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Background: Most cardiac surgery patients experience postoperative anemia. Delirium and Atrial Fibrillation (AF) are common and independent predictors of morbidity and mortality. Few reports examine their association with postoperative anemia. This study aims to quantify the association between anemia and these outcomes in patients undergoing cardiac surgery., Methods: This post-hoc analysis of the DECADE randomized controlled trial ran at six academic US hospitals. Patients aged 18-85 years with heart rate > 50 bpm undergoing cardiac surgery who had daily hemoglobin measurements in the first 5 Postoperative Days (POD) were included. Delirium was assessed twice daily with the Confusion Assessment Method for the ICU (CAM - ICU), preceded by the Richmond Agitation and Sedation Scale, with patients excluded from assessment if sedated. Patients had daily hemoglobin measurements, continuous cardiac monitoring plus twice-daily 12-lead electrocardiograms, up to POD4. AF was diagnosed by clinicians blinded to hemoglobin levels., Results: Five hundred and eighty-five patients were included. Mean postoperative hemoglobin Hazard Ratio (HR): 0.99 (95% CI 0.83, 1.19; p = 0.94) per 1 g.dL -1 hemoglobin decrease. 197 (34%) developed AF, mainly on POD = 2.3. Estimated HR = 1.04 (95% CI 0.93, 1.17; p = 0.51) per 1 g.dL -1 hemoglobin decrease., Conclusions: Most patients undergoing major cardiac surgery were anemic in the postoperative phase. AF and delirium occurred in 34% and 12% of patients, respectively, but neither were significantly correlated with postoperative hemoglobin., Competing Interests: Conflicts of interest None., (Copyright © 2023. Published by Elsevier España S.L.U.)

Objectives: Examine the: 1) relative role of hemodynamic determinants of acute kidney injury (AKI) obtained in the immediate postcardiac surgery setting compared with established risk factors, 2) their predictive value, and 3) extent mediation via central venous pressure (CVP) and mean arterial pressure (MAP)., Design: Retrospective observational study. The main outcome of the study was moderate to severe AKI, per kidney disease: improving global outcomes, within 14 days of surgery., Setting: U.S. academic medical center., Patients: Adult patients undergoing cardiac surgery between January 2000 and December 2019 ( n = 40,426) in a single U.S.-based medical center. Pulmonary artery catheter measurements were performed at a median of 102 minutes (11, 132) following cardiopulmonary bypass discontinuation., Interventions: None., Measurements and Results: The median age of the cohort was 67 years (58, 75), and 33% were female; 70% had chronic hypertension, 29% had congestive heart failure, and 3% had chronic kidney disease. In a multivariable model, which included comorbidities and traditional intraoperative risk factors, CVP ( p < 0.0001), heart rate ( p < 0.0001), cardiac index ( p < 0.0001), and MAP ( p < 0.0001), were strong predictors of AKI, and superseded factors such as surgery type and cardiopulmonary bypass duration. The cardiac index had a significant interaction with heart rate ( p = 0.026); a faster heart rate had a differentiating effect on the relationship of cardiac index with AKI, where a higher heart rate heightened the risk of AKI primarily in patients with low cardiac output. There was also significant interaction observed between CVP and MAP ( p = 0.009); where the combination of elevated CVP and low MAP had a synergistic effect on AKI incidence., Conclusions: Hemodynamic factors measured within a few hours of surgery showed a strong association with AKI. Furthermore, determinants of kidney perfusion, namely CVP and arterial pressure are interdependent; as are constituents of stroke volume, that is, cardiac output and heart rate., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: Persons who inject drugs and require surgery for infective endocarditis have 2 potentially lethal diseases. Current postoperative rehabilitation efforts seem ineffective in preventing loss to follow-up, injection drug use relapse (relapse), and death., Objectives: The purpose of this study was to characterize drug use, psychosocial issues, surgical outcome, and postoperative addiction management, as well as loss to follow-up, relapse, and mortality and their risk factors., Methods: From January 2010 to June 2020, 227 persons who inject drugs, age 36 ± 9.9 years, underwent surgery for infective endocarditis at a quaternary hospital having special interest in developing addiction management programs. Postsurgery loss to follow-up, relapse, and death were assessed as competing risks and risk factors identified parametrically and by machine learning. CIs are 68% (±1 SE)., Results: Heroin was the most self-reported drug injected (n = 183 [81%]). Psychosocial issues included homelessness (n = 56 [25%]), justice system involvement (n = 150 [66%]), depression (n = 118 [52%]), anxiety (n = 104 [46%]), and post-traumatic stress disorder (n = 33 [15%]). Four (1.8%) died in-hospital. Medication for opioid use disorder prescribed at discharge increased from 0% in 2010 to 100% in 2020. At 1 and 5 years, conditional probabilities of loss to follow-up were 16% (68% CI: 13%-22%) and 59% (68% CI: 44%-65%), relapse 32% (68% CI: 28%-34%) and 79% (68% CI: 74%-83%), and mortality 21% (68% CI: 18%-23%) and 68% (68% CI: 62%-72%). Younger age, heroin use, and lower education level were predictors of relapse., Conclusions: Infective endocarditis surgery can be performed with low mortality in persons who inject drugs, but addiction is far more lethal. Risk of loss to follow-up and relapse require more effective addiction strategies without which this major loss to society will continue., Competing Interests: Funding Support and Author Disclosures Support was provided by the Drs Sidney and Becca Fleischer Heart and Vascular Education Chair (to Dr Blackstone), The Peter and Elizabeth C. Tower Family Endowed Chair in Cardiothoracic Research (to Dr Unai), James and Sharon Kennedy, The Slosburg Family Charitable Trust, and The Stephen and Saundra Spencer Fund for Cardiothoracic Research. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Case Summary: A 31-year-old female presented to a regional hospital at 27 weeks pregnant and was found to have COVID-19 ARDS. She underwent intubation and caesarian section for worsening hypoxia and non-reassuring fetal heart tones. Hypoxemia was refractory to proning requiring ECMO and transfer to a tertiary care center. Admission chest radiography showed a new right lower lobe cavitating lesion with computed tomography scan revealing a large multi-loculated cavity in the right lung and extensive bilateral ground-glass opacities. The patient was started on amphotericin and posaconazole, with final respiratory cultures growing Lichtheimia spp. Source control was discussed via possible open thoracostomy, but medical management alone was continued. Total ECMO support was 3 weeks. At the time of discharge to acute rehab, 1 month of amphotericin and posaconazole had been completed, with continuation of posaconazole. At last update, she had been discharged from rehab and was back home with her infant. Conclusion: Pulmonary mucormycosis, even in the non-ECLS population, carries a high mortality. Treatment in pulmonary disease with surgery improves mortality but is not always feasible. Salvage therapy with extended course antifungal medications may be an option for those not amendable.

Background: No previous studies exist examining two inhaled epoprosternol formulations (Flolan compared with Veletri) in a homogenous cardiothoracic surgery patient population., Objective: To compare the impact of inhaled Flolan and inhaled Veletri on the effectiveness, safety, or cost in cardiothoracic surgery patients., Materials and Methods: This was a retrospective, noninferiority study comparing inhaled Flolan and inhaled Veletri in cardiothoracic surgery patients. Participants included were ≥18 years old, admitted to the cardiothoracic intensive care unit, and received inhaled Flolan or inhaled Veletri therapy for ≥1 hour., Results: A total of 244 patients were included in the primary outcome analysis (122 patients per group). The primary outcome, change in the partial pressure of arterial oxygen to fraction of inspired oxygen (PaO 2 /FiO 2 ) ratio 1 hour after administration of inhaled Flolan or inhaled Veletri, did not cross the lower limit of the noninferiority margin (95% CI = -14.8 to 65.4). Significant differences in secondary outcomes included duration of mechanical ventilation (4.4 vs 2.6 days; P < 0.01), number of tracheostomies (24 vs 9; P = 0.01), number of patients initiated on dialysis (25 vs 12; P = 0.02), and cost per median duration of therapy ($257 vs $183; P = 0.02) in the inhaled Flolan and inhaled Veletri groups, with the average duration of therapy being 1.6 and 1.3 days, respectively., Conclusions and Relevance: Inhaled Veletri was demonstrated to be non-inferior to inhaled Flolan when comparing change in PaO 2 /FiO 2 ratio 1 hour post -therapy initiation,and inhaled Veletri was an acceptable alternative to inhaled Flolan in a cardiothoracic surgery patient population.

Background: The Fédération Internationale de Football Association (FIFA) 11+ program has been shown to be an effective injury prevention program in the female soccer cohort, but there is a paucity of research to demonstrate its efficacy in the male population., Hypothesis: To examine the efficacy of the FIFA 11+ program in men's collegiate United States National Collegiate Athletic Association (NCAA) Division I and Division II soccer., Study Design: Randomized controlled trial; Level of evidence, 1., Methods: Before the commencement of the fall 2012 season, every NCAA Division I and Division II men's collegiate soccer team (N = 396) was solicited to participate in this research study. Human ethics review board approval was obtained through Quorum Review IRB. Sixty-five teams were randomized: 34 to the control group (CG; 850 players) and 31 to the intervention group (IG; 675 players). Four teams in the IG did not complete the study, reducing the number for analysis to 61. The FIFA 11+ injury prevention program served as the intervention and was utilized weekly. Athlete-exposures (AEs), compliance, and injury data were recorded using a secure Internet-based system., Results: In the CG, 665 injuries (mean ± SD, 19.56 ± 11.01) were reported for 34 teams, which corresponded to an incidence rate (IR) of 15.04 injuries per 1000 AEs. In the IG, 285 injuries (mean ± SD, 10.56 ± 3.64) were reported for 27 teams, which corresponded to an IR of 8.09 injuries per 1000 AEs. Total days missed because of injury were significantly higher for the CG (mean ± SD, 13.20 ± 26.6 days) than for the IG (mean ± SD, 10.08 ± 14.68 days) (P = .007). There was no difference for time loss due to injury based on field type (P = .341)., Conclusion: The FIFA 11+ significantly reduced injury rates by 46.1% and decreased time loss to injury by 28.6% in the competitive male collegiate soccer player (rate ratio, 0.54 [95% CI, 0.49-0.59]; P < .0001) (number needed to treat = 2.64)., (© 2015 The Author(s).)

Objective: Perioperative hypothermia might be detrimental to the patient undergoing off-pump coronary artery bypass surgery. We assessed the efficacy of the Allon thermoregulation system (MTRE Advanced Technologies Ltd, Or-Akiva, Israel) compared with that of routine thermal care in maintaining normothermia during and after off-pump coronary artery bypass surgery., Methods: Patients undergoing off-pump coronary artery bypass surgery were perioperatively and randomly warmed with the 2 techniques (n = 45 per group). Core temperature, hemodynamics, and troponin I, interleukin 6, interleukin 8, and interleukin 10 blood levels were assessed., Results: The mean temperature of the patients in the Allon thermoregulation system group (AT group) was significantly ( P < .005) higher than that of the patients receiving routine thermal care (the RTC group); less than 40% of the latter reached 36 degrees C compared with 100% of the former. The cardiac index was higher and the systemic vascular resistance was lower ( P < .05) by 16% and 25%, respectively, in the individuals in the AT group compared with in the individuals in the RTC group during the 4 postoperative hours. End-of-surgery interleukin 6 levels and 24-hour postoperative troponin I levels were significantly ( P < .01) lower in the patients in the AT group than in the RTC group. The RTC group's troponin levels closely correlated with their interleukin 6 levels at the end of the operation ( R = 0.51, P = .002)., Conclusions: Unlike routine thermal care, the Allon thermoregulation system maintains core normothermia in more than 80% of patients undergoing off-pump coronary artery bypass surgery. Normothermia is associated with better cardiac and vascular conditions, a lower cardiac injury rate, and a lower inflammatory response. The close correlation between the increased interleukin 6 and troponin I levels in the routine thermal care group indicates a potential deleterious effect of lowered temperature on the patient's outcome.

Objective: To evaluate the effectiveness and safety of the ALLON 2001 microprocessor-based thermoregulation system in pediatric patients undergoing cardiac surgery requiring hypothermic cardiopulmonary bypass compared with the routine thermal care., Design: Prospective randomized clinical study., Setting: Single tertiary academic medical center., Participants: Infants (0-1 year) who underwent congenital heart surgery requiring hypothermic cardiopulmonary bypass (n = 18). Patients with open wounds and/or patients treated with an investigational drug or device within 30 days of surgery were excluded., Interventions: Randomized use of thermoregulation system (warming garment, n = 9) or routine thermal care (control, n = 9) after separating from cardiopulmonary bypass until the arrival to the pediatric intensive care unit (PICU)., Measurements and Main Results: There were no statistically significant differences in the demographic data, cardiopulmonary bypass time, operating room time, incidence of deep hypothermic circulatory arrest, and cooling temperature between the groups. The nasopharyngeal temperature was significantly higher in the warming garment group after separation from cardiopulmonary bypass. Nasopharyngeal temperature at 20 minutes was 36.5 degrees C versus 35.01 degrees C (p = 0.0047), at 40 minutes was 36.98 degrees C versus 35.30 degrees C (p = 0.034), and at admission to the PICU was 36.09 degrees C versus 35.31 degrees C (p = not significant). There was no difference in the core-to-peripheral temperature gradient (nasopharyngeal-to-skin temperature) between the 2 study groups at any time point. No adverse events related to the use of the warming garment thermoregulation system were observed., Conclusion: The investigated thermoregulation system was effective in preventing the after-drop of temperature that occurs after cardiopulmonary bypass in small infants compared with routine warming methods.

One-lung ventilation is used to facilitate thoracic and cardiac surgery. This article describes the development and clinical use of a new device, the bronchial blocker tube, to establish one-lung ventilation. The bronchial blocker tube has two circular lumen joined together, one for ventilation and one for acceptance of a bronchial blocker. In this setting, the bronchial blocker is a separate device which is replaceable, rotatable, and removable. In the authors' experience, the bronchial blocker tube was effective and easy to use.

Unlabelled: Shivering after cardiac surgery is common, and may be a result of intraoperative hypothermia. Another possible etiology is fever and chills secondary to activation of the inflammatory response and release of cytokines by cardiopulmonary bypass. Dexamethasone decreases the gradient between core and skin temperature and modifies the inflammatory response. The goal of this study was to determine whether dexamethasone can reduce the incidence of shivering. Two hundred thirty-six patients scheduled for elective coronary and/or valvular surgery were randomly assigned to receive either dexamethasone 0.6 mg/kg or placebo after the induction of anesthesia. All patients received standard monitoring and anesthetic management. After arrival in the intensive care unit (ICU), nurses unaware of the treatment groups recorded visible shivering, as well as skin and pulmonary artery temperatures. Analysis of shivering rates was performed by using chi2 tests and logistic regression analysis. Compared with placebo, dexamethasone decreased the incidence of shivering (33.0% vs 13.1%; P = 0.001). It was an independent predictor of reduced incidence of shivering and was also associated with a higher skin temperature on ICU admission and a lower central temperature in the early postoperative period., Implications: Dexamethasone is effective in decreasing the incidence of shivering. The effectiveness of dexamethasone is independent of temperature and duration of cardiopulmonary bypass. Shivering after cardiac surgery may be part of the febrile response that occurs after release of cytokines during cardiopulmonary bypass.

Objective: This study was designed to evaluate whether a continuous low-dose lidocaine infusion reduces postoperative pain and anxiety in patients undergoing coronary artery bypass grafting (CABG) and to retrospectively examine time to extubation, intensive care unit stay (ICU), and hospital length of stay., Design: A double-blinded, randomized, and prospective approach., Setting: Hospital patients undergoing first-time CABG., Participants: After informed consent, 100 patients were enrolled in this study., Interventions: Lidocaine infusion or placebo substitute was begun after induction of anesthesia. The fentanyl/midazolam infusion was discontinued on ICU admission; lidocaine or placebo continued until ICU discharge. Supplemental fentanyl, midazolam, or propranolol was administered for pain, anxiety, or hemodynamic stress., Measurements and Main Results: Drug dosages were compared between groups. Postoperative assessment included visual analog pain score, hemodynamics, sedation score, and nursing assessment. Mean total dosages of fentanyl, midazolam, and propranolol between the lidocaine and placebo groups were 620.40 +/- 815.74 microgram versus 689.16 +/- 692.99 microgram, p = 0.244; 0.54 +/- 1.13 mg versus 1.20 +/- 2.44 mg p = 0.465; 0.11 +/- 0.75 mg versus 3.56 +/- 17.2 mg, p = 0.564, respectively. Times to extubation, ICU length of stay, and hospital stay did not achieve statistical significance., Conclusions: Continuous infusion of low-dose lidocaine did not significantly decrease supplemental fentanyl, midazolam, or propranolol requirement postoperatively. Similarly, a lidocaine infusion does not result in reduced time to extubation. ICU stay, or hospital length of stay.