Association of positive fluid balance and cardiovascular complications after thoracotomy for noncancer lesions

Tanyong Pipanmekaporn,1,2 Yodying Punjasawadwong,2 Somrat Charuluxananan,3 Worawut Lapisatepun,2 Pavena Bunburaphong,3 Somchareon Saeteng41Clinical Epidemiology Program, 2Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; 3Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; 4Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, ThailandObjective: The purpose of this study was to explore the influence of positive fluid balance on cardiovascular complications after thoracotomy for noncancer lesions.Methods: After approval from an institutional review board, a retrospective cohort study was conducted. All consecutive patients undergoing thoracotomy between January 1, 2005 and December 31, 2011 in a single medical center were recruited. The primary outcome of the study was the incidence of cardiovascular complications, which were defined as cardiac arrhythmia, cardiac arrest, heart failure, myocardial ischemia, and pulmonary embolism. Univariable and multivariable risk regression analyses were used to evaluate the association between positive fluid balance and cardiovascular complications.Results: A total of 720 patients were included in this study. The incidence of cardiovascular complications after thoracotomy for noncancer lesions was 6.7% (48 of 720). Patients with positive fluid balance >2,000 mL had a significantly higher incidence of cardiovascular complications than those with positive fluid balance ≤2,000 mL (22.2% versus 7.0%, P=0.005). Cardiac arrhythmias were the most common complication. Univariable risk regression showed that positive fluid balance >2,000 mL was a significant risk factor (risk ratio =3.15, 95% confident interval [CI] =1.44–6.90, P-value =0.004). After adjustment for all potential confounding variables during multivariable risk regression analysis, positive fluid balance >2,000 mL remained a strong risk factor for cardiovascular complications (risk ratio =2.18, 95% CI =1.36–3.51, P-value =0.001). Causes of positive fluid balance >2,000 mL included excessive hemorrhage (48%), hypotension without excessive hemorrhage (29.6%), and liberal fluid administration (22.4%).Conclusion: Positive fluid balance was a significant risk factor for cardiovascular complications. Strategies to minimize positive fluid balance during surgery for patients at high risk of cardiovascular complications include preparing adequate blood and blood products, considering appropriate hemoglobin level as a transfusion trigger, and adjusting the optimal dose of local anesthetic for intraoperative thoracic epidural analgesia.Keywords: cardiac arrhythmias, cardiac arrest, heart failure, myocardial ischemia, hemorrhag

Validity and reliability of the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)

Tanyong Pipanmekaporn,1 Nahathai Wongpakaran,2 Sirirat Mueankwan,3 Piyawat Dendumrongkul,2 Kaweesak Chittawatanarat,3 Nantiya Khongpheng,3 Nongnut Duangsoy31Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; 2Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; 3Division of Surgical Critical Care and Trauma, Department of Surgery, Chiang Mai University Hospital, Chiang Mai, ThailandPurpose: The purpose of this study was to determine the validity and reliability of the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), when compared to the diagnoses made by delirium experts.Patients and methods: This was a cross-sectional study conducted in both surgical intensive care and subintensive care units in Thailand between February–June 2011. Seventy patients aged 60 years or older who had been admitted to the units were enrolled into the study within the first 48 hours of admission. Each patient was randomly assessed as to whether they had delirium by a nurse using the Thai version of the CAM-ICU algorithm (Thai CAM-ICU) or by a delirium expert using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.Results: The prevalence of delirium was found to be 18.6% (n=13) by the delirium experts. The sensitivity of the Thai CAM-ICU’s algorithms was found to be 92.3% (95% confidence interval [CI] =64.0%-99.8%), while the specificity was 94.7% (95% CI =85.4%-98.9%). The instrument displayed good interrater reliability (Cohen’s κ=0.81; 95% CI =0.64-0.99). The time taken to complete the Thai CAM-ICU was 1 minute (interquatile range, 1-2 minutes).Conclusion: The Thai CAM-ICU demonstrated good validity, reliability, and ease of use when diagnosing delirium in a surgical intensive care unit setting. The use of this diagnostic tool should be encouraged for daily, routine use, so as to promote the early detection of delirium and its rapid treatment.Keywords: delirium, surgical intensive care unit, Confusion Assessment Method for the ­intensive care unit, validity, reliabilit