Impact of malnutrition on postoperative delirium development after on pump coronary artery bypass grafting

Background & aims: Even though malnutrition is frequently observed in cardiac population outcome data after cardiac surgery in malnourished patients is very rare. No thorough research was done concerning the impact of malnutrition on neuropsychological outcomes after cardiac surgery. The aim of our study was to analyze the incidence of postoperative delirium development in malnourished patients undergoing on pump bypass grafting. Methods: We performed a cohort study of adults admitted to Vilnius University Hospital Santariskiu Clinics for elective coronary artery bypass grafting. The nutritional status of the patients was assessed by Nutritional Risk Screening 2002 (NRS-2002) questionnaire the day before surgery. Patients were considered as having no risk of malnutrition when NRS-2002 score was less than 3 and at risk of malnutrition when NRS-2002 score was ≥3. During ICU stay patients were screened for postoperative delirium development using the CAM-ICU method. and divided into two groups: delirium and non delirium. The statistical analysis was preformed to evaluate the differences between the two independent groups. The logistic regression model was used to evaluate the potential preoperative and intraoperative risk factors of postoperative delirium. Results: Ninety-nine patients were enrolled in the study. Preoperative risk of malnutrition was detected in 24 % (n = 24) of the patients. The incidence of early postoperative delirium in overall study population was 8.0 % (n = 8). The incidence of the patients at risk of malnutrition was significantly higher in the delirium group (5 (62.5 %) vs 19 (20.9 %), p <0.0191). In multivariate logistic regression analysis risk of malnutrition defined by NRS 2002 was an independent preoperative and intraoperative risk factor of postoperative delirium after coronary artery bypass grafting (OR: 6.316, 95 % CI: 1.384-28.819 p = 0.0173). Conclusions: Preoperative malnutrition is common in patients undergoing elective coronary artery bypass grafting. Nutrition deprivation is associated with early postoperative delirium after on pump coronary artery bypass grafting

Milrinono ir intraaortinės baliolinės kontrapulsacijos įtaka didelės rizikos miokardo revaskuliarizavimo operacijų rezultatams

Įvadas / tikslas Profilaktinis milrinono skyrimas gerina širdies veiklą, sumažina pooperacinės intraaortinės balioninės kontrapulsacijos (IABK) poreikį. Keletas atliktų tyrimų patvirtino priešoperacinės IABK naudą išgyvenamumui. Pagrindinis mūsų tyrimo tikslas buvo palyginti IABK arba milrinono skyrimo didelės rizikos pacientams, kuriems atliekamos miokardo revaskuliarizacijos operacijos, įtaką hemodinamikos rodikliams ir pooperaciniam sergamumui. Ligoniai ir metodai Tai retrospektyvioji 29-ių didelės rizikos pacientų, kuriems atliktos miokardo revaskuliarizacijos operacijos per vienerius metus tame pačiame centre, duomenų analizė. Pacientai, kurie operuoti be dirbtinės kraujo apytakos, į tyrimą neįtraukti. Milrinonu gydyta 14 pacientų, intraaortine balionine kontrapulsacija – 15 pacientų. Abiejų grupių pacientų hemodinamika stebėta įkišus Swan-Ganz kateterį. Buvo vertinami priešoperaciniai rizikos veiksniai, operaciniai duomenys, pooperacinis sergamumas ir hemodinamikos rodikliai. Rezultatai Palyginus grupes prieš operaciją, jos statistiškai patikimai nesiskyrė pagal amžių (64 ± 10 vs 66 ± 9), lyčių pasiskirstymą (vyrai/moterys, 12/3 vs 11/3) ar operacinę riziką, vertinamą Euroscore balais (5,5 ± 3,8 vs 4,9 ± 2, p=0,69). Kairiojo skilvelio išvaromoji frakcija buvo mažesnė pacientų, gydytų taikant intraaortinę kontrapulsaciją (35 ± 5 proc. vs 39 ± 5 proc., p=0,03). Palygintas operacinis ir pooperacinis minutinis širdies tūris. Milrinonu gydytiems pacientams reikėjo didesnių dozių norepinefrino pirmosiomis pooperacinėmis valandomis (0 val. 0,07 ± 0,06 vs 0,01 ± 0,02 μg/kg/min., p=0,01, ir po 4 val. 0,08 ± 0,05 vs 0,03 ± 0,02 μg/kg/min., p=0,01). Pooperacinės komplikacijos tarp grupių statistiškai patikimai nesiskyrė: širdies nepakankamumas (29 proc. vs 33 proc.), insultas (7 proc. vs 7 proc.), inkstų funkcijos sutrikimas (7 proc. vs 13 proc.), delyras (22 proc. vs 13 proc.). Gydymo trukmė Reanimacijos ir intensyviosios terapijos skyriuje buvo panaši (6 ± 7 vs 4 ± 2 dienos). Keturiems (29 proc.) milrinono grupės pacientams prireikė IABK širdies nepakankamumui gydyti pooperaciniu laikotarpiu. Išvados Profilaktinė IABK dažniau skirta pacientams, kurių kairiojo skilvelio išvaromoji frakcija mažesnė. Priešoperacinis milrinono ar IABK skyrimas turėjo panašią įtaką pacientų širdies veiklos gerinimui. Abiejų grupių ligonių pooperacinis sergamumas nesiskyrė. Tačiau 29 proc. milrinonu gydytų pacientų prireikė intraaortinės kontrapulsacijos pooperaciniu laikotarpiu. Reikšminiai žodžiai: miokardo revaskuliarizavimas, intraaortinė balioninė kontrapulsacija, milrinonas Preemptive milrinone versus intraaortic balloon pump in high risk coronary artery bypass grafting surgery Background / objective Pre-emptive milrinone infusion improves cardiac performance. The decrease of postoperative IABP insertions was possibly related with the increased use of phosphodiesterase inhibitors. The survival benefit of preoperative treatment with IABP was shown in several studies. The aim of our study was to compare the impact of the prophylactic administration of milrinone or IABP on haemodynamics and postoperative morbidity in high-risk patients undergoing on-pump CABG surgery. Patients and methods The retrospective analysis involved 29 elective high-risk CABG patients operated on during one year period in a single institution. Patients operated off-pump were excluded from the study. Pretreatment with milrinone was performed in 14 patients while prophylactic IABP was used in 15 cases. A Swan–Ganz catheter was inserted for haemodynamic monitoring in all cases. Preoperative risk factors, intraoperative variables, postoperative morbidity and haemodynamics were compared between the groups. Results Preoperative patient profile was comparable between the groups. There were no difference in patient age (64 ± 10 vs 66 ± 9), male / female ratio (12/3 vs 11/3) or preoperative Euroscore (5.5 ± 3.8 vs 4.9 ± 2, p = 0.69). However, the left ventricle ejection fraction was lower in the IABP-treated patient group (35 ± 5 perc. vs 39 ± 5 perc., p = 0.03). Inrtaoperative and postoperative cardiac output was comparable between the groups. Milrinone-treated patients had higher requirement of norepinephrine on ICU arrival (0.07 ± 0.06 vs 0.01 ± 0.02 μg/kg/min, p = 0.01) and 4 hours following surgery (0.08 ± 0.05 vs 0.03 ± 0.02 μg/kg/min, p = 0.01). No differences were found in the rate of heart failure (29 perc. vs 33 perc.), stroke (7 perc. vs 7 perc.), renal failure (7 perc. vs 13 perc.), postoperative delyrium (22 perc. vs 13 perc.) or ICU stay duration ( 6 ± 7 vs 4 ± 2 days). Four of 14 (29 perc.) patients needed IABP insertion in the postoperative period due to heart failure progression. Conclusions Prophylactic treatment with IABP was used in patients with a lower left ventricle ejection fraction. Pre-emptive milrinone infusion and IABP insertion before surgery had a similar impact on the improvement of cardiac performance during on-pump CABG surgery. No difference in postoperative morbidity was found between the groups of patients. However, almost 29 perc. of patients treated with milrinone needed IABP insertion in the postoperative period. Key words: coronary revascularization, intraaortic balloon counterpulsation, milrinon

Prevalence, assessment and effects of malnutrition on early postoperative complications in cardiac surgery

Malnutrition (MN) and its assessment is still a major clinical and scientific problem. The purpose of the research is to identify the impact of preoperative MN on early postoperative complications in cardiac surgery. After analysing the data of 712 patients gathered during the study, the following conclusions were made: a phase angle (PA) determined by bioelectrical impedance analysis (BIA) is an indicator of nutritional status with the cut-off value of <15 percentile being a marker of MN; the most accurate screening tool to detect MN risks in cardiac surgery patients is Nutritional Risk Screening 2002 (NRS-2002); MN detected by BIA-derived PA was diagnosed for 17,8 % of low-risk cardiac surgery patients and 22,9 % overall and is more frequently diagnosed than low fat-free mass index (FFMI) and body mass index (BMI); preoperative malnutrition is associated with structural and functional affection of the heart, co-morbidities, appetite, mobility and immune system’s condition and the development of early postoperative complications increasing the odds of postoperative morbidity by 2.5 times and length of hospital stay, but it has no effects on postoperative mortality.Practical recommendations: preoperative assessment of nutritional status for cardiac surgery patients is recommended using the PA or Nutritional Risk Screening 2002 (NRS-2002) with special attention payed to patients with the following risk factors for malnutrition: heart failure in functional NYHA class IV, faulty heart valves (particularly, mitral valve insufficiency ≥II°), preoperative renal failure, low BMI or loss of weight, lack of appetite, impaired mobility, anaemia and the elevated C-reactive protein level; after diagnosing malnutrition or nutritional risk to inform a clinical nutrition team and/or establish protocols for nutritional monitoring and dietary adjustments

Incidence and Risk Factors of Early Delirium after Cardiac Surgery

Introduction. The aim of our study was to identify the incidence and risk factors of delirium after cardiac surgery implementing Intensive Care Delirium Screening Checklist (ICDSC). Material and Methods. 87 patients, undergoing cardiac surgery at Vilnius University hospital, were prospectively monitored for postoperative delirium development, during intensive care unit stay. Results. The incidence of postoperative delirium was 13.30%. No statistically relevant preoperative predictors of delirium were found. The duration of surgery was significantly longer in delirium group ( versus hours, ). Patients in delirium group more often had blood product transfusions (1.50 (± 1.57) versus 0.49 (± 0.91) ) and had a higher incidence of low cardiac output syndrome (33.30% versus 3.00%, ); they were significantly longer mechanically ventilated ( versus 8.78 ± 4.77 ()) hours (OR = 1.15 ()) and had twice longer ICU stay ( versus 2.60 ± 1.10 ()) days (OR = 1.91 ()). Conclusions. The incidence of delirium after cardiac surgery was 13.3%. Independent predictors of delirium were duration of postoperative mechanical ventilation and intensive care unit stay

Use of ringer’s lactate solution does not eliminate the risk of strong ion difference related metabolic acidosis following on pump cardiac surgery

Perioperative use of Normal Saline is linked to hyper- chloraemic or Strong Ion Difference (SID) related acido- sis. It has been suggested, that this can be avoided by the use of balanced crystalloid solutions including Ringer’s Lactate (RL). Significant changes in SID were noted pre- viously in cardiac surgery, however recent publication disproved the link between SID and hydrogen ion con- centratio

Ūminio inkstų funkcijos pažeidimo vertinimas širdies chirurgijoje: glomerulų filtracijos greičio ir liesosios kūno masės reikšmė

Background: eGFR (estimated glomerular filtration rate) formulas may be inaccurate in overweight cardiac surgery patients, overestimating the kidney reserve. The aim of this study was to modify the eGFR formulas and to determine whether the modified eGFR is a more accurate predictor of acute kidney injury (AKI). Materials and methods: The patients were assigned into 4 BMI groups as follows: normal weight (18.5–25 kg/m2), pre-obesity (25–30 kg/m2), class I obese (30–35 kg/m2), class II and III obese (≥35 kg/m2). Cockcroft–Gault (CG) eGFR formula was modified by using the fat-free mass (FFM) derived from bioelectrical impedance. ROC-AUC curves were analyzed to identify the accuracy of the eGFR formulas (CG, CG modified with FFM, Mayo Clinic Quadratic equation, CKD-EPI, MDRD) to predict the AKI in each group. Results: Although all of the used equations showed similar predictive power in the normal weight and overweight category, Mayo formula had the highest AUC in predicting the occurrence of AKI (ROC-AUC 0.717 and 0.624, p35 kg/m2). Conclusions: eGFR is a poor predictor of AKI, especially in the obese patients undergoing cardiac surgery. The only equation with a moderate predictive power for the class I obese patients was the CG formula modified with the fat-free mass

Comparison of mortality risk evaluation tools efficacy in critically ill COVID-19 patients

Background: As the COVID-19 pandemic continues, the number of patients admitted to the intensive care unit (ICU) is still increasing. The aim of our article is to estimate which of the conventional ICU mortality risk scores is the most accurate at predicting mortality in COVID-19 patients and to determine how these scores can be used in combination with the 4C Mortality Score. Methods: This was a retrospective study of critically ill COVID-19 patients treated in tertiary reference COVID-19 hospitals during the year 2020. The 4C Mortality Score was calculated upon admission to the hospital. The Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II, and Sequential Organ Failure Assessment (SOFA) scores were calculated upon admission to the ICU. Patients were divided into two groups: ICU survivors and ICU non-survivors. Results: A total of 249 patients were included in the study, of which 63.1% were male. The average age of all patients was 61.32 ± 13.3 years. The all-cause ICU mortality ratio was 41.4% (n = 103). To determine the accuracy of the ICU mortality risk scores a ROC-AUC analysis was performed. The most accurate scale was the APACHE II, with an AUC value of 0.772 (95% CI 0.714–0.830; p < 0.001). All of the ICU risk scores and 4C Mortality Score were significant mortality predictors in the univariate regression analysis. The multivariate regression analysis was completed to elucidate which of the scores can be used in combination with the independent predictive value. In the final model, the APACHE II and 4C Mortality Score prevailed. For each point increase in the APACHE II, mortality risk increased by 1.155 (OR 1.155, 95% CI 1.085–1.229; p < 0.001), and for each point increase in the 4C Mortality Score, mortality risk increased by 1.191 (OR 1.191, 95% CI 1.086–1.306; p < 0.001), demonstrating the best overall calibration of the model. Conclusions: The study demonstrated that the APACHE II had the best discrimination of mortality in ICU patients. Both the APACHE II and 4C Mortality Score independently predict mortality risk and can be used concomitantly

Predictors of long-term HRQOL following cardiac surgery: a 5-year follow-up study

Background The study aimed to evaluate the long-term change of health-related quality of life (HRQOL) and to identify predictors of HRQOL 5 years after cardiac surgery. Methods Consecutive adult patients, undergoing elective cardiac surgery were enrolled in the study. HRQOL was measured using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) questionnaire before and 5-years after cardiac surgery. A multivariate latent change modeling approach was used for data analysis. Results 210 participants (30.5% female) were reached at 5-year follow-up and included in final data analysis. The study revealed, after controlling for gender effects, a significant long-term positive change, in physical functioning (PF, Mslope = 19.79, p < 0.001), social functioning (SF, Mslope = 17.27, p < 0.001), vitality (VT, Mslope = 6.309, p < 0.001) and mental health (MH, Mslope = 8.40, p < .001) in the total sample. Lower education was associated with an increase in PF (Mslope = 24.09, p < 0.001) and VT (Mslope = 8.39, p < 0.001), more complicated surgery (other than the coronary artery bypass graft (CABG) predicted increase in general health (GH, Mslope = 6.76, p = 0.005). Arrhythmia was a significant predictor for lower pre- and post-operative VT and SF. Conclusions Overall HRQOL in our sample improved from baseline to five years postoperatively. Further studies including larger patient groups are needed to confirm these findings