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Cardiothoracic Surgery Morbidity and Mortality

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Cardiothoracic Surgery Morbidity and Mortality Powered By Docstoc
					Surgical Critical Care

   Philip Goodney, MD
    October 26th, 2005
                  Format
• Question and Answer (multiple choice)

• Review of reading in Sabiston and Greenfield
  Chapter
           Neurologic dysfunction
• Which criteria is NOT necessary to declare brain
  death?
   –   A: absence of cerebral function
   –   B: absence of pupillary light reflex
   –   C: absence of corneal reflex
   –   D: absence of vestibulo-ocular reflex
   –   E: absence of radio-isotope uptake on brain scan
   –   F: absence of oropharyngeal reflex
   –   G: apnea in the presence of “adequate stimulation” (PaCO2
       > 60 mm Hg for 30 seconds).
          Neurologic dysfunction
• Which criteria is NOT necessary to declare brain
  death?
   – A: absence of cerebral function
   – B: absence of pupillary light reflex
   – C: absence of corneal reflex
   – D: absence of vestibulo-ocular reflex
   – E: absence of radio-isotope uptake on brain scan
   – F: absence of oropharyngeal reflex
   – G: apnea in the presence of “adequate stimulation” (PaCO2
     > 60 mm Hg for 30 seconds).
   – Provides supportive evidence only.
         Neurologic dysfunction
–   Damage to the midbrain affects level of
    consciousness via the

    a)   the reticular activating system
    b)   Cerebral cortex
    c)   Uncus
    d)   Internal capsule
         Neurologic dysfunction
–   Damage to the midbrain affects level of
    consciousness via the

    a)   the reticular activating system
    b)   Cerebral cortex
    c)   Uncus
    d)   Internal capsule
         Neurologic dysfunction
–   Depolarizing neuromuscular blockers mimic

    a)   Vecuronium
    b)   Cisatricurium
    c)   Acetylcholine
    d)   Pseudocholineserase
         Neurologic dysfunction
–   Depolarizing neuromuscular blockers mimic

    a)   Vecuronium
    b)   Cisatricurium
    c)   Acetylcholine
    d)   Pseudocholineserase

    Succinylcholine, the only available depolarizing NMB, works by
        binding the acetylcholine receptors and causing depolarization
        (clinically seen as muscle fasciculations). Succinylcholine is
        characterized by a rapid onset and short half-life; it is most useful
        for short invasive procedures
           Neurologic dysfunction
•    A dose of vecuronium lasts for ___ minutes,
     and is cleared by the _____.
    a)   15 / liver
    b)   90 / kidneys
    c)   10 / plasma ester hydrolysis
    d)   30 / liver and kidneys
             Neurologic dysfunction
•    A dose of vecuronium lasts for ___ minutes, and is
     cleared by the _____.
    a)   15 / liver
    b)   90 / kidneys
    c)   10 / plasma ester hydrolysis
    d)   30 / liver and kidneys
         Vec – 30 minutes, longer in px with hepatic/renal dysfunc
         Panc: 90 min, don’t use in px with cardiac dx b/c vagolytic
         Atricur/cistatricur: eliminated by plasma ester hydrolysis, so useful in
             patients with liver/kidney dysfunction
     Cardiovascular dysfunction
• Patients who require afterload reduction with
  nitroprusside warrant observation for cyanide
  toxicity, as cyanide is a breakdown product of
  nitroprusside. How is it detected?
     Cardiovascular dysfunction
• Patients who require afterload reduction with
  nitroprusside warrant observation for cyanide
  toxicity, as cyanide is a breakdown product of
  nitroprusside. How is it detected?
  – Elevated mixed venous oxygen saturation
     Cardiovascular dysfunction
• Treatment of cyanide toxicity is:
     Cardiovascular dysfunction
• Treatment of cyanide toxicity is:
  – Sodium nitrite (10 ml)
  – Followed by 1mg/kg methelyne blue
  – HD
       Cardiovascular dysfunction
• Acts primarily on the heart, increasing heart
  rate, contractility, and atrioventricular
  conduction
  –   Alpha 1
  –   Beta 1
  –   Beta 2
  –   Dopamine1
  –   Dopamine2
       Cardiovascular dysfunction
• Acts primarily on the heart, increasing heart
  rate, contractility, and atrioventricular
  conduction
  –   Alpha 1
  –   Beta 1
  –   Beta 2
  –   Dopamine1
  –   Dopamine2
       Cardiovascular dysfunction
• Decreases heart rate
  –   Alpha 1
  –   Beta 1
  –   Beta 2
  –   Dopamine1
  –   Dopamine2
       Cardiovascular dysfunction
• Decreases heart rate
  –   Alpha 1
  –   Beta 1
  –   Beta 2
  –   Dopamine1
  –   Dopamine2
       Cardiovascular dysfunction
• Causes arterial vasodilation
  –   Alpha 1
  –   Beta 1
  –   Beta 2
  –   Dopamine1
  –   Dopamine2
       Cardiovascular dysfunction
• Causes arterial vasodilation
  –   Alpha 1
  –   Beta 1
  –   Beta 2
  –   Dopamine1
  –   Dopamine2
        Pulmonary dysfunction
• At which part of the hemoglobin – O2
  dissociation curve do continued increases in
  PaO2 result in very little increase in SaO2 ?
        Pulmonary dysfunction
• At which part of the hemoglobin – O2
  dissociation curve do continued increases in
  PaO2 result in very little increase in SaO2 ?
  – Upper part of the curve
     Pulmonary dysfunction
The pathogenesis of ARDS involves three stages.
1. First (exudative) phase
2. Second (fibroproliferative) phase
3. Third (resolution) phase
What kind of cells are destroyed in Stg 1?
a)        macrophages
b)        type II pneumocytes
c)        alveolar epithelium
d)        mesenchymal cells
       Pulmonary dysfunction
The pathogenesis of ARDS involves three stages.
1. First (exudative) phase
2. Second (fibroproliferative) phase
3. Third (resolution) phase
What kind of cells are destroyed in Stg 1?
a)         macrophages (cause the damage)
b)         type II pneumocytes
c)         alveolar epithelium (disrupted, not destroyed)
d)         mesenchymal cells (fill the space and initiate
                                  fibrosis)
           Pulmonary dysfunction
• Low tidal volume ventilation translates into
  how many ml/kg tidal volumes?
  –   3
  –   6
  –   9
  –   12
            Pulmonary dysfunction
• Low tidal volume ventilation translates into how
  many ml/kg tidal volumes?
   –   3
   –   6
   –   9
   –   12

   NEJM: In 861 patients, trial stopped because in-hospital
    mortality was 31% with Tv = 6 ml/kg, and 40% in TV 12
    ml/kg
               GI dysfunction
• Grade 2 abdominal compartment syndrome
  should be treated with:
  –   IVF
  –   Observation
  –   Paralytics
  –   Decompression
               GI dysfunction
• Grade 2 abdominal compartment syndrome
  should be treated with:
  –   IVF
  –   Observation
  –   Paralytics
  –   Decompression
        GI dysfunction
Grade    IAP         Rx

I        10-14       IVF

II       15-24       Supranormal IVF

III      25-35       Decompression

IV       >35         Emergent
                     decompression
             GI dysfunction
• The average nutritional requirement for a
  patient is calculated by the Harris-Benedict
  equation. However, a reasonable estimate for
  patients of normal body habitus is ___
  kcal/kg/day
  –   15
  –   30
  –   45
  –   60
                     GI dysfunction
• The average nutritional requirement for a patient is
  calculated by the Harris-Benedict equation.
  However, a reasonable estimate for patients of normal
  body habitus is ___ kcal/kg/day
   –   15
   –   30
   –   45
   –   60
        • 35 kcal/kg/day for underweight px, 25 kcal/kg/day for overwieght
          patients
              GI dysfunction
• Patients with severe stress should receive ___
  g/kg/day of protein in their TPN
  –   0.5
  –   1.5
  –   2.5
  –   3.5
              GI dysfunction
• Patients with severe stress should receive ___
  g/kg/day of protein in their TPN
  –   0.5
  –   1.5
  –   2.5
  –   3.5

  – Normal – 2.0g/kg/day of protein in tpn
                          GI dysfunction
                 Match the nutrient with the beneficial effect




                                •oxidative fuel for enterocytes and other rapidly
•   Arginine.                   replicating cells.
•   Glutamine                   •promotes normal T-cell distribution and function and
•   The ω-3 fatty acids         aids in wound healing.
•   Nucleotides                 •enhance the replication of rapidly dividing cells as
                                well as immune responsiveness.
                                •compete with arachidonic acid in cyclooxygenase
                                metabolism, resulting in production of prostaglandins
                                of the three series and leukotrienes of the five series.
                          GI dysfunction
                 Match the nutrient with the beneficial effect




                                •oxidative fuel for enterocytes and other rapidly
•   Arginine.                   replicating cells.
•   Glutamine                   •promotes normal T-cell distribution and function and
•   The ω-3 fatty acids         aids in wound healing.
•   Nucleotides                 •enhance the replication of rapidly dividing cells as
                                well as immune responsiveness.
                                •compete with arachidonic acid in cyclooxygenase
                                metabolism, resulting in production of prostaglandins
                                of the three series and leukotrienes of the five series.
            Renal dysfunction
• True or false:
  – Continuous renal replacement therapy has been
    proven to be safer in the ICU patient than
    intermittent HD
             Renal dysfunction
• True or false:
  – Continuous renal replacement therapy has been
    proven to be safer in the ICU patient than
    intermittent HD

  – False: While Continuous RRT techniques offer the
    advantage of improved hemodynamic stability and
    relatively less resource utilization, but they require
    some anticoagulation and have not been proven
    superior to hemodialysis in improving outcomes.
           Hepatic dysfunction
• Which of these clinical entities does not exist
  in hepatorenal syndrome:
  – Decreased activity of the renin-angiotensin-
    aldosterone system
  – Systemic vasodilation
  – Azotemia
  – High urine sodium
  – High urine osmolality
           Hepatic dysfunction
• Which of these clinical entities does not exist
  in hepatorenal syndrome:
  – Decreased activity of the renin-angiotensin-
    aldosterone system (should be increased)
  – Systemic vasodilation
  – Azotemia
  – High urine sodium (Una should be <10)
  – High urine osmolality
        Hematologic dysfunction
• Heparin induced thrombocytopenia typically
  occurs how long after a patient is exposed to
  heparin?
  –   2 days
  –   4 days
  –   6 days
  –   8 days
         Hematologic dysfunction
• Heparin induced thrombocytopenia typically
  occurs how long after a patient is exposed to
  heparin?
  –   2 days
  –   4 days
  –   6 days
  –   8 days (5 days if the patient has been sensitized
      before)
                        Sepsis
•     APC is an endogenous protein that
    (Choose all that apply)
    a)   Promotes fibrinolysis
    b)   inhibits thrombosis
    c)   Inhibits inflammation
    d)   Modulates of the coagulation cascade
    e)   Limits cell apoptosis
                        Sepsis
•     APC is an endogenous protein that
    (Choose all that apply)
    a)   Promotes fibrinolysis
    b)   inhibits thrombosis
    c)   Inhibits inflammation
    d)   Modulates of the coagulation cascade
    e)   Limits cell apoptosis
                  Sepsis
Complications of therapy with APC, in a large RCT
  of 1690 patients with sepsis, was limited to

a)       infection
b)       seizures
c)       somnolence
d)       bleeding
                  Sepsis
Complications of therapy with APC, in a large RCT
  of 1690 patients with sepsis, was limited to

a)       infection
b)       seizures
c)       somnolence
d)       bleeding
             Coagulopathy
Recombinant factor VIIa …

a) is contraindicated in trauma
b) induces a thrombin burst with formation of fibrin
   clots
c) Has no effect on measured prothrombin time
d) Activates the intrinsic coagulation cascade
e) Combines with platelets to enhance platelet plug
   formation
             Coagulopathy
Recombinant factor VIIa …

a) is contraindicated in trauma
b) induces a thrombin burst with formation of fibrin
   clots
c) Has no effect on measured prothrombin time
d) Activates the intrinsic coagulation cascade
e) Combines with platelets to enhance platelet plug
   formation
             Inflammation
All of the following cytokines or proteins
    are pro-inflammatory and
    procoagulant except:
a) tumor necrosis factora,
b) interleukin-1b
c) interleukin-6
d) Thrombin
e) Activated Protein C
             Inflammation
All of the following cytokines or proteins
    are pro-inflammatory and
    procoagulant except:
a) tumor necrosis factora,
b) interleukin-1b
c) interleukin-6
d) Thrombin
e) Activated Protein C
          PROWESS Study
• Activated protein C, endogenous
  protein
 promotes fibrinolysis
 inhibits thrombosis
 inhibits inflammation
 is an important modulator of the
   coagulation and inflammation
   associated with severe sepsis
• Reduced levels correlated with
  increased risk of death in patients with
PROWESS Study
          PROWESS Study
• We therefore evaluated whether the
  administration of drotrecogin alfa
  activated would reduce the rate of
  death from all causes at 28 days in
  patients with severe sepsis and have
  an acceptable safety profile.
   PROWESS Study: Eligibility
• Known or suspected infection on the
  basis of
• Three or more signs of systemic
  inflammation
• sepsis-induced dysfunction of at least
  one
  organ or system that lasted no longer
  than 24 hours.
• Patients had to begin treatment within
    PROWESS Study: Treatment
• Randomized to saline or DrAA
• Dose = 24ug per kg infused over 96 hours
• Evaluation:
  – D-dimer (marker of coagulopathy)
  – IL-6 (marker of inflammation)
  – Mortality
      PROWESS Study: Results
• Trial stopped at second interim analysis (1520
  patients analyzed)
• 1728 patients randomized, 1690 received DrAA or
  placebo
• Twenty-eight days after the start of the
  infusion,
   259 of 840 patients in the placebo group
  (30.8 percent) and 210 of 850 (24.7
  percent) of the patients in the drotrecogin
  alfa activated group had died.
      Absolute reduction = 6.1 % (p<0.005)
      Relative risk reduction = 19.5%
PROWESS Study: Results
     (Survival)
PROWESS Study: Results (IL-6)
PROWESS Study: Complications
           PROWESS Study:
• Discussion points:
  – Was the effect of DrAA dependant upon the type
    or location of the infection?
  – What kind of patients underwent bleeding
    complications?
            ADDRESS Study
• Similar study, required as part of the FDA
  approval of DrAA

• PROWESS: high risk patients



• ADDRESS: examine the response in patients
  of lower risk
            ADDRESS Study
• Methods: excluded patients with high risk.



• After 1500 patients enrolled, trial was stopped
  because of <5% chance of effect
ADDRESS Study (results)
             ADDRESS Study
• No survival effect
• Complications:
  – Bleeding, both during the infusion period and
    subsequently thereafter in the 28 day study period.
ADDRESS Study
              ADDRESS Study
• Study halted given the lack of effect, and the
  increased complication

• Discussion: “inexperienced sites”, “APACHE…
  good for populations, less useful in predicting the
  outcome of individual patients”

• Conclusion: No role for DrAA in low risk patients.