The Risk Factors of Prolonged Mechanical Ventilation after Isolated Coronary Artery Bypass Graft Surgery

Background: Failure to wean a patient from mechanical ventilation after cardiac surgery is associatedwith poor outcome.Aim: The present study was performed aimed to investigate the risk factors of prolonged mechanicalventilation (PMV) following isolated coronary artery bypass graft (CABG) surgery.Method: This retrospective cohort study was performed on 2155 consecutive adult patientsundergoing isolated coronary artery bypass graft surgery (May 2012 to November 2016 at Imam Rezahospital, Mashhad, Iran). The subjects were assessed for duration of weaning from mechanicalventilation, predictive risk factors for prolonged mechanical ventilation and associated outcomesincluding intensive care unit (ICU) and hospital length of stay (LOS), and mortality. Data wereanalyzed by SPSS (version 22). P<0.05 was considered statistically significant.Results: The median (25 -75 percentile) duration of mechanical ventilation was 360 (225-540)minutes. Also, 51.20%, 45.80% and 2.30% patients were weaned from mechanical ventilation in lessthan 6 hours, 7 to 24 hours, and more than 24 hours, respectively. Cerebral vascular accident was themost common cause of PMV (34.04%). After adjustment for confounder variables, on-pump CABG(P<0.05), duration of surgery (P<0.01), preoperative renal failure (P<0.05) and New York HeartAssociation (NYHA) class 4 were associated with PMV (P <0.05). PMV was associated withincreased length of ICU and hospital stay (P<0.01). There was a higher mortality rates in patients withPMV (P<0.001).Implications for Practice: Most patients are weaned from mechanical ventilation within 24 hoursuneventfully after isolated CABG. Furthermore, on-pump CABG, prolonged surgery, preoperativerenal insufficiency, and NYHA class 4 were independent predictors of prolonged mechanicalventilation. Identifying the risk factors causing PMV can prevent its adverse consequences

Hydatid cyst of the middle mediastinum complicated by fistulated ascending aorta: A case report and review of the literature

Abstract Clinicians must pay attention to the clinical presentation and consequences of hydatid cysts in rare sites. Cysts close to the aorta require planning and assistance of a cardiac or vascular surgeon before surgical intervention can be considered

Exogenous Fibrinogen Pertains Beneficial Effects in Managing Post-Cardiac Surgery Bleeding: A Randomized Clinical Trial

Introduction: Post cardiac surgery hemorrhagic syndromes, potentialized by implementing   cardiopulmonary bypass, leads to increased hazards of blood products transfusion and          pertains serious impacts on immediate patients outcome. The objective of this clinical trial was to investigate the efficiency of exogenous fibrinogen to control hemorrhagic syndromes following cardiac surgery in the intensive care unit. Materials and Methods: Eighty patients undergoing open heart surgery at Imam Reza Hospital, Mashhad, Iran with blood drainage more than 200 ml per hour were randomly divided to receive either fibrinogen 2 grams or placebo. The patients were investigated for amount of blood drainage, units of required blood product, length of stay in intensive care unit (ICU), and mortality. Results:  The first early 3-hours drainage (443.97±169.98 vs 606.66±235.93ml; p value =0.001) and total first 24 hours drainage (1025.30 ml and 1377.60 ml; p value: 0.041) showed significant difference in favor of fibrinogen receiving group. The fibrinogen group required significantly lesser units of red blood cells, and fresh frozen plasma (FFP) (1.62 and 2.55) compared to placebo group (2.74 and 3.21) (p values: 0.010 and 0.032). Platelets units requirement did not reach significant difference between the groups.   ICU length of stay was shorter in fibrinogen group (2.82 days versus 4.02 days; p value 0.045), while mechanical ventilation time did not significantly differ among the two groups. In addition, there was a trend towards decreased  early mortality in fibrinogen receiving group (7.5% versus 17.5 % ; p value = 0.02). Conclusion: Administration of low dose of fibrinogen in patients with postoperative bleeding can reduce ongoing and total blood drainage, transfusion of blood products, ICU length and early mortality

Selenium, Vitamin C and N-Acetylcysteine do not Reduce the Risk of Acute Kidney Injury after Off-Pump CABG: a Randomized Clinical Trial

Abstract Objective: The aim of this study was to investigate the impact of perioperative administration of N-acetylcysteine, selenium and vitamin C on the incidence and outcomes of acute kidney injury after off-pump coronary bypass graft surgery. Methods: 291 patients requiring elective off-pump coronary bypass graft surgery were randomized to receive either N-acetylcysteine, vitamin C and selenium 600 mg, 1500 mg, 0.5 mg, and nothing orally twice a day, respectively, from the day before to 2 days after surgery. They were assessed for the development of acute kidney injury using Acute Kidney Injury Network criteria, time of onset, its severity and duration, duration of mechanical ventilation, intensive care unit and hospital length of stay, and in-hospital mortality. Results: 272 patients completed the study. The total incidence of acute kidney injury was 22.1% (n=60) with 14 (20.9%), 15 (22.1%), 21 (31.8%), and 10 (14.1%) patients in the vitamin C, NAC, selenium, and control groups, respectively (P=0.096). We did not register significant differences in the incidence, the time of occurrence, the severity and the duration of acute kidney injury, as well as the duration of mechanical ventilation, the intensive care unit and hospital length of stay, and the in-hospital mortality among the four groups. Conclusion: We found that perioperative administration of N-acetylcysteine, vitamin C and selenium were not effective in preventing acute kidney injury and associated morbidity and mortality after off-pump coronary bypass graft surgery

Effects of virtual reality on chest tube removal pain management in patients undergoing coronary artery bypass grafting: a randomized clinical trial

Abstract The pain associated with chest tube removal (CTR) is one of the significant complications of cardiac surgery. The management of this pain is recognized as a vital component of nursing care. The application of distraction techniques using virtual reality (VR) is an effective and straightforward non-pharmacological approach to alleviate pain. This study aimed to determine the impact of VR technology on the management of pain caused by CTR following coronary artery bypass grafting (CABG). This randomized clinical trial was conducted on 70 patients undergoing CABG at Imam Reza and Qaem hospitals in Mashhad, Iran, in 2020. The patients were randomly divided into two groups of 35. For the intervention group, a 360-degree video was played using VR glasses 5 min before the CTR procedure. The pain intensity was measured before, immediately after, and 15 min after CTR, using the Visual Analogue Scale. Also, the Depression Anxiety and Stress Scale-21 (DASS-21), and the Rhoten Fatigue Scale (RFS) were used to evaluate intervention and control groups before the CTR procedure. The collected data was analyzed using statistical tests, such as Chi-square, independent t-test, and Mann–Whitney test. The patients were homogeneous in terms of stress, anxiety, and fatigue levels before CTR, and they did not show any significant differences (P > 0.05). The average pain intensity score of patients in the intervention group significantly decreased immediately and 15 min after CTR, compared to the control group (P < 0.001). Given the positive impact of VR distraction on the severity of pain associated with CTR in patients undergoing CABG, this technique can serve as an effective, accessible, and cost-efficient non-pharmacological approach for managing pain in these patients. Trial registration: This study was registered in the Iranian Registry of Clinical Trials (code: IRCT20190708044147N1; approval date, 08/26/2019)

Propranolol for infantile hemangioma: An evaluation of its efficacy and safety in Iranian infants

Background: Propranolol has been recently indicated to inhibit the rapid growth and involution of infantile hemangioma. In the present study, we investigated the efficacy and safety of propranolol in Iranian infants. Methods: A total of 30 infants with indications for medical intervention, such as large hemangiomas, wounds with or without secondary infection, or active trauma-induced bleeding, were selected. First, a total concentration of 1 mg/kg/day was orally administered to the infants; the dosage further increased (2-3 mg/kg/day) in case the infants experienced no adverse effects. Following weekly (one month after treatment) and monthly (up to six months) follow-ups, hemangioma activity score (HAS) was calculated to evaluate swelling, color of the lesion, and ulcer size. Results: In the present study, infants with the mean age of 5.33±3.50 years received therapy. Improvement was observed in the lesions of all patients, characterized by a significant decline in size, change in color, and reduction in ulcer size (

Selenium, Vitamin C and N-Acetylcysteine do not Reduce the Risk of Acute Kidney Injury after Off-Pump CABG: a Randomized Clinical Trial

<div><p>Abstract Objective: The aim of this study was to investigate the impact of perioperative administration of N-acetylcysteine, selenium and vitamin C on the incidence and outcomes of acute kidney injury after off-pump coronary bypass graft surgery. Methods: 291 patients requiring elective off-pump coronary bypass graft surgery were randomized to receive either N-acetylcysteine, vitamin C and selenium 600 mg, 1500 mg, 0.5 mg, and nothing orally twice a day, respectively, from the day before to 2 days after surgery. They were assessed for the development of acute kidney injury using Acute Kidney Injury Network criteria, time of onset, its severity and duration, duration of mechanical ventilation, intensive care unit and hospital length of stay, and in-hospital mortality. Results: 272 patients completed the study. The total incidence of acute kidney injury was 22.1% (n=60) with 14 (20.9%), 15 (22.1%), 21 (31.8%), and 10 (14.1%) patients in the vitamin C, NAC, selenium, and control groups, respectively (P=0.096). We did not register significant differences in the incidence, the time of occurrence, the severity and the duration of acute kidney injury, as well as the duration of mechanical ventilation, the intensive care unit and hospital length of stay, and the in-hospital mortality among the four groups. Conclusion: We found that perioperative administration of N-acetylcysteine, vitamin C and selenium were not effective in preventing acute kidney injury and associated morbidity and mortality after off-pump coronary bypass graft surgery.</p></div

Frequency of Acute Kidney Injury in Patients Treated With Normal Saline after Off-Pump Coronary Artery Bypass Grafting

Introduction: Acute kidney injury (AKI) is a common postoperative complication of cardiac surgery, which is associated with an increased risk of morbidity and mortality. This study investigated the frequency of postoperative AKI in low risk adult patients undergoing off-pump coronary artery bypass grafting (CABG).Materials & Methods: All consecutive adult patients of American Society of Anesthesiologists (ASA) class II and III, who were transferred to the post-operative cardiac surgery ICU after off-pump CABG and were low risk for AKI from October 2013 to September 2014 at Emam Reza Hospital, Mashhad, Iran were enrolled in this prospective cohort study at a teaching hospital. The patients were explored for AKI development, based on risk-injury-failure-loss- end stage kidney disease (RIFLE) and acute kidney injury network (AKIN) criteria, frequency of metabolic acidosis, hypernatremia, hyperchloremia, and length of stay in ICU.Results: According to the results of the present study, 479 patients with the mean age of 60.8±10.75 yrs were included. AKI occurred in 22 (4.4%) and23 (4.8%) patients, based on both the RIFLE and AKIN criteria, respectively with the highest rate of AKI, reported on the third and fourth post-operative days. Additionally, hyperchloremia and hypernatremia were observed in 71 (14.8%) and 76 (15.9%) patients, respectively. Only one case of mortality occurred during the study. Metabolic acidosis was reported in 112 (23.4%) patients with a high anion gap in 60 (12.5%) cases.Conclusion: The current study demonstrated that hypernatremia and metabolic acidosis but not AKI are frequently seen in patients receiving normal saline following off pump CABG with low risk for AKI

Effects of dexmedetomidine on heart arrhythmia prevention in off-pump coronary artery bypass surgery: A randomized clinical trial

Background: Arrhythmia occurring during and after surgery is one of the major complications in open-heart surgery. Dexmedetomidine is an intravenous alpha-2 agonist and very specific short-acting drug to protect the various organs against ischemic injuries and blood reflow. However, the effect of dexmedetomidine for preventing intraoperative heart arrhythmias has not been recognized. Objective: This study aimed to determine the effect of dexmedetomidine on the incidence rate of heart arrhythmias and anesthetic required in off-pump coronary artery bypass surgery. Methods: This randomized clinical trial was conducted on patients who were candidates for off-pump coronary artery bypass referring to Imam Reza Hospital of Mashhad, Iran, from July 2016 through January 2017. The patients were randomly assigned to two groups of intervention (infusion of 0.5 mcg/kg/h dexmedetomidine together with induction followed by infusion of 0.5 mcg/kg/h by the end of the surgery) or control (saline infusion). Mean arterial pressure (MAP) and heart rate (HR) were measured before induction, during surgery operation and ICU admission. Data were analyzed by SPSS version 18 using Chi Square and independent- samples t-test. Results: A total of 76 patients with a mean age of 59.8 ± 8.2 years (in two groups of 38) were studied. The two groups had no statistically significant difference in terms of background variables. The MAP and HR values before induction, during surgery and ICU admission were significantly higher in the control group than in the intervention group (p=0.001). Out of the studied arrhythmias, the values of PAC (55.2% vs. 15.7%), PVC (81.5% vs. 21.0%), AF (26.3% vs. 7.8%), VTAC (21.0% vs. 2.6%) were significantly lower in dexmedetomidine group (p=0.001). Conclusion: It seems that dexmedetomidine administration during induction and surgery can cause significant reduction in most of the common arrhythmias in off-pump coronary bypass surgery. The use of dexmedetomidine maintains MAP and HR at significantly lower values, and changes compared to the control group as well as reduces the need for anesthetic compounds. Trial Registration: The present study has been registered at the Iranian Registry of Clinical Trials (www.IRCT.IR) with a code of IRCT2016072413159N9 before starting the study. Founding: This study was fully sponsored by the Research Deputy at Mashhad University of Medical Sciences, Iran (grant number 941413)

Therapeutic Outcomes of Pectoralis Major Muscle Turnover Flap in Mediastinitis

Background: This study aimed to evaluate the therapeutic results and safety of pectoralis major muscle turnover flaps in the treatment of mediastinitis after coronary artery bypass grafting (CABG) procedures. Methods: Data regarding 33 patients with post-CABG deep sternal wound infections (DSWIs) who underwent pectoralis major muscle turnover flap procedures in the Emam Reza and Ghaem Hospitals of Mashhad, Iran were reviewed in this study. For each patient, age, sex, hospital stay duration, remission, recurrence, and associated morbidity and mortality were evaluated. Results: Of the 2,447 CABG procedures that were carried out during the time period encompassed by our study, DSWIs occurred in 61 patients (2.5%). Of these 61 patients, 33 patients (nine females [27.3%] and 24 males [72.7%]) with an average age of 63±4.54 years underwent pectoralis major muscle turnover flap placement. Symptoms of infection mainly occurred within the first 10 days after surgery (mean, 10.24±13.62 days). The most common risk factor for DSWIs was obesity (n=16, 48.4%) followed by diabetes mellitus (n=13, 39.4%). Bilateral and unilateral pectoralis major muscle turnover flaps were performed in 20 patients (60.6%) and 13 patients (39.4%), respectively. Complete remission was achieved in 25 patients (75.7%), with no recurrence in the follow-up period. Four patients (12.1%) needed reoperation. The mean hospitalization time was 11.69±6.516 days. Four patients (12.1%) died during the course of the study: three due to the postoperative complication of respiratory failure and one due to pulmonary thromboembolism. Conclusion: Pectoralis major muscle turnover flaps are an optimal technique in the treatment of post-CABG mediastinitis. In addition to leading to favorable therapeutic results, this flap is associated with minimal morbidity and mortality, as well as a short hospitalization time