Search

Objectives: Surgical-site infections (SSIs) after cardiac surgery increase morbidity and mortality, consume health care resources, impair recovery, and diminish patients' quality of life. Numerous guidelines and expert consensus documents have been published to address the prevention and management of SSIs. Our objective is to integrate these documents into an order set that will facilitate the adoption and implementation of evidence-based best practices for preventing and managing SSIs after cardiac surgery., Methods: Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set for SSI reduction. Orders derived from consistent class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the turnkey order set in bold type. Selected orders that were inconsistent class I or IIA, class IIB or otherwise supported by published evidence, were also included in italicized type., Results: Preventative care begins with the preoperative identification of both modifiable and nonmodifiable SSI risks by health care providers. Assessment tools can be used to assist in identifying patients at a high risk of SSI. Preoperative recommendations include screening for and treating Staphylococcus aureus nasal carriage. Intraoperatively, tailored prophylactic intravenous antibiotics and maintaining blood glucose levels below 180 mg/dL are essential elements. Postoperative care includes maintaining normothermia, glucose control and patient engagement., Conclusions: Despite the well-documented advantages of a multidisciplinary care pathway for SSI in cardiac surgery, there are inconsistencies in its adoption and implementation. This article provides an order set that incorporates recommendations from existing guidelines to prevent SSI in the cardiac surgical population., Competing Interests: Conflict of Interest Statement A.R. and V.M.B. reported speaker's bureau for Edwards Lifesciences. A.J.G. reported speaker and advisory activities for Edwards Lifesciences. R.C.A. reported honoraria from Edwards Lifesciences and HLS Therapeutics. In addition, he has function on an ad board for Renibus Therapeutics Inc. S.C. served on advisory boards for Edwards Lifesciences, La Jolla Pharmaceutical Company, Baxter Healthcare, and Eagle Pharmaceuticals. D.T.E. reported Device Safety Monitoring Board: Edwards Lifesciences Transcatheter Valves and Trial Steering Committees: Renibus, Alexion, Medical Advisory Boards: Astellas, Terumo, Medela, Arthrex, and AtriCure. R.S. reported consulting/advisory relationships with Zimmer Biomet, AtriCure, La Jolla, Terumo, Encare, and Edwards Lifesciences. K.W.L. reported consultant for Abiomed, Alexion, Medela, Medtronic, and Renibus. G.M. reported consultant for Edwards Lifesciences. S.R. reported advisor and speaker for 3M. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: There are multiple published guidelines on comprehensive patient blood management (PBM), centered on the 3 pillars of PBM: managing preoperative anemia, minimizing blood loss, and tolerating intraoperative/postoperative anemia. We sought to create an order set to facilitate widespread implementation of evidence-based PBM for cardiac surgery patients., Methods: Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set (TKO) for PBM. Orders derived from consistent class I, class IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistently class I or IIA, class IIB, or supported by published evidence are presented in italic type., Results: Preoperatively, there are strong recommendations to screen and treat preoperative anemia with iron replacement and erythropoietin and to discontinue dual antiplatelet therapy if the patient can safely wait for surgery. Intraoperative orders outline the routine use of an antifibrinolytic agent, cell saver, point of care viscoelastic testing, and use of a standard transfusion algorithm. The order set also reflects strong recommendations intraoperatively and postoperatively for agreed-upon hemoglobin thresholds to consider transfusion of packed red blood cells. A hemoglobin threshold should be adopted according to local team consensus and should trigger a discussion regarding transfusion., Conclusions: The benefit of a multidisciplinary PBM care pathway in cardiac surgery has been well established, yet implementation remains variable. Using recommendations from existing guidelines, we have created a TKO to facilitate the implementation of PBM., Competing Interests: Conflict of Interest Statement D.T.E. reports serving on a device safety monitoring board for Edwards Lifesciences Medical and on advisory boards for Astellas Pharma, Alexion, Terumo, Medela, and Renibus Therapeutics. R.C.A. reports honoraria from Edwards Lifesciences and HLS Therapeutics and serving on an advisory board for Renibus Therapeutics. R.S. discloses consulting/advisory relationships with Zimmer Biomet, Atricure, La Jolla, Terumo, Encare, and Edwards Lifesciences. S.H. discloses a consultant relationship with Encare. J.R. reports research support from and advisory board work for Octapharma, and serving on the Executive Board for the CRPTICS Trial (NCT 04709705). K.W.L. reports consulting for Abiomed, Alexion, Medela, Medtronic, and Renibus. S.C. has served on Advisory Boards for Edwards Lifesciences, La Jolla Pharmaceuticals, Baxter Pharmaceuticals, and Eagle Pharmaceuticals. A.J.G. reports speaker and advisory activities for Edwards Lifesciences. V.M-B. reports serving on a speakers bureau for Edwards Lifesciences. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

This year, we have again assembled an expert opinion on several key topics that pertain to the perioperative and critical care management of the cardiac surgery patient and for patients requiring extracorporeal membrane oxygenation. Approximately 1 in 3 patients undergoing cardiac surgery have diabetes mellitus; contemporary glycemic control management of these patients to minimize perioperative complications are reviewed. Goal directed fluid therapy remains an area on interest and controversy; the use of albumin as a resuscitation fluid and recent clinical trial data is reviewed. Delirium is characterized as an acute confusional state occurring in 20-25% of patients after cardiac surgery. Insights on integrating the whole interdisciplinary team, including the family, with the DELirium Team Approach (DELTA) program are discussed. Optimal management for refractory hypoxemia with venovenous extracorporeal membrane oxygenation (VV-ECMO) and the role of prone positioning remain a question. Data supporting this technique during VV-ECMO is reviewed-lastly, the contemporary management and supporting evidence for refractory postoperative vasoplegic shock after cardiopulmonary bypass is provided., (Copyright © 2024. Published by Elsevier Inc.)

Objective(s): In light of the absence of patient and caregiver input in Enhanced Recovery After Surgery Cardiac Surgery guideline development, we conducted a scoping review to identify patient and caregiver preferences and prioritized outcomes related to perioperative care in cardiac surgery and its lifelong impact., Methods: Five electronic databases were searched to retrieve studies investigating patient or caregiver preferences and prioritized outcomes. Information was charted in duplicate and analyzed using descriptive statistics or thematic analysis. A patient and caregiver consultation workshop validated scoping review findings and solicited novel preferences and outcomes., Results: Of the 5292 articles retrieved, 43 met inclusion criteria. Most were from Europe (n = 19, 44%) or North America (n = 15, 35%) and qualitative and quantitative designs were represented in equal proportions. Fifty-two methods were used to obtain stakeholder preferences and prioritized outcomes, the majority being qualitative in nature (n = 32, 61%). Based on the collective preferences of 3772 patients and caregivers from the review and 17 from the consultation workshop, a total of 108 patient preferences, 32 caregiver preferences, and 19 prioritized outcomes were identified. The most commonly identified theme was "information and education." Improved quality of life was the most common patient-prioritized outcome, and all caregiver-prioritized outcomes were derived from the consultation workshop., Conclusions: Patient and caregiver preferences overlap with Enhanced Recovery After Surgery Cardiac Surgery recommendations targeting preoperative risk reduction strategies, prehabilitation, patient engagement technology, and intra- and postoperative strategies to reduce discomfort. To support clinical practice, future research should investigate associations with key surgical outcomes., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Long-term data on patient survivors after extracorporeal membrane oxygenation (ECMO) support remains limited. This study sought to examine the 5-year survival and health-related quality of life (HRQoL) of patients treated with venoarterial (VA)- or venovenous (VV)-ECMO., Methods: A single-center retrospective chart review and survival analysis was conducted on all patients who required ECMO from December 2007 to June 2019. Cross-sectional HRQoL assessments were performed using 8 standardized questionnaires among survivors., Results: Records for 370 ECMO patients (288 VA-ECMO, 82 VV-ECMO) were reviewed. Survival at 5 years was 33% (VA-ECMO) and 36% (VV-ECMO). Among patients that survived to 30 days, 5-year survival rates were 73% (VA-ECMO) and 71% (VV-ECMO). Sixty surviving patients (56%) had HRQoL assessments (48 VA-ECMO, 12 VV-ECMO). Median follow-up time was 4.2 (VA-ECMO) and 5.7 years (VV-ECMO). Fourteen (29%) VA-ECMO patients and 9 (75%) VV-ECMO patients reported difficulty with any activity of daily living whereas 13 (27%) VA-ECMO patients and 8 (67%) VV-ECMO patients reported difficulty with any instrumental activity of daily living. Eleven (23%) VA-ECMO patients and 7 (58%) VV-ECMO patients reported a high post-traumatic stress disorder score. Low decision regret scores in both cohorts indicated minimal regret that ECMO was initiated., Conclusions: Five-year clinical and patient-centered outcomes of patients requiring ECMO support is acceptable in those who survived the initial 30 days. Among ECMO survivors, persistent HRQoL concerns were apparent, highlighting the importance of longer-term postdischarge follow-up., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Delirium is prevalent and underdetected among cardiac surgery patients on the postoperative ward. This study aimed to validate the 4 A's Test delirium screening tool and evaluate its accuracy both when used by research assistants and when subsequently implemented by nursing staff on the ward., Methods: This single-center, prospective observational study evaluated the performance of the 4 A's Test administered by research assistants (phase 1) and nursing staff (phase 2). Assessments were undertaken during the patients' first 3 postoperative days on the postcardiac surgery ward along with previous routine nurse-led Confusion Assessment Method assessments. These index tests were compared with a reference standard diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Surveys regarding delirium screening were administered to nurses pre- and postimplementation of the 4 A's Test in phase 2 of the study., Results: In phase 1, a total of 137 patients were enrolled, of whom 24.8% experienced delirium on the postoperative cardiac ward. The 4 A's Test had a sensitivity of 85% (95% confidence interval, 73-93) and a specificity of 90% (95% confidence interval, 85-93) compared with the reference standard. The nurse-assessed Confusion Assessment Method had a sensitivity of 23% (95% confidence interval, 13-37) and specificity of 100% (95% confidence interval, 99-100). In phase 2, nurses (n = 51) screened 179 patients for delirium using the 4 A's Test. Compared with the reference rater, the 4 A's Test had a sensitivity of 58% (95% confidence interval, 28-85) and specificity of 94% (95% confidence interval, 85-98). Postimplementation, 64% of nurses thought that the 4 A's Test improved their confidence in delirium detection, and 76% of nurses would consider routine 4 A's Test use., Conclusions: The 4 A's Test demonstrated moderate sensitivity and high specificity to detect delirium in a real-world setting after cardiac surgery on the postoperative ward. A modified model of use with less frequent administration, along with increased engagement of the postoperative team, is recommended to improve early delirium detection on the cardiac surgery postoperative ward., (Copyright © 2021 The American Association for Thoracic Surgery. All rights reserved.)

For yet another year, our lives have been dominated by a pandemic. This year in review, we feature an expert panel opinion regarding extracorporeal support in the context of COVID-19, challenging previously held standards. We also feature survey results assessing the impact of the pandemic on cardiac surgical volume. Furthermore, we focus on a single center experience that evaluated the use of pulmonary artery catheters and the comparison of transfusion strategies in the Restrictive and Liberal Transfusion Strategies in Patients With Acute Myocardial Infarction (REALITY) trial. Additionally, we address the impact of acute kidney injury on cardiac surgery and highlight the controversy regarding the choice of fluid resuscitation. We close with an evaluation of dysphagia in cardiac surgery and the impact of prehabilitation to optimize surgical outcomes., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Delirium after cardiac surgery is associated with prolonged intensive care unit (ICU) and hospital length of stay and elevated rates of mortality. The Society of Thoracic Surgery National Database (STS-ND) includes delirium in routine data collection but restricts its definition to hyperactive symptoms. The objective is to determine whether the Confusion Assessment Method for ICU (CAM-ICU), which includes hypo- and hyperactive symptoms, is associated with improved prediction of poor 1-year functional survival following cardiac surgery., Methods: Clinical and administrative databases were used to determine the influence of postoperative delirium on 1-year poor functional survival, defined as being institutionalized or deceased at 1 year. Patients experiencing postoperative delirium using the STS-ND definition (2007-2009) were compared with patients with delirium identified by the CAM-ICU (2010-2012). A propensity score match was undertaken, and multivariable Cox proportional hazards regression models were generated to determine risk of poor 1-year functional survival., Results: There were 2756 and 2236 patients in the STS-ND and CAM-ICU cohorts, respectively. Propensity matching resulted in a cohort of 1835 patients (82.1% matched). The overall rate of delirium in the matched study population was 7.6% in the STS-ND cohort and 13.0% in the CAM-ICU cohort (P < .001). Delirium in the CAM-ICU cohort was independently associated with poor 1-year functional survival (hazard ratio, 2.58; 95% confidence interval, 1.20-5.54; P = .02); delirium in the STS-ND cohort was not associated with poor 1-year functional survival (hazard ratio, 0.92; 95% confidence interval, 0.49-1.71; P = .79)., Conclusions: A systematic screening tool identifies postoperative delirium with improved prediction of poor 1-year functional survival following cardiac surgery., (Copyright © 2020 The American Association for Thoracic Surgery. All rights reserved.)

Objective: Spinal cord ischemia (SCI) is a devastating complication of thoracoabdominal aortic aneurysm repair. We aim to characterize current practices pertaining to SCI prevention and treatment across Canada., Methods: Two questionnaires were developed by the Canadian Thoracic Aortic Collaborative and the Canadian Cardiovascular Critical Care Society targeting aortic surgeons and intensivists. A list of experts in the management of patients at risk of SCI was developed, with representation from each of the Canadian centers that perform complex aortic surgery., Results: The response rate was 91% for both intensivists (21/23), and from cardiac and vascular surgeons (39/43). Most surgeons agreed that staging is important during endovascular repair of extent II thoracoabdominal aortic aneurysm (60%) but not for open repair (34%). All of the surgeons felt prophylactic lumbar drains were effective in reducing SCI, whereas only 66.7% of intensivists felt that lumbar drains were effective (P < .001). There was consensus among surgeons over when to employ lumbar drains. A majority of surgeons preferred to keep the hemoglobin over 100 g/L if the patient demonstrated loss of lower-extremity function, whereas most intensivists felt a target of 80 g/L was adequate (P < .001). Management of perioperative antihypertensives, use of intraoperative adjuncts, and management of venous thromboembolism prophylaxis in the presence of a lumbar drain, were highly variable., Conclusions: We observed some consensus but considerable variability in the approach to SCI prevention and management across Canada. Future studies focused on the areas of variability may lead to more consistent and improved care for this high-risk population., (Copyright © 2020. Published by Elsevier Inc.)

The COVID-19 pandemic necessitates aggressive infection mitigation strategies to reduce the risk to patients and healthcare providers. This document is intended to provide a framework for the adult cardiac surgeon to consider in this rapidly changing environment. Preoperative, intraoperative, and postoperative detailed protective measures are outlined. These are guidance recommendations during a pandemic surge to be used for all patients while local COVID-19 disease burden remains elevated., (Copyright © 2020. Published by Elsevier Inc.)

In the setting of the current novel coronavirus pandemic, this document has been generated to provide guiding statements for the adult cardiac surgeon to consider in a rapidly evolving national landscape. Acknowledging the risk for a potentially prolonged need for cardiac surgery procedure deferral, we have created this proposed template for physicians and interdisciplinary teams to consider in protecting their patients, institution, and their highly specialized cardiac surgery team. In addition, recommendations on the transition from traditional in-person patient assessments and outpatient follow-up are provided. Lastly, we advocate that cardiac surgeons must continue to serve as leaders, experts, and relevant members of our medical community, shifting our role as necessary in this time of need., (Copyright © 2020. Published by Elsevier Inc.)

Objectives: Earlier extubation after cardiac surgery is reported to have benefits on length of stay and complication rates, but the influence on postoperative delirium remains unclear. We sought to determine the effect of earlier extubation on delirium after coronary artery bypass grafting., Methods: A single-center retrospective review of consecutive isolated coronary artery bypass grafting patients from January 1, 2010, to December 31, 2015, was conducted. Baseline demographic characteristics, preoperative comorbidities, intraoperative data, and postoperative data were collected. A multivariable logistic regression was performed with analysis limited to extubation within the first 24 hours postoperatively., Results: We identified 2561 eligible patients. Delirium occurred in 13.9% (n = 357). Duration of postoperative mechanical ventilation was associated with higher delirium rates following adjustment, particularly after 12 to 24 hours (hourly odds ratio, 1.12; 95% confidence interval, 1.05-1.19; P < .001). No association was observed during the time period from 0 to 12 hours (hourly odds ratio, 1.02; 95% confidence interval, 0.99-1.06; P = .218). Major adverse events were associated with duration of ventilation after 0 to 12 hours (hourly odds ratio, 1.08; 95% confidence interval, 1.03-1.14; P < .002) but not after 12 to 24 hours (hourly odds ratio, 1.04; 95% CI, 0.96-1.14; P = .316). The overall rate of reintubation was 2.9% (n = 73)., Conclusions: Our findings suggest that delirium rates increase with lengthier postoperative ventilation times. This study provides the basis for consideration of the appropriate selection of earlier extubation to minimize delirium in patients undergoing cardiac surgery., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Iron regulation is an important modifier of renal ischemia-reperfusion injury, but the role of iron-binding proteins during cardiopulmonary bypass remains unclear. The goal was to characterize iron-binding proteins throughout ischemia-reperfusion injury to determine their association with acute kidney injury development., Methods: A prospective observational cohort of adult patients who underwent cardiac surgery (n = 301) was obtained, and acute kidney injury was defined by Kidney Disease Improving Global Outcomes. Serum ferritin, transferrin saturation, and urine hepcidin-25 were measured., Results: Intraoperative serum ferritin was lower at the start of cardiopulmonary bypass (P = .005) and 1-hour cardiopulmonary bypass (P = .001) in patients with acute kidney injury versus patients without acute kidney injury. Lower serum ferritin and higher transferrin saturation at 1-hour cardiopulmonary bypass were independent predictors of acute kidney injury (serum ferritin odds ratio, 0.66; 95% confidence interval [CI], 0.48-0.91; transferrin saturation odds ratio, 1.26; 95% CI, 1.02-1.55) and improved model discrimination (area under the curve [AUC], 0.76; 95% CI, 0.67-0.85) compared with clinical prediction alone (AUC, 0.72; 95% CI, 0.62-0.81; ΔAUC and net reclassification index, P = .01). Lower ferritin, higher transferrin saturation at 1-hour cardiopulmonary bypass, and lower urine hepcidin-25 at postoperative day 1 were also independent predictors for acute kidney injury development, and this model demonstrated an AUC of 0.80 (0.72-0.87), which was superior to clinical prediction (ΔAUC P = .002, integrated discrimination improvement and net reclassification index P = .003)., Conclusions: Our findings suggest that lower levels of intraoperative iron-binding proteins may reflect an impaired capacity to rapidly handle catalytic iron released during cardiopulmonary bypass, leading to kidney injury. These data highlight the importance of iron homeostasis in human ischemia-reperfusion injury and suggest it is a potentially modifiable risk during cardiac surgery. Intraoperative detection of incipient acute kidney injury may be feasible and could be used as an enrichment strategy for clinical trials., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Delirium is a common neurologic complication after cardiac surgery. Our primary objective was to determine the impact of delirium on self-reported problems with midterm cognitive functioning and mood postcardiac surgery., Methods: A single-center, prospective cohort study was conducted, enrolling 197 patients undergoing coronary artery bypass grafting or valve replacement. Baseline cognition and mood were assessed preoperatively in elective patients as a part of routine care using the Montreal Cognitive Assessment and Patient Health Questionnaire 9, respectively. During hospitalization, delirium was diagnosed using the Confusion Assessment Method (Confusion Assessment Method/Confusion Assessment Method Intensive Care Unit). Follow-up assessments were carried out via telephone interview at 6 to 9 months after cardiac surgery using the EuroQoL-5D, Patient Health Questionnaire 9, Alcohol Use Disorders Identification Test Consumption, Memory Impairment Screen, and Category Fluency Test assessments. We examined resultant scores in the domains of cognition and mood among delirious and nondelirious cohorts, controlling for confounders deemed clinically relevant., Results: A total of 197 patients were enrolled in the study, of whom 44 (22%) developed postoperative delirium. After adjustment, no differences were observed in cognitive functioning between the delirious and nondelirious subjects after 6 to 9 months. However, delirious patients were more likely to experience self-reported problems in affective (depression and anxiety) functioning as measured by the EuroQoL-5D (odds ratio, 4.41; 95% confidence interval, 1.51-12.92; P < .01)., Conclusions: Postoperative delirium is associated with increased anxiety and depression at 6 to 9 months postcardiac surgery. Future investigation should seek to evaluate the utility of screening programs for affective disorders in those individuals who develop delirium in the postoperative period., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)