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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether ultrasound probe central line placement reduced complications and time to placement in patients undergoing coronary artery bypass grafting surgery. Altogether, 193 papers were found from Medline using the reported search of which 6 papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses and comments were tabulated. We conclude that in patients with a potentially difficult central line insertion, the ultrasound technique reduces complications and time to insertion. However, in those patients where no difficulty is predicted, there is no evidence that the ultrasound technique confers any advantage.

A short cut review was carried out to establish whether cardiopulmonary bypass improves survival and function after cardiac arrest resistant to ACLS. Altogether 387 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Previous studies have resulted in conflicting results regarding the predictive effect of various clinical symptoms, signs, and plain imaging for intracranial pathology in adults with minor head injury. We sought to perform a meta-analysis of the literature to assess the significance of these factors for the prediction of intracranial hemorrhage (ICH). The literature was searched using Medline, Embase, Experts, and the Grey literature. Reference lists of major guidelines were crosschecked. Included were control or nested case control studies of patients attending hospital with head injury that recorded clinical correlates relating to the outcome variable of presence or absence of ICH. The common relative risk ratio was calculated using the Mantel-Haenszel test with a pooled estimate. Thirty-five papers containing 83,636 patients were included in the meta-analysis after systematic review of the literature. Relative risk ratios were calculated for 23 clinical correlates from the history, the mechanism of injury, and the examination. In addition, adjusted relative risks were presented for those variables that showed significant heterogeneity across studies. Reasons for the heterogeneity are discussed. This study has determined the relative risks of 23 clinical variables that may predict the presence of an ICH in patients after minor head injury. These risks should prove invaluable to clinicians for the assessment of individual patients as well as the assessment of guidelines presented for the management of minor head injuries.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the antero-posterior position is superior to the antero-lateral position for the placement of electrodes for cardioversion of atrial fibrillation. Altogether 167 papers were found using the reported search, of which 5 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is no clinical difference between the two positions although if one position fails to convert the patient, the alternative position may still achieve success.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether clopidogrel is superior to aspirin in preventing adverse events post coronary arterial bypass grafting. Altogether 220 papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that if aspirin is not tolerated, clopidogrel is an acceptable alternative, but there is no strong evidence that clopidogrel is superior to aspirin postcoronary surgery.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether any intervention effectively reduces the pain associated with chest drain removal. Altogether 94 papers were found using the reported search, of which 6 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is minimal evidence for the effectiveness of a single approach to providing analgaesia for chest drain removal. Studies in the literature contain small numbers and are underpowered to address the questions they ask.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether an early invasive approach (involving early coronary angiography followed by revascularisation if suitable) is superior to a conservative approach (with revascularisation only in patients with failed medical therapy) in patients with acute coronary syndrome. Altogether 282 papers were found using the reported search, of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that in patients diagnosed with acute coronary syndrome, an early invasive approach is clearly superior to a conservative approach.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether haloperidol or a benzodiazepine is the safest treatment for acute psychosis in the critically ill patient. Altogether 294 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that haloperidol should be considered the first line drug for agitated patients post cardiac surgery, however lorazepam either alone or in conjunction with haloperidol is an acceptable alternative.

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether there is any survival benefit to the employment of the technique of radical lymph node dissection in the management of operable non-small cell lung cancer (NSCLC). Altogether 305 papers were found using the reported search, of which eight presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that extensive lymph node sampling is of benefit in accurately staging NSCLC, however, the design of studies in the literature has failed to account for the staging effect of extensive lymph node dissection on upstaging cancer patients when trying to determine a survival advantage.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether low dose (renal dose) dopamine in the critically ill patient prevents acute renal failure. Altogether 141 papers were found using the reported search, of which three presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is no evidence to support the use of low-dose dopamine to treat acute renal failure in critically ill patients.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether changing operative technique based on epiaortic ultrasound reduces the incidence of intra-operative stroke during cardiac surgery? Altogether 179 papers were found using the reported search, of which eight presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that epiaortic ultrasound is superior to manual palpation in detecting atherosclerosis in the ascending aorta, and the severity of atherosclerosis found is closely correlated to the incidence of postoperative stroke. No touch techniques in patients with severe atherosclerosis may avert this increase in the incidence of stroke.

A short cut review was carried out to establish whether antibiotics improve recovery in patients with acute exacerbations of COPD. Altogether 200 papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed is whether the figure-of-eight technique is superior to the simple wire technique for closing of the sternum? Altogether 111 papers were found in Medline of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that the figure-of-eight wire technique is not superior to the simple wire technique for closure of the sternum.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was which medical strategy is the optimal treatment for stable patients going into atrial fibrillation post cardiac surgery. Altogether 281 papers were found from medline and 83 from the Cochrane Central Register of Controlled Trials using the reported search, of which 12 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is very little evidence to support any one strategy over another.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether use of aprotinin in coronary artery bypass graft surgery adversely affects graft patency. Altogether 45 papers were identified using the below mentioned search, of which 10 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that aprotinin clearly reduces blood loss, requirement for blood transfusion, and the risk of reoperation for bleeding, but does increase the risk of saphenous vein graft occlusion.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, what is the optimal dose of aspirin post cardiac surgery that should be given to prevent graft occlusion and prolong survival. Altogether, 114 papers were found from Medline and 59 papers were found from the Cochrane Central Register of Controlled Trials using the reported search, of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that best evidence suggests that 325 mg optimally improves vein graft survival and mortality, and does not cause an increase in complications compared to lower doses.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether prophylactic haemofiltration during cardiopulmonary bypass is of benefit during cardiac surgery? Altogether 273 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that haemofiltration will increase the haematocrit, reduce some inflammatory markers and may increase the variability of heparin levels. It may also reduce post-operative blood transfusion and possibly increase BP and cardiac index immediately after haemofiltration, although no differences in morbidity or mortality has ever been shown.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether aspirin given 6 h after coronary arterial bypass grafting optimises graft patency. Altogether 201 papers were found using the reported search, of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is good evidence that Aspirin given <6 h post surgery optimally reduces graft occlusion, without an increase in bleeding.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether there is a group of patients who would benefit from a prophylactic intra-aortic balloon pump prior to cardiac surgery. Altogether 110 papers were found using the reported search, of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is evidence to support preoperative intra-aortic balloon pump insertion in patients with two of left ventricular ejection factor <30 or 40%, left main stem disease, unstable angina or redo-operation.

The spectrum of patients receiving cardiac surgery are increasing in age and severity of illness. With the reduction of complications caused by the placement of an intra-aortic balloon pump (IABP) there is increasing interest in the placement of an IABP prophylactically. We sought to derive a scoring system to guide the placement of IABPs. A total of 3927 patients from the Blackpool Victoria Open Heart Registry were used to derive a range of clinical decision scores using a range of established and novel statistical techniques. This database included 127 patients who received an IABP. The derived scores and rules were then validated on the North Staffordshire Open Heart Registry, containing 3070 patients, and 161 patients who received an IABP. We derived and validated a clinical score that has a sensitivity of 50% and a specificity of 96.5% in the prediction of those patients requiring an IABP. This was robust in the validation dataset and outperformed the Parsonnet score in this context. Our validated clinical scoring system will be useful both to guide individual clinical decision making and to compare variation of IABP usage among institutions.

Cardiothoracic surgeons are faced with the dilemma that many clinical questions in their daily practice to do not have universally agreed answers, but patients increasingly demand the 'best practice' from their doctors. In addition time pressures mean that clinicians are unable to keep up with the full spectrum of published research and current resources that collate evidence for clinicians have few if any resources for cardiothoracic surgeons. We have adopted an approach pioneered in emergency medicine, namely the Best Evidence Topic or BestBET. Clinicians select a clinical scenario from their daily practice that highlighted an area of controversy. From this, a three-part question is generated and this is used to search Medline for relevant papers. Once the relevant papers are found, these papers are critically appraised using validated checklists and the results are summarized. A clinical bottom line is reached after this process. To add confidence to the quality of the search a second author and then an Evidence Based Journal Club checks the BET to ensure that no relevant evidence is missed. These BETs will then be posted on the ICVTS website prior to publication for widespread commentary. The resulting BETs, written by practising cardiothoracic surgeons, will then provide robust evidence-based answers to important clinical questions asked during our daily practice.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether high doses of protamine causes increased bleeding in patients post cardiac surgery. Altogether 268 papers were found using the reported search, of which five presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that high doses of protamine can cause increased bleeding and impaired platelet function but these effects have never been demonstrated below a ratio of 2.6:1 protamine to heparin.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether bone wax increases the risk of mediastinitis in patients undergoing cardiac surgery. Altogether 276 papers were found using the reported search, of which five presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that animal studies indicate that there are strong reasons for concern over the liberal usage of bone wax.

A short cut review was carried out to establish whether ultrasonic guidance reduces the complication rate during central line placement in the emergency department. Altogether 349 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

A short cut review was carried out to establish whether the tongue blade test is useful in the clinical assessment of patients with mandibular trauma. Altogether 269 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Background: A common postoperative complication after CABG with internal mammary artery (IMA) harvest is the evolution of a pleural effusion. Our aim was to see if the intra-operative insertion of a Bellovac drain to the pleural cavity, with drainage continuing for 4-days post operation, eliminates the complication of pleural effusion., Methods: Using our computerised audit database, 500 consecutive patients were identified who had undergone CABG including at least one internal mammary graft by a single consultant at Blackpool Victoria Hospital. All these patients received Bellovac drainage for 4 days on the side of the harvested IMA. The chest X-ray reports were retrospectively collected from the hospital computer databases. The 4-day post-operative, and the 6-week post-operative films were found. In the cases where no consultant radiologist report was found J.D. reviewed the film, and any abnormalities were also reviewed by R.W.J.M., Results: Out of 500 radiographs, six patients (1.2%) died, 25 patients had no traceable record of a chest X-ray, 434 patients had an entirely normal chest X-ray and 461 patients had no effusion at 6 weeks. Six patients had a small effusion at 6 weeks, two had a moderate effusion successfully treated conservatively, and no patients had a pleural effusion that required drainage., Conclusion: In patients undergoing coronary arterial bypass grafting with internal mammary artery harvest, the intra-operative insertion of a Bellovac drain on the side of the harvested IMA reduces the risk of postoperative pleural effusions

Objective: Prolonged ventilation post surgery causes logistic problems on cardiac surgical intensive care units (CSU). We thus sought to derive and validate a clinical decision rule to predict patients at high risk of prolonged ventilation, so that the timing of operations on high risk patients can be optimised in the context of the workload of the CSU., Methods: The North Staffordshire Royal Infirmary (NSRI) Open Heart Registry was analysed from April 1998 to May 2002. Prolonged ventilation was defined as that which was longer than 24 h. The Parsonnet score was assessed for its ability to predict these patients. Univariate analysis was first performed to identify predictive variables. Recursive partitioning and logistic regression was then performed to identify the optimal decision rule. This rule was then validated on the Blackpool Victoria Hospital (BVH) Open Heart Registry., Results: A total of 3,070 patients were analysed of whom 201 were ventilated for more than 24 h. A Parsonnet score of 10 predicted 49% of high risk patients but 618 low risk patients are misclassified. Our rule that uses Parsonnet score over 7, ejection fraction, operation status, PA pressure and age, to identify high risk patients identifies 50% of those needing prolonged ventilation and only incorrectly identifies 282 of the 2869 patients with normal ventilation times giving a specificity of over 90%. Validation in the BVH database demonstrated similar findings., Conclusion: Our rule identifies 14% of all our patients as high risk and 50% of these required prolonged ventilation. Such a rule allows more efficient use of scarce CSU resources by appropriate surgical scheduling.