Impact of a natural versus commercial enteral-feeding on the occurrence of diarrhea in critically ill cardiac surgery patients. A retrospective cohort study

Diarrhea is an important complication in critically ill patients undergoing enteral feeding. The occurrence of diarrhea may lead to systemic and local complications and negatively impacts on nursing workload and patient's wellbeing. An enteral feeding based on blenderized natural food could be beneficial in reducing the risk of diarrhea. No study has compared natural and commercial enteral feedings in critically ill cardiac surgery patients

Routine use of bilateral internal thoracic artery grafting in women: A risk factor analysis for poor outcomes

Background: Concerns about increased risk of postoperative complications, primarily deep sternal wound infection (DSWI), prevent liberal use of bilateral internal thoracic artery (BITA) grafting inwomen. Consequently, outcomes after routine BITA grafting remain largely unexplored in female gender. Methods: Of 786 consecutivewomenwithmultivessel coronary diseasewho underwent isolated coronary bypass surgery at the authors' institution from 1999 throughout 2014, 477 (60.7%; mean age: 70 +/- 7.7 years) had skeletonized BITA grafts; their risk profiles, operative data, hospital mortality and postoperative complications were reviewed retrospectively. Risk factor analysis for hospital death, DSWI and poor late outcomes were performed by means of multivariable models. Results: There were 19 (4%) hospital deaths (mean EuroSCORE II: 5.2 +/- 6.1%); glomerular filtration rate b 50 ml/min was an independent risk factor (p = 0.035). Prolonged invasive ventilation (11.3%), multiple blood transfusion (12.1%) and DSWI (10.7%) were most frequent major postoperative complications. Predictors of DSWI were body mass index N35 kg/m2 (p = 0.0094), diabetes (p =0.005), non-elective surgical priority (p = 0.0087) and multiple blood transfusions (p = 0.016). The mean follow-up was 6.8 +/- 4.5 years. The nonparametric estimates of the 13-year freedom from cardiac and cerebrovascular deaths, major adverse cardiac and cerebrovascular events, and repeat myocardial revascularization were 76.1 [95% confidence interval (CI): 73.1-79.1], 59.5 (95% CI: 55.9-63.1) and 91.9% (95% CI: 90.1-93.7), respectively. Preoperative congestive heart failure (p = 0.04) and left main coronary artery disease (p = 0.0095) were predictors of major adverse cardiac and cerebrovascular events. Conclusions: BITA grafting could be performed routinely even in women. The increased rates of early postoperative complications do not prevent excellent late outcomes

Ultrasound-guided deep-arm veins insertion of long peripheral catheters in patients with difficult venous access after cardiac surgery

Objectives To analyze success rate, dwell-time, and complications of long peripheral venous catheters (L-PVCs) inserted under ultrasound guidance. Background In difficult venous access (DVA) patients, L-PVC can represent an alternative to central or midline catheters. Methods Prospective observational study. L-PVCs were positioned in DVA patients. The outcome of the cannulation procedure and the times and reasons for catheters removal were analyzed. Results A 100% placement success rate was documented. The catheter dwell-time was 14.7 \ub1 11.1 days. Most catheters were removed at end-use in the absence of complications. The rate of catheters appropriately or inappropriately removed before completing the intravenous therapies was 27.7/1000 catheter-days. Two thrombophlebitis (1.91/1000 catheter-days) and 1 catheter-related bloodstream infection (0.96/1000 catheter-days) occurred. Conclusions L-PVC could be a viable solution in DVA patients, as it may reduce the need for multiple vein punctures, patients' discomfort, and nursing workload. A better adherence to catheter management recommendations should further reduce complications

Tunnelling a midline catheter: When the traffic light shifts from yellow to green

Introduction: A safe, largely used practice for difficult venous access patients is positioning a catheter in deeper veins under ultrasound guide. However, the risk of complications is increased when there is a high catheter-to-vein ratio or when the insertion site is in a zone with particular anatomical/physiological characteristics. Case description: A 60-year-old woman admitted to a post-operative intensive care unit after cardiac surgery had a complicated post-operative course. After the removal of a central venous catheter, it was necessary to insert a midline catheter. A complete ultrasound evaluation showed that only the axillary vein was suitable for direct cannulation. To avoid creating an exit site in the axillary cavity, the decision was made to tunnel the catheter to locate an exit site in a safer position. A guidewire was introduced through a needle in the axillary vein. A tunnel was created using a subcutaneous injection of lidocaine. A 14 G/13.3 cm peripheral venous catheter was inserted in the subcutaneous tract. A 4 Fr/20 cm catheter was introduced through the peripheral venous catheter and moved to the axillary vein through the previously inserted sheath. No acute complications occurred. The catheter was accessed several times a day during the period following its insertion to infuse drugs and take blood samples. It was removed 50 days after its placement because it was no longer needed. No symptomatic thrombosis or infections occurred. Conclusion: The placement of the tunnelled midline catheter is shown to be a safe and effective way to ensure vascular access for almost 2 months

Methylprednisolone infusion for life-threatening H1N1-virus infection

Background: During winter 2009 we treated with prolonged corticosteroid infusion eight consecutive patients affected by H1N1-virus infection and severe pneumonia. The most severe patient was a previously healthy 30-year-old man admitted to hospital because of bilateral pneumonia and severe acute respiratory failure. Method: H1N1-virus infection was detected by broncho-alveolar lavage performed on day 1. After some days following admission the patient was still in a life-threatening state, not responding to oseltamivir, protective mechanical ventilation and veno-arterial extracorporeal membrane oxygenation (ECMO). Results: The addition of methylprednisolone infusion at a stress dose (1 mg/kg/24 h) as rescue therapy significantly and rapidly improved the clinical condition. Weaning from ECMO and invasive mechanical ventilation was possible within a relatively few days. Conclusion: According to the literature reports more than 34% of H1N1-virus severe infections were treated with corticosteroids. This report and our experience may suggest a possible life-saving use of corticosteroids at a stress dose in severely ill patients with an H1N1-virus infection that is not responding to the most advanced treatments

Urgent Coronary Revascularization with Bilateral Internal Thoracic Artery Grafting: Is the Risk Justified?

Background\u2003The frequent need of immediate institution of cardiopulmonary bypass because of ischemia and increased risk of bleeding and longer duration of surgery limit the use of bilateral internal thoracic artery (BITA) grafting in urgency. Patients and Methods\u2003Of 4,525 consecutive patients with multivessel coronary artery disease who underwent isolated coronary bypass surgery at the authors' institution (1999-September 2015), 121 (2.7%) patients had an operation before the beginning of the next working day after decision to operate, which is the definition for emergency according to the European System for Cardiac Operative Risk Evaluation II. BITA and single internal thoracic artery (SITA) grafting were used in 52 and 46 of these patients, respectively; venous grafts alone were used in the remaining cases. BITA and SITA patients were compared as risk profiles, operative data, and outcomes. A propensity score (PS)-matched analysis was also performed. Results\u2003Between BITA and SITA patients, there was no significant difference as hospital mortality, both in the overall (3.8 vs. 6.5%; p\u2009=\u20090.66) and the PS-matched series (0 vs. 4.3%; p\u2009=\u20091). Among the postoperative complications, only bleeding (but not blood transfusion nor mediastinal re-exploration) was increased both in the overall (p\u2009=\u20090.037) and the PS-matched series of BITA patients (p\u2009=\u20090.092); duration of surgery was increased but not quite significantly (p\u2009=\u20090.12). Freedom from cardiac and cerebrovascular deaths, and major adverse cardiac and cerebrovascular events were higher in PS-matched BITA patients, even though not quite significantly (p\u2009=\u20090.11 for both). Conclusion\u2003BITA grafting may be performed even in urgency. With respect to SITA grafting, hospital mortality and postoperative complications other than bleeding are not increased; late outcomes seem to be better

Routine use of bilateral internal thoracic artery grafts for left-sided myocardial revascularization in insulin-dependent diabetic patients: early and long-term outcomes

Despite encouraging late outcomes, the use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization in diabetic patients remains controversial because of an increased risk of sternal complications. In the present study, early and long-term outcomes of the routine use of left-sided BITA grafting in insulin-dependent diabetic patients were reviewed retrospectively

Bilateral internal thoracic artery grafting in octogenarians: where are the benefits?

The use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization is usually discouraged in the very elderly because of increased risk of perioperative complications. The aim of the study was to analyze early and late outcomes of BITA grafting in octogenarians. From January 1999 throughout February 2014, 236 consecutive octogenarians with multivessel coronary artery disease underwent primary isolated coronary bypass surgery at the authors' institution. Six of these patients underwent emergency surgery and were excluded from this retrospective study; consequently, 135 BITA patients were compared with 95 single internal thoracic artery (SITA) patients according to early and late outcomes. Between BITA and SITA patients, there was no significant difference in the operative risk (EuroSCORE II: 8\ua0\ub1\ua07.7 vs. 7.6\ua0\ub1\ua06.1\ua0%, p\ua0=\ua00.65). There was a lower aortic manipulation in BITA patients. Hospital mortality (3 vs. 4.2\ua0%, p\ua0=\ua00.44) and perioperative complications were similar except that only BITA patients experienced sternal wound infection (5.2\ua0%, p\ua0=\ua00.022). The mean follow-up was 4.7\ua0\ub1\ua03.3\ua0years. There were no differences between the two groups in overall survival (p\ua0=\ua00.79), freedom from cardiac and cerebrovascular deaths (p\ua0=\ua00.73), major adverse cardiac and cerebrovascular events (p\ua0=\ua00.63) and heart failure hospital readmission (p\ua0=\ua00.64). Predictors of decreased late survival were diabetes (p\ua0=\ua00.0062) and congestive heart failure (p\ua0=\ua00.0004). BITA grafting can be routinely used in octogenarians with atherosclerotic ascending aorta without an increase in hospital mortality or major adverse cardiac and cerebrovascular complications. However, there is an increased risk of sternal wound infection without a demonstrable long-term benefit

Predictors of immediate and long-term outcomes of coronary bypass surgery in patients with left ventricular dysfunction

Despite encouraging improvements, outcomes of coronary artery bypass grafting (CABG) in the presence of left ventricular (LV) dysfunction remain poor. In the present study, the authors' experience on this subject was reviewed to establish the predictors of immediate and long-term results of surgery. Out of 4383 consecutive patients with multivessel coronary artery disease who underwent primary isolated CABG at the authors' institution from January 1999 throughout September 2014, 300 patients (mean age 66.1\ua0\ub1\ua09.6\ua0years) suffered preoperatively from LV dysfunction (defined as LV ejection fraction 6435\ua0%). The mean expected operative risk (EuroSCORE II) was 10.3\ua0\ub1\ua013\ua0%. Hospital deaths and perioperative complications were analyzed retrospectively. Outcomes were evaluated during a mean follow-up of 6.2\ua0\ub1\ua04\ua0years. None, one or both internal thoracic arteries (ITAs) were used in 6.3, 29 and 64.7\ua0% of cases, respectively. There were 16 (5.3\ua0%) hospital deaths. Prolonged invasive ventilation (17.7\ua0%), acute kidney injury (14.7\ua0%) and multiple blood transfusion (21.3\ua0%) were the most frequent major postoperative complications. The 10-year non-parametric estimates of freedom from all-cause death, cardiac death, and major adverse cardiac and cerebrovascular events (MACCEs) were 47.8 [95\ua0% confidence interval (CI) 44.1-51.5], 65.3 (95\ua0% CI 61.4-69.2), and 42.3\ua0% (95\ua0% CI 38.3-46.3), respectively. Shared predictors of decreased late survival and MACCEs were old age (P\ua0<\ua00.04), chronic lung disease (P\ua0<\ua00.01), chronic dialysis (P\ua0<\ua00.0001) and extracardiac arteriopathy (P\ua0<\ua00.045). After adjustment for corresponding risk factors, freedom from cardiac death was higher when both ITAs were used but only for patients with significant increase of LV ejection fraction early after surgery (P\ua0=\ua00.04). In patients with LV dysfunction, CABG may be performed with acceptable hospital mortality and long-term survival. Late outcomes depend mainly on preoperative characteristics of the patients. The use of both ITAs for myocardial revascularization may give long-term survival benefits but only for patients whose LV function improves significantly early after surgery

A risk factor analysis for in-hospital mortality after surgery for infective endocarditis and a proposal of a new predictive scoring system

Risk stratification is of utmost importance for patients with infective endocarditis (IE) who need surgery. However, for these critically ill patients, aspecific scoring systems are used to predict the risk of death after surgery. The aim of this study was both to analyze the risk factors for in-hospital death, which complicates surgery for IE and to create a mortality risk score based on the results of this analysis