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Cardiac anaesthesia risk evaluation score (Care Score) versus EuroSCORE II. Mortality and morbidity analysis in Spanish cardiac surgery population
Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) S70–S85
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Contents lists available at ScienceDirect
journal homepage: www.jcvaonline.com
ORAL ABSTRACT PRESENTATIONS Best Poster Abstracts Presentations 304 Friday, 21 April 2017 08:30 - 10:30, Auditorium 3
OP46, PP08 Can foreign trainees be distractive in terms of communication during cardiac surgery?
Keiko Okuyama1, SA Ariffn2, M Nomura1 1
Tokyo Women’s Medical University, Department of Anaesthesiology, Tokyo, Japan 2 National Heart Institute of Malaysia, Kuala Lumpur, Malaysia Introduction: We sometimes experience misunderstandings/ miscommunication due to a different background or a language barrier in our life. Our hypothesis was that there were more communication errors in actual surgical settings where there were foreign doctors who had a different cultural and linguistic background. The aim of this study was to explore and quantify the effect dissimilar languages and cultures could have in the operating theatre, especially in cardiac surgery which requires effective communication to achieve excellent surgical performance. Methods: Fifty elective conventional coronary artery bypass grafting (CABG) cases were randomly selected, and observed following obtaining written consent forms from the patient. All communication-related events from administration of heparin to chest closure, where all team members were present in the operating theatre, were documented. These events were then examined by the researchers whether it matched our definition of “communication error”. With those which had been addressed as a communication error, the number of total communication error in theatres with foreign trainees was statistically compared to those without. The surgery time was also statistically analysed. Results: In 38 cases (76%), there was at least one foreign doctor in the theatres (mode ¼ 1, minimum 0, maximum 3), and in 12 cases (24%), there was only local staff. None of the foreign doctors, in our sample, had English as their first language. In 43 cases (86%) in this study, English
was spoken throughout or predominantly in the surgical procedure, and in 7 cases which were all local-language speakers, the local language only was spoken. There was not a significant difference in the number of communication errors between theatres with foreign doctor(s) and those without (p 4 0.05) by Mann-Whitney test. Surgery time was also not statistically different between these two groups (p 4 0.05, mean: 211.1 vs. 181.3 mins). Discussion: Our study found that foreign trainees who had different cultural backgrounds did not have a negative impact on communication during CABG against our hypothesis. In the institute where the study was conducted there were no required English language qualifications, and we often do experience language barriers. It implies that understanding surgical procedure and flow may cover language barriers in terms of communication during cardiac surgery.
OP47, PP07 Cardiac anaesthesia risk evaluation score (Care Score) versus EuroSCORE II. Mortality and morbidity analysis in Spanish cardiac surgery population
Manuel Bertomeu-Cornejo, A Hernandez-Fernandez, A Alvarez, JM Borrego-Dominguez Virgen del Rocio Hospital, Department of Anaesthesia, Seville, Andalusia, Spain Introduction: EuroSCORE II and CARE score are risk indices for predicting mortality after cardiac surgery. This study evaluates its ability to predict mortality in a contemporary cardiac surgical population. Methods: The probability of mortality was estimated with the EuroSCORE II, and the CARE score, for 405 patients undergoing cardiac surgery (Aortic Valve, Aortic þ CABG, CABG,Aorta disease) in one institution between 1 January 2009 and 31 December 2010. The discrimination capacity of the models was obtained by calculating the Area Under the Curve (AUC) ROC curves and calibration using the goodness of fit test appropriate to each model. Results: The AUC-ROC was 0.84 (95% CI: 0.83-0.85) for the EuroSCORE II, and CI 0.79 (95%: 0.78-0.81) with the CARE
ORAL ABSTRACT PRESENTATIONS / Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) S70–S85
score. The EuroSCORE II have poor calibration with x2 of 23.4 and p o 0.0001. As a consequence, the risk-adjusted mortality obtained with these models is significantly underestimated. The CARE score presents a good X2 calibration 15,62Y p ¼ 0,054. Analyzing the Risk-adjusted Mortality Rate(RAMR) for the EuroSCORE II and CARE score we find that the first underestimate in the cohort of patients while the CARE score fits better except in the Aortic Valve Replacement and Aorta Surgery of Aorta where it underestimates and overestimates, respectively. Conclusions: The EuroSCORE II significantly overestimates the mortality risk after cardiac surgery in our population. Despite its minor discrimination compared to EuroSCORE, the CARE score is simple and still calibrated more than a decade after its development. It is as robust as the EuroSCORE II to carry out risk-adjusted mortality analysis.
OP48, PP12 Low cardiac output syndrome after adult cardiac surgery: predictive value of peak systolic global longitudinal strain
Philippe Amabili, I Noirot, L Roediger, M Senard, B Hubert, A-F Donneau, J-F Brichant, G Hans
S71
under the receiver operating characteristic curve (ROC) and the integrated discrimination index (IDI). Secondary endpoints included times to complete weaning from inotropic support, discharge from the ICU, and discharge from the hospital and were analysed using cox proportionalhazards regressions. Finally, 30-day mortality was compared between patients with normal and low GLS. Results: The GLS was successfully calculated in 275 patients and significantly associated with LCOS (P o 0.001) at the univariate level. A GLS 4 -17 was found to best predict LCOS. Other predictors of LCOS retained in the first model were CPB duration, low preoperative left ventricular ejection fraction, and NYHA functional class III or IV. Adding the GLS to the model improved the prediction of LCOS (P ¼ 0.02). However, areas under the ROC were similar for the two models (0.83 vs 0.84, P ¼0.37). The IDI associated with addition of GLS was 0.022 (P ¼0.03). Times to complete weaning from inotropes, ICU discharge, and hospital discharge did not differ between patients with normal and low GLS. Eventually, after adjustment for EuroSCORE II, no association was found between GLS and 30-day mortality (P ¼ 0.53). Discussion: Pre-CPB GLS is an independent predictor of LCOS after on-pump cardiac surgery. Its incremental value over other established risk factors of post-operative LCOS is however limited.
CHU of Liege, Department of Anaesthesia and Intensive Care Medicine, Liege, Belgium OP49, PP26 Introduction: Low cardiac output syndrome (LCOS) requiring inotropic support complicates 10 to 20 per cent of cardiac surgery procedures performed under cardiopulmonary bypass (CPB). Early identification of patients at risk of post-operative LCOS is important for timely introduction of therapeutic measures. We hypothesized that the global longitudinal strain (GLS) measured using the pre-CPB transoesophageal echo (TOE) images predicts postoperative LCOS and has an incremental value over established predictors of LCOS after cardiac surgery. Methods: Our ethics committee approved the study. GLS of patients who had on-pump cardiac surgery between January 2015 and June 2016 was calculated retrospectively using 2Dspeckle tracking echocardiography and the TOE images obtained before establishment of CPB. The primary endpoint of the study, LCOS, was defined as the need for an inotropic or mechanical circulatory support during more than 24 hours postoperatively. Patient and procedure characteristics associated with LCOS at the univariate level (P r 0.05) were entered into a forward stepwise logistic regression to create a first predictive model. A second model was created by adding the GLS dichotomized at the optimal cut-point and the two models were compared using the likelihood-ratio test, the area
Time to central venous catheter imaging on the Cardiothoracic Intensive Care Unit (CICU)
Rabiya Farrukh, A Spong, N Soneji, DL Braham Imperial College Healthcare NHS Trust, Department of Anaesthetics, London, UK Introduction: There is great disparity amongst policies relating to the routine imaging of Central Venous Catheters (CVCs) post-insertion on Cardiac Surgical Units. Literature review uncovered conflicting evidence with some proponents of routine chest radiographs (CXR) , while others felt the difficulty of insertion was a good indicator of whether a CXR post-insertion was warranted , and still others who felt that this was entirely unnecessary. CVC Policy within our hospital stated that all CVCs should have a CXR but it did not place a time restriction on this. Our initial audit looking at time to imaging and complications of line insertion changed this policy. Now all CVCs must be imaged within 6 hours from admission to the CICU. We conducted a re-audit after implementation of this policy, and the results are discussed below.
HOSTED BY
Contents lists available at ScienceDirect
journal homepage: www.jcvaonline.com
ORAL ABSTRACT PRESENTATIONS Best Poster Abstracts Presentations 304 Friday, 21 April 2017 08:30 - 10:30, Auditorium 3
OP46, PP08 Can foreign trainees be distractive in terms of communication during cardiac surgery?
Keiko Okuyama1, SA Ariffn2, M Nomura1 1
Tokyo Women’s Medical University, Department of Anaesthesiology, Tokyo, Japan 2 National Heart Institute of Malaysia, Kuala Lumpur, Malaysia Introduction: We sometimes experience misunderstandings/ miscommunication due to a different background or a language barrier in our life. Our hypothesis was that there were more communication errors in actual surgical settings where there were foreign doctors who had a different cultural and linguistic background. The aim of this study was to explore and quantify the effect dissimilar languages and cultures could have in the operating theatre, especially in cardiac surgery which requires effective communication to achieve excellent surgical performance. Methods: Fifty elective conventional coronary artery bypass grafting (CABG) cases were randomly selected, and observed following obtaining written consent forms from the patient. All communication-related events from administration of heparin to chest closure, where all team members were present in the operating theatre, were documented. These events were then examined by the researchers whether it matched our definition of “communication error”. With those which had been addressed as a communication error, the number of total communication error in theatres with foreign trainees was statistically compared to those without. The surgery time was also statistically analysed. Results: In 38 cases (76%), there was at least one foreign doctor in the theatres (mode ¼ 1, minimum 0, maximum 3), and in 12 cases (24%), there was only local staff. None of the foreign doctors, in our sample, had English as their first language. In 43 cases (86%) in this study, English
was spoken throughout or predominantly in the surgical procedure, and in 7 cases which were all local-language speakers, the local language only was spoken. There was not a significant difference in the number of communication errors between theatres with foreign doctor(s) and those without (p 4 0.05) by Mann-Whitney test. Surgery time was also not statistically different between these two groups (p 4 0.05, mean: 211.1 vs. 181.3 mins). Discussion: Our study found that foreign trainees who had different cultural backgrounds did not have a negative impact on communication during CABG against our hypothesis. In the institute where the study was conducted there were no required English language qualifications, and we often do experience language barriers. It implies that understanding surgical procedure and flow may cover language barriers in terms of communication during cardiac surgery.
OP47, PP07 Cardiac anaesthesia risk evaluation score (Care Score) versus EuroSCORE II. Mortality and morbidity analysis in Spanish cardiac surgery population
Manuel Bertomeu-Cornejo, A Hernandez-Fernandez, A Alvarez, JM Borrego-Dominguez Virgen del Rocio Hospital, Department of Anaesthesia, Seville, Andalusia, Spain Introduction: EuroSCORE II and CARE score are risk indices for predicting mortality after cardiac surgery. This study evaluates its ability to predict mortality in a contemporary cardiac surgical population. Methods: The probability of mortality was estimated with the EuroSCORE II, and the CARE score, for 405 patients undergoing cardiac surgery (Aortic Valve, Aortic þ CABG, CABG,Aorta disease) in one institution between 1 January 2009 and 31 December 2010. The discrimination capacity of the models was obtained by calculating the Area Under the Curve (AUC) ROC curves and calibration using the goodness of fit test appropriate to each model. Results: The AUC-ROC was 0.84 (95% CI: 0.83-0.85) for the EuroSCORE II, and CI 0.79 (95%: 0.78-0.81) with the CARE
ORAL ABSTRACT PRESENTATIONS / Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) S70–S85
score. The EuroSCORE II have poor calibration with x2 of 23.4 and p o 0.0001. As a consequence, the risk-adjusted mortality obtained with these models is significantly underestimated. The CARE score presents a good X2 calibration 15,62Y p ¼ 0,054. Analyzing the Risk-adjusted Mortality Rate(RAMR) for the EuroSCORE II and CARE score we find that the first underestimate in the cohort of patients while the CARE score fits better except in the Aortic Valve Replacement and Aorta Surgery of Aorta where it underestimates and overestimates, respectively. Conclusions: The EuroSCORE II significantly overestimates the mortality risk after cardiac surgery in our population. Despite its minor discrimination compared to EuroSCORE, the CARE score is simple and still calibrated more than a decade after its development. It is as robust as the EuroSCORE II to carry out risk-adjusted mortality analysis.
OP48, PP12 Low cardiac output syndrome after adult cardiac surgery: predictive value of peak systolic global longitudinal strain
Philippe Amabili, I Noirot, L Roediger, M Senard, B Hubert, A-F Donneau, J-F Brichant, G Hans
S71
under the receiver operating characteristic curve (ROC) and the integrated discrimination index (IDI). Secondary endpoints included times to complete weaning from inotropic support, discharge from the ICU, and discharge from the hospital and were analysed using cox proportionalhazards regressions. Finally, 30-day mortality was compared between patients with normal and low GLS. Results: The GLS was successfully calculated in 275 patients and significantly associated with LCOS (P o 0.001) at the univariate level. A GLS 4 -17 was found to best predict LCOS. Other predictors of LCOS retained in the first model were CPB duration, low preoperative left ventricular ejection fraction, and NYHA functional class III or IV. Adding the GLS to the model improved the prediction of LCOS (P ¼ 0.02). However, areas under the ROC were similar for the two models (0.83 vs 0.84, P ¼0.37). The IDI associated with addition of GLS was 0.022 (P ¼0.03). Times to complete weaning from inotropes, ICU discharge, and hospital discharge did not differ between patients with normal and low GLS. Eventually, after adjustment for EuroSCORE II, no association was found between GLS and 30-day mortality (P ¼ 0.53). Discussion: Pre-CPB GLS is an independent predictor of LCOS after on-pump cardiac surgery. Its incremental value over other established risk factors of post-operative LCOS is however limited.
CHU of Liege, Department of Anaesthesia and Intensive Care Medicine, Liege, Belgium OP49, PP26 Introduction: Low cardiac output syndrome (LCOS) requiring inotropic support complicates 10 to 20 per cent of cardiac surgery procedures performed under cardiopulmonary bypass (CPB). Early identification of patients at risk of post-operative LCOS is important for timely introduction of therapeutic measures. We hypothesized that the global longitudinal strain (GLS) measured using the pre-CPB transoesophageal echo (TOE) images predicts postoperative LCOS and has an incremental value over established predictors of LCOS after cardiac surgery. Methods: Our ethics committee approved the study. GLS of patients who had on-pump cardiac surgery between January 2015 and June 2016 was calculated retrospectively using 2Dspeckle tracking echocardiography and the TOE images obtained before establishment of CPB. The primary endpoint of the study, LCOS, was defined as the need for an inotropic or mechanical circulatory support during more than 24 hours postoperatively. Patient and procedure characteristics associated with LCOS at the univariate level (P r 0.05) were entered into a forward stepwise logistic regression to create a first predictive model. A second model was created by adding the GLS dichotomized at the optimal cut-point and the two models were compared using the likelihood-ratio test, the area
Time to central venous catheter imaging on the Cardiothoracic Intensive Care Unit (CICU)
Rabiya Farrukh, A Spong, N Soneji, DL Braham Imperial College Healthcare NHS Trust, Department of Anaesthetics, London, UK Introduction: There is great disparity amongst policies relating to the routine imaging of Central Venous Catheters (CVCs) post-insertion on Cardiac Surgical Units. Literature review uncovered conflicting evidence with some proponents of routine chest radiographs (CXR) , while others felt the difficulty of insertion was a good indicator of whether a CXR post-insertion was warranted , and still others who felt that this was entirely unnecessary. CVC Policy within our hospital stated that all CVCs should have a CXR but it did not place a time restriction on this. Our initial audit looking at time to imaging and complications of line insertion changed this policy. Now all CVCs must be imaged within 6 hours from admission to the CICU. We conducted a re-audit after implementation of this policy, and the results are discussed below.