Post-Bypass Dexmedetomidine Use and Postoperative Acute Kidney Injury in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass

Background

And Objectives: The aim of this retrospective investigation was to study the relationships among chronic kidney disease, acute kidney injury (AKI), and potential benefits by post-bypass dexmedetomidine use in patients undergoing cardiac surgery.

Methods

The patient data were reviewed from the institutional Society of Thoracic Surgeons National Adult Cardiac Surgery Database after IRB approval. 1,133 patients were identified and divided into two groups: those who received dexmedetomidine or those who did not during the post-bypass period. The postoperative outcomes include the incidence of AKI, any complication and all cause of mortality.

Results

Post-bypass dexmedetomidine use was associated with significantly reduced the incidence of total AKI (26.1% vs. 33.75%; adjusted OR, 0.7033; 95%CI, 0.540 to 0.916; p=0.0089). In addition, post-bypass dexmedetomidine use was more likely to reduce the incidence of AKI in these patients with preoperative normal kidney function (Stage1; 32.8% to 22.8%; p=0.0233) and mild CKD (Stage 2; 32.8% to 24.7; p=0.0003) after cardiac surgery. Post-bypass infusion of dexmedetomidine was associated with significantly reduced incidence of any complication and 30-day mortalities.

Conclusions

Post-bypass dexmedetomidine use is associated with a significant reduction in the incidence of AKI, especially mild AKI in patients with preoperative normal renal function and mild CKD undergoing cardiac surgery.     

ICU 应用IABP 治疗心脏外科术后患者的护理临床效应

目的:探讨应用主动脉内球囊反搏术(IABP)治疗心脏外科术后患者的护理方法与临床效果。方法:回顾性分析总结我院2008年6月～2009年12月收治的25例心脏外科术后应用主动脉内球囊反搏术患者的临床资料。结果:本组患者25例患者均无并发症发生,其中23例症状改善,2例病情恶化。护士应熟练掌握IABP机的工作原理及报警项目;应重视基础护理,密切监测生命体征及各项检查结果;早期观察和预防并发症发生。结论:在临床护理中,应组织护士学习IABP相关知识,使护士熟要掌握相关的临床护理技术,从而确保IABP良好的的治疗效果。     

心脏手术围术期的血糖波动与术后急性肾损伤

心脏手术围术期高血糖与术后并发症的关系已经得到大量研究,高血糖与术后肾功能损伤的关系存在着不同的观点,但是对于围术期血糖水平的波动与术后肾损伤的研究甚少。本文概述了心脏手术围术期血糖水平波动对术后肾功能损伤的影响,简要分析其损伤机制。研究表明,多种因素可以增加围术期血糖水平的波动,对多项围术期高血糖是否增加术后肾功能损伤的研究争议分析发现,围术期血糖水平的波动对术后肾损伤的发生起到潜在作用,其损伤机制主要在于引起氧化应激和血流动力学的波动。相信围术期血糖水平的波动对术后肾功能损伤的影响的进一步的研究,将有助于降低心脏手术后急性肾损伤患者术后并发症的发生率。     

Measurement of Cardiac Index by Transpulmonary Thermodilution Using an Implanted Central Venous Access Port: A Prospective Study in Patients Scheduled for Oncologic High-Risk Surgery

Background

Transpulmonary thermodilution allows the measurement of cardiac index for high risk surgical patients. Oncologic patients often have a central venous access (port-a-catheter) for chronic treatment. The validity of the measurement by a port-a-catheter of the absolute cardiac index and the detection of changes in cardiac index induced by fluid challenge are unknown.

Methods

We conducted a monocentric prospective study. 27 patients were enrolled. 250 ml colloid volume expansions for fluid challenge were performed during ovarian cytoreductive surgery. The volume expansion-induced changes in cardiac index measured by transpulmonary thermodilution by a central venous access (CIcvc) and by a port-a-catheter (CIport) were recorded.

Results

23 patients were analyzed with 123 pairs of measurements. Using a Bland and Altman for repeated measurements, the bias (lower and upper limits of agreement) between CIport and CIcvc was 0.14 (−0.59 to 0.88) L/min/m². The percentage error was 22%. The concordance between the changes in CIport and CIcvc observed during volume expansion was 92% with an r = 0.7 (with exclusion zone). No complications (included sepsis) were observed during the follow up period.

Conclusions

The transpulmonary thermodilution by a port-a-catheter is reliable for absolute values estimation of cardiac index and for measurement of the variation after fluid challenge.

Trial Registration

clinicaltrials.gov NCT02063009     

Electrocardiographic Screening for Prolonged QT Interval to Reduce Sudden Cardiac Death in Psychiatric Patients: A Cost-Effectiveness Analysis

ImportanceSudden cardiac death is a leading cause of mortality in psychiatric patients. Long QT (LQT) is common in this population and predisposes to Torsades-de-Pointes (TdP) and subsequent mortality.ObjectiveTo estimate the cost-effectiveness of electrocardiographic screening to detect LQT in psychiatric inpatients.ResultsIn the base-case scenario, the numbers of patients needed to screen were 1128 and 2817 to avoid one TdP and one death, respectively. The ICER of systematic ECG screening was $8644 (95%CI, 3144-82 498) per QALY. The probability of cost-effectiveness was 96% at a willingness-to-pay of $50 000 for one QALY. In sensitivity analyses, results were sensitive to the case-fatality of TdP episodes and to the TdP reduction following the diagnosis of LQT.

Conclusion and Relevance

In psychiatric hospitals, performing systematic ECG screening at admission help reduce the number of sudden cardiac deaths in a cost-effective fashion.     

Statins Do Not Reduce Atrial Fibrillation After Cardiac Valvular Surgery: A Single Centre Observational Study

Introduction

Statins may theoretically reduce postoperative atrial fibrillation (AF) in patients after cardiac valvular surgery due to preservation of endothelial function and anti-ischaemic, anti-inflammatory and anti-remodelling effects.

Methods

Two hundred seventy-two patients who underwent cardiac workup and subsequently cardiac valvular surgery without AF and concomitant coronary artery bypass grafting (CABG) at our hospital were selected. Preoperative drug use and postoperative AF were recorded. AF was defined as any episode of AF longer than 10 s. In addition, results from echocardiography and blood samples were retrieved.

Results

Baseline characteristics were as follows: mean age was 65 ± 11 years, 142 (52%) patients were male, 189 (70%) had undergone aortic valve surgery and the mean left ventricular ejection fraction was 57 ± 12%. Statins were used by 79 patients (29%). Statin users, more often, had a prior percutaneous coronary intervention (25% vs 9%, p < 0.001) or CABG (24% vs 4%, p < 0.001), diabetes mellitus (22% vs 5%, p < 0.001) and more often used β-blockers (51% vs 24%, p < 0.001). Patients in the non-statin group more often had surgery on more than one valve (10% vs 3%, p = 0.043) and had a higher cholesterol level (222 ± 48 vs 190 ± 43 mg/dl, p < 0.001). Postoperative AF occurred in 54% (43/79) of the patients with and in 55% (106/193) of the patients without statins (p = 0.941). There was also no difference in the timing of onset of AF or duration of hospital stay.

Conclusion

In this observational study, statin use was not associated with a reduced incidence of AF in patients after cardiac valvular surgery.     

Implementation of a Bundle of Care to Reduce Surgical Site Infections in Patients Undergoing Vascular Surgery

Background

Surgical site infections (SSI’s) are associated with severe morbidity, mortality and increased health care costs in vascular surgery.

Objective

To implement a bundle of care in vascular surgery and measure the effects on the overall and deep-SSI’s rates.

Design

Prospective, quasi-experimental, cohort study.

Methods

A prospective surveillance for SSI’s after vascular surgery was performed in the Amphia hospital in Breda, from 2009 through 2011. A bundle developed by the Dutch hospital patient safety program (DHPSP) was introduced in 2009. The elements of the bundle were (1) perioperative normothermia, (2) hair removal before surgery, (3) the use of perioperative antibiotic prophylaxis and (4) discipline in the operating room. Bundle compliance was measured every 3 months in a random sample of surgical procedures and this was used for feedback.

Results

Bundle compliance improved significantly from an average of 10% in 2009 to 60% in 2011. In total, 720 vascular procedures were performed during the study period and 75 (10.4%) SSI were observed. Deep SSI occurred in 25 (3.5%) patients. Patients with SSI’s (28,5±29.3 vs 10.8±11.3, p<0.001) and deep-SSI’s (48.3±39.4 vs 11.4±11.8, p<0.001) had a significantly longer length of hospital stay after surgery than patients without an infection. A significantly higher mortality was observed in patients who developed a deep SSI (Adjusted OR: 2.96, 95% confidence interval 1.32–6.63). Multivariate analysis showed a significant and independent decrease of the SSI-rate over time that paralleled the introduction of the bundle. The SSI-rate was 51% lower in 2011 compared to 2009.

Conclusion

The implementation of the bundle was associated with improved compliance over time and a 51% reduction of the SSI-rate in vascular procedures. The bundle did not require expensive or potentially harmful interventions and is therefore an important tool to improve patient safety and reduce SSI’s in patients undergoing vascular surgery.     

Surgery Issue: Tissue-Engineered Blood Vessels in Pediatric Cardiac Surgery

Pediatric cardiovascular surgeons often encounter patients requiring surgical intervention utilizing foreign materials to repair complex lesions. However, the materials that are commonly used lack growth potential, and long-term results have revealed several material-related failures, such as stenosis, thromboembolization, calcium deposition, and risk of infection. To solve these problems, in particular for children who require the implantation of dynamic material with growth potential, we sought to develop optimal filling materials with biocompatibility and growth potential. Previously, we reported the advantages of tissue-engineered vascular autografts (TEVAs) in animal models and in human clinical applications utilizing autologous cells and biodegradable scaffolds. The key benefits from utilizing such scaffolds is that they degrade in vivo, thereby avoiding the long-term presence of foreign ma-terials, and the seeded cells proliferate and differentiate to construct new tissue.     

The Influence of Perioperative Dexmedetomidine on Patients Undergoing Cardiac Surgery: A Meta-Analysis

BackgroundThe use of dexmedetomidine may have benefits on the clinical outcomes of cardiac surgery. We conducted a meta-analysis comparing the postoperative complications in patients undergoing cardiac surgery with dexmedetomidine versus other perioperative medications to determine the influence of perioperative dexmedetomidine on cardiac surgery patients.MethodsRandomized or quasi-randomized controlled trials comparing outcomes in patients who underwent cardiac surgery with dexmedetomidine, another medication, or a placebo were retrieved from EMBASE, PubMed, the Cochrane Library, and Science Citation Index.ResultsA total of 1702 patients in 14 studies met the selection criteria among 1,535 studies that fit the research strategy. Compared to other medications, dexmedetomidine has combined risk ratios of 0.28 (95% confidence interval [CI] 0.15, 0.55, P = 0.0002) for ventricular tachycardia, 0.35 (95% CI 0.20, 0.62, P = 0.0004) for postoperative delirium, 0.76 (95% CI 0.55, 1.06, P = 0.11) for atrial fibrillation, 1.08 (95% CI 0.74, 1.57, P = 0.69) for hypotension, and 2.23 (95% CI 1.36, 3.67, P = 0.001) for bradycardia. In addition, dexmedetomidine may reduce the length of intensive care unit (ICU) and hospital stay.ConclusionsThis meta-analysis revealed that the perioperative use of dexmedetomidine in patients undergoing cardiac surgery can reduce the risk of postoperative ventricular tachycardia and delirium, but may increase the risk of bradycardia. The estimates showed a decreased risk of atrial fibrillation, shorter length of ICU stay and hospitalization, and increased risk of hypotension with dexmedetomidine.     

The Significance of Post-operative Creatinine in Predicting Prognosis in Cardiac Surgery Patients

The purpose of the study is to investigate the effectiveness of serum creatinine, the most common indicator of acute kidney injury (AKI), in predicting the prognosis of critically ill patients after cardiac surgery. Also, we sought to validate the use of this biomarker in assessing the direct outcome of a clinical setting. We selected 592 patients from our hospital; the relevant information including name, disease, gender, age, EuroSCORE, length of stay (LOS), days of mechanical ventilation, days of noninvasive positive pressure ventilation, days of continuous renal replacement treatment, and mortality was recorded. Creatinine of pre-operative, 24, and 48 h post-operation specimens were analyzed. The difference in serum creatinine levels at various time points was compared using t test. Spearman correlation was used to analyze the correlation of serum creatinine to AKI and hard outcomes. Receiver-operating characteristic curves were generated, and the areas under the curves (AUCs) were compared to validate the adequacy of creatinine in predicting the post-operative AKI. The 48 h post-operative and pre-operative serum creatinine were found to be informative in predicting the outcome of patients as indicated by the t test and Spearman correlation analysis. The 48 h creatinine with AUC of 0.811 was indicated to be significantly associated with the hard outcome. However, the 24 h and pre-operative creatinine with AUCs of 0.701 and 0.658, respectively, were not adequately related to the outcomes. In conclusion, contrary to the existing belief that creatinine is not an informative parameter for the diagnosis and prognosis of AKI, we found that when measured at 48 h of cardiac surgery, serum creatinine is reflective of the outcome.     

碳酸钙沉淀法回收琼脂糖凝胶中DNA的探讨

采用碳酸钙沉淀法回收琼脂糖凝胶中的DNA,达到分离纯化目的,回收后的DNA可用于重组、PCR等研究。首先将含有目的DNA的琼脂糖凝胶用Nal溶液融解,然后加入cacl2,和NaHCO3,生成CaCO3,沉淀,DNA与cac03形成复合物,通过离心分离出沉淀复合物,利用稀酸溶解沉淀,再用无水乙醇沉降,即可回收目标DNA。利用该方法回收了质粒、毛白杨和转基因羊基因组DNA,同收率为20％～50％,0D260／OD280,为1．7～19,最大回收了21kb片段,最小回收250bp片段,回收后的DNA样品进行了PCR扩增和限制性内切酶反应,PCR可以扩增出目的片段,同时限制性内切酶可以将回收后的DNA切开,表明DNA质量良好。利用碳酸钙沉淀法可以回收琼脂糖凝胶中的DNA,此法简单、易行,较为有效。     

高级别生物安全实验室降低高致病性病毒实验生物安全防护水平的科研策略

高级别生物安全实验室的主要任务是探索高致病性病毒的致病、免疫机制,开发疫苗、药物和诊断试剂,保障人类和动物的健康.在高级别生物安全实验室内,高致病性病毒实验活动的经济成本和时间成本都是高昂的.为了安全、高效、低成本地开展科学研究,高级别生物安全实验室可采取降低高致病性病毒实验活动生物安全水平(例如生物安全四级降至二级)的科研策略,这些策略包括本科属的低致病性病毒、缺陷型病毒、病毒样颗粒、假病毒、重新编译遗传密码子和计算机辅助药物设计.     

An Effective Method to Identify Heritable Components from Multivariate Phenotypes

Multivariate phenotypes may be characterized collectively by a variety of low level traits, such as in the diagnosis of a disease that relies on multiple disease indicators. Such multivariate phenotypes are often used in genetic association studies. If highly heritable components of a multivariate phenotype can be identified, it can maximize the likelihood of finding genetic associations. Existing methods for phenotype refinement perform unsupervised cluster analysis on low-level traits and hence do not assess heritability. Existing heritable component analytics either cannot utilize general pedigrees or have to estimate the entire covariance matrix of low-level traits from limited samples, which leads to inaccurate estimates and is often computationally prohibitive. It is also difficult for these methods to exclude fixed effects from other covariates such as age, sex and race, in order to identify truly heritable components. We propose to search for a combination of low-level traits and directly maximize the heritability of this combined trait. A quadratic optimization problem is thus derived where the objective function is formulated by decomposing the traditional maximum likelihood method for estimating the heritability of a quantitative trait. The proposed approach can generate linearly-combined traits of high heritability that has been corrected for the fixed effects of covariates. The effectiveness of the proposed approach is demonstrated in simulations and by a case study of cocaine dependence. Our approach was computationally efficient and derived traits of higher heritability than those by other methods. Additional association analysis with the derived cocaine-use trait identified genetic markers that were replicated in an independent sample, further confirming the utility and advantage of the proposed approach.     

Robbery-Related Injury in Convenience Stores: Estimating Lifetime Risk and Identifying High-Risk Populations

Robbery-related injuries constitute a major risk for convenience store workers in the United States. Studies that focus on the injury outcomes associated with convenience store robbery are extremely limited in number. This is a prospective study of 1271 convenience stores in three metropolitan areas of Virginia between February 1, 1995 and September 30, 1996. The study quantifies the lifetime risk for an occupational robbery-related injury occurrence and determines the relative importance of various types of factors in the classification of high risk stores. Lifetime risk was estimated by calculating the probability in convenience stores for having one or more employee(s) sustain at least one robbery-related injury over a range of years that a store could be in operation. Results indicate that knowledge of the circumstances of the robbery are needed to maximize the identification of high risk stores. Estimated lifetime risk reaches 567 stores with an occupational robbery-related injury occurrence per 1,000 stores in operation after 45 years. This study addresses limitations of previous research by including information on clerk resistance and the number of robbers in its analysis. These two circumstantial characteristics of robbery have been previously hypothesized to be associated with robbery-related injury.     

用降钙素原和白细胞联合能预测心脏手术病人的感染

为了探讨通过结合C反应蛋白(C-reactive protein, CRP)、白细胞(leukocyte, WBC)和降钙素原(procalcitonin, PCT)来预测大批心脏病手术患者术后感染的可行性,本研究病例对照研究涉及423例接受心肺心脏搭桥手术的心脏病患者。基于在术后期间是否有严重的败血症或化脓性休克,病人被分成两组。在重症监护病房的第1天,提取用于生物测量(PCT, CRP和WBC)的血液样本,然后每天早上提取1次,直到术后第10天。研究发现,两组群体的CRP中值类似。在10 d术后期间,感染病人群体中的WBC和PCT中值明显比未感染的群体高。高程截止≤3次(概率:4.058, 95%置信区间:2.206～7.463; p=0.001)和高程截止≥4次(概率:10.274, 95%置信区间:3.690～28.604; p<0.001),在术后第2天,随着感染的发展,PCT中值(1.7 ng/mL)和/或WBC中值(13 000个细胞/mm3)发生了明显的变化。本研究初步表明,在术后前3 d,PCT和WBC水平结合,能够预测接下来30 d心脏手术的术后感染情况,具有一定的临床应用价值。     

Genetic Polymorphisms in Endothelin-1 as Predictors for Long-Term Survival and the Cardiac Index in Patients Undergoing On-Pump Cardiac Surgery

Genetic variants within the endothelin-1 gene (EDN1) have been associated with several cardiovascular diseases and may act as genetic prognostic markers. Here, we explored the overall relevance of EDN1 polymorphisms for long-term survival in patients undergoing on-pump cardiac surgery. A prospectively collected cohort of 455 Caucasian patients who underwent cardiac surgery with cardiopulmonary bypass was followed up for 5 years. The obtained genotypes and inferred haplotypes were analyzed for their associations with the five-year mortality rate (primary endpoint). The EDN1 T-1370G and K198N genotype distributions did not deviate from Hardy–Weinberg equilibrium and the major allele frequencies were 83% and 77%, respectively. The cardiovascular risk factors were equally distributed in terms of the different genotypes and haplotypes associated with the two polymorphisms. The five-year mortality rate did not differ among the different EDN1 T-1370G and K198N genotypes and haplotypes. Haplotype analysis revealed that carriers of the G-T (compound EDN1 T-1370G G/K198N T) haplotype had a higher cardiac index than did non-carriers (p = 0.0008); however, this difference did not reach significance after adjusting for multiple testing. The results indicate that common variations in EDN1 do not act as prognostic markers for long-term survival in patients undergoing on-pump cardiac surgery.     

The Value of Pulmonary Function Studies in the Assessment of Patients for Cardiac Surgery

Preoperative pulmonary function, intracardiac pressures and degree of dyspnea were related to the incidence of postoperative respiratory insufficiency in 102 adult patients who underwent cardiac surgery. The purpose was to seek a reliable method of prognosticating the risk of postoperative respiratory insufficiency, especially after the use of cardiopulmonary bypass. When the heart-lung pump was used, 24 of 30 patients with a vital capacity less than 80% of the predicted normal developed respiratory insufficiency, whereas only eight of 41 patients with a normal vital capacity had this complication. In 26 patients where the vital capacity and gas diffusion were both normal, only three developed postoperative respiratory insufficiency. Other single or combined pulmonary function abnormalities, including tests of the mechanics of breathing, were of no greater value in predicting the postoperative course. The degree of dyspnea and the level of intracardiac pressures, although sometimes helpful, were often misleading.     

Cardiac Coherence Training to Reduce Anxiety in Remitted Schizophrenia,a Pilot Study

Health care that addresses the emotional regulation capacity of patients with schizophrenia confronted with daily stress may contribute to a less anxious life. A psycho-physiological training [cardiac coherence training (CCT)] focusing on emotion regulation is known to decrease anxiety for healthy individuals. We performed a pilot cross sectional survey to explore the benefits of CCT for clinically stable patients with schizophrenia. Ten patients were enrolled in the program consisting of twelve weekly 1-h session programs monitored over a 2-month period. Standardised questionnaires were used before and after the intervention to assess anxiety, well-being outcomes, and how patients deal with stress and stressors. Results showed that this quite-well accepted intervention improved (or tended to improve) well-being outcomes, state-anxiety, and emotional stressors evaluation. The successful transformations were higher for patients with the highest clinical and emotional suffering. Thus, this pilot study revealed that CCT may help patients with schizophrenia to deal with anxiety in daily life.