Prolonged mechanical ventilation after cardiac surgery: substudy of the Transfusion Requirements in Cardiac Surgery III trial

Ashwin Sankar, Alexandra J Rotstein, Bijan Teja, François Martin Carrier, Emilie P Belley-Côté, Daniel Bolliger, Tarit Saha, Paula Carmona, Michael Sander, Nadine Shehata, Kevin E Thorpe, C David Mazer, Ashwin Sankar, Alexandra J Rotstein, Bijan Teja, François Martin Carrier, Emilie P Belley-Côté, Daniel Bolliger, Tarit Saha, Paula Carmona, Michael Sander, Nadine Shehata, Kevin E Thorpe, C David Mazer

Abstract

Purpose: Prolonged mechanical ventilation (MV) is a major complication following cardiac surgery. We conducted a secondary analysis of the Transfusion Requirements in Cardiac Surgery (TRICTS) III trial to describe MV duration, identify factors associated with prolonged MV, and examine associations of prolonged MV with mortality and complications.

Methods: Four thousand, eight hundred and nine participants undergoing cardiac surgery at 71 hospitals worldwide were included. Prolonged MV was defined based on the Society of Thoracic Surgeons definition as MV lasting 24 hr or longer. Adjusted associations of patient and surgical factors with prolonged MV were examined using multivariable logistic regression. Associations of prolonged MV with complications were assessed using odds ratios, and adjusted associations between prolonged MV and mortality were evaluated using multinomial regression. Associations of shorter durations of MV with survival and complications were explored.

Results: Prolonged MV occurred in 15% (725/4,809) of participants. Prolonged MV was associated with surgical factors indicative of complexity, such as previous cardiac surgery, cardiopulmonary bypass duration, and separation attempts; and patient factors such as critical preoperative state, left ventricular impairment, renal failure, and pulmonary hypertension. Prolonged MV was associated with perioperative but not long-term complications. After risk adjustment, prolonged MV was associated with perioperative mortality; its association with long-term mortality among survivors was weaker. Shorter durations of MV were not associated with increased risk of mortality or complications.

Conclusion: In this substudy of the TRICS III trial, prolonged MV was common after cardiac surgery and was associated with patient and surgical risk factors. Although prolonged MV showed strong associations with perioperative complications and mortality, it was not associated with long-term complications and had weaker association with long-term mortality among survivors.

Study registration: www.

Clinicaltrials: gov (NCT02042898); registered 23 January 2014. This is a substudy of the Transfusion Requirements in Cardiac Surgery (TRICS) III trial.

Keywords: Critical care; Critical care outcomes; Mechanical; Postoperative complications; Pulmonary medicine; Thoracic surgery; Ventilators.

© 2022. Canadian Anesthesiologists' Society.

Figures

Fig. 1
Fig. 1
Duration of mechanical ventilation
Fig. 2
Fig. 2
Unadjusted survival curves based on mechanical ventilation status
Fig. 3
Fig. 3
Survival among patients ventilated

References

    1. Cohen AJ, Katz MG, Frenkel G, Medalion B, Geva D, Schachner A. Morbid results of prolonged intubation after coronary artery bypass surgery. Chest. 2000;118:1724–1731. doi: 10.1378/chest.118.6.1724.
    1. Engoren M, Buderer NF, Zacharias A. Long-term survival and health status after prolonged mechanical ventilation after cardiac surgery. Crit Care Med. 2000;28:2742–2749. doi: 10.1097/00003246-200008000-00010.
    1. Fernandez-Zamora MD, Gordillo-Brenes A, Banderas-Bravo E, et al. Prolonged mechanical ventilation as a predictor of mortality after cardiac surgery. Respir Care. 2018;63:550–557. doi: 10.4187/respcare.04915.
    1. Trouillet JL, Combes A, Vaissier E, et al. Prolonged mechanical ventilation after cardiac surgery: outcome and predictors. J Thorac Cardiovasc Surg. 2009;138:948–953. doi: 10.1016/j.jtcvs.2009.05.034.
    1. Winkley Shroyer AL, Bakaeen F, Shahian DM, et al. The Society of Thoracic Surgeons Adult Cardiac Surgery database: the driving force for improvement in cardiac surgery. Semin Thorac Cardiovasc Surg. 2015;27:144–151. doi: 10.1053/j.semtcvs.2015.07.007.
    1. Shahian DM, Edwards FH, Ferraris VA, et al. Quality measurement in adult cardiac surgery: part 1—conceptual framework and measure selection. Ann Thorac Surg. 2007;83:S3–12. doi: 10.1016/j.athoracsur.2007.01.053.
    1. Clough RA, Leavitt BJ, Morton JR, et al. The effect of comorbid illness on mortality outcomes in cardiac surgery. Arch Surg. 2002;137:428–433. doi: 10.1001/archsurg.137.4.428.
    1. Kollef MH, Wragge T, Pasque C. Determinants of mortality and multiorgan dysfunction in cardiac surgery patients requiring prolonged mechanical ventilation. Chest. 1995;107:1395–1401. doi: 10.1378/chest.107.5.1395.
    1. Sharma V, Rao V, Manlhiot C, Boruvka A, Fremes S, Wąsowicz M. A derived and validated score to predict prolonged mechanical ventilation in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2017;153:108–115. doi: 10.1016/j.jtcvs.2016.08.020.
    1. Thompson MJ, Elton RA, Mankad PA, et al. Prediction of requirement for, and outcome of, prolonged mechanical ventilation following cardiac surgery. Cardiovasc Surg. 1997;5:376–381. doi: 10.1016/s0967-2109(97)00024-0.
    1. Totonchi Z, Baazm F, Chitsazan M, Seifi S, Chitsazan M. Predictors of prolonged mechanical ventilation after open heart surgery. J Cardiovasc Thorac Res. 2014;6:211–6. doi: 10.15171/jcvtr.2014.014.
    1. Wise ES, Stonko DP, Glaser ZA, et al. Prediction of prolonged ventilation after coronary artery bypass grafting: data from an artificial neural network. Heart Surg Forum. 2017;20:E007–14. doi: 10.1532/hsf.1566.
    1. Zante B, Kubik M, Reichenspurner H. Predictors of prolonged mechanical ventilation after cardiac surgery. Thorac Cardiovasc Surg. 2010;58:P45. doi: 10.1055/s-0029-1246815.
    1. Hessels L, Coulson TG, Seevanayagam S, et al. Development and validation of a score to identify cardiac surgery patients at high risk of prolonged mechanical ventilation. J Cardiothorac Vasc Anesth. 2019;33:2709–2716. doi: 10.1053/j.jvca.2019.03.009.
    1. Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or liberal red-cell transfusion for cardiac surgery. N Engl J Med. 2017;377:2133–2144. doi: 10.1056/nejmoa1711818.
    1. Mazer CD, Whitlock RP, Fergusson DA, et al. Six-month outcomes after restrictive or liberal transfusion for cardiac surgery. N Engl J Med. 2018;379:1224–1233. doi: 10.1056/nejmoa1808561.
    1. Bainbridge D, Cheng D. Current evidence on fast track cardiac recovery management. Eur Heart J Suppl. 2017;19:A3–7. doi: 10.1093/eurheartj/suw053.
    1. Wong WT, Lai VK, Chee YE, Lee A. Fast‐track cardiac care for adult cardiac surgical patients. Cochrane Database Syst Rev 2016; 9: CD003587. 10.1002/14651858.cd003587.pub3
    1. Shehata N, Whitlock R, Fergusson DA, et al. Transfusion requirements in cardiac surgery III (TRICS III): study design of a randomized controlled trial. J Cardiothorac Vasc Anesth. 2018;32:121–129. doi: 10.1053/j.jvca.2017.10.036.
    1. Ball L, Costantino F, Pelosi P. Postoperative complications of patients undergoing cardiac surgery. Curr Opin Crit Care. 2016;22:386–392. doi: 10.1097/mcc.0000000000000319.
    1. Shahian DM, Jacobs JP, Badhwar V, et al. The Society of Thoracic Surgeons 2018 Adult cardiac surgery risk models: part 1—background, design considerations, and model development. Ann Thorac Surg. 2018;105:1411–1418. doi: 10.1016/j.athoracsur.2018.03.002.
    1. O’Brien SM, Feng L, He X, et al. The Society of Thoracic Surgeons 2018 adult cardiac surgery risk models: part 2—statistical methods and results. Ann Thorac Surg. 2018;105:1419–1428. doi: 10.1016/j.athoracsur.2018.03.003.
    1. Nashef SA, Roques F, Sharples LD, et al. EuroSCORE II. Eur J Cardiothorac Surg. 2012;41:734–744. doi: 10.1093/ejcts/ezs043.
    1. Denault AY, Tardif JC, Mazer CD, Lambert J, BART Investigators. Difficult and complex separation from cardiopulmonary bypass in high-risk cardiac surgical patients: a multicenter study. J Cardiothorac Vasc Anesth 2012; 26: 608–16. 10.1053/j.jvca.2012.03.031
    1. Monaco F, Di Prima AL, Kim JH, et al. Management of challenging cardiopulmonary bypass separation. J Cardiothorac Vasc Anesth. 2020;34:1622–1635. doi: 10.1053/j.jvca.2020.02.038.
    1. Sinclair DG, Haslam PL, Quinlan GJ, Pepper JR, Evans TW. The effect of cardiopulmonary bypass on intestinal and pulmonary endothelial permeability. Chest. 1995;108:718–724. doi: 10.1378/chest.108.3.718.
    1. Dekker NA, Veerhoek D, Koning NJ, et al. Postoperative microcirculatory perfusion and endothelial glycocalyx shedding following cardiac surgery with cardiopulmonary bypass. Anaesthesia. 2019;74:609–618. doi: 10.1111/anae.14577.
    1. Giacinto O, Satriano U, Nenna A, et al. Inflammatory response and endothelial dysfunction following cardiopulmonary bypass: pathophysiology and pharmacological targets. Recent Pat Inflamm Allergy Drug Discov. 2019;13:158–173. doi: 10.2174/1872213x13666190724112644.
    1. Gottlieb SS, Abraham W, Butler J, et al. The prognostic importance of different definitions of worsening renal function in congestive heart failure. J Card Fail. 2002;8:136–141. doi: 10.1054/jcaf.2002.125289.
    1. Kjaergaard J, Akkan D, Iversen KK, et al. Prognostic importance of pulmonary hypertension in patients with heart failure. Am J Cardiol. 2007;99:1146–1150. doi: 10.1016/j.amjcard.2006.11.052.
    1. Vincens JJ, Temizer D, Post JR, Edmunds LH, Jr, Herrmann HC. Long-term outcome of cardiac surgery in patients with mitral stenosis and severe pulmonary hypertension. Circulation. 1995;92:137–142. doi: 10.1161/01.cir.92.9.137.
    1. Robitaille A, Denault AY, Couture P, et al. Importance of relative pulmonary hypertension in cardiac surgery: the mean systemic-to-pulmonary artery pressure ratio. J Cardiothorac Vasc Anesth. 2006;20:331–339. doi: 10.1053/j.jvca.2005.11.018.
    1. Suarez-Pierre A, Fraser CD, Zhou X, et al. Predictors of operative mortality among cardiac surgery patients with prolonged ventilation. J Card Surg. 2019;34:759–766. doi: 10.1111/jocs.14118.
    1. Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA. 2002;287:345–355. doi: 10.1001/jama.287.3.345.
    1. Lim ZJ, Subramaniam A, Reddy MP, et al. Case fatality rates for patients with COVID-19 requiring invasive mechanical ventilation. a meta-analysis. Am J Respir Crit Care Med 2021; 203: 54–66. 10.1164/rccm.202006-2405oc
    1. Grant MC, Isada T, Ruzankin P, et al. Results from an enhanced recovery program for cardiac surgery. J Thorac Cardiovasc Surg. 2020;159:1393–1402. doi: 10.1016/j.jtcvs.2019.05.035.
    1. Flynn BC, He J, Richey M, Wirtz K, Daon E. Early extubation without increased adverse events in high-risk cardiac surgical patients. Ann Thorac Surg. 2019;107:453–459. doi: 10.1016/j.athoracsur.2018.09.034.
    1. Richey M, Mann A, He J, et al. Implementation of an early extubation protocol in cardiac surgical patients decreased ventilator time but not intensive care unit or hospital length of stay. J Cardiothorac Vasc Anesth. 2018;32:739–744. doi: 10.1053/j.jvca.2017.11.007.
    1. Gregory AJ. Learning from failure: the future of quality improvement for early extubation. J Cardiothorac Vasc Anesth. 2021;35:1971–1973. doi: 10.1053/j.jvca.2021.03.044.
    1. Goeddel LA, Hollander KN, Evans AS. Early extubation after cardiac surgery: a better predictor of outcome than metric of quality? J Cardiothorac Vasc Anesth. 2018;32:745–747. doi: 10.1053/j.jvca.2017.12.037.
    1. He S, Wu F, Wu X, et al. Ventilator-associated events after cardiac surgery: evidence from 1,709 patients. J Thorac Dis 2018; 10: 776–83. 10.21037/jtd.2018.01.49
    1. Mathis MR, Duggal NM, Likosky DS, et al. Intraoperative mechanical ventilation and postoperative pulmonary complications after cardiac surgery. Anesthesiology. 2019;131:1046–1062. doi: 10.1097/aln.0000000000002909.
    1. Lidén K, Ivert T, Sartipy U. Death in low-risk cardiac surgery revisited. Open Heart. 2020 doi: 10.1136/openhrt-2020-001244.

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere