Chest
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Post-cardiac surgery atrial fibrillation (AF) places patients at risk for thromboembolism and stroke, while the surgery and cardiopulmonary bypass alter the multiple factors of coagulation and may increase the tendency to bleed. It is in the context of this complex clinical picture that the physician must make decisions regarding the risks and benefits of anticoagulation therapy to lower the risk for thromboembolism and stroke associated with postoperative AF. ⋯ No randomized, controlled clinical trials are available that specifically address the problem of anticoagulation therapy for the postoperative AF. In that context, recommendations are based on the established therapy for nonsurgical situations modified by the potential risk of bleeding in the postoperative patient.
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A comprehensive evidence review was conducted of the medical literature regarding the relationship between intraoperative interventions and the incidence of postoperative atrial arrhythmias, including, most commonly, atrial fibrillation (AF). Fifteen randomized, controlled studies and one large-scale concurrent cohort study were identified that reported on the following issues: systemic temperature during surgery (one report); "beating heart" surgery vs conventional bypass surgery (three reports); type of myocardial protection (five reports); the use of adjunctive posterior pericardiotomy (one report); the use of thoracic epidural anesthesia (TEA) [two reports]; the use of glucose-insulin-potassium (GIK) solutions (two reports); and the use of heparin-coated circuits for cardiopulmonary bypass (CPB) [two reports]. Based on a systematic review of the reported data and an analysis of the quality of the reported data, we recommend the following: (1) that mild hypothermia, rather than moderate hypothermia, may be effective in reducing the frequency of postoperative AF; (2) the use of posterior pericardiotomy may be a useful adjunct to reduce the frequency of postoperative AF; and (3) the use of heparin-coated CPB circuits is associated with less postoperative AF. Because of conflicting or inadequate data, we cannot conclude that the frequency of postoperative AF is affected by (1) the use of beating-heart techniques, (2) the type of myocardial protection strategy used, (3) the use of TEA, or (4) the use of GIK solutions perioperatively.
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A comprehensive evidence review was conducted of the medical literature regarding the relationship between intraoperative interventions and the incidence of postoperative atrial arrhythmias, including, most commonly, atrial fibrillation (AF). Fifteen randomized, controlled studies and one large-scale concurrent cohort study were identified that reported on the following issues: systemic temperature during surgery (one report); "beating heart" surgery vs conventional bypass surgery (three reports); type of myocardial protection (five reports); the use of adjunctive posterior pericardiotomy (one report); the use of thoracic epidural anesthesia (TEA) [two reports]; the use of glucose-insulin-potassium (GIK) solutions (two reports); and the use of heparin-coated circuits for cardiopulmonary bypass (CPB) [two reports]. Based on a systematic review of the reported data and an analysis of the quality of the reported data, we recommend the following: (1) that mild hypothermia, rather than moderate hypothermia, may be effective in reducing the frequency of postoperative AF; (2) the use of posterior pericardiotomy may be a useful adjunct to reduce the frequency of postoperative AF; and (3) the use of heparin-coated CPB circuits is associated with less postoperative AF. Because of conflicting or inadequate data, we cannot conclude that the frequency of postoperative AF is affected by (1) the use of beating-heart techniques, (2) the type of myocardial protection strategy used, (3) the use of TEA, or (4) the use of GIK solutions perioperatively.
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Peripherally inserted central venous catheters (PICCs) are now widely used for intermediate and long-term access in current-day health care, especially in the inpatient setting, where they are increasingly supplanting conventional central venous catheters (CVCs) placed percutaneously into the internal jugular, subclavian, or femoral veins. Data on the risk of PICC-related bloodstream infection (BSI) with PICCs used in hospitalized patients are limited. ⋯ This prospective study shows that PICCs used in high-risk hospitalized patients are associated with a rate of catheter-related BSI similar to conventional CVCs placed in the internal jugular or subclavian veins (2 to 5 per 1,000 catheter-days), much higher than with PICCs used exclusively in the outpatient setting (approximately 0.4 per 1,000 catheter-days), and higher than with cuffed and tunneled Hickman-like CVCs (approximately 1 per 1,000 catheter-days). A randomized trial of PICCs and conventional CVCs in hospitalized patients requiring central access is needed. Our data raise the question of whether the growing trend in many hospital hematology and oncology services to switch from use of cuffed and tunneled CVCs to PICCs is justified, particularly since PICCs are more vulnerable to thrombosis and dislodgment, and are less useful for drawing blood specimens. Moreover, PICCs are not advisable in patients with renal failure and impending need for dialysis, in whom preservation of upper-extremity veins is needed for fistula or graft implantation.
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New-onset atrial fibrillation (AF) occurs frequently after cardiac surgery. The utility of prophylactic atrial pacing to prevent AF following cardiac surgery has been investigated in a number of trials, but clinical guidelines for its use are lacking. Trials of prophylactic atrial pacing to prevent AF following cardiac surgery were identified by searching PubMed, the Cochrane database, selected medical journals, and references in selected articles. ⋯ Prophylactic biatrial pacing (BAP) reduced the incidence of AF significantly in four studies, reduced it nonsignificantly in one study, and had no effect in one study. On the basis of the literature that was reviewed and graded for quality, it was concluded that prophylactic atrial pacing to prevent AF after cardiac surgery is safe. We recommend that BAP be considered, particularly in patients who are at high risk for the development of postoperative AF.