| 1. |
- Alström, Ulrica, et al.
(författare)
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Cost analysis of re-exploration for bleeding after coronary artery bypass graft surgery
- 2012
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Ingår i: British Journal of Anaesthesia. - : Oxford University Press (OUP): Policy B. - 0007-0912 .- 1471-6771. ; 108:2, s. 216-222
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Tidskriftsartikel (refereegranskat)abstract
- Background. Re-exploration for bleeding after cardiac surgery is an indicator of substantial haemorrhage and is associated with increased hospital resource utilization. This study aimed to analyse the costs of re-exploration and estimate the costs of haemostatic prophylaxis. less thanbrgreater than less thanbrgreater thanMethods. A total of 4232 patients underwent isolated, first-time, coronary artery bypass graft (CABG) surgery during 2005-8. Each patient re-explored for bleeding (n = 127) was matched with two controls not requiring re-exploration (n = 254). Cost analysis was based on resource utilization from completion of CABG until discharge. A mean cost per patient for re-exploration was calculated. Based on this, the net cost of prophylactic treatment with haemostatic drugs for preventing re-exploration was calculated. less thanbrgreater than less thanbrgreater thanResults. Patients undergoing re-exploration had higher exposure to clopidogrel before operation, prolonged stays in the intensive care unit, and more blood transfusions than controls. The mean incremental cost for re-exploration was (sic)6290 [95% confidence interval (CI) (sic)3408-(sic)9173] per patient, of which 48% [(sic)3001 (95% CI (sic)249-(sic)2147)] was due to prolonged stay, 31% [(sic)1928 (95% CI (sic)1710-(sic)2147)] to the cost of surgery/anaesthesia, 20% [(sic)1261 (95% CI (sic)1145-(sic)1378)] to the increased number of blood transfusions, and andlt;2% [(sic)100 (95% CI (sic)39-(sic)161)] to the cost of haemostatic drugs. A cost model, at an estimated 50% efficacy for recombinant activated clotting factor VIIa and a 50% expected risk for re-exploration without prophylaxis, demonstrated that to be cost neutral, prophylaxis of four patients needed to result in one avoided re-exploration. less thanbrgreater than less thanbrgreater thanConclusions. The resource utilization costs were substantially higher in patients requiring re-exploration for bleeding. From a strict cost-effectiveness perspective, clinical interventions to prevent haemorrhage might be underutilized.
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| 2. |
- Eriksson, Jenny, et al.
(författare)
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Functional impairment after treatment with pectoral muscle flaps because of deep sternal wound infection
- 2011
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Ingår i: Scandinavian Cardiovascular Journal. - : Informa Healthcare. - 1401-7431 .- 1651-2006. ; 45:3, s. 174-180
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Tidskriftsartikel (refereegranskat)abstract
- Objective. Pectoral muscle flaps (PMF) are effective in terminating protracted sternal wound infections (SWI) but long-term outcome remains uncertain. Therefore, the aim of this study was to evaluate long-term outcome in patients treated with PMF. Design. Thirty-four of 263 patients revised because of deep SWI from 1991-2005 were treated with PMF. Of the 21 patients alive, 11 had left-sided, two right-sided and eight bilateral procedures. Sternal debridement without closure of the sternum was done in 17 patients. Nineteen of 21 patients responded to a questionnaire. Results. At follow-up on average 5.9 years (range 1.9-14.8 years) after surgery 63% (12/19) experienced unstable chest. Two thirds (12/18) reported problems carrying a grocery bag and 37% (7/19) had problems putting on a coat. Reduction of power and mobility was more common in the right arm and shoulder even in patients with left-sided PMF. Thirty-two percent (6/19) would have preferred alternative treatment if possible to avoid sternal instability even if healing had been substantially delayed. Conclusions. Surgery with PMF and sternal debridement was associated with long-term disability, which appeared to be significant in one third of the patients. The function of the right arm and shoulder was affected more often despite the majority of procedures being left-sided suggesting that loss of skeletal continuity of the chest wall is more disabling than loss of pectoral muscle function.
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| 3. |
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| 4. |
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| 5. |
- Holm, Jonas, et al.
(författare)
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EuroSCORE II and N-terminal pro-B-type natriuretic peptide for risk evaluation : an observational longitudinal study in patients undergoing coronary artery bypass graft surgery
- 2014
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Ingår i: British Journal of Anaesthesia. - : Oxford University Press. - 0007-0912 .- 1471-6771. ; 113:1, s. 75-82
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Tidskriftsartikel (refereegranskat)abstract
- Background: Postoperative heart failure remains the major cause of death after cardiac surgery. As N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a predictor for postoperative heart failure, the aim was to evaluate if preoperative NT-proBNP could provide additional prognostic information to the recently launched EuroSCORE II.Methods: A total of 365 patients with acute coronary syndrome (ACS) undergoing isolated coronary artery bypass graft (CABG) surgery were studied prospectively. Preoperative NT-proBNP and EuroSCORE II were evaluated with regard to severe circulatory failure after operation according to prespecified criteria. To assess what clinical outcomes are indicated by NT-proBNP levels in different risk categories, the patients were stratified according to EuroSCORE II. Based on receiver operating characteristics analysis, these cohorts were assessed with regard to preoperative NT-proBNP below or above 1028 ng litre(-1). The follow-up time averaged 4.4 (0.7) yr.Results: Preoperative NT-proBNP >= 1028 ng litre(-1) [odds ratio (OR) 9.9,95% confidence interval (CI) 1.01-98.9; P=0.049] and EuroSCORE II (OR 1.24, 95% CI 1.06-1.46; P=0.008) independently predicted severe circulatory failure after operation. In intermediate-risk patients (EuroSCORE II 2.0-10.0), NT-proBNP >= 1028 ng litre(-1) was associated with a higher incidence of severe circulatory failure (6.6% vs 0%; P=0.007), renal failure (14.8% vs 5.4%; P=0.03), stroke (6.6% vs 0.7%; P=0.03), longer intensive care unit stay [37 (35) vs 27 (38) h; P=0.002], and worse long-term survival.Conclusions: Combining EuroSCORE II and preoperative NT-proBNP appears to improve risk prediction with regard to severe circulatory failure after isolated CABG for ACS. NT-proBNP may be particularly useful in patients at intermediate risk according to EuroSCORE II.
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| 6. |
- Holm, Jonas, 1971-
(författare)
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Markers of hemodynamic state and heart failure as predictors for outcome in cardiac surgery : with special reference to mixed venous oxygen saturation and natriuretic peptides
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Postoperative heart failure or low cardiac output syndrome is the major cause for morbidity and mortality in cardiac surgery. Unfortunately commonly used methods to assess hemodynamic state and heart failure are not well documented with regard to outcome. The aim for this dissertation was to study the predictive values of postoperative Mixed Venous Oxygen saturation (SvO2) and preoperative NT-proBNP for outcomes related to postoperative heart failure.SvO2 was studied retrospectively in two cohorts of patients, one cohort operated with isolated Aortic Valve Replacement (AVR) for aortic stenosis, (n=396) and one operated with isolated Coronary Artery Bypass Grafting (CABG), (n=2755). SvO2 measured early after surgery, on admission to the intensive care unit (ICU), predicted postoperative morbidity and mortality. Our results suggest that, on admission to ICU SvO2 < 55 - 60% after AVR and SvO2 < 60% after CABG merits increased attention.Preoperative NT-proBNP was studied in a cohort of patients with acute coronary syndrome (ACS) undergoing CABG with or without concomitant procedure. These patients (n=383) were included prospectively and evaluated with regard to mortality and severe circulatory failure postoperatively by an end-points committee blinded to NT-proBNP results. Preoperative NT-proBNP ≥ 1028 ng/L independently predicted increased risk for severe circulatory failure postoperatively in patients with ACS undergoing isolated CABG. Preoperative NT-proBNP provided additional prognostic information to EuroSCORE II in this cohort, particularly in patients at intermediate risk. Preoperative NT-proBNP appears to be markedly higher in patients having CABG with concomitant procedures than in patients undergoing isolated CABG. Further studies are warranted to identify preoperative NTproBNP risk thresholds for different heart conditions and surgery-specific cohorts.In conclusion this dissertation shows that:Postoperative SvO2 on admission to ICU is a prognostic marker for morbidity and mortality after AVR and CABG.Preoperative NT-proBNP ≥ 1028 ng/L independently predicts severe circulatory failure postoperatively in patients undergoing isolated CABG and provides additional prognostic information to EuroSCORE II.The high negative predictive value of the identified cutoff levels for preoperative NTproBNP and postoperative SvO2 could be useful for pre and postoperative decisionmaking.
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| 7. |
- Holm, Jonas, et al.
(författare)
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Mixed venous oxygen saturation is a prognostic marker after surgery for aortic stenosis
- 2010
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Ingår i: ACTA ANAESTHESIOLOGICA SCANDINAVICA. - : Blackwell Publishing Ltd. - 0001-5172 .- 1399-6576. ; 54:5, s. 589-595
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Tidskriftsartikel (refereegranskat)abstract
- Background Adequate monitoring of the hemodynamic state is essential after cardiac surgery and is vital for medical decision making, particularly concerning hemodynamic management. Unfortunately, commonly used methods to assess the hemodynamic state are not well documented with regard to outcome. Mixed venous oxygen saturation (SvO(2)) was therefore investigated after cardiac surgery. Methods Detailed data regarding mortality were available on all patients undergoing aortic valve replacement for isolated aortic stenosis during a 5-year period in the southeast region of Sweden (n=396). SvO(2) was routinely measured on admission to the intensive care unit (ICU) and registered in a database. A receiver operating characteristics (ROC) analysis of SvO(2) in relation to post-operative mortality related to cardiac failure and all-cause mortality within 30 days was performed. Results The area under the curve (AUC) was 0.97 (95% CI 0.96-1.00) for mortality related to cardiac failure (P=0.001) and 0.76 (95% CI 0.53-0.99) for all-cause mortality (P=0.011). The best cutoff for mortality related to cardiac failure was SvO(2) 53.7%, with a sensitivity of 1.00 and a specificity of 0.94. The negative predictive value was 100%. The best cutoff for all-cause mortality was SvO(2) 58.1%, with a sensitivity of 0.75 and a specificity of 0.84. The negative predictive value was 99.4%. Post-operative morbidity was also markedly increased in patients with a low SvO(2). Conclusion SvO(2), on admission to the ICU after surgery for aortic stenosis, demonstrated excellent sensitivity and specificity for post-operative mortality related to cardiac failure and a fairly good AUC for all-cause mortality, with an excellent negative predictive value.
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| 8. |
- Holm, Jonas, et al.
(författare)
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Mixed venous oxygen saturation predicts short- and long-term outcome after coronary artery bypass grafting surgery: a retrospective cohort analysis
- 2011
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Ingår i: British Journal of Anaesthesia. - : Oxford University Press (OUP). - 0007-0912 .- 1471-6771. ; 107:3, s. 344-350
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Tidskriftsartikel (refereegranskat)abstract
- Background. Complications of an inadequate haemodynamic state are a leading cause of morbidity and mortality after cardiac surgery. Unfortunately, commonly used methods to assess haemodynamic status are not well documented with respect to outcome. The aim of this study was to investigate SV(O2) as a prognostic marker for short-and long-term outcome in a large unselected coronary artery bypass grafting (CABG) cohort and in subgroups with or without treatment for intraoperative heart failure. less thanbrgreater than less thanbrgreater thanMethods. Two thousand seven hundred and fifty-five consecutive CABG patients and subgroups comprising 344 patients with and 2411 patients without intraoperative heart failure, respectively, were investigated. SV(O2) was routinely measured on admission to the intensive care unit (ICU). The mean (SD) follow-up was 10.2 (1.5) yr. less thanbrgreater than less thanbrgreater thanResults. The best cut-off for 30 day mortality related to heart failure based on receiver-operating characteristic analysis was SV(O2) 60.1%. Patients with SV(O2) andlt;60% had higher 30 day mortality (5.4% vs 1.0%; P andlt; 0.0001) and lower 5 yr survival (81.4% vs 90.5%; P andlt; 0.0001). The incidences of perioperative myocardial infarction, renal failure, and stroke were also significantly higher, leading to a longer ICU stay. Similar prognostic information was obtained in the subgroups that were admitted to ICU with or without treatment for intraoperative heart failure. In patients admitted to ICU without treatment for intraoperative heart failure and SV(O2) andgt;= 60%, 30 day mortality was 0.5% and 5 yr survival 92.1%. less thanbrgreater than less thanbrgreater thanConclusions. SV(O2) andlt;60% on admission to ICU was related to worse short- and long-term outcome after CABG, regardless of whether the patients were admitted to ICU with or without treatment for intraoperative heart failure.
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| 9. |
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| 10. |
- Holm, Jonas, et al.
(författare)
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Preoperative NT-proBNP independently predicts outcome in patients with acute coronary syndrome undergoing CABG
- 2013
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Ingår i: Scandinavian Cardiovascular Journal. - : Informa Healthcare. - 1401-7431 .- 1651-2006. ; 47:1, s. 28-35
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Tidskriftsartikel (refereegranskat)abstract
- Objectives. The predictive value of preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) was evaluated in patients with acute coronary syndrome undergoing coronary artery bypass grafting (CABG). Design. As a substudy to a clinical trial 383 patients with acute coronary syndrome undergoing CABG were studied. 17 patients had a concomitant procedure. NT-proBNP was measured immediately preoperatively and evaluated with regard to in-hospital mortality, and severe circulatory failure postoperatively according to prespecified criteria. Follow-up was 3.2 +/- 0.9 years. Results. In patients with isolated CABG, receiver operating characteristics (ROC) analysis showed an area under the curve (AUC) of 0.82 for in-hospital mortality and 0.87 for severe circulatory failure respectively with a best cut-off for preoperative NT-proBNP of 1028 ng/L. This cut-off level independently predicted severe circulatory failure. Patients with NT-proBNP andlt; 1028 ng/L had significantly better long-term survival (p = 0.004). Preoperative NT-proBNP was higher in patients with concomitant procedure than isolated CABG (2146 +/- 1858 v 887 +/- 1635 ng/L; p = 0.0005). In patients with concomitant procedure ROC analysis showed an AUC of 0.93 for severe circulatory failure with a best cut-off for preoperative NT-proBNP of 3145 ng/L. Conclusions. Preoperative NT-proBNP predicted in-hospital mortality, severe circulatory failure postoperatively and long-term survival in patients undergoing surgery for acute coronary syndrome but a higher threshold was found in patients having concomitant procedures.
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