Prospective validation and refinement of the APPROACH cardiovascular surgical intensive care unit readmission score

This research by Verma et al was published online in the Journal of Critical Care during August 2019.
Purpose:  The APPROACH cardiovascular surgical intensive care unit (CVICU) readmission score has excellent discrimination and calibration for CVICU readmission after discharge to a surgical ward; however, it has not been prospectively validated.
Material and methods:  In a prospective consecutive cohort of 805 patients ≥18 years admitted to the CVICU after coronary artery bypass and/or valvular surgery, the APPROACH CVICU readmission score was calculated at the time of discharge to a surgical ward. The study compared observed versus predicted CVICU readmission and the model discrimination was evaluated using AUC c-index. The incremental prognostic utility of 6 pre-specified prospectively collected respiratory (re-intubation, tracheostomy, oxygen at discharge) and hemodynamic variables (heart rate, systolic blood pressure, inotropes at discharge) were tested using net reclassification index (NRI) and integrated discrimination improvement (IDI).
Results:  A total of 37 (4.6%) patients were readmitted to the CVICU. The median CVICU length of stay (9.0 vs 2.0 days, p < .001) and all-cause in-hospital mortality (8.1% vs 0.4%, p < .001) was higher among readmitted patients. The model had good discrimination (c-index = 0.748). Systolic blood pressure at discharge yielded the largest improvement in model discrimination (c-index = 0.782; Hosmer-Lemshow p = .749).
Conclusions:  In a prospective validation cohort, the APPROACH CVICU readmission risk score had good discrimination and could be operationalized in future research and clinical practice.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Latest Issue of “Intensive Care Medicine” Volume 43 Number 5


To view Intensive Care Medicine’s latest issue’s contents page follow this link.

Articles included in this issue are a review of “Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future” and “Monitoring dynamic arterial elastance as a means of decreasing the duration of norepinephrine treatment in vasoplegic syndrome following cardiac surgery: a prospective, randomized trial”

To read the full text of these articles from the journal’s homepage requires a personal subscription to “Intensive Care Medicine”.  Individual articles can be ordered from the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make article requests online via this link.

The full text of articles from issues older than one year ago is available via this link to an archive of issues of Intensive Care Medicine.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Latest issue of Critical Care Reviews Newsletter 275 19th March 2017

Welcome to the 275th Critical Care Reviews Newsletter, bringing you the best critical care research and opecritcal care reviewsn access articles from across the medical literature over the past seven days. This week’s edition is packed with cardiology trials from the American College of Cardiology Meeting in Washington DC. The highlight of this newsletter is the LEVO-CTS trial, examing levosimend
an in patients with left ventricular dysfunction undergoing cardiac surgery. There are also excellent reviews on hepatorenal syndrome  and perfusion indices, as well as correspondence on the HYBERNATUS and INFORM trials.  The 7th and 8th talks from #CCR17 are out also – Prof Donat Spahn gives the annual honorary John Hinds Trauma Lecture and Prof John Myburgh delivers a fascinating presentation on clinical trials in “The Path to Truth“.

The full newsletter can be accessed via this link.

High-flow nasal cannula oxygen therapy vs conventional oxygen therapy in cardiac surgical patients: A meta-analysis

This article is to be published in the Journal of Critical Care.  The full text of the article can be accessed via this link.

Introduction:  The use of high-flow nasal cannula (HFNC) for the treatment of many diseases has gained increasing popularity. In the present meta-analysis, we aimed to assess the efficacy and safety of HFNCs compared with conventional oxygen therapy (COT) in adult postextubation cardiac surgical patients.

Method:  We reviewed the Embase, PubMed, Cochrane Central Register of Controlled Trials, Wanfang databases, and the China National Knowledge Infrastructure. Two investigators independently collected the data and assessed the quality of each study. RevMan 5.3 was used for the present meta-analysis.

Results:  We included 495 adult postextubation cardiac surgical patients. There was no significant heterogeneity among the studies. Compared with COT, HFNCs were associated with a significant reduction in the escalation of respiratory support (risk ratio, 0.61; 95% confidence interval [CI], 0.46-0.82; z = 3.32, P < .001). There were no significant differences in the reintubation rate (risk ratio, 0.96; 95% CI, 0.04-24.84; z = 0.02, P = .98) or length of intensive care unit stay (weighted mean difference, 0.13; 95% CI, −0.88 to 7.92; z = 1.57, P = .12) between the 2 groups. No severe complications were reported in either group.

Conclusions:  The HFNC could reduce the need for escalation of respiratory support compared with COT, and it could be safely administered in adult postextubation cardiac surgical patients.

Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock After Cardiac Surgery: The VANCS Randomized Controlled Trial

This article was published in the Critical Care Medicine journal’s website in November 2017.  The full text of the article can be accessed by subscribers via this link.

Background:  Vasoplegic syndrome is a common complication after cardiac surgery and impacts negatively on patient outcomes. The objective of this study was to evaluate whether vasopressin is superior to norepinephrine in reducing postoperative complications in patients with vasoplegic syndrome.

Methods:  This prospective, randomized, double-blind trial was conducted at the Heart Institute, University of Sao Paulo, Brazil, between January 2012 and March 2014. Patients with vasoplegic shock (defined as mean arterial pressure less than 65 mmHg resistant to fluid challenge and cardiac index greater than 2.2 l · min−2 · m−2) after cardiac surgery were randomized to receive vasopressin (0.01 to 0.06 U/min) or norepinephrine (10 to 60 μg/min) to maintain arterial pressure. The primary endpoint was a composite of mortality or severe complications (stroke, requirement for mechanical ventilation for longer than 48 h, deep sternal wound infection, reoperation, or acute renal failure) within 30 days.

Results:  A total of 330 patients were randomized, and 300 were infused with one of the study drugs (vasopressin, 149; norepinephrine, 151). The primary outcome occurred in 32% of the vasopressin patients and in 49% of the norepinephrine patients (unadjusted hazard ratio, 0.55; 95% CI, 0.38 to 0.80; P = 0.0014). Regarding adverse events, the authors found a lower occurrence of atrial fibrillation in the vasopressin group (63.8% vs. 82.1%; P = 0.0004) and no difference between groups in the rates of digital ischemia, mesenteric ischemia, hyponatremia, and myocardial infarction.

Conclusions:  The authors’ results suggest that vasopressin can be used as a first-line vasopressor agent in postcardiac surgery vasoplegic shock and improves clinical outcomes.

Acute kidney injury following cardiac surgery: current understanding and future directions

O’Neal, J.B. et al. Critical Care. Published online: 4 July 2016
Image source: Pfree2014 – Wikimedia // CC BY-SA 4.0

Acute kidney injury (AKI) complicates recovery from cardiac surgery in up to 30 % of patients, injures and impairs the function of the brain, lungs, and gut, and places patients at a 5-fold increased risk of death during hospitalization. Renal ischemia, reperfusion, inflammation, hemolysis, oxidative stress, cholesterol emboli, and toxins contribute to the development and progression of AKI.

Preventive strategies are limited, but current evidence supports maintenance of renal perfusion and intravascular volume while avoiding venous congestion, administration of balanced salt as opposed to high-chloride intravenous fluids, and the avoidance or limitation of cardiopulmonary bypass exposure. AKI that requires renal replacement therapy occurs in 2–5 % of patients following cardiac surgery and is associated with 50 % mortality. For those who recover from renal replacement therapy or even mild AKI, progression to chronic kidney disease in the ensuing months and years is more likely than for those who do not develop AKI.

Cardiac surgery continues to be a popular clinical model to evaluate novel therapeutics, off-label use of existing medications, and nonpharmacologic treatments for AKI, since cardiac surgery is fairly common, typically elective, provides a relatively standardized insult, and patients remain hospitalized and monitored following surgery. More efficient and time-sensitive methods to diagnose AKI are imperative to reduce this negative outcome. The discovery and validation of renal damage biomarkers should in time supplant creatinine-based criteria for the clinical diagnosis of AKI.

Read the full article here