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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Tag: cardiac surgery (Page 1 of 2)

Cardiac surgery and sepsis in postoperative period – our experience


The occurrence of sepsis after cardiac surgery is a rare event; however, its occurrence showed catastrophic clinical outcomes. The high morbidity and mortality revealed the need to improve treatment, aiming at patients’ better clinical outcome.

Patients that develop sepsis, regardless of the infectious focus and the subjacent disease, present high morbidity and mortality, which vary from 17% to 65%. The main predictors of infections in the postoperative period are: body mass index ≥40kg/m², haemodialysis in the preoperative period, pre-op cardiogenic shock, age ≥80 years, pre-op treatment with immunosuppressive agents, diabetes mellitus, ECC time ≥200 minutes, mechanical circulatory support, three or more revascularized vessels.

From January 2015 to December 2015, we studied 675 adult patients who underwent cardiac surgery. Prophylactic antibiotic therapy was prescribed and given according to our protocol, from the induction of anaesthesia to the first postoperative day.

Sepsis in the postoperative period was defined as evidence on infection associated with two or more criteria of systemic inflammatory response syndrome: body temperature >38°C or <36°C, leukocytes >12,000 cells/mm³, positive blood cultures, respiratory rate >20/min, heart rate >100/min.

Key words: sepsis, postoperative period, cardiac surgery

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Methicillin-Resistant Staphylococcus Species in a cardiac surgical intensive care unit


Objective. Multi-drug resistant bacterial infections, in particular when Methicillin-Resistant Staphylococcus Aureus (MRSA) is involved, have become a relevant problem in both general and specialized intensive care units. The aim of this study was to identify the epidemiology of MRSA infections in a Cardiac Surgical Intensive Care Unit, to assess their impact on mortality and to identify predictors of MRSA infection and mortality in this population.

Design and settings. A 7-year observational study in a cardiac surgery teaching center.

Participants. Eight thousand, one hundred and sixty-two microbiological samples were obtained from 7,313 patients who underwent cardiac surgery in the study period.

Interventions. None.

Variables of interest and main results. Twenty-eight patients (0.38%) had MRSA infection. The most frequent site of MRSA isolation was from bronchoalveolar samples. Hospital mortality was 50% in patients with MRSA infection and 2% in patients without MRSA infection (p<0.001).

Few preoperative independent predictors of MRSA infection and hospital mortality were found at multivariate analysis. Outcomes were found to be most influenced by perioperative variables. MRSA infection was the strongest predictor of mortality, with an odds ratio of 20.5 (95% CI 4.143-101.626).

Conclusions. Methicillin-resistant Staphylococcus aureus infections following cardiac surgery still have a strong impact on the patients’ outcome. More efforts should be directed toward the development of new risk analysis models that might implement health care practices and might become precious instruments for infection prevention and control.

Key words: Methicillin-Resistant Staphylococcus Aureus, infections, cardiac surgery, mortality, intensive care, cardiac anaesthesia

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Thromboelastometry in neonates and infants undergoing cardiac surgery


Introduction. Rotational thromboelastometry (ROTEM) in monitoring coagulation in children undergoing cardiac surgery has been studied with promising results. Since the data about ROTEM in infants and neonates undergoing cardiac surgery are scarce, the aim of our study was to asses ROTEM abnormalities in this patient group.

Methods. Infants and neonates undergoing cardiac surgery on cardiopulmonary bypass were included in this prospective, observational study conducted in a level III multidisciplinary neonatal and pediatric intensive care unit (ICU) between May 2011 and January 2012. ROTEM analysis, together with determination of platelet count, international normalized ratio of prothrombin time (INR), activated partial thromboplastin time (PTT), and fibrinogen concentration, was done in all neonates and infants before surgery (t1), after admission to ICU (t2) and 24 hours after surgery (t3).

Results. Twenty infants and neonates were operated on during the time of the study. ROTEM abnormalities seen after surgery (t2) were: thrombocytopenia 14, hypofibrinogenemia 1, mixed hypofibrinogenemia and coagulation factor deficiency 1, and mixed thrombocytopenia with mild hyperfibrinolysis 1. Three patients were found to have normal ROTEM results. The median values of all except one of the ROTEM tests, as well as platelet count, INR, PTT, and fibrinogen concentration, showed significant prolongation or deterioration after admission to ICU and these deteriorations persisted in several parameters for 24 hours.

Conclusions. In our neonates and infants, cardiac surgery on cardiopulmonary bypass predominantly affects platelets, although most of the ROTEM parameters deteriorated after admission to ICU.

Key words: thromboelastometry, cardiac surgery, neonate, infant, thrombocytopenia, hypofibrinogenemia.

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Continuous infusion versus bolus injection of furosemide in pediatric patients after cardiac surgery: a meta-analysis of randomized studies


Introduction. Acute renal failure and fluid retention are common problems in pediatric patients after cardiac surgery. Furosemide, a loop diuretic drug, is frequently administered to increase urinary output. The aim of the present study was to compare efficacy and complications of continuous infusion of furosemide vs bolus injection among pediatric patients after cardiac surgery.

Methods. A systematic review and meta-analysis was performed in compliance with The Cochrane Collaboration and the Quality of Reporting of Meta-Analysis (QUORUM) guidelines. The following inclusion criteria were employed for potentially relevant studies: a) random treatment allocation, b) comparison of furosemide bolus vs continuous infusion, c) surgical or intensive care pediatric patients. Non-parallel design randomized trials (e.g. cross-over), duplicate publications and non-human experimental studies were excluded.

Results. Up to August 2008, only three studies were found, with 92 patients randomized (50 to continuous infusion and 42 to bolus treatment). Overall analysis showed that continuous infusion and bolus administration were equally effective in achieving the predefined urinary output, and were associated with a similar amount of administered furosemide (WMD=-1.71 mg/kg/day [-5.20; +1.78], p for effect=0.34, p for heterogeneity<0.001, I2=99.0). However, in the continuous infusion group, patients had a significantly reduced urinary output (WMD=-0.48 ml/kg/day [-0.88; -0.08], p for effect=0.02, p for heterogeneity <0.70, I2=0%).

Conclusions. Existing data comparing furosemide bolus injection with a continuous infusion are insufficient to confidently assess the best way to administer furosemide to pediatric patients after cardiac surgery. Larger studies are needed before any recommendations can be made.

Key words: furosemide, cardiac surgery, meta-analysis, intensive care unit, paediatric, acute kidney failure

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Nesiritide and clinically relevant outcomes in cardiac surgery: a meta-analysis of randomized studies


B-type natriuretic peptide is a cardiac hormone that relaxes vascular smooth muscle and causes arterial dilatation. Nesiritide has been  associated with increased urine output; reduced diuretic requirements; and suppression of aldosterone, endothelin, and norepinephrine. We have independently conducted the first systematic review and meta-analysis of randomized trials to determine the impact of nesiritide on renal replacement therapy and death in patients undergoing cardiac surgery. We performed a meta-analysis of 6 randomized controlled studies including 560 patients (280 receiving nesiritide and 280 assigned to the control group). Two unblinded reviewers selected randomized trials studying  nesiritide  in patients undergoing cardiac surgery. Nesiritide doses ranged from 0.005 mcg/kg/min to 0.01 mcg/kg/min. Nesiritide did not reduce postoperative creatinine peak values: -0.16 [-0.42, 0.10], p for effect=0.23, p for heterogeneity<0.01, I2=90.5%) or the need for  renal replacement therapy (1/177 in the nesiritide group vs 4/176 in the control group OR 0.39 [0.07, 2.06], p for effect=0.27, p for heterogeneity=0.70, I2=0%). We observed an interesting trend toward a reduction in mortality in the nesiritide group:13/280 (4.6%) vs 22/280 (7.8%) OR 0.57 [0.28, 1.15], p for effect=0.12, p for heterogeneity=0.43, I2=0%. Nesiritide did not reduce time of mechanical ventilation -8.77 hours [-21.42, 3.88], p=0.17, length of hospital stay -2.67 days [-6.50, 1.16], p=0.17 or intensive care unit (ICU) stay -0.94 days [-2.83, 0.95], p=0.33. In conclusion, further randomized controlled trials are needed to support the hypothesis that nesiritide improves clinically relevant outcomes in cardiac surgery.

Key words: Nesiritide, meta-analysis, cardiac surgery, renal replacement therapy, mortality.

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