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While extracorporeal membrane oxygenation (ECMO) is an effective method of oxygenation for patients with respiratory failure, further refinement of its incorporation into airway guidelines is needed. We present a case of severe glottic stenosis from advanced thyroid carcinoma in which gas exchange was facilitated by veno-arterial ECMO prior to achieving a definitive airway. We also conducted a systematic review of the MEDLINE, EMBASE, CINAHL, and Web of Science databases, using the keywords “airway/ tracheal obstruction”, “anesthesia”, “extracorporeal”, and “cardiopulmonary bypass” to identify reports where ECMO was initiated as the a priori method of oxygenation during difficult airway management.Thirty-six papers were retrieved discussing the use of ECMO or cardiopulmonary bypass (CPB) for the management of critical airway obstruction. Forty-five patients underwent pre-induction of anesthesia institution of CPB or ECMO for airway obstruction. The patients presenting with critical airway obstruction had a range of airway pathologies with tracheal tumours (31%), tracheal stenosis (20%), and head and neck cancers (20%) being the most common. All cases reported a favourable patient outcome with all patients surviving to hospital discharge without significant complications.While most practitioners are familiar with the fundamental airway techniques of bag-mask ventilation, supraglottic airway use, tracheal intubation, and front-of-neck airway access for oxygenation, these techniques have limitations in managing patients with pre-existing severe airway obstruction. The use of ECMO should be considered in patients with severe (or near-complete) airway obstruction secondary to anterior neck or tracheal disease. This approach can provide essential tissue oxygenation while attempts to secure a definitive airway are carried out in a controlled environment.

Comprehension of risks, benefits and alternative treatment options is poor among patients referred for cardiac surgery interventions. We sought to explore the impact of a formalized shared decision-making (SDM) process on patient comprehension and decisional quality among older patients referred for cardiac surgery. We developed and evaluated a paper-based decision aid for cardiac surgery within the context of a prospective SDM design. Surgeons were trained in SDM through a Web-based program. We acted as decisional coaches, going through the decision aids with the patients and their families, and remaining available for consultation. Patients (aged ≥ 65 yr) undergoing isolated valve, coronary artery bypass graft (CABG) or CABG and valve surgery were eligible. Participants in the non-SDM phase followed standard care. Participants in the SDM group received a decision aid following cardiac catheterization, populated with individualized risk assessment, personal profile and comorbidity status. Both groups were assessed before surgery on comprehension, decisional conflict, decisional quality, anxiety and depression. We included 98 patients in the SDM group and 97 in the non-SDM group. Patients who received decision aids through a formalized SDM approach scored higher in comprehension (median 15.0, interquartile range [IQR] 12.0-18.0) than those who did not (median 9.0, IQR 7.0-12.0, < 0.001). Decisional quality was greater in the SDM group (median 82.0, IQR 73.0-91.0) than in the non-SDM group (median 76.0, IQR 62.0-82.0, < 0.05). Decisional conflict scores were lower in the SDM group (mean 1.76, standard deviation [SD] 1.14) than in the non-SDM group (mean 5.26, SD 1.02, < 0.05). Anxiety and depression scores showed no significant difference between groups. Institution of a formalized SDM process including individualized decision aids improved comprehension of risks, benefits and alternatives to cardiac surgery, as well as decisional quality, and did not result in increased levels of anxiety.

Delirium is a temporary mental disorder that occurs frequently among hospitalized patients. In this study we sought to develop a user-friendly scorecard based on perioperative features to identify patients at risk of developing agitated delirium after cardiac surgery. Retrospective analysis was performed on adult patients undergoing cardiac surgery in a single center. A parsimonious predictive model was created, with subsequent internal validation. Then a simple scorecard was developed that can be used to predict the probability of agitated delirium. Among the 5584 patients who met the study criteria, 614 (11.4%) developed postoperative agitated delirium. Independent predictors of postoperative agitated delirium were age, male gender, history of cerebrovascular disease, procedure other than isolated Coronary Arteries Bypass Surgery, transfusion of blood products within the first 48h, mechanical ventilation for >24h, length of stay in the Intensive Care Unit. The scorecard stratified patients into 4 categories at risk of postoperative agitated delirium ranging from <5% to >30%. Using a large cohort of adult patient's undergoing cardiac surgery, a user-friendly scorecard was developed and validated, which will facilitate the implementation of timely interventions to mitigate adverse effects of agitated delirium in this high risk population. •Cardiac surgery patients are at higher risk of developing agitated delirium.•Agitated delirium after cardiac surgery will impact recovery and increase morbidity.•Early identification of agitated delirium will enable the initiation of early interventions.•Averting agitated delirium will improve the quality of care and optimize outcomes.

Background The use of 1 or more mediastinal chest tubes has traditionally been routine for all cardiac surgery procedures to deal with bleeding. However, it remains unproven whether multiple chest tubes offer a benefit over a single chest tube. Methods All consecutive patients undergoing cardiac surgery (2005–2010) received at least 1 chest tube at the time of surgery based on surgeon preference. Patients were grouped into those receiving a single chest tube (SCT) and those receiving multiple chest tubes (MCT). The primary outcome was return to the operating room for bleeding or tamponade. Results A total of 5698 consecutive patients were assigned to 2 groups: 3045 to the SCT and 2653 to the MCT group. Patients in the SCT group were older, more often female and less likely to undergo isolated coronary artery bypass graft than those in the MCT group. Unadjusted outcomes for SCT and MCT, respectively, were return to the operating room for bleeding or tamponade (4.7% v. 5.0%; p = 0.50), intensive care unit stay longer than 48 hours (25.5% v. 27.9%; p = 0.041, postoperative stay > 9 days (31.5% v. 33.1%; p = 0.20) and mortality (3.8% v. 4.6%; p = 0.16). Logistic regression analysis, adjusted for clinical differences between groups, showed that the number of chest tubes was not associated with return to the operating room for bleeding or tamponade. Conclusion The use of multiple mediastinal chest tubes after cardiac surgery confers no advantage over a single chest tube in preventing return to the operating room for bleeding or tamponade.

Increasingly, patients are being referred for coronary artery bypass grafting (CABG) for management of symptoms after prior percutaneous coronary intervention (PCI). In this study, we assessed the impact of prior PCI on inhospital mortality after CABG. Perioperative data were collected on patients who underwent first-time CABG at 2 surgical centers. Patients who underwent PCI and CABG during the same admission were excluded. Patients with prior PCI were compared with patients with no prior PCI, and the risk-adjusted impact of prior PCI on inhospital mortality after CABG was determined using both multivariate techniques and propensity score matching techniques. Six thousand thirty-two patients met inclusion criteria. Patients with prior PCI were less likely to be between the ages of 70 and 80 ( P < .0001), to have an ejection fraction <0.40 ( P < .0001), and to have 3-vessel/left main disease ( P < .0001). They were, however, more likely to have Canadian Cardiovascular Society class IV symptoms ( P < .0001) and to have an urgent status ( P = .02). Rates of inhospital mortality after CABG were higher in patients with prior PCI (3.6% vs 2.3%, P = .02). Using multivariate techniques, prior PCI emerged as an independent predictor of postoperative inhospital mortality (odds ratio 1.93, P = .003). When patients with prior PCI were matched to patients with no prior PCI using propensity scores, inhospital mortality remained higher among patients with prior PCI (3.6% vs 1.7%, P = .01). Patients with prior PCI presented for CABG with less comorbidity and diminished coronary disease; yet, they had more advanced symptoms and greater urgency. After adjusting for these differences, prior PCI emerged as an independent predictor of inhospital mortality after CABG.

Contexte : La patientèle orientée vers une chirurgie cardiaque n'a pas une bonne compréhension des risques et des avantages de l'intervention ni des autres options thérapeutiques. Nous voulions donc explorer les effets du processus de prise de décision partagée (PDP) sur cette compréhension et sur la qualité des décisions chez la tranche la plus âgée de cette patientèle. Méthodes : Nous avons conçu et évalué un document papier d'aide à la décision concernant les chirurgies cardiaques dans le contexte d'un concept potentiel de PDP. Les chirurgiennes et chirurgiens ont été formés à la PDP dans un programme en ligne. Nous avons assumé le rôle de coachs pour accompagner la patientèle et les familles dans l'usage du matériel d'aide à la décision, et sommes restés disponibles pour des consultations. Les patientes et patients de 65 ans ou plus se préparant à une chirurgie valvulaire, à un pontage aorto-coronarien par greffe, ou à la double intervention étaient admissibles. Les participantes et participants hors du groupe de PDP sont passés par le protocole de soins habituel; celles et ceux du groupe de PDP ont reçu à la suite de leur cathétérisme cardiaque un document d'aide à la décision qui présentait l'évaluation individualisée de leurs risques ainsi que leur profil personnel et leurs comorbidités. Les 2 groupes ont été évalués avant l'intervention chirurgicale sur les plans de la compréhension, du conflit décisionnel, de la qualité des décisions, de l'anxiété et de la dépression. Résultats : Nous avons inclus 98 patientes et patients dans le groupe de PDP et 97 dans le groupe témoin. Il en ressort que la patientèle qui a reçu le matériel d'aide à la décision dans le cadre d'un processus de PDP officiel obtient un meilleur résultat au chapitre de la compréhension (médiane 15,0, écart interquartile [ÉI] 12,0-18,0) que celle de l'autre groupe (médiane 9,0, ÉI 7,0-12, p < 0,001). La qualité des décisions était aussi meilleure chez le groupe de PDP (médiane 82,0, ÉI 73,0-91,0) que le groupe témoin (médiane 76,0, ÉI 62,0-82,0, p < 0,05). Le score de conflit décisionnel était plus bas dans le groupe de PDP (moyenne 1,76, écart type [ÉT] 1,14) que dans l'autre groupe (moyenne 5,26, ÉT 1,02, p < 0,05). Pour ce qui est de l'anxiété et de la dépression, il n'y avait aucune différence significative entre les groupes. Conclusion : Il appert que l'instauration d'un processus officiel de PDP qui s'accompagne de matériel individualisé pour l'aide à la décision améliore à la fois la qualité des décisions et la compréhension des risques et avantages de la chirurgie cardiaque ainsi que des autres options thérapeutiques, et ce, sans venir accroÎtre le niveau d'anxiété.

Objective To date only a few randomized controlled studies have compared grafting strategies in patients with multi-vessel coronary disease. This study represents a pilot RCT designed to test the feasibility of a trial comparing conventional CABG performed with a LIMA-LAD plus saphenous vein grafts (LIMA+SVG) and CABG performed with total arterial grafting (TAG). Methods Consenting patients undergoing non-redo isolated CABG surgery at a single institution were randomized to TAG or LIMA+SVG groups. Exclusion criteria included prior CABG, emergent procedure, concomitant procedure, varicose veins and renal dysfunction. The primary endpoints were: enrolment >20% and completion of CT coronary angiography at 6 months >80%. Statistical investigation was performed on an intention to treat analysis. Results Of 421 eligible patients, 60 were enrolled and 2 withdrew (n = 30 in TAG, n = 28 LIMA+SVG) for 14% enrolment rate. Patient characteristics were similar in each group. No patients died in hospital and adverse events such as MI, stroke and deep sternal wound infection were not significantly different between groups. Clinical follow-up was complete in 100% of patients, with 44/58 (76%) undergoing CT coronary angio at 6 months. Graft occlusion occurred in 2 patients in each group for patency rates of 89% (TAG) and 91% (LIMA+SVG). Conclusions We provide evidence that an RCT comparing grafting strategy is possible but also show that achieving recruitment or follow-up CT may be difficult. Given the excellent patency results and little difference between groups, our findings suggest that the sample size required may make it infeasible to compare graft patency at 6 months as a study end-point. Trial registration Randomized Controlled Trial number: ISRCTN80270323 . Ultra-mini abstract Few RCT’s exist comparing conventional CABG performed with a LIMA-LAD plus saphenous vein grafts (LIMA+SVG) compared to CABG performed with total arterial grafting (TAG). This study is a pilot RCT designed to test the feasibility of such a trial and identify pitfalls.

The use of 1 or more mediastinal chest tubes has traditionally been routine for all cardiac surgery procedures to deal with bleeding. However, it remains unproven whether multiple chest tubes offer a benefit over a single chest tube. All consecutive patients undergoing cardiac surgery (2005–2010) received at least 1 chest tube at the time of surgery based on surgeon preference. Patients were grouped into those receiving a single chest tube (SCT) and those receiving multiple chest tubes (MCT). The primary outcome was return to the operating room for bleeding or tamponade. A total of 5698 consecutive patients were assigned to 2 groups: 3045 to the SCT and 2653 to the MCT group. Patients in the SCT group were older, more often female and less likely to undergo isolated coronary artery bypass graft than those in the MCT group. Unadjusted outcomes for SCT and MCT, respectively, were return to the operating room for bleeding or tamponade (4.7% v. 5.0%; p = 0.50), intensive care unit stay longer than 48 hours (25.5% v. 27.9%; p = 0.041, postoperative stay > 9 days (31.5% v. 33.1%; p = 0.20) and mortality (3.8% v. 4.6%; p = 0.16). Logistic regression analysis, adjusted for clinical differences between groups, showed that the number of chest tubes was not associated with return to the operating room for bleeding or tamponade. The use of multiple mediastinal chest tubes after cardiac surgery confers no advantage over a single chest tube in preventing return to the operating room for bleeding or tamponade. De tout temps, lors de chirurgies cardiaques, on a posé 1 ou plusieurs drains thoraciques médiastinaux pour gérer les saignements. Or, il n’a pas été démontré que la pose de plusieurs drains plutôt que d’un seul confère un avantage. On a posé au moins un drain thoracique à tous les patients consécutifs soumis à une chirurgie cardiaque (2005–2010) au moment de l’intervention, selon la préférence des chirurgiens. Les patients ont été regroupés selon qu’on leur avait posé un seul drain thoracique (SDT) ou plusieurs (PDT). Le paramètre principal était le retour au bloc opératoire pour hémorragie ou tamponnade. En tout 5698 patients consécutifs ont été scindés en 2 groupes: 3045 dans le groupe SDT et 2653 dans le groupe PDT. Les patients du groupe SDT étaient plus âgés, plus souvent de sexe féminin et moins susceptibles de subir un pontage aortocoronarien isolé comparativement au groupe PDT. Les paramètres non ajustés pour les groupes SDT et PDT, respectivement, ont été retour au bloc opératoire pour hémorragie ou tamponnade (4,7 % c. 5,0 %; p = 0,50), séjour de plus de 48 heures à l’unité des soins intensifs (25,5 % c. 27,9 %; p = 0,04), durée du séjour postopératoire > 9 jours (31,5 % c. 33,1 %; p = 0,20) et mortalité (3,8 % c. 4,6 %; p = 0,16). L’analyse de régression logistique ajustée pour tenir compte des différences cliniques entre les groupes a révélé l’absence de lien entre le nombre de drains thoraciques et un retour au bloc opératoire pour hémorragie ou tamponnade. La pose de plusieurs drains thoraciques plutôt que d’un seul après la chirurgie cardiaque ne confère aucun avantage en ce qui concerne le retour au bloc opératoire pour hémorragie ou tamponnade.

There is limited evidence demonstrating the effectiveness of preoperative intraaortic balloon pump (IABP) use in isolated coronary artery bypass graft (CABG) surgery. A single-center randomized trial demonstrated its benefit. We undertook a multicenter observational study to verify this finding. In 29 950 consecutive patients undergoing isolated CABG between 1995 and 2000 at 10 centers, we compared patients with and without a preoperative IABP. We also compared the effect of preoperative IABP use within 7 high-risk clinical subgroups. To validate the previous randomized trial, patients with any 2 of the following were also analyzed: left main >70%, ejection fraction <40%, redo CABG, or preoperative intravenous nitroglycerin. Preoperative IABPs were used in 1896 patients (6.3%). These patients had more comorbid conditions and a higher crude mortality than those who did not have preoperative IABPs (9.5% vs 2.3%, P < .0001). Preoperative IABP patients were caliper matched to non–preoperative IABP patients using a propensity score. Excess mortality associated with preoperative IABP persisted (9.2% vs 5.8%, P = .0004). In 7 high-risk subgroups, mortality was significantly higher with preoperative IABP. We used propensity caliper matching to compare preoperative IABP with non–preoperative IABP patients who met trial criteria (n = 4332). Preoperative IABP was associated with higher mortality (11.0% vs 6.5%, P = .0009). Removing emergency patients did not alter results. Use of preoperative IABPs was consistently associated with higher mortality. Despite detailed statistical analysis, we were unable to show benefit from preoperative IABP use or confirm the results of a single-center trial that demonstrated its benefit. Assessment of preoperative IABP efficacy will require a randomized trial.

Percutaneous coronary intervention (PCI) is increasingly being offered to patients with coronary artery disease. The purpose of this study was to determine the impact of this change in coronary revascularization strategy on PCI and coronary artery bypass grafting (CABG) utilization across Canada. All cases of PCI and isolated CABG between years 1994 and 2005 were identified through the Canadian Institute for Health Information. Age- and sex-standardized rates of PCI and CABG per 100,000 population as well as PCI-to-CABG ratios were calculated by year and province and across age, sex, income, diabetes, and recent acute coronary syndrome subgroups. In addition, risk-adjusted rates of in-hospital mortality after PCI and CABG were reported by year. Between 1994 and 2005, PCI rates increased from 85.6/100,000 to 186.7/100,000 ( P < .001), whereas CABG rates remained stable (75.6/100,000-70.8/100,000; P = .43), resulting in an increase in PCI-to-CABG ratio (1.13-2.64; P < .001). Significant increases in PCI-to-CABG ratios were seen across all provinces (except Newfoundland and Alberta), as well as across all age, sex, income, diabetes, and recent acute coronary syndrome categories. Decline in risk-adjusted in-hospital mortality was seen after both CABG (3.9%-2.2%; P < .001) and PCI (1.6%-1.3%; P < .001) but appeared larger after CABG. Since 1994, rates of PCI have increased significantly as compared to CABG. During the same period, greater declines in risk-adjusted rates of in-hospital mortality were seen among CABG versus PCI patients. Further study is needed to determine the appropriateness of PCI and CABG rates in terms of clinical outcomes and resource utilization.