RESUMO
OBJECTIVES: The aim of this analysis was to compare the effect of extubating in the operating room (OR) versus and the intensive care unit (ICU) among patients undergoing coronary artery bypass grafting (CABG). DESIGN: A retrospective cohort analysis. SETTING: Ten cardiac referral hospitals in Latin America; participants of the São Paulo Registry of Cardiovascular Surgery II (REPLICCAR II). PARTICIPANTS: The database included a total of 4,015 patients who underwent primary and isolated CABG surgery and were ≥18 years old, of whom 205 patients were extubated in the OR. INTERVENTIONS: The analysis was made after a propensity score matching (PSM) adjustment in the population sample of patients extubated in the OR and ICU by the following variables: sex, age, body mass index, smoking, type of surgery, chronic obstructive pulmonary disease, preoperative atrial fibrillation, cardiopulmonary bypass time, preoperative creatinine, and preoperative left ventricular ejection fraction. MEASUREMENTS AND MAIN RESULTS: This study focused on the analysis of the ICU and hospital length of stay, need for reintubation, morbidity, and mortality. After PSM, 402 patients were analyzed. Both groups had similar baseline characteristics, such as age (p = 0.132), sex (p = 1.00), and estimated risk of prolonged ventilation (>24 hours, p = 0.168); however, the median ventilation time was significantly shorter in the group extubated in the OR compared to the ICU group (5.67 hours v 17.55 hours, p < 0.001). The group of patients extubated in the ICU had a longer postoperative stay (7.54 ± 3.40 days v 6.41 ± 2.91 days, p < 0.001) and longer total hospitalization time (11.49 ± 5.70 days v 10.36 ± 5.72, p = 0.013) compared to those extubated in the OR. The authors did not observe a significant difference in the need for reintubation, morbidity, or mortality rates among the evaluated groups. CONCLUSIONS: In the REPLICCAR II database, extubation performed in the OR was associated with a reduced length of postoperative and total hospital stays compared to extubation in the ICU.
Assuntos
Extubação , Salas Cirúrgicas , Humanos , Adolescente , Tempo de Internação , Estudos Retrospectivos , Volume Sistólico , Brasil , Função Ventricular Esquerda , Ponte de Artéria Coronária/efeitos adversosRESUMO
BACKGROUND: Endotracheal intubation (ETI), which is the gold standard in coronary artery bypass grafting (CABG), may cause myocardial ischaemia by disturbing the balance between haemodynamic changes and oxygen supply and consumption of the myocardium as a result of sympathetic stimulation. In this study, we aimed to compare two different videolaryngoscopes (C-MAC and Airtraq) in the hemodynamic response to ETI. METHODS: Fifty ASA II...III CABG surgery patients were randomly assigned to C-MAC or Airtraq. The hemodynamic data included arterial blood pressure [systolic (SAP), diastolic (DAP) and mean (MAP)] and heart rate (HR) and were recorded at six different points in time: before laryngoscopy-T1, during laryngoscopy-T2, immediately after intubation-T3, and 3 (T4), 5 (T5) and 10 (T6) minutes after intubation. Intraoperative complications were recorded. Patients were questioned about postoperative complications 2 and 24...hours following extubation. RESULTS: The hemodynamic response to ETI was significantly greater with C-MAC. The increase in HR started with the laryngoscopy procedure, whereas increases in SAP, DAP, and MAP started immediately after ETI (p...=...0.024; p...=...0.012; p...=...0.030; p...=...0.009, respectively). In group analyses, T1...T2, T2...T3 and T1...T3 comparisons did not show any significant differences in HR with Airtraq. However, with C-MAC, HR after intubation increased significantly compared to the pre-laryngoscopy values (T1...T3) (p...=...0.004). The duration of laryngoscopy was significantly reduced with C-MAC (p...<...0.001), but the duration of intubation and total intubation were similar (p...=...0.36; p...=...0.79). CONCLUSIONS: Compared to C-MAC, the hemodynamic response to ETI was less with Airtraq. Thus, Airtraq may be preferred in CABG patients for ETI.
RESUMO
Continuous positive airway pressure (CPAP) has been used to improve gas exchange and diaphragmatic function, among others benefits. Moreover, it can be used to increase exercise tolerance and positively influence ventilatory function and breathing pattern (BP) during exercise. However, there is no information about the long-term effects of CPAP, as an adjunct to an inpatient cardiac rehabilitation (CR) program, on BP and heart rate variability (HRV) of patients after coronary artery bypass grafting surgery (CABG). Twenty patients were allocated to receive, after randomization, standard inpatient CR without CPAP (control group - CG) or CR with CPAP between 10 to 12 cmH2O (CPAP group - CPG) associated with the exercises. Participants were assessed preoperatively and on the discharge day, in the sitting rest position. Outcome measurements included BP variables, collected by respiratory inductive plethysmography, and HRV, collected by polar precision performance. The CPG presented lower values of percent rib cage inspiratory and expiratory contributions to tidal volume (%RCi and %RCe) at discharge time, compared to CG. No statistical differences between groups were observed for HRV variables and both groups presented lower values of these indices, compared to preoperative ones. In this context, the patients who received CPAP throughout the whole rehabilitation program were discharged with a better BP, which could indicate more synchronized breathing. CPAP did not influence cardiac autonomic modulation in the long term.
Assuntos
Exercício Físico , Pressão Positiva Contínua nas Vias Aéreas , Respiração , Ponte de Artéria Coronária , Frequência CardíacaRESUMO
Patients with diabetes mellitus (DM) often exhibit a complex coronary anatomy, making coronary revascularization challenging. Coronary artery bypass grafting surgery (CABG) is currently considered the preferred revascularization method in patients with DM and multivessel disease. Percutaneous coronary intervention (PCI) has advanced with new stent generations having been developed in the recent years, but they have not yet been adequately compared against CABG in the population with DM. Comorbidities, such as renal disease and heart failure, lead to worse prognosis following a revascularization procedure and require especial consideration when choosing between CABG versus PCI. The presence of significant left main disease may also impose additional challenges to coronary revascularization, particularly when accompanied by the involvement of multivessel disease. Most of the evidence regarding revascularization in patients with DM is compiled from studies enrolling patients with stable ischemic heart disease, and trials with patients in the acute coronary syndrome setting are lacking.
Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/cirurgia , Diabetes Mellitus Tipo 2/epidemiologia , Angiopatias Diabéticas/cirurgia , Intervenção Coronária Percutânea/métodos , Idoso , Comorbidade , Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/diagnóstico por imagem , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Angiopatias Diabéticas/diagnóstico por imagem , Angiopatias Diabéticas/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/métodos , Intervenção Coronária Percutânea/efeitos adversos , Prognóstico , Medição de Risco , Taxa de Sobrevida , Resultado do TratamentoRESUMO
Cardiopulmonary bypass (CPB) with extracorporeal circulation produces changes in the immune system accompanied by an increase in proinflammatory cytokines and a decrease in anti-inflammatory cytokines. We hypothesize that dexmedetomidine (DEX) as an anesthetic adjuvant modulates the inflammatory response after coronary artery bypass graft surgery with mini-CPB. In a prospective, randomized, blind study, 12 patients (4 females and 8 males, age range 42-72) were assigned to DEX group and compared with a conventional total intravenous anesthesia (TIVA) group of 11 patients (4 females and 7 males). The endpoints used to assess inflammatory and biochemical responses to mini-CPB were plasma interleukin (IL)-1, IL-6, IL-10, interferon (INF)-γ, tumor necrosis factor (TNF)-α, C-reactive protein, creatine phosphokinase, creatine phosphokinase-MB, cardiac troponin I, cortisol, and glucose levels. These variables were determined before anesthesia, 90 min after beginning CPB, 5 h after beginning CPB, and 24 h after the end of surgery. Endpoints of oxidative stress, including thiobarbituric acid reactive species and delta-aminolevulinate dehydratase activity in erythrocytes were also determined. DEX+TIVA use was associated with a significant reduction in IL-1, IL-6, TNF-α, and INF-γ (P<0.0001) levels compared with TIVA (two-way ANOVA). In contrast, the surgery-induced increase in thiobarbituric acid reactive species was higher in the DEX+TIVA group than in the TIVA group (P<0.01; two-way ANOVA). Delta-aminolevulinate dehydratase activity was decreased after CPB (P<0.001), but there was no difference between the two groups. DEX as an adjuvant in anesthesia reduced circulating IL-1, IL-6, TNF-α, and INF-γ levels after mini-CPB. These findings indicate an interesting anti-inflammatory effect of DEX, which should be studied in different types of surgical interventions.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Anestesia Intravenosa/métodos , Ponte de Artéria Coronária/métodos , Dexmedetomidina/farmacologia , Síndrome de Resposta Inflamatória Sistêmica/prevenção & controle , Agonistas de Receptores Adrenérgicos alfa 2/farmacologia , Análise de Variância , Glicemia/análise , Proteína C-Reativa/análise , Ponte de Artéria Coronária/efeitos adversos , Creatina Quinase/sangue , Citocinas/sangue , Hidrocortisona/sangue , Estudos Prospectivos , Valores de Referência , Síndrome de Resposta Inflamatória Sistêmica/sangue , Substâncias Reativas com Ácido Tiobarbitúrico/análise , Fatores de Tempo , Troponina I/sangueRESUMO
OBJECTIVE: To determine long-term survival, identify preoperative factors predictive of a favorable outcome, and assess functional improvement after coronary artery bypass grafting in patients with advanced left ventricular dysfunction. METHODS: Between 1995 and 2001, 244 patients who underwent coronary artery bypass grafting and had a preoperative left ventricular ejection fraction less than or equal to 35% were included. left ventricular ejection fraction was determined by uniplanar or biplanar ventriculography during left heart catheterization. Indication for surgery was predominance of tissue viability. Functional improvement was evaluated through echocardiography and gated scintigraphy at exercise/rest. Survival was determined by Kaplan-Meier analysis. RESULTS: Mean left ventricular ejection fraction was 29+/-4% (ranged from 9% to 35%). An average of 3.01 coronary bypass grafts per patient were performed. In-hospital mortality was 3.7% (9 patients). The 4-year survival rate was 89.7%. Multivariate correlates of favorable short- and long-term outcome were preoperative New York Heart Association Funcional classification for congestive heart failure class I/II, lower PAsP, higher left ventricular ejection fraction and gated left ventricular ejection fraction Ex/Rest ratio >5%. Left ventricular ejection fraction rise from 32+/-5% to 39+/-5%, p <0.001. Gated left ventricular ejection fraction at exercise/rest increased markedly after surgery: from 27+/-8%/23+/-7% to 37+/-5%/31+/-6%, p <0.001. CONCLUSIONS: In selected patients with severe ischemic left ventricular dysfunction and predominance of tissue viability, coronary artery bypass grafting may be capable of implement preoperative clinical/functional parameters in predicting outcome as left ventricular ejection fraction and gated left ventricular ejection fraction at exercise/rest.
Assuntos
Cardiomiopatias/cirurgia , Ponte de Artéria Coronária/mortalidade , Cuidados Pré-Operatórios/normas , Volume Sistólico/fisiologia , Disfunção Ventricular Esquerda/cirurgia , Cardiomiopatias/diagnóstico por imagem , Cardiomiopatias/fisiopatologia , Métodos Epidemiológicos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/métodos , Cintilografia , Resultado do Tratamento , Ultrassonografia , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/fisiopatologiaRESUMO
Objective: To determine long-term survival, identify preoperative factors predictive of a favorable outcome, and assess functional improvement after coronary artery bypass grafting in patients with advanced left ventricular dysfunction. Methods: Between 1995 and 2001, 244 patients who underwent coronary artery bypass grafting and had a preoperative left ventricular ejection fraction less than or equal to 35 percent were included. left ventricular ejection fraction was determined by uniplanar or biplanar ventriculography during left heart catheterization. Indication for surgery was predominance of tissue viability. Functional improvement was evaluated through echocardiography and gated scintigraphy at exercise/ rest. Survival was determined by Kaplan-Meier analysis. Results: Mean left ventricular ejection fraction was 29±4 percent (ranged from 9 percent to 35 percent). An average of 3.01 coronary bypass grafts per patient were performed. In-hospital mortality was 3.7 percent (9 patients). The 4-year survival rate was 89.7 percent. Multivariate correlates of favorable short- and long-term outcome were preoperative New York Heart Association Funcional classification for congestive heart failure class I/II, lower PAsP, higher left ventricular ejection fraction and gated left ventricular ejection fraction Ex/Rest ratio >5 percent. Left ventricular ejection fraction rise from 32±5 percent to 39±5 percent, p <0.001. Gated left ventricular ejection fraction at exercise/ rest increased markedly after surgery: from 27±8 percent/ 23±7 percent to 37±5 percent/ 31±6 percent, p <0.001. Conclusions: In selected patients with severe ischemic left ventricular dysfunction and predominance of tissue viability, coronary artery bypass grafting may be capable of implement preoperative clinical/ functional parameters in predicting outcome as left ventricular ejection fraction and gated left ventricular ejection fraction at exercise/ rest.
Assuntos
Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cardiomiopatias/cirurgia , Ponte de Artéria Coronária/mortalidade , Cuidados Pré-Operatórios/normas , Volume Sistólico/fisiologia , Disfunção Ventricular Esquerda/cirurgia , Cardiomiopatias/fisiopatologia , Cardiomiopatias , Cardiomiopatias , Métodos Epidemiológicos , Mortalidade Hospitalar , Cuidados Pré-Operatórios/métodos , Resultado do Tratamento , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Esquerda , Disfunção Ventricular EsquerdaRESUMO
The pharmacokinetics of some β-blockers are altered by cardiopulmonary bypass (CPB). The objective of this study was to compare the effect of coronary artery bypass graft (CABG) surgery employing CPB on the pharmacokinetics of propranolol and atenolol. We studied patients receiving oral propranolol with doses ranging from 80 to 240 mg (N = 11) or atenolol with doses ranging from 25 to 100 mg (N = 8) in the pre- and postoperative period of CABG with moderately hypothermic CPB (32°C). On the day before and on the first day after surgery, blood samples were collected before β-blocker administration and every 2 h thereafter. Plasma levels were determined using high-performance liquid chromatography and data were treated by pharmacokinetics-modelling. Statistical analysis was performed using ANOVA or the Friedman test, as appropriate, and P < 0.05 was considered to be significant. A prolongation of propranolol biological half-life from 5.41 ± 0.75 to 11.46 ± 1.66 h (P = 0.0028) and an increase in propranolol volume of distribution from 8.70 ± 2.83 to 19.33 ± 6.52 L/kg (P = 0.0032) were observed after CABG with CPB. No significant changes were observed in either atenolol biological half-life (from 11.20 ± 1.60 to 11.44 ± 2.89 h) or atenolol volume of distribution (from 2.90 ± 0.36 to 3.83 ± 0.72 L/kg). Total clearance was not changed by surgery. These CPB-induced alterations in propranolol pharmacokinetics may promote unexpected long-lasting effects in the postoperative period while the effects of atenolol were not modified by CPB surgery.