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P-48 Is troponin an important marker in cardiac surgery?
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S53
Discussion. There are marked differences between the haemodynamic management of post-operative cardiac surgical patients in cardiothoracic ICUs in UK centres compared with non-UK centres. UK centres have fewer advanced monitoring and therapeutic devices available and prefer naturally occurring inotropes to the newer, synthetic agents preferred outside the UK. These differences may be accounted for by differences in the cost of equipment, differences in funding available, or differences in local guidelines and preferences. REFERENCE 1. Gillies M, Bellomo R, Doolan L, et al. Bench-to-bedside review: Inotropic drug therapy after adult cardiac surgery - a systematic literature review. Critical Care 2005; 9: 266-79. P-46 Hyperglycaemia significantly increases lactate levels following cardiothoracic surgery Gabriel Adelsmayr, Wolfgang Schaubmayr, Sophie Frantal, Michael Hiesmayr, Helmut Hager Department of Cardiothoracic Anaesthesiology and Intensive Care, Medical University Vienna, Vienna, Austria Introduction. An increased glucose level following cardiothoracic surgery is a common finding in the intensive care unit (ICU). Though hyperglycaemia’s adverse effects are recognized, the target range of perioperative blood glucose is controversially discussed [1;2]. The aim of this study was to analyse a possible impact of perioperative glucose control on perioperative blood lactate levels. Method. We analysed a database of 2,153 patients who underwent cardiothoracic or vascular surgery between 2000 and 2008. We examined blood lactate in the glucose target ranges of 80-110 mg/dL [1] and 80-180 mg/dL [2] and above and below on ICU-admission, using ANOVA. We used linear regression to depict a correlation of blood glucose with lactate in the target ranges. Furthermore we conducted a multivariate regression analysis to demonstrate an independent influence of admission glucose on admission lactate levels. Results. Glucose did not correlate significantly with lactate in the target range of 80-110 mg/dL (n⫽551; P⫽0.94). Glucose correlated significantly with lactate in the target range of 80-180 mg/dL (n⫽1,729; P⬍0.001). For both groups, ANOVA was significant (P⬍0.001). Moreover, multivariate regression with the entire patient population was significant when including several patient variables (P⬍0.001). Conclusion. The positive interrelation between perioperative blood glucose and lactate suggests a consideration of perioperative blood lactate levels when identifying the ideal glucose target range. Blood lactate, itself a strong predictor of outcome, could help explain adverse effects of hyperglycaemia in cardiothoracic patients. REFERENCES 1. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001; 345: 1359-67. 2. Finfer S, Chitock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360: 1283-97.
P-47 Predictors of tracheostomy requirement following cardiac surgery Justin Ratnasingham, James McShane, Omar Al Rawi, Tim Ridgway Liverpool Heart and Chest Hospital, Liverpool, UK Introduction. Currently there is little information about the likelihood of the need for tracheostomy after cardiac surgery. Identification of predictive factors would help patient information and consent. Method. A search of the literature was performed and predictive factors identified [1,2]. Our database was analysed over a nine-year period using these factors. Over 14,000 patients were included in the analysis with the tracheostomy group compared with the non-tracheostomy group. Results. The total number of tracheostomies performed was 414 (2.92%). The prevalence of preoperative factors was compared between the two groups and any differences analysed for statistical significance. Bivariate analysis was performed using the Mann Whitney U test for continuous data and the Chisquared test for categorical data. Increasing age, current/recent smoker, BMI ⬍18.5, poor LV function and non-elective surgery were found to be statistically significant, all with a P value ⬍0.0001. Discussion. This analysis of over 14,000 patients provides new information about the likelihood of tracheostomy requirement post cardiac surgery. Chronic renal impairment, urgent surgery, poor left ventricular function and pre-existing obstructive airways disease have been shown to be predictors for requiring a tracheostomy post cardiac surgery. We believe that the anticipated need for tracheostomy is a marker for prolonged intensive care and that patients should be informed prior to surgery. REFERENCES 1. Hoskote A, Cohen G, Goldman A, et al. Tracheostomy in infants and children after cardiothoracic surgery: indications, associated risk factors, and timing. J Thorac Cardiovasc Surg 2005; 130: 1086-93. 2. Nicholls J. The use of tracheostomy following major open cardiac surgery: a review of 64 cases. Thorax 1968; 23: 652-6. P-48 Is troponin an important marker in cardiac surgery? Oana Mihailescu, Alina Paunescu, Mihail Luchian, Oana Ghenu, Simona Marin, Ovidiu Chioncel, Luminita Iliuta, Horatiu Moldovan, Vlad Iliescu, Daniela Filipescu Emergency Institute of Cardiovascular “Prof.Dr. C.C.Iliescu”, Bucharest, Romania
Diseases,
Introduction. Cardiac biomarker sensitivity is crucial for detecting postoperative myocardial infarction (PMI) and consequently, for prediction of outcome after cardiac surgery. However, defining PMI after cardiac surgery is often difficult. The aim of our prospective study was to evaluate the dynamics of troponin I in the postoperative period, the value of cardiac troponin I for diagnosis PMI and its value in risk stratification after coronary artery bypass graft (CABG) surgery. Method. Troponin I, creatinine kinase and MB fraction, electrocardiogaphic tracings and echocardiography images were registered preoperatively, in the first 24 h and on the 7th day after
S54
FREE POSTER SESSIONS
CABG surgery in 158 consecutive patients. Demographic data, past medical and surgical history, medications, EuroSCORE, duration of extracorporeal circulation, aortic-clamp time, type of revascularization, APACHE II score, SOFA score, complications, ICU lengths of stay, lengths of hospitalization and mortality, were recorded using case report forms. PMI was considered when new pathological Q-waves or new LBBB was registered on ECG and new abnormality of LV wall motion was detected on echocardiography. Results. One hundred and twenty two men and 36 women were included in our prospective study. Mean troponin level increased in the first day after surgery compared to baseline values and fell until the 7th day (on the operation day the value of troponin was normal). The mean value of troponin on day 1 after surgery was 5.078 ⫾ 9.38 ng/ml and on the 7th day 0.38 ⫾ 0.825 ng/ml. PMI was found in 2.5% of patients. Statistical analyses performed, using area under the curve (AUC) in receiver operating characteristic (ROC) curves in a multivariable model found no correlation between value of troponin in the first day and postoperative myocardial infarction, or with ICU length of stay or length of hospitalization. A significant correlation between the value of troponin on the first postoperative day and the duration of extracorporeal circulation (r⫽0.231, P⫽0.004) was detected. Using compared analysis of variance (oneway ANOVA) we found two independent predictors for relative decrease of troponin in the postoperative period, left ventricular mass (r⫽0.206; P⫽0.023) and the need of inotropic therapy (P⫽0.005). Conclusion. Troponin I value on the first postoperative day is not a marker for PMI, ICU length of stay or duration of hospitalization. Left ventricular mass and the need for inotropic therapy did influence the dynamics of troponin in the postoperative period and this fact may have clinical relevance for choosing adequate myocardial protection. P-49
(11) or vascular (29) surgery and 63 of them for non p.o. care. 32 pts (3.65%) died while in ICU, 19 after p.o. (2.3%) and 13 after non p.o. care (20.6%). ICU stay: mean 4.48⫾6.89 days; survived pts: 4.2⫾6.3 days; non-survivors 11.7⫾14.09 days. Adm score: survived pts 4.95⫾5.5, non survivors 18.5⫾7.5. DD score: survived pts 1.24⫾1.40, non survivors 20.3⫾7.9. Adm score was related to ICU stay (R⫽0.503 in the overall population, R⫽0.548 in survived pts). Adm score ⱖ20 was observed in 31 pts. 13 pts with Adm score ⱖ20 didn’t survive (41.9%). 5 of them were admitted for cardiogenic shock treated by medical therapy, 2 for cardiogenic shock treated by ECMO, 2 after lung transplant, 1 after heart transplant and 3 after valve surgery. 18 pts with Adm score ⱖ20 survived, 11 of them being admitted for p.o. care after heart transplant (7), LVAD implant (4), valve plus coronary surgery (5), pulmonary thromboendoarterectomy (1), Glenn operation (1). Discussion. Although weighing p.o. support in CTV ICU can be useful to optimize pts late allocation and resource use, the estimate of post-Adm support in CTV ICU may be considered as an adjunct to evaluation of early pts’ response to surgery. Our analysis suggests a longer ICU stay and worse outcome for pts showing a high Adm score. Pts who have undergone LVAD implantation or heart transplantation show a prerequisite for more effective surgical therapy in spite of a high Adm score.
REFERENCE 1. Ettema RG, Peelen LM, Schuurmans MJ, et al. Prediction models for prolonged intensive care unit stay after cardiac surgery: systematic review and validation study. Circulation 2010; 122: 682-9.
Early postoperative support profile and mortality in a cardiothoracic-vascular surgery ICU
P-50
Roberto Paino, Sandra Nonini, Filippo Michele Mondino, Silvia Zannoli, Aldo Cannata
Milazzo,
Postoperative use of dobutamine after cardiac surgery is associated with an increased inflammatory syndrome
Cardio-Thoraco-Vascular Anaesth. ICU, Niguarda Hospital, Milano, Italy
Michel Durand, Marine Rossi, Amélie Bataillard, Myriam Casez, Olivier Chavanon, Pierre Albaldejo
Introduction. Although pre-operative patient risk factors can predict patient (pt) ICU stay and mortality after cardiac surgery [1], intra-operative events may also affect them. No data are available about the relationship between early post-operative (p.o.) support and ICU stay and mortality in cardiac surgery. Our aim was to study post-admission (Adm) dependency on drugs and devices in a cardiothoracic vascular (CTV) ICU. Method. 877 pts consecutively admitted to our CTV ICU were retrospectively studied by an already assessed home-made data base specifically oriented to weigh post-Adm support. A value from 0 to 6 was daily assigned to 13 items concerning overall support to each pt from the first post-Adm day to pt discharge or death (DD). The following p.o. supports were considered: ventilation, IABP, ECMO, cardiac rhythm control, coagulation control, inotropes, vasoconstrictors, pulmonary vasodilators, systemic vasodilators, targeted insulin infusion, renal function control, thermal control and sedation. An overall score was therefore daily assigned to every pt. We retrospectively considered only Adm and DD score. Results. Among 877 admitted pts 797 were adult and 80 paediatric. 814 of them were admitted after cardiac (774), thoracic
University Hospital, Grenoble, France Introduction. The use of dobutamine (D) after coronary artery surgery (CABG) or cardiogenic shock is associated with an increased mortality [1,2]. Inotropic agents have pro-inflammatory properties [3]. In this study we aimed to see if infusion of D after CABG was associated with an increased inflammatory syndrome. Method. 1,279 consecutive CABG patients were retrospectively divided into 3 groups: no D (n⫽ 993), D ⬍5g kg-1 min-1 for ⬎3 hours (n⫽239) and D ⱖ5g kg-1 min-1 for ⬎3 hours (n⫽47). CRP levels from day 0 to day 7 after surgery were compared with an analysis of variance for repeated measures. Results. Age was 66⫾11 years, EuroSCORE, 4.5⫾3.3. Mortality (2.6%) increased significantly with the dose of D. CRP levels increased after day 4 in the groups who had received D (P⬍0.0001). This difference was significant in patients with cardiac index ⱖ2.2 L min-1 m2.
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Discussion. There are marked differences between the haemodynamic management of post-operative cardiac surgical patients in cardiothoracic ICUs in UK centres compared with non-UK centres. UK centres have fewer advanced monitoring and therapeutic devices available and prefer naturally occurring inotropes to the newer, synthetic agents preferred outside the UK. These differences may be accounted for by differences in the cost of equipment, differences in funding available, or differences in local guidelines and preferences. REFERENCE 1. Gillies M, Bellomo R, Doolan L, et al. Bench-to-bedside review: Inotropic drug therapy after adult cardiac surgery - a systematic literature review. Critical Care 2005; 9: 266-79. P-46 Hyperglycaemia significantly increases lactate levels following cardiothoracic surgery Gabriel Adelsmayr, Wolfgang Schaubmayr, Sophie Frantal, Michael Hiesmayr, Helmut Hager Department of Cardiothoracic Anaesthesiology and Intensive Care, Medical University Vienna, Vienna, Austria Introduction. An increased glucose level following cardiothoracic surgery is a common finding in the intensive care unit (ICU). Though hyperglycaemia’s adverse effects are recognized, the target range of perioperative blood glucose is controversially discussed [1;2]. The aim of this study was to analyse a possible impact of perioperative glucose control on perioperative blood lactate levels. Method. We analysed a database of 2,153 patients who underwent cardiothoracic or vascular surgery between 2000 and 2008. We examined blood lactate in the glucose target ranges of 80-110 mg/dL [1] and 80-180 mg/dL [2] and above and below on ICU-admission, using ANOVA. We used linear regression to depict a correlation of blood glucose with lactate in the target ranges. Furthermore we conducted a multivariate regression analysis to demonstrate an independent influence of admission glucose on admission lactate levels. Results. Glucose did not correlate significantly with lactate in the target range of 80-110 mg/dL (n⫽551; P⫽0.94). Glucose correlated significantly with lactate in the target range of 80-180 mg/dL (n⫽1,729; P⬍0.001). For both groups, ANOVA was significant (P⬍0.001). Moreover, multivariate regression with the entire patient population was significant when including several patient variables (P⬍0.001). Conclusion. The positive interrelation between perioperative blood glucose and lactate suggests a consideration of perioperative blood lactate levels when identifying the ideal glucose target range. Blood lactate, itself a strong predictor of outcome, could help explain adverse effects of hyperglycaemia in cardiothoracic patients. REFERENCES 1. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001; 345: 1359-67. 2. Finfer S, Chitock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360: 1283-97.
P-47 Predictors of tracheostomy requirement following cardiac surgery Justin Ratnasingham, James McShane, Omar Al Rawi, Tim Ridgway Liverpool Heart and Chest Hospital, Liverpool, UK Introduction. Currently there is little information about the likelihood of the need for tracheostomy after cardiac surgery. Identification of predictive factors would help patient information and consent. Method. A search of the literature was performed and predictive factors identified [1,2]. Our database was analysed over a nine-year period using these factors. Over 14,000 patients were included in the analysis with the tracheostomy group compared with the non-tracheostomy group. Results. The total number of tracheostomies performed was 414 (2.92%). The prevalence of preoperative factors was compared between the two groups and any differences analysed for statistical significance. Bivariate analysis was performed using the Mann Whitney U test for continuous data and the Chisquared test for categorical data. Increasing age, current/recent smoker, BMI ⬍18.5, poor LV function and non-elective surgery were found to be statistically significant, all with a P value ⬍0.0001. Discussion. This analysis of over 14,000 patients provides new information about the likelihood of tracheostomy requirement post cardiac surgery. Chronic renal impairment, urgent surgery, poor left ventricular function and pre-existing obstructive airways disease have been shown to be predictors for requiring a tracheostomy post cardiac surgery. We believe that the anticipated need for tracheostomy is a marker for prolonged intensive care and that patients should be informed prior to surgery. REFERENCES 1. Hoskote A, Cohen G, Goldman A, et al. Tracheostomy in infants and children after cardiothoracic surgery: indications, associated risk factors, and timing. J Thorac Cardiovasc Surg 2005; 130: 1086-93. 2. Nicholls J. The use of tracheostomy following major open cardiac surgery: a review of 64 cases. Thorax 1968; 23: 652-6. P-48 Is troponin an important marker in cardiac surgery? Oana Mihailescu, Alina Paunescu, Mihail Luchian, Oana Ghenu, Simona Marin, Ovidiu Chioncel, Luminita Iliuta, Horatiu Moldovan, Vlad Iliescu, Daniela Filipescu Emergency Institute of Cardiovascular “Prof.Dr. C.C.Iliescu”, Bucharest, Romania
Diseases,
Introduction. Cardiac biomarker sensitivity is crucial for detecting postoperative myocardial infarction (PMI) and consequently, for prediction of outcome after cardiac surgery. However, defining PMI after cardiac surgery is often difficult. The aim of our prospective study was to evaluate the dynamics of troponin I in the postoperative period, the value of cardiac troponin I for diagnosis PMI and its value in risk stratification after coronary artery bypass graft (CABG) surgery. Method. Troponin I, creatinine kinase and MB fraction, electrocardiogaphic tracings and echocardiography images were registered preoperatively, in the first 24 h and on the 7th day after
S54
FREE POSTER SESSIONS
CABG surgery in 158 consecutive patients. Demographic data, past medical and surgical history, medications, EuroSCORE, duration of extracorporeal circulation, aortic-clamp time, type of revascularization, APACHE II score, SOFA score, complications, ICU lengths of stay, lengths of hospitalization and mortality, were recorded using case report forms. PMI was considered when new pathological Q-waves or new LBBB was registered on ECG and new abnormality of LV wall motion was detected on echocardiography. Results. One hundred and twenty two men and 36 women were included in our prospective study. Mean troponin level increased in the first day after surgery compared to baseline values and fell until the 7th day (on the operation day the value of troponin was normal). The mean value of troponin on day 1 after surgery was 5.078 ⫾ 9.38 ng/ml and on the 7th day 0.38 ⫾ 0.825 ng/ml. PMI was found in 2.5% of patients. Statistical analyses performed, using area under the curve (AUC) in receiver operating characteristic (ROC) curves in a multivariable model found no correlation between value of troponin in the first day and postoperative myocardial infarction, or with ICU length of stay or length of hospitalization. A significant correlation between the value of troponin on the first postoperative day and the duration of extracorporeal circulation (r⫽0.231, P⫽0.004) was detected. Using compared analysis of variance (oneway ANOVA) we found two independent predictors for relative decrease of troponin in the postoperative period, left ventricular mass (r⫽0.206; P⫽0.023) and the need of inotropic therapy (P⫽0.005). Conclusion. Troponin I value on the first postoperative day is not a marker for PMI, ICU length of stay or duration of hospitalization. Left ventricular mass and the need for inotropic therapy did influence the dynamics of troponin in the postoperative period and this fact may have clinical relevance for choosing adequate myocardial protection. P-49
(11) or vascular (29) surgery and 63 of them for non p.o. care. 32 pts (3.65%) died while in ICU, 19 after p.o. (2.3%) and 13 after non p.o. care (20.6%). ICU stay: mean 4.48⫾6.89 days; survived pts: 4.2⫾6.3 days; non-survivors 11.7⫾14.09 days. Adm score: survived pts 4.95⫾5.5, non survivors 18.5⫾7.5. DD score: survived pts 1.24⫾1.40, non survivors 20.3⫾7.9. Adm score was related to ICU stay (R⫽0.503 in the overall population, R⫽0.548 in survived pts). Adm score ⱖ20 was observed in 31 pts. 13 pts with Adm score ⱖ20 didn’t survive (41.9%). 5 of them were admitted for cardiogenic shock treated by medical therapy, 2 for cardiogenic shock treated by ECMO, 2 after lung transplant, 1 after heart transplant and 3 after valve surgery. 18 pts with Adm score ⱖ20 survived, 11 of them being admitted for p.o. care after heart transplant (7), LVAD implant (4), valve plus coronary surgery (5), pulmonary thromboendoarterectomy (1), Glenn operation (1). Discussion. Although weighing p.o. support in CTV ICU can be useful to optimize pts late allocation and resource use, the estimate of post-Adm support in CTV ICU may be considered as an adjunct to evaluation of early pts’ response to surgery. Our analysis suggests a longer ICU stay and worse outcome for pts showing a high Adm score. Pts who have undergone LVAD implantation or heart transplantation show a prerequisite for more effective surgical therapy in spite of a high Adm score.
REFERENCE 1. Ettema RG, Peelen LM, Schuurmans MJ, et al. Prediction models for prolonged intensive care unit stay after cardiac surgery: systematic review and validation study. Circulation 2010; 122: 682-9.
Early postoperative support profile and mortality in a cardiothoracic-vascular surgery ICU
P-50
Roberto Paino, Sandra Nonini, Filippo Michele Mondino, Silvia Zannoli, Aldo Cannata
Milazzo,
Postoperative use of dobutamine after cardiac surgery is associated with an increased inflammatory syndrome
Cardio-Thoraco-Vascular Anaesth. ICU, Niguarda Hospital, Milano, Italy
Michel Durand, Marine Rossi, Amélie Bataillard, Myriam Casez, Olivier Chavanon, Pierre Albaldejo
Introduction. Although pre-operative patient risk factors can predict patient (pt) ICU stay and mortality after cardiac surgery [1], intra-operative events may also affect them. No data are available about the relationship between early post-operative (p.o.) support and ICU stay and mortality in cardiac surgery. Our aim was to study post-admission (Adm) dependency on drugs and devices in a cardiothoracic vascular (CTV) ICU. Method. 877 pts consecutively admitted to our CTV ICU were retrospectively studied by an already assessed home-made data base specifically oriented to weigh post-Adm support. A value from 0 to 6 was daily assigned to 13 items concerning overall support to each pt from the first post-Adm day to pt discharge or death (DD). The following p.o. supports were considered: ventilation, IABP, ECMO, cardiac rhythm control, coagulation control, inotropes, vasoconstrictors, pulmonary vasodilators, systemic vasodilators, targeted insulin infusion, renal function control, thermal control and sedation. An overall score was therefore daily assigned to every pt. We retrospectively considered only Adm and DD score. Results. Among 877 admitted pts 797 were adult and 80 paediatric. 814 of them were admitted after cardiac (774), thoracic
University Hospital, Grenoble, France Introduction. The use of dobutamine (D) after coronary artery surgery (CABG) or cardiogenic shock is associated with an increased mortality [1,2]. Inotropic agents have pro-inflammatory properties [3]. In this study we aimed to see if infusion of D after CABG was associated with an increased inflammatory syndrome. Method. 1,279 consecutive CABG patients were retrospectively divided into 3 groups: no D (n⫽ 993), D ⬍5g kg-1 min-1 for ⬎3 hours (n⫽239) and D ⱖ5g kg-1 min-1 for ⬎3 hours (n⫽47). CRP levels from day 0 to day 7 after surgery were compared with an analysis of variance for repeated measures. Results. Age was 66⫾11 years, EuroSCORE, 4.5⫾3.3. Mortality (2.6%) increased significantly with the dose of D. CRP levels increased after day 4 in the groups who had received D (P⬍0.0001). This difference was significant in patients with cardiac index ⱖ2.2 L min-1 m2.