length of stay in ICU, total duration of ventilation including reintubations, and total length of stay in hospital and in hospital mortality, were collected from the clinical information system. Pulmonary hypertension was noted in 60% of patients from which 30% needed nitric oxide therapy. Nearly 2.5% of patients needed permanent pacemaker implantation. Thorax was closed secondarily in 7% of patients. In 3.8% of patients, reoperations due to residual defects were undertaken. Duration of hospital stay was 14.5 ± 4.7 days. The in-hospital mortality was 0%. CONCLUSION: Protocolized perioperative management leads to excellent outcome in AV canal defect repair surgery.

Impact of the post-anesthetic care unit opening hours on fast-track success in cardiac surgery.

BACKGROUND: Fast-track (FT) treatment in cardiac anesthesia is a state-of-the-art technique. The aim of our study was to compare FT treatment in a post-anesthetic care unit (PACU) with limited opening hours with a PACU opened for unlimited hours. Primary endpoints were extubation time (ET), length of stay (LOS) in PACU and LOS in intermediate care unit (IMC). Secondary endpoints were FT success/failure, hospital LOS, re-intubation and in hospital mortality. METHODS: At our institution, FT is usually managed in a PACU with limited opening hours from 10 a.m. to 10 p.m., Monday to Friday (PACU12). Due to reconstruction work in 2011, this PACU was open 24 hours a day, Monday to Saturday (PACU24). We retrospectively compared patients admitted to PACU24 during 2011 (January to December) and patients admitted to PACU12 during 2013 (January to December). RESULTS: A total of 2174 patients were primarily included in the study, 319 of them had to be excluded. Primary endpoints in PACU12 compared to PACU24 were significantly shorter: median ET (2.0 [95% confidence interval: 1.4-2.8] vs. 3.3 [95% CI: 2.2-5.0] hours), median LOS in PACU (4.8 [95% CI: 4.0-5.9] vs. 21.2 [95% CI: 18.3-23.5] hours) and median LOS in IMC (24 [95% CI: 18-64] vs. 38 [95% CI: 22-77] hours). FT success was significantly higher in PACU12 compared to PACU24 (75.3% vs. 39.6%). The in-hospital mortality and re-intubation rate were not significantly different. CONCLUSIONS: FT treatment in a PACU with limited opening hours leads to more effective treatment for patients regarding extubation time and LOS in IMC than in a PACU with limited opening hours, without compromising safety.