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Author(s): Luciano Gattinoni [sup.1] [sup.2] , Pierpaolo Giomarelli [sup.3] Author Affiliations: (1) grid.414818.0, 0000000417578749, Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, , Milan, Italy [...]

Abstract Background Patients undergoing heart surgery continue to be the largest demand on blood transfusions. The need for transfusion is based on the risk of complications due to poor cell oxygenation, however large transfusions are associated with increased morbidity and risk of mortality in heart surgery patients. The aim of this study was to identify preoperative and intraoperative risk factors for transfusion and create a reliable model for planning transfusion quantities in heart surgery procedures. Methods We performed an observational study on 3315 consecutive patients who underwent cardiac surgery between January 2000 and December 2007. To estimate the number of packs of red blood cells (PRBC) transfused during heart surgery, we developed a multivariate regression model with discrete coefficients by selecting dummy variables as regressors in a stepwise manner. Model performance was assessed statistically by splitting cases into training and testing sets of the same size, and clinically by investigating the clinical course details of about one quarter of the patients in whom the difference between model estimates and actual number of PRBC transfused was higher than the root mean squared error. Results Ten preoperative and intraoperative dichotomous variables were entered in the model. Approximating the regression coefficients to the nearest half unit, each dummy regressor equal to one gave a number of half PRBC. The model assigned 4 units for kidney failure requiring preoperative dialysis, 2.5 units for cardiogenic shock, 2 units for minimum hematocrit at cardiopulmonary bypass less than or equal to 20%, 1.5 units for emergency operation, 1 unit for preoperative hematocrit less than or equal to 40%, cardiopulmonary bypass time greater than 130 minutes and type of surgery different from isolated artery bypass grafting, and 0.5 units for urgent operation, age over 70 years and systemic arterial hypertension. Conclusions The regression model proved reliable for quantitative planning of number of PRBC in patients undergoing heart surgery. Besides enabling more rational resource allocation of costly blood-conservation strategies and blood bank resources, the results indicated a strong association between some essential postoperative variables and differences between the model estimate and the actual number of packs transfused.

Abstract Background Different methods have recently been proposed for predicting morbidity in intensive care units (ICU). The aim of the present study was to critically review a number of approaches for developing models capable of estimating the probability of morbidity in ICU after heart surgery. The study is divided into two parts. In this first part, popular models used to estimate the probability of class membership are grouped into distinct categories according to their underlying mathematical principles. Modelling techniques and intrinsic strengths and weaknesses of each model are analysed and discussed from a theoretical point of view, in consideration of clinical applications. Methods Models based on Bayes rule, k-nearest neighbour algorithm, logistic regression, scoring systems and artificial neural networks are investigated. Key issues for model design are described. The mathematical treatment of some aspects of model structure is also included for readers interested in developing models, though a full understanding of mathematical relationships is not necessary if the reader is only interested in perceiving the practical meaning of model assumptions, weaknesses and strengths from a user point of view. Results Scoring systems are very attractive due to their simplicity of use, although this may undermine their predictive capacity. Logistic regression models are trustworthy tools, although they suffer from the principal limitations of most regression procedures. Bayesian models seem to be a good compromise between complexity and predictive performance, but model recalibration is generally necessary. k-nearest neighbour may be a valid non parametric technique, though computational cost and the need for large data storage are major weaknesses of this approach. Artificial neural networks have intrinsic advantages with respect to common statistical models, though the training process may be problematical. Conclusion Knowledge of model assumptions and the theoretical strengths and weaknesses of different approaches are fundamental for designing models for estimating the probability of morbidity after heart surgery. However, a rational choice also requires evaluation and comparison of actual performances of locally-developed competitive models in the clinical scenario to obtain satisfactory agreement between local needs and model response. In the second part of this study the above predictive models will therefore be tested on real data acquired in a specialized ICU.

Abstract Background Popular predictive models for estimating morbidity probability after heart surgery are compared critically in a unitary framework. The study is divided into two parts. In the first part modelling techniques and intrinsic strengths and weaknesses of different approaches were discussed from a theoretical point of view. In this second part the performances of the same models are evaluated in an illustrative example. Methods Eight models were developed: Bayes linear and quadratic models, k-nearest neighbour model, logistic regression model, Higgins and direct scoring systems and two feed-forward artificial neural networks with one and two layers. Cardiovascular, respiratory, neurological, renal, infectious and hemorrhagic complications were defined as morbidity. Training and testing sets each of 545 cases were used. The optimal set of predictors was chosen among a collection of 78 preoperative, intraoperative and postoperative variables by a stepwise procedure. Discrimination and calibration were evaluated by the area under the receiver operating characteristic curve and Hosmer-Lemeshow goodness-of-fit test, respectively. Results Scoring systems and the logistic regression model required the largest set of predictors, while Bayesian and k-nearest neighbour models were much more parsimonious. In testing data, all models showed acceptable discrimination capacities, however the Bayes quadratic model, using only three predictors, provided the best performance. All models showed satisfactory generalization ability: again the Bayes quadratic model exhibited the best generalization, while artificial neural networks and scoring systems gave the worst results. Finally, poor calibration was obtained when using scoring systems, k-nearest neighbour model and artificial neural networks, while Bayes (after recalibration) and logistic regression models gave adequate results. Conclusion Although all the predictive models showed acceptable discrimination performance in the example considered, the Bayes and logistic regression models seemed better than the others, because they also had good generalization and calibration. The Bayes quadratic model seemed to be a convincing alternative to the much more usual Bayes linear and logistic regression models. It showed its capacity to identify a minimum core of predictors generally recognized as essential to pragmatically evaluate the risk of developing morbidity after heart surgery.

Objective: A less-invasive method has been developed that may provide an alternative to monitor cardiac output from arterial pressure: beat-to-beat values of cardiac output can be obtained by pressure recording analytical method (PRAM). The purpose of this study was to assess the reliability of cardiac output determination by PRAM in cardiac surgery. Methods: Cardiac output was measured in 28 patients undergoing coronary artery bypass grafting at 15 min after anaesthesia induction, 30 min after extracorporeal circulation, 1 and 3 h after arrival in the intensive care unit using thermodilution (ThD) method through a pulmonary artery catheter and PRAM. ThD cardiac output was calculated as the mean of five separate measurements. PRAM provided beat-by-beat cardiac output data continuously throughout the study and the cardiac output values displayed on a dedicated personal computer at each time point were recorded. Correlations were calculated and differences were compared by Bland–Altman analysis. Results: A total of 112 measurements were obtained. Cardiac output ranged from 2.3 to 7.4 l/min, and a good linear correlation (R2=0.78, P<0.0001) was found between ThD and PRAM. The highest degree of correlation (R2=0.86) was obtained at 3 h after arrival in the intensive care unit. The lower degree of correlation (R2=0.70) was obtained 30 min after extracorporeal circulation. At Bland–Altman analysis, the overall estimates of cardiac output measured by PRAM closely agreed with ThD (mean difference, 0.027; standard deviation, 0.43; limits of agreement, -0.83 and +0.89). Conclusions: Under the studied conditions, our results demonstrate good agreement between PRAM data and ThD measurements, and this new method has shown to be accurate for real-time monitoring of cardiac output in cardiac surgery. Further studies will be required to assess this method in higher-risk patients and in the setting of haemodynamic instability or arrhythmias. This is the first study designed to assess the accuracy of PRAM in cardiac surgery. [Copyright &y& Elsevier]