RESUMEN
BACKGROUND AND PURPOSE: Cerebral injury after cardiac surgery is now recognized as a serious and costly healthcare problem mandating immediate attention. To effect solution, those subgroups of patients at greatest risk must be identified, thereby allowing efficient implementation of new clinical strategies. No such subgroup has been identified; however, patients undergoing intracardiac surgery are thought to be at high risk, but comprehensive data regarding specific risk, impact on cost, and discharge disposition are not available. METHODS: We prospectively studied 273 patients enrolled from 24 diverse US medical centers, who were undergoing intracardiac and coronary artery surgery. Patient data were collected using standardized methods and included clinical, historical, specialized testing, neurological outcome and autopsy data, and measures of resource utilization. Adverse outcomes were defined a priori and determined after database closure by a blinded independent panel. Stepwise logistic regression models were developed to estimate the relative risks associated with clinical history and intraoperative and postoperative events. RESULTS: Adverse cerebral outcomes occurred in 16% of patients (43/273), being nearly equally divided between type I outcomes (8.4%; 5 cerebral deaths, 16 nonfatal strokes, and 2 new TIAs) and type II outcomes (7.3%; 17 new intellectual deterioration persisting at hospital discharge and 3 newly diagnosed seizures). Associated resource utilization was significantly increased--prolonging median intensive care unit stay from 3 days (no adverse cerebral outcome) to 8 days (type I; P<0.001) and from 3 to 6 days (type II; P<0.001), and increasing hospitalization by 50% (type II, P=0.04) to 100% (type I, P<0.001). Furthermore, specialized care after hospital discharge was frequently necessary in those with type I outcomes, in that only 31% returned home compared with 85% of patients without cerebral complications (P<0.001). Significant risk factors for type I outcomes related primarily to embolic phenomena, including proximal aortic atherosclerosis, intracardiac thrombus, and intermittent clamping of the aorta during surgery. For type II outcomes, risk factors again included proximal aortic atherosclerosis, as well as a preoperative history of endocarditis, alcohol abuse, perioperative dysrhythmia or poorly controlled hypertension, and the development of a low-output state after cardiopulmonary bypass. CONCLUSIONS: These prospective multicenter findings demonstrate that patients undergoing intracardiac surgery combined with coronary revascularization are at formidable risk, in that 1 in 6 will develop cerebral complications that are frequently costly and devastating. Thus, new strategies for perioperative management--including technical and pharmacological interventions--are now mandated for this subgroup of cardiac surgery patients.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Embolia y Trombosis Intracraneal/epidemiología , Anciano , Femenino , Humanos , Embolia y Trombosis Intracraneal/etiología , Masculino , Estudios Prospectivos , Medición de Riesgo , Factores de RiesgoRESUMEN
Atheromatous disease in the transverse aortic arch is associated with an increased incidence of perioperative stroke. In addition, tissue erosion in the aortic arch is caused by the high-velocity jet emerging from an aortic cannula during cardiopulmonary bypass (CPB), termed the "sandblast effect". To quantify this phenomenon, flow in the aortic arch was measured intraoperatively by epiaortic ultrasonography in 18 patients undergoing CPB. All were cannulated in the ascending aorta, 10 with a short (1.5 cm) cannula and 8 with a long (7.0 cm) cannula. The peak forward aortic flow velocities (mean +/- standard deviation) measured on the caudal luminal surface of the aortic arch were 0.80 +/- 0.23 m/s off CPB and 2.42 +/- 0.69 m/s on CPB (p < 0.001) for the short cannula and 0.53 +/- 0.20 m/s off CPB and 0.18 m/s on CPB for the long cannula. Thus, during CPB the peak forward aortic flow velocity with the short cannula was significantly greater (p < 0.001) than before CPB, whereas the long cannula produced a lower peak forward aortic flow velocity during CPB. Furthermore, Doppler examination revealed severe turbulence in the aortic arch in all patients with a short cannula. No arch turbulence, however, was seen in 7 patients with a long cannula, and only mild turbulence appeared in the remaining patient with a long cannula. These results show that use of a long aortic cannula results in a significant decrease in peak forward aortic flow velocity and turbulence in the aortic arch during CPB, which may reduce the risk of erosion or disruption of existing atheroma and ensuing embolic complications.
Asunto(s)
Enfermedades de la Aorta/etiología , Arteriosclerosis/etiología , Puente Cardiopulmonar/instrumentación , Cateterismo/instrumentación , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/fisiopatología , Enfermedades de la Aorta/prevención & control , Arteriosclerosis/prevención & control , Velocidad del Flujo Sanguíneo , Puente Cardiopulmonar/efectos adversos , Puente Cardiopulmonar/métodos , Ecocardiografía Doppler en Color , Ecocardiografía Doppler de Pulso , Ecocardiografía Transesofágica , Diseño de Equipo , Humanos , Monitoreo Intraoperatorio , Cuidados Posoperatorios , Cuidados PreoperatoriosRESUMEN
Two hundred routine chest x-rays were evaluated to determine their value in the management of critically ill patients in a Medical ICU (MICU). Seventy-four x-rays (37%) were of suboptimal value or were delivered to the MICU too late for inclusion on morning rounds. Of the remaining 126 films, 54 (43%) showed worsening of a known, or development of a new, cardiopulmonary abnormality, or an unexpected misplacement of an invasive device. On the basis of these findings, routine daily chest radiographs were judged to be valuable in identifying abnormalities in critically ill patients. However, the system for providing this service was only 63% efficient, and improvement must be sought in this regard.