Search

Multiple arterial grafting (MAG) utilizes more than one arterial graft with any additional grafts being saphenous vein grafts (SVG). It remains an infrequently used coronary surgical revascularization technique, especially in elderly patients. Our study aims to evaluate the age-related association with the relative outcomes of multiple versus single arterial grafting (SAG). The Australian and New Zealand national registry was used to identify adult patients undergoing primary isolated CABG with at least two grafts. Exclusion criteria included reoperations, concomitant or previous cardiac surgery, and the absence of arterial grafting. Propensity score matching was used to match patient groups. The primary outcome was all-cause late mortality and the secondary outcomes were 30-day mortality and 30-day hospital readmission. We selected 69,624 eligible patients with a mean (standard deviation) age of 65.0 (10.2) years old. Matching between MAG and SAG generated 16,882 pairs of patients < 70 years old and 10,921 pairs of patients ≥ 70 years old. At a median [interquartile range] follow-up duration of 5.9 [3.2–9.6] years, MAG was associated with significantly reduced mortality compared to SAG (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.68–0.78; p < 0.001) in the younger subgroup as well as the elderly subgroup (HR, 0.84; 95% CI, 0.79–0.88; p < 0.001). In conclusion, MAG offers a survival benefit over SAG, in both younger and elderly patients.

Background Where each patient has all three conduits of internal mammary artery (IMA), saphenous vein graft (SVG) and radial artery (RA), most confounders affecting comparison between conduits can be mitigated. Additionally, since SVG progressively fails over time, restricting patient angiography to the late period only can mitigate against early SVG patency that may have occluded in the late period. Methods Research protocol driven conventional angiography was performed for patients with at least one of each conduit of IMA, RA and SVG and a minimum of 7 years postoperative. The primary analysis was perfect patency and secondary analysis was overall patency including angiographic evidence of conduit lumen irregularity from conduit atheroma. Multivariable generalized linear mixed model (GLMM) was used. Patency excluded occluded or “string sign” conduits. Perfect patency was present in patent grafts if there was no lumen irregularity. Results Fifty patients underwent coronary angiography at overall duration postoperative 13.1 ± 2.9, and age 74.3 ± 7.0 years. Of 196 anastomoses, IMA 62, RA 77 and SVG 57. Most IMA were to the left anterior descending territory and most RA and SVG were to the circumflex and right coronary territories. Perfect patency RA 92.2% was not different to IMA 96.8%, P = 0.309; and both were significantly better than SVG 17.5%, P P = 0.169, and both arterial conduits were significantly higher than SVG 82.5%, P = 0.029. Grafting according to coronary territory was not significant for perfect patency, P = 0.997 and patency P = 0.289. Coronary stenosis predicted perfect patency for RA only, P = 0.030 and for patency, RA, P = 0.007, and SVG, P = 0.032. When both arterial conduits were combined, perfect patency, P P = 0.017, were superior to SVG. Conclusions All but one patent internal mammary artery or radial artery grafts had perfect patency and had superior perfect patency and overall patency compared to saphenous vein grafts.

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research. post-print 2.282 KB

Background Failed extubation from mechanical ventilation in critically ill patients is multifactorial, complex and not well understood. We aimed to identify whether combined transthoracic echocardiography, lung and diaphragmatic ultrasound can predict extubation failure in critically ill patients. Results Fifty-three participants who were intubated > 48 h and deemed by the treating intensivist ready for extubation underwent a 60-min pre-extubation weaning trial (pressure support ≤ 10 cmH2O and positive end expiratory pressure 5 cmH2O). Prior to extubation, data collected included ultrasound assessment of left ventricular ejection fraction, left atrial area, early diastolic trans-mitral flow velocity wave (E), early diastolic trans-mitral flow velocity wave/late diastolic trans-mitral flow velocity wave (E/A), early diastolic trans-mitral flow velocity wave/early diastolic mitral annulus velocity (E/E′), interatrial septal motion, lung loss of aeration score and diaphragm movement. At the end of the weaning trial, the rapid shallow breathing index and serum B-type natriuretic peptide concentration were measured. Success and failure of weaning was assessed by defined criteria. Decision to extubate was at the discretion of the treating intensivist. Failure of extubation was defined as re-intubation, non-invasive ventilation or death within 48 h after extubation. Of 53 extubated participants, 11 failed extubation. Failed extubation was associated with diabetes, ischaemic heart disease, higher E/E′ (OR 1.27, 95% CI 1.05–1.54), left atrial area (OR 1.14, CI 1.02–1.28), fixed rightward curvature of the interatrial septum (OR 12.95, CI 2.73–61.41), and higher loss of aeration score of anterior and lateral regions of the lungs (OR 1.41, CI 1.01–1.82). Conclusions Failed extubation in mechanically ventilated patients is more prevalent if markers of left ventricular diastolic dysfunction and loss of lung aeration are present.

Background The routine implementation of sternal precautions to prevent sternal complications that restrict the use of the upper limbs is currently worldwide practice following a median sternotomy. However, evidence is limited and drawn primarily from cadaver studies and orthopaedic research. Sternal precautions may delay recovery, prolong hospital discharge and be overly restrictive. Recent research has shown that upper limb exercise reduces post-operative sternal pain and results in minimal micromotion between the sternal edges as measured by ultrasound. The aims of this study are to evaluate the effects of modified sternal precautions on physical function, pain, recovery and health-related quality of life after cardiac surgery. Methods/design This study is a phase II, double-blind, randomised controlled trial with concealed allocation, blinding of patients and assessors, and intention-to-treat analysis. Patients (n = 72) will be recruited following cardiac surgery via a median sternotomy. Sample size calculations were based on the minimal important difference (two points) for the primary outcome: Short Physical Performance Battery. Thirty-six participants are required per group to counter dropout (20%). All participants will be randomised to receive either standard or modified sternal precautions. The intervention group will receive guidelines encouraging the safe use of the upper limbs. Secondary outcomes are upper limb function, pain, kinesiophobia and health-related quality of life. Descriptive statistics will be used to summarise data. The primary hypothesis will be examined by repeated-measures analysis of variance to evaluate the changes from baseline to 4 weeks post-operatively in the intervention arm compared with the usual-care arm. In all tests to be conducted, a p value

Introduction: The postoperative quality of recovery scale (PostopQRS) is a widely used tool to assess the postoperative quality of recovery. Our aim was to translate, culturally adapt, and validate the PostopQRS questionnaire in Arabic. Methodology: A systematic translation process was used to translate the original English PostopQRS into Arabic. After the pilot study, the translated version was validated among patients who underwent different types of surgeries. We examined the reliability (using internal consistency) and validity of the translated version. To examine the responsiveness of the translated PostopQRS, the questionnaire was administered 6 times among the same group of patients (once before surgery as baseline measure, and 5 times after surgery, up to 1 week after surgery). Results: A total of 190 patients (10 men, 180 women) were included. Internal consistencies vary across each domain and overtime, with mostly good to excellent reliability. Most patients found the PostopQRS questions to be clear and easy to understand and thought the questionnaire items covered all their problem areas regarding their quality of recovery. In general, patients showed recovery across all five domains starting from postoperative day 1 (POD1). Patients showed the fastest recovery in the emotional domain, and the proportion of recovered patients remained stable over time. Most patients were recovered in the cognitive domain by POD1. Although only a small proportion of patients were recovered in the physiological and activities of daily living domains in POD1, most patients were recovered by POD3. The proportion of patients recovered in the nociceptive domain declined initially, but more patients showed recovery by POD3 and most were recovered by POD7. Furthermore, quality of recovery was related to the extent of surgery (major vs. minor). Conclusion: Our translated version of PostopQRS was reliable and valid for use among Arabic-speaking patients. In addition, we showed that the PostopQRS was able to track the changes in recovery among patients in our study.

David J Canty, Johan Heiberg, Yang Yang, Alistair G Royse, Swaroop Margale, Nagesh Nanjappa ... et al.

BACKGROUND: Studies have described different recovery profiles of sevoflurane and desflurane typically early after surgery.METHODS: We conducted a randomized superiority trial to determine whether Overall Recovery 3 days after knee arthroscopy would be superior with desflurane. Adult participants undergoing knee arthroscopic surgery with general anesthesia were randomized to either desflurane or sevoflurane general anesthesia. Intraoperative and postoperative drugs and analgesics were administered at the discretion of the anesthesiologist. Postoperative quality of recovery was assessed using the "Postoperative Quality of Recovery Scale". The primary outcome was Overall Recovery 3 days after surgery and secondary outcomes were individual recovery domains at 15 minutes, 40 minutes, 1 day, 3 days, 1 month, and 3 months. Patients and researchers were blinded.RESULTS: 300 patients were randomized to sevoflurane or desflurane (age 51.7±14.1 vs. 47.3±13.5 years; duration of anesthesia 24.9±11.1 vs. 23.3±8.3 minutes). The proportion achieving baseline or better scores in all domains increased over the follow-up period in both groups but was not different at day 3 (sevoflurane 43% vs. desflurane 37%, p = 0.314). Similarly, rates of recovery increased over time in the five subdomains, with no differences between groups for physiological, p = 0.222; nociceptive, p = 0.391; emotive, p = 0.30; Activities-of-daily-living, p = 0.593; and cognitive recovery, p = 0.877.CONCLUSION: No significant difference in the quality of recovery scale could be shown using sevoflurane or desflurane general anesthesia after knee arthroscopy in adult participants.

Background: Ultrasound-assisted examination of the cardiovascular system with focused cardiac ultrasound by the treating physician is non-invasive and changes diagnosis and management of patient’s with suspected cardiac disease. This has not been reported in a general practice setting. Aim: To determine whether focused cardiac ultrasound performed on patients aged over 50 years changes the diagnosis and management of cardiac disease by a general practitioner. Design and setting: A prospective observational study of 80 patients aged over 50years and who had not received echocardiography or chest CT within 12months presenting to a general practice. Method: Clinical assessment and management of significant cardiac disorders in patients presenting to general practitioners were recorded before and after focused cardiac ultrasound. Echocardiography was performed by a medical student with sufficient training, which was verified by an expert. Differences in diagnosis and management between conventional and ultrasound-assisted assessment were recorded. Results and conclusion: Echocardiography and interpretation were acceptable in all patients. Significant cardiac disease was detected in 16 (20%) patients, including aortic stenosis in 9 (11%) and cardiac failure in 7 (9%), which were missed by clinical examination in 10 (62.5%) of these patients. Changes in management occurred in 12 patients (15% overall and 75% of those found to have significant cardiac disease) including referral for diagnostic echocardiography in 8 (10%), commencement of heart failure treatment in 3 (4%) and referral to a cardiologist in 1 patient (1%). Routine focused cardiac ultrasound is feasible and frequently alters the diagnosis and management of cardiac disease in patients aged over 50years presenting to a general practice.

The Postoperative Quality Recovery Scale is a brief instrument of six domains designed to assess quality of recovery from early to long term after surgery. This study aims to validate the Portuguese version of the Postoperative Quality Recovery Scale.In this observational study 101 adult patients undergoing elective surgery completed the Postoperative Quality Recovery Scale at 15 minutes and 40 minutes, one and three days after surgery. Three constructs were assessed for validity: increased recovery over time; effect of gender and recovery association with muscle strength. Reliability, responsiveness, feasibility and acceptability were also assessed.Construct validity was shown by increased recovery over time; worse recovery for female patients in emotive, nociceptive, activities of daily living and overall recovery; improved muscle strength in recovered patients. Internal consistency for activities of daily living was acceptable at all-time points (Cronbach's α value of 0.772 or higher), indicating scale reliability. The scale was able to detect differences in postoperative quality of recovery between the neuromuscular blockade reversal agents, neostigmine and sugammadex, indicating scale responsiveness. The time to conduct the Portuguese version at baseline was 95 - 581 seconds (median 319 seconds) and it was reduced with subsequent assessments. The proportion of patients completing all scale items was 87%, 75%, 65% and 94% for the four time periods evaluated, indicating scale feasibility and acceptability.This study shows that the Portuguese version of the Postoperative Quality Recovery Scale, demonstrates construct validity, reliability, responsiveness, feasibility and acceptability.This study allowed validation of the Portuguese version of the Postoperative Quality Recovery Scale.Introdução: A Escala da Qualidade da Recuperação Pós-Operatória é um instrumento de seis domínios, desenhada para avaliar a qualidade da recuperação no período pós-operatório precoce e tardio. Este estudo teve como objetivo validar a versão portuguesa da Escala da Qualidade da Recuperação Pós-Operatória. Material e Métodos: Neste estudo observacional foi obtida uma amostra de 101 doentes adultos submetidos a cirurgia eletiva e que preencheu a Escala da Qualidade da Recuperação Pós-Operatória aos 15 e 40 minutos, um e três dias após a cirurgia. Três teorias foram avaliadas para aferir a validade teórica da escala: aumento da recuperação ao longo do tempo, efeito do género e a associação da recuperação com a força muscular. Foram também avaliadas a fiabilidade, poder de resposta, viabilidade e aceitabilidade. Resultados: A validade teórica foi demonstrada pelo aumento da recuperação ao longo do tempo, assim como uma pior recuperação para doentes do sexo feminino em atividades emotivas, nociceptivas, diárias e de recuperação geral. Detetou-se ainda uma melhoria da força muscular em doentes recuperados. A coerência interna no domínio das atividades da vida diária foi aceitável em todos os tempos (valor α de Cronbach de 0,772 ou superior), indicando a fiabilidade da escala. Com esta escala foi possível detetar diferenças na qualidade pós-operatória da recuperação entre os agentes de reversão de bloqueio neuromuscular, a neostigmina e o sugammadex, indicando que a escala apresenta poder de resposta. O tempo para aplicar a versão portuguesa no período inicial (baseline) foi de 95 - 581 segundos (mediana 319 segundos) com uma diminuição em avaliações subsequentes. A proporção de doentes que completaram todos os itens da escala foi de 87%, 75%, 65% e 94% nos quatro períodos avaliados, indicando viabilidade e aceitabilidade da escala. Discussão: A versão portuguesa da Escala da Qualidade da Recuperação Pós-Operatória demonstrou ter validade, fiabilidade, poder de resposta, viabilidade e aceitabilidade. Conclusões: Este estudo permitiu a validação da versão Portuguesa da Escala da Qualidade da Recuperação Pós-Operatória.

Background We reported previously that, in patients undergoing cardiac surgery who were at moderate-to-high risk for death, a restrictive transfusion strategy was noninferior to a liberal strategy with respect to the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis by hospital discharge or 28 days after surgery, whichever came first. We now report the clinical outcomes at 6 months after surgery. Methods We randomly assigned 5243 adults undergoing cardiac surgery to a restrictive red-cell transfusion strategy (transfusion if the hemoglobin concentration was

BACKGROUND The effect of a restrictive versus liberal red-cell transfusion strategy on clinical outcomes in patients undergoing cardiac surgery remains unclear. METHODS In this multicenter, open-label, noninferiority trial, we randomly assigned 5243 adults undergoing cardiac surgery who had a European System for Cardiac Operative Risk Evaluation (EuroSCORE) I of 6 or more (on a scale from 0 to 47, with higher scores indicating a higher risk of death after cardiac surgery) to a restrictive red-cell transfusion threshold (transfuse if hemoglobin level was

Objective There is initial evidence that the use of volatile anesthetics can reduce the postoperative release of cardiac troponin I, the need for inotropic support, and the number of patients requiring prolonged hospitalization following coronary artery bypass graft (CABG) surgery. Nevertheless, small randomized controlled trials have failed to demonstrate a survival advantage. Thus, whether volatile anesthetics improve the postoperative outcome of cardiac surgical patients remains uncertain. An adequately powered randomized controlled trial appears desirable. Design Single blinded, international, multicenter randomized controlled trial with 1:1 allocation ratio. Setting Tertiary and University hospitals. Interventions Patients (n = 10,600) undergoing coronary artery bypass graft will be randomized to receive either volatile anesthetic as part of the anesthetic plan, or total intravenous anesthesia. Measurements and main results The primary end point of the study will be one-year mortality (any cause). Secondary endpoints will be 30-day mortality; 30-day death or non-fatal myocardial infarction (composite endpoint); cardiac mortality at 30 day and at one year; incidence of hospital re-admission during the one year follow-up period and duration of intensive care unit, and hospital stay. The sample size is based on the hypothesis that volatile anesthetics will reduce 1-year unadjusted mortality from 3% to 2%, using a two-sided alpha error of 0.05, and a power of 0.9. Conclusions The trial will determine whether the simple intervention of adding a volatile anesthetic, an intervention that can be implemented by all anesthesiologists, can improve one-year survival in patients undergoing coronary artery bypass graft surgery.

A considerable burden of cerebral embolism in association with cardiac surgery reflects dislodgement of aortic atheroma caused by manipulating the aorta during a surgical procedure (Barbut and Gold 1996; Van Zaane, Zuithoff et al. 2008; Whitley and Glas 2008; Yamaguchi, Adachi et al. 2009). It clearly makes logical sense to identify and attempt to avoid dislodgement of aortic atheroma. This strategy depends on two key elements; the accurate detection of atheroma in the aorta, and the surgeons ability to avoid or otherwise minimise manipulation of atheromatous disease.

Left ventricular tissue Doppler imaging (TDI) velocities are used to monitor systolic and diastolic function, but it is not known how these may change in a hyperdynamic circulation, as often occurs in anesthesia and critical care medicine. Twenty-six healthy young volunteers were recruited and left ventricular systolic and diastolic tissue Doppler velocities measured at rest, light exercise, strenuous exercise, and recovery (10 minutes after exercise). At rest, TDI velocities significantly decreased from base to apex ( 𝑃 < . 0 0 1 ). Within basal, mid, and apical sections, systolic and diastolic peak velocities differed between segments ( 𝑃 < . 0 5 ), except for systolic middle ( 𝑃 = . 0 9 4 ) and late diastolic apical velocities ( 𝑃 = . 2 5 7 ). Basal septal velocities differed from basal lateral, for systolic ( 𝑃 = . 0 4 1 ) but not diastolic peak values. Inferobasal radial values differed from basal lateral values for both systolic and diastolic velocities ( 𝑃 < . 0 5 ). Both systolic and diastolic TDI velocities increased significantly in all segments in a proportionate manner with a hyperdynamic circulation.

expertise (diagnostic versus focused) was highest in TTE (32 %) compared with TOE (22 %) and LU (12 %). The proportions of intensivists untrained in TTE and LU was 41 % and 30 %, respectively. Perceived barriers included lack of organized training (38 %) and time for training (25 %). Other barriers included a perceived lack of need for training (18 %), insufficient equipment (14 %), and resistance from other ultrasound providers (4 %). The most commonly reported training programs were tertiary courses, such as provided by the Australasian Society of Ultrasound in Medicine (68 %) and University of Melbourne (59 %), rather than board examinations or hands-on workshops. We conclude that although TTE and LU are used frequently in Australasian teaching ICUs, many ICU physicians are yet to be trained due to lack of ICU training programs and time for training. Although tertiary courses are popular and provide training to diagnostic level, they are lengthy and depend on trainers and patient caseload and are not, therefore, scalable. An attractive alternative is to begin training in medical school and to train more physicians in basic ultrasound with shorter, more efficient, and hands-on courses utilizing the internet and ultrasound simulators [1], advancing to a diagnostic level only if required.