Background: The vasoactive-inotropic score (VIS) predicts mortality and morbidity after paediatric cardiac surgery. Here we examined whether VIS also predicted outcome in adults after cardiac surgery, and compared predictive capability between VIS and three widely used scoring systems. Methods: This single-centre retrospective cohort study included 3213 cardiac surgery patients. Maximal VIS (VIS max ) was calculated using the highest doses of vasoactive and inotropic medications administered during the first 24 h postsurgery. We established five VIS max categories: 0e5, >5e15, >15e30, >30e45, and >45 points. The predictive accuracy of VIS max was evaluated for a composite outcome, which included 30-day mortality, mediastinitis, stroke, acute kidney injury, and myocardial infarction. Results: VIS max showed good prediction accuracy for the composite outcome [area under the curve (AUC), 0.72; 95% confidence interval (CI), 0.69e0.75]. The incidence of the composite outcome was 9.6% overall and 43% in the highest VIS max group (>45). VIS max predicted 30-day mortality (AUC, 0.76; 95% CI, 0.69e0.83) and 1-yr mortality (AUC, 0.70; 95% CI, 0.65e0.74). Prediction accuracy for unfavourable outcome was significantly better with VIS max than with Acute Physiology and Chronic Health Evaluation II (P¼0.01) and Simplified Acute Physiological Score II (P¼0.048), but not with the Sequential Organ Failure Assessment score (P¼0.32). Conclusions: In adults after cardiac surgery, VIS max predicted a composite of unfavourable outcomes and predicted mortality up to 1 yr after surgery.
In cardiac surgery, postoperative low cardiac output has been shown to correlate with increased rates of organ failure and mortality. Catecholamines have been the standard therapy for many years, although they carry substantial risk for adverse cardiac and systemic effects, and have been reported to be associated with increased mortality. On the other hand, the calcium sensitiser and potassium channel opener levosimendan has been shown to improve cardiac function with no imbalance in oxygen consumption, and to have protective effects in other organs. Numerous clinical trials have indicated favourable cardiac and non-cardiac effects of preoperative and perioperative administration of levosimendan. A panel of 27 experts from 18 countries has now reviewed the literature on the use of levosimendan in on-pump and off-pump coronary artery bypass grafting and in heart valve surgery. This panel discussed the published evidence in these various settings, and agreed to vote on a set of questions related to the cardioprotective effects of levosimendan when administered preoperatively, with the purpose of reaching a consensus on which patients could benefit from the preoperative use of levosimendan and in which kind of procedures, and at which doses and timing should levosimendan be administered. Here, we present a systematic review of the literature to report on the completed and ongoing studies on levosimendan, including the newly commenced LEVO-CTS phase III study (NCT02025621), and on the consensus reached on the recommendations proposed for the use of preoperative levosimendan.
Although common, the incidence of persistent pain after sternotomy was lower than previously reported. Also, reassuringly, 1 year after surgery this pain was mostly mild in nature both at rest and on movement.
There are no studies evaluating S(+)-ketamine for pain management after sternotomy. In this prospective, randomized, double-blind, placebo-controlled clinical trial, we evaluated the efficacy and feasibility of S(+)-ketamine as an adjunctive analgesic after cardiac surgery. Ninety patients scheduled for elective coronary artery bypass grafting (CABG) were randomized to receive either a 75 microg/kg bolus of S(+)-ketamine followed by a continuous infusion of 1.25 microg . kg(-1) . min(-1) for 48 h (n = 44) or placebo (normal saline bolus and infusion) (n = 46). From the time of tracheal extubation, patients could access an opioid (oxycodone) via a patient-controlled analgesia device, and the cumulative oxycodone doses were measured over 48 h. Pain was evaluated on a visual analog scale three times daily. The quality of recovery, patient satisfaction with pain management, and adverse effects were recorded. The cumulative oxycodone consumption during the first 48 postoperative hours was less in the S(+)-ketamine group (103 +/- 44 mg) than in the placebo group (125 +/- 45 mg; mean difference, 22 mg; 95% confidence interval for the difference, 3-40 mg; P = 0.023). Pain scores did not differ between the groups at rest (P = 0.17) or during a deep breath (P = 0.23). Patient satisfaction was superior in S(+)-ketamine-treated patients: 26 (60%) of 44 in the S(+)-ketamine group compared with 16 (35%) of 46 in the placebo group were very satisfied with the analgesic management (P = 0.032). Nausea and vomiting were the most common adverse events, with similar frequencies in both groups. Four patients in the S(+)-ketamine group developed transient hallucinations during the infusion, versus none in the placebo group. In conclusion, small-dose S(+)-ketamine decreased opioid consumption in CABG patients during the first 48 h after surgery.
In the present study, levosimendan infusion reduced the incidence of heart failure in cardiac surgery patients but was associated with arterial hypotension and increased requirement of vasopressor agents postoperatively. Improved mortality or morbidity was not demonstrated.
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