As a new discipline, the cardiac surgery has a great development in the modern age, but still faces many problems and disputes. The emergence of the evidence-based medicine(EBM),which emphasizes the best evidence, and combines the doctor’s clinical experience to make the best judgment, gives the development of the cardiac surgery a new thinking . Four systematic reviews published in The Cochrane Library (Issue 3, 2004) have interprated the importance of EBM on how to resolve the actual problems in different field of the cardiac surgery.
ObjectiveTo evaluate clinical outcomes of real-time ultrasound-guided percutaneous dilatational tracheostomy (PDT)for patients after cardiac surgery.
MethodsFrom July 2008 to August 2012, 51 patients received tracheostomy after cardiac surgery in Nanjing Drum Tower Hospital of Nanjing University Medical School, including 20 patients after heart valve replacement, 17 patients after aortic dissection (De Bakey type I)surgery, 11 patients after coronary artery bypass grafting and 3 patients after surgical correction of congenital heart diseases. According to different surgical methods, all the patients were divided into 3 groups. In surgical tracheostomy (ST)group, there were 17 patients including 10 males and 7 females with their average age of 58.0±15.2 years. In fiberoptic bronchoscope guided PDT (FOB-PDT)group, there were 21 patients including 15 males and 6 females with their average age of 63.5±13.5 years. In real-time ultrasound-guided PDT (US-PDT)group, there were 13 patients including 7 males and 6 females with their average age of 64.5±10.2 years. Surgical outcomes were compared among the 3 groups.
ResultsAll PDT operations were successfully completed. There was 1 failed patient in ST group. The incidence of bleeding was 41.18% in ST group, 9.53% in FOB-PDT group and 7.70% in US-PDT group (P=0.038). The incidence of mediastinal infection was 17.65% in ST group, 0% in FOB-PDT and US-PDT group (P=0.046). There was no statistical difference in endotracheal tube retention time, length of ICU stay and hospitalization, mortality or morbidity (hypoxemia, pneumothorax, subcutaneous emphysema)among the 3 groups. One patient in ST group developed late tracheal stenosis.
ConclusionReal-time ultrasound can provide information about cervical anatomy and help choose puncture site for PDT, which can improve the safety and reduce surgical difficulty and morbidity of PDT of patients after cardiac surgery.
Acute renal failure(ARF) is a serious complication after cardiac surgery. It is an important influential factor of increasing mortality, extending mechanical ventilation time and intensive care unit time, resulting in cognition functional impairment and respiratory function failure et al, and increasing cost of hospitalization. Extracorporeal circulation, intra-aortic balloon pump, renal inadequacy before surgery, diabetes and peripheral vascular disease are all risk factors of ARF after operation. These factors can lead to ARF by constriction of capacitance vessel, filling defect of renal and ischemia-reperfusion injury et al. Appropriate drug treatment, haemodialysis and hemofiltration could protect renal function and improve prognosis of ARF.
The concept of enhanced recovery after surgery (ERAS) is composed of multidisciplinary, multimodal, and evidence-based approaches, providing a safe and cost-effective method for perioperative management to improve patient prognosis without increasing the incidence of complications. At present, ERAS for cardiac surgery has developed slowly. This article provides a review of the application and prospects of ERAS concept in the perioperative period of cardiac surgery. The measures for applying ERAS concept to the perioperative period of cardiac surgery are divided into three parts: preoperative, intraoperative, and postoperative. The aim is to provide information for the perioperative management of cardiac surgery patients and assist in their rapid recovery during the perioperative period.
Object ive To summar ize recent advance in the appl icat ion and research of ar t i f icial chordae tendineae. Methods The cl inical and experimental research l iterature was extensively reviewed and analyzed. Results The follow-up results showed that artificial chordae tendineae replacement was superior to other operation methods in valve repair. But, it was compl icated and difficult-to-learn. In recent years with the development of many surgical skills and new techniques, good cl inical results were achieved. Conclusion With the development of surgical equi pment, chordae material, and implanting skills, artificial chordae tendineae implanting will be easier and the scope of appl ication will be larger.
ObjectiveTo investigate the effect of delayed sternal closure (DSC) on sternal wound debridement after pediatric cardiac surgery.
MethodsWe retrospectively analyzed clinical data of 491 pediatric patients underwent DSC in Guangdong General Hospital between June 2009 and June 2014. There were 333 males and 158 females with age of 1 day to 153.37 (5.68±17.24) months. The rate of sternal wound debridement between the DSC patients and the non-DSC patients was compared.
ResultsA total of 454 pediatric patients with DSC initiated in the operation room. And 37 patients with DSC initiated in intensive care unit after emergency sternotomy. A total of 392 patients with delayed sternal closure were discharged. Eight patients gave up treatment for family reasons and 91 patients died. Patients with DSC had higher incidence of sternal wound debridement than the patients with non-DSC did (χ2=6.693, P=0.010).
ConclusionDSC is an effective treatment for children with severe cardiac surgery, while it causes higher incidence of sternal wound debridement.
Anxiety is a strong behavioral and psychological reaction with fear components, while depression is a mental disorder dominated by high or low mood, both of which are accompanied by cognitive and behavioral changes, and are common comorbidities in patients with heart disease. Cardiac surgery is one of the important factors which trigger specific emotional and physiological reactions of patients. Persistent or initial depression and anxiety after surgery will not only increase surgical complications, short- or long-term mortality and medical costs, but also seriously affect patients' social function and quality of life. With the transformation of bio-psycho-social medical model, it is necessary to evaluate the perioperative psychological state and biological risk of patients undergoing cardiac surgery. This article reviews the characteristics, related mechanisms and therapeutic interventions of anxiety and depression in patients undergoing cardiac surgery.
Objective To evaluate clinical effects of strict control vs. conventional control of blood glucose in perioperative cardiac surgery. Methods Databases including PubMed, EMbase, HighWire, The Cochrane Library, CBM and VIP were searched to collect the randomized controlled trials (RCTs) on strict control vs. conventional control of blood glucose in perioperative cardiac surgery, published from 2000 to 2011. Two reviewers independently screened articles according to the inclusion and exclusion criteria, extracted data, and assessed quality of the included studies. Then meta-analysis was performed using RevMan 5.1. Results A total of 8 RCTs involving 2 250 patients were included. The results of meta-analysis showed that compared with the conventional group, the strict control of blood glucose could reduce postoperative short-term mortality (OR=0.52, 95% CI 0.30 to 0.91, P=0.02) and postoperative incidence rate of both atrial fibrillation (OR=0.64, 95%CI 0.43 to 0.96, P=0.03) and incision infection (OR=0.30, 95%CI 0.15 to 0.57, P=0.000 2), and shorten hospital stay (MD=1.75, 95%CI –3.18 to –0.32, Plt;0.02) and time of mechanical ventilation (MD=–0.9, 95%CI –1.43 to –0.38, Plt;0.000 8). Conclusion Current evidence shows that the strict control of blood glucose in perioperative cardiac surgery can reduce postoperative short-term mortality and postoperative incidence rate of both atrial fibrillation and incision infection, shorten hospital stay and time of mechanical ventilation, and have important clinical values and social and economic significance. However, this conclusion has to be proved by more high-quality and large-scale RCTs for the limitation of quantity and quality of the included studies.
ObjectiveTo analyze the changes of perioperative thyroid hormone in patients undergoing cardiac surgery under cardiopulmonary bypass, and to provide guidance for postoperative cardiac management.MethodsThe clinical data of 72 patients receiving cardiac surgery under cardiopulmonary bypass in our hospital from January to May 2019 were collected, including 35 males and 37 females, aged 19-72 (52.35±10.40) years. The changes of thyroid hormones before operation, 2 hours and 24 hours after operation were analyzed.ResultsThere was a statistical difference in thyroid stimulating hormone (TSH), triiodothyronine (T3), tetraiodothyronine (T4) and free tetraiodothyronine (FT4) between postoperative 2 hours and preoperation (P<0.05). There was a statistical difference in TSH, T3, free triiodothyronine (FT3), T4 and FT4 between postoperative 24 hours and preoperation (P<0.05). There was a statistical difference in TSH, T3, FT3 and T4 between postoperative 24 hours and 2 hours (P<0.05). Postoperatively T3 and FT3 decreased, TSH increased and then decreased while T4 and FT4 were within the normal range. Repeated measures analysis of variance showed a statistical difference of time effect in TSH, T3, FT3, T4 and FT4.ConclusionPatients with cardiac surgery under cardiopulmonary bypass have different thyroid hormones postoperatively compared with preoperatively. T3 and FT3 decrease, TSH increases and then decreases, while T4 and FT4 are in the normal range. The results require further large-scale, multi-center, high-quality clinical studies to be confirmed.
ObjectiveTo investigate acute physiologic and chronic health evaluation Ⅱ(APACHE Ⅱ) score system for severity evaluation and prognosis prediction of patients undergoing cardiac surgery.
MethodsA total of 3 566 patients who were admitted in ICU after cardiac surgery in the Department of Cardiovascular Surgery of General Hospital of Shenyang Military between December 1, 2011 and August 31, 2013 were enrolled in this study. There were 1 873 males and 1 693 females with their average age of 45.8±23.7 years (range, 10 days to 82 years). All the patients were evaluated with APACHE Ⅱ and expected mortality was calculated. Receiver operating characteristic(ROC) curve was drawn to compare expected and actual mortality and evaluate predictive value of APACHE Ⅱ.
ResultsA total of 3 373 patients survived the operation, and 193 patients died postoperatively with the mortality of 5.41%. The area under the ROC curve was 0.917 (P=0.000) with 95% confidence interval of[0.885,0.949]. The cut-off point of APACHE Ⅱ was 15.50, with a sensitivity of 80.3%,a specificity of 95.6%,an accuracy rate of 79.5%,a positive predictive value of 86.9%,and a negative predictive value of 93.1%. Expected and actual mortality increased with increasing APACHE Ⅱ,which were both positively correlated.
ConclusionAPACHE Ⅱ score system can be used to evaluate severity and predict prognosis of patients undergoing cardiac surgery, which provides reference for rational utilization of ICU resource.
