Clinical significance and risk factors for new onset and recurring atrial fibrillation following cardiac surgery - a retrospective data analysis

Abstract Background Although mortality after cardiac surgery has significantly decreased in the last decade, patients still experience clinically relevant postoperative complications. Among others, atrial fibrillation (AF) is a common consequence of cardiac surgery, which is associated with prolonged hospitalization and increased mortality. Methods We retrospectively analyzed data from patients who underwent coronary artery bypass grafting, valve surgery or a combination of both at the University Hospital Muenster between April 2014 and July 2015. We evaluated the incidence of new onset and intermittent/permanent AF (patients with pre- and postoperative AF). Furthermore, we investigated the impact of postoperative AF on clinical outcomes and evaluated potential risk factors. Results In total, 999 patients were included in the analysis. New onset AF occurred in 24.9% of the patients and the incidence of intermittent/permanent AF was 59.5%. Both types of postoperative AF were associated with prolonged ICU length of stay (median increase approx. 2 days) and duration of mechanical ventilation (median increase 1 h). Additionally, new onset AF patients had a higher rate of dialysis and hospital mortality and more positive fluid balance on the day of surgery and postoperative days 1 and 2. In a multiple logistic regression model, advanced age (odds ratio (OR) = 1.448 per decade increase, p < 0.0001), a combination of CABG and valve surgery (OR = 1.711, p = 0.047), higher C-reactive protein (OR = 1.06 per unit increase, p < 0.0001) and creatinine plasma concentration (OR = 1.287 per unit increase, p = 0.032) significantly predicted new onset AF. Higher Horowitz index values were associated with a reduced risk (OR = 0.996 per unit increase, p = 0.012). In a separate model, higher plasma creatinine concentration (OR = 2.125 per unit increase, p = 0.022) was a significant risk factor for intermittent/permanent AF whereas higher plasma phosphate concentration (OR = 0.522 per unit increase, p = 0.003) indicated reduced occurrence of this arrhythmia. Conclusions New onset and intermittent/permanent AF are associated with adverse clinical outcomes of elective cardiac surgery patients. Different risk factors implicated in postoperative AF suggest different mechanisms might be involved in its pathogenesis. Customized clinical management protocols seem to be warranted for a higher success rate of prevention and treatment of postoperative AF

Additional file 2: of Clinical significance and risk factors for new onset and recurring atrial fibrillation following cardiac surgery - a retrospective data analysis

Supplementary material (Figure S1: Plasma creatinine concentration changes over the time course of ICU stay, Figure S2: Horowitz index over the time course of ICU stay for new onse AF vs no AF patients and Figure S3: Plasma phosphate concentration changes over the time course of ICU stay for disappeared AF vs intermittent/permanent AF patients). (DOCX 391 kb

An innovative telemedical network to improve infectious disease management in critically ill patients and outpatients: a stepped-wedge, cluster randomized controlled trial (TELnet@NRW)

Marx G, Greiner W, Juhra C, et al. An innovative telemedical network to improve infectious disease management in critically ill patients and outpatients: a stepped-wedge, cluster randomized controlled trial (TELnet@NRW). Journal of Medical Internet Research . 2022.BACKGROUND: Evidence-based infectious disease and intensive care management is more relevant than ever. Medical expertise in the two disciplines is often geographically limited to university institutions. In addition, the interconnection between inpatient and outpatient care is often insufficient (e.g., no shared electronic health record, no digital transfer of patient findings).; OBJECTIVE: To establish and evaluate a telemedical inpatient-outpatient network based on expert teleconsultations to increase treatment quality in intensive care medicine and infectious diseases.; METHODS: We performed a multicentre, stepped-wedge cluster randomised trial (Feb 2017 - Jan 2020) to establish a telemedicine inpatient-outpatient network among university hospitals, hospitals, and outpatient physicians in North Rhine Westphalia, Germany. Patients ≥ 18 years of age in the intensive care unit (ICU) or consulting with a physician in the outpatient setting were eligible. We provided expert knowledge from intensivists and infectious disease specialists through advanced training courses and expert teleconsultations with 24/7/365 availability on demand resp. once per week to enhance treatment quality. The primary outcome was adherence to the ten Choosing Wisely recommendations for infectious disease management. Guideline adherence was analysed using binary logistic regression models.; RESULTS: Overall, 159,424 patients (10,585 inpatients, 148,839 outpatients) from 17 hospitals and 103 outpatient physicians were included. There was a significant increase in guideline adherence in the management of Staphylococcus aureus infections (OR 4.00 [95% CI 1.83, 9.20], P<.01) and in sepsis management in critically ill patients (OR 6.82 [95% CI 1.27, 56.61], P=.04). There was a statistically non-significant decrease in sepsis related mortality from 28.8% (19/66) in the control group to 23.8% (50/210) in the intervention group. Furthermore, the extension of treatment with prophylactic antibiotics after surgery was significantly less likely (OR 9.37 [95% CI 1.52, 111.47], P=.04). Patients treated by outpatient physicians, who were regularly taking part in expert teleconsultations, were also more likely to be treated according to guideline recommendations regarding antibiotic therapy for uncomplicated upper respiratory tract infections (OR 1.34 [95% CI 1.16, 1.56], P<.01) and asymptomatic bacteriuria (OR 9.31 [95% CI 3.79, 25.94], P<.01). For the other recommendations, we found no significant effects, or we had too few observations to generate models. Key limitations of our study include selection effects due to the applied on-site triage of patients as well as the limited possibilities to control for secular effects.; CONCLUSIONS: Telemedicine facilitates a direct round-the-clock interaction over broad distances between intensivists or infectious disease experts and physicians who care for patients in hospitals without ready access to these experts. Expert teleconsultations increase guideline adherence and treatment quality in infectious disease and intensive care management creating added value for critically ill patients.; CLINICALTRIAL: ClinicalTrials.gov, NCT03137589, https://clinicaltrials.gov/ct2/show/NCT03137589