Marina de Albuquerque Gonçalves Costa

Effects of different PEEP levels on respiratory mechanics and oxygenation after coronary artery bypass grafting.

OBJECTIVE To compare the effects of different levels of positive end-expiratory pressure on respiratory mechanics and oxygenation indexes in the immediate postoperative period of coronary artery bypass grafting. METHODS Randomized clinical trial in which 136 patients underwent coronary artery bypass grafting between January 2011 and March 2012 were divided into three groups and admitted to mechanical ventilation with different positive end-expiratory pressure levels: Group A, 5 cmH2O (n=44), Group B, 8 cmH2O (n=47) and Group C, 10 cmH2O (n=45). Data about respiratory mechanics were obtained from mechanical ventilator monitor and oxygenation indexes from arterial blood gas samples, collected twenty minutes after intensive care unit admission. Patients with chronic obstructive pulmonary disease and patients submitted to off-pump, emergency or combined operations were not included. For statistical analysis, we used Kruskal-Wallis, G and Chi-square tests, considering results significant when P<0.05. RESULTS Groups were homogeneous in terms of demographic, clinical and surgical variables. Patients ventilated with positive end-expiratory pressure of 10 cmH2O (Group C) had best compliance (P=0.04) and airway resistance values, this, however, without statistical significance. They also had best oxygenation indexes, with statistical difference in all analyzed variables, and lower frequency of hypoxemia (P=0.03). CONCLUSION Higher levels of positive end-expiratory pressure in immediate postoperative period of coronary artery bypass grafting improved pulmonary compliance values and increased oxygenation indexes, resulting in lower frequency of hypoxemia.

Factors associated to hypoxemia in patients undergoing coronary artery bypass grafting

INTRODUCTION Hypoxemia is a frequent pulmonary complication in the postoperative coronary artery bypass graft. Detection of factors associated with their occurrence may indicate patients at risk for this complication, which allows tracing specific therapeutic and consequently reduce morbidity and mortality. OBJECTIVE To identify related factors to hypoxemia occurrence in immediate coronary artery bypass graft postoperative. METHODS In this retrospective cohort study, we studied 100 patients submitted to elective om-pump artery bypass graft , between April 2010 and December 2011, at a reference university hospital for cardiac surgery in the state of Maranhão. It was considered hypoxemia gas exchange ratio less than or equal to 300 mmHg. Associated variables with perioperative hypoxemia were defined by the Student T test, G or Mann-Whitney tests, Chi-square, or Fishers exact test and multiple linear regression. RESULTS Among studied variables, high body mass index (P=0.036) and smoking (P=0.024) were significantly associated with hypoxemia in the immediate coronary artery bypass graft postoperative. Hypoxemia incidence in this period was 55% and did not affects mechanical ventilation duration and Intensive Care Unit lengh of stay. CONCLUSION In this sample, body mass index and smoking were associated to hypoxemia. These data reinforce the importance of clinical assessment to identify patients at risk for this complication, considering its high incidence in immediate postoperative period.

Effects of Positive End-Expiratory Pressure on Mechanical Ventilation Duration after Coronary Artery Bypass Grafting: A Randomized Clinical Trial

Patients undergoing cardiac surgery remain on mechanical ventilation postoperatively until they regain consciousness. Positive end-expiratory pressure (PEEP) may influence the duration of mechanical ventilation after coronary artery bypass grafting (CABG). The aim of this study was to compare the effects of different levels of PEEP on the duration of mechanical ventilation after coronary artery bypass grafting. This was a randomized clinical trial with 136 patients undergoing CABG between January 2011 and March 2012. We divided the patients into three groups with different levels of PEEP at the onset of mechanical ventilation: Group A, PEEP=5 cmH2O (n=44); Group B, PEEP=8 cmH2O (n=47) and Group C, PEEP=10 cmH2O (n=45). Mechanical ventilation time was obtained from a Physical Therapy Evaluation Form. We excluded patients with chronic obstructive pulmonary disease and those requiring concomitant, emergency or off-pump surgeries. For statistical analysis, we used the Kruskal-Wallis, G and Chi-square tests, with p<0.05 considered significant. From the point of weaning from mechanical ventilation until 12 hours after intensive care unit (ICU) admission, we saw a statistically different duration of mechanical ventilation between groups (p=0.029). In Group A, the average mechanical ventilation time was 6.7±3.2 hours; it was 6.8±3.3 hours in Group B and 5.1±2.9 hours in Group C. The use of higher levels of PEEP was associated with shorter duration of mechanical ventilation in postoperative CABG patients.

Application of Mechanical Ventilation Weaning Predictors After Elective Cardiac Surgery

OBJECTIVE To test several weaning predictors as determinants of successful extubation after elective cardiac surgery. METHODS The study was conducted at a tertiary hospital with 100 adult patients undergoing elective cardiac surgery from September to December 2014. We recorded demographic, clinical and surgical data, plus the following predictive indexes: static compliance (Cstat), tidal volume (Vt), respiratory rate (f), f/ Vt ratio, arterial partial oxygen pressure to fraction of inspired oxygen ratio (PaO2/FiO2), and the integrative weaning index (IWI). Extubation was considered successful when there was no need for reintubation within 48 hours. Sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were used to evaluate each index. RESULTS The majority of the patients were male (60%), with mean age of 55.4±14.9 years and low risk of death (62%), according to InsCor. All of the patients were successfully extubated. Tobin Index presented the highest SE (0.99) and LR+ (0.99), followed by IWI (SE=0.98; LR+ =0.98). Other scores, such as SP, NPV and LR-were nullified due to lack of extubation failure. CONCLUSION All of the weaning predictors tested in this sample of patients submitted to elective cardiac surgery showed high sensitivity, highlighting f/Vt and IWI.

Relationship between pre-extubation positive end- expiratory pressure and oxygenation after coronary artery bypass grafting

Introduction After removal of endotracheal tube and artificial ventilation, ventilatory support should be continued, offering oxygen supply to ensure an arterial oxygen saturation close to physiological. Objective The aim of this study was to investigate the effects of positive-end expiratory pressure before extubation on the oxygenation indices of patients undergoing coronary artery bypass grafting. Methods A randomized clinical trial with seventy-eight patients undergoing coronary artery bypass grafting divided into three groups and ventilated with different positive-end expiratory pressure levels prior to extubation: Group A, 5 cmH2O (n=32); Group B, 8 cmH2O (n=26); and Group C, 10 cmH2O (n=20). Oxygenation index data were obtained from arterial blood gas samples collected at 1, 3, and 6 h after extubation. Patients with chronic pulmonary disease and those who underwent off-pump, emergency, or combined surgeries were excluded. For statistical analysis, we used Shapiro-Wilk, G, Kruskal-Wallis, and analysis of variance tests and set the level of significance at P<0.05. Results Groups were homogenous with regard to demographic, clinical, and surgical variables. There were no statistically significant differences between groups in the first 6 h after extubation with regard to oxygenation indices and oxygen therapy utilization. Conclusion In this sample of patients undergoing coronary artery bypass grafting, the use of different positive-end expiratory pressure levels before extubation did not affect gas exchange or oxygen therapy utilization in the first 6 h after endotracheal tube removal.

Influence of physiotherapeutic practice in mechanical ventilation process of patients admitted to the ICU overnight after non-complicated cardiac surgery

Este estudo pretendeu verificar se a presenca do fisioterapeuta influencia no processo de ventilacao mecânica de pacientes submetidos a cirurgia cardiaca nao complicada e admitidos em UTI cardiologica no periodo noturno. Trata-se de estudo documental retrospectivo com pacientes adultos submetidos a cirurgia cardiaca e admitidos na UTI no periodo noturno nos meses de novembro de 2010 a outubro de 2011, com assistencia fisioterapeutica por 12 horas (n=51) e entre novembro de 2011 e outubro de 2012, periodo com assistencia fisioterapeutica por 24 horas (n=43), no Hospital Universitario da Universidade Federal do Maranhao. Para analise estatistica, foram utilizados os testes qui-quadrado, t de Student e G, sendo os dados considerados estatisticamente significantes quando p<0,05. A duracao da ventilacao mecânica foi menor quando ocorreu assistencia fisioterapeutica no periodo noturno (6,7±3,7 horas vs. 8,7±3,1 horas, p=0,02). Nesse mesmo periodo, o numero de pacientes extubados em tempo inferior a seis horas tambem foi significativamente maior (53,4% vs. 27,4%, p=0,0182), assim como o numero de extubacoes programadas (79% vs. 43,1%, p=0,009). A atuacao fisioterapeutica influenciou o processo de ventilacao mecânica de pacientes submetidos a cirurgia cardiaca nao complicada e admitidos na UTI no periodo noturno, reduzindo o tempo de ventilacao mecânica e aumentando o numero de extubacoes em tempo inferior a seis horas e o numero de extubacoes programadas durante a noite.ABSTRACT | The aim of this study was to verify the influence of physical therapists on the mechanical ventilation process of patients who underwent non-complicated cardiac surgery admitted to the Cardiac ICU overnight. Documentary and retrospective study with adult patients who underwent cardiac surgery admitted to the ICU overnight from November 2010 to October 2011 with physiotherapeutic care for 12 hours (n=51), and from November 2011 to October 2012 with physiotherapeutic care for 24 hours (n=43), at the University Hospital of the Federal University of Maranhao. For statistical analysis, we used Chi-square, Student’s t, and G tests; data were considered statistically significant when p<0.05. The duration of the mechanical ventilation was lower when physiotherapeutic care occurred at night (6.7±3.7 h vs. 8.7±3.1 h, p=0.02). In this same period, the number of patients extubated in less than 6 hours was also significantly higher (53.4% vs. 27.4%, p=0.0182), as well as the number of scheduled extubations (79% vs. 43.1%, p=0.009). The physiotherapeutic practice influenced the mechanical ventilation process of patients who underwent non-complicated cardiac surgery admitted to the ICU overnight, reducing the time of mechanical ventilation and increasing the number of extubations in less than 6 hours, as well as the number of extubations scheduled during the night.

La influencia de la acción fisioterapéutica en el proceso de ventilación mecánica de pacientes internados en UCI durante el periodo nocturno tras realizar cirugía cardiaca no complicada

Este estudo pretendeu verificar se a presenca do fisioterapeuta influencia no processo de ventilacao mecânica de pacientes submetidos a cirurgia cardiaca nao complicada e admitidos em UTI cardiologica no periodo noturno. Trata-se de estudo documental retrospectivo com pacientes adultos submetidos a cirurgia cardiaca e admitidos na UTI no periodo noturno nos meses de novembro de 2010 a outubro de 2011, com assistencia fisioterapeutica por 12 horas (n=51) e entre novembro de 2011 e outubro de 2012, periodo com assistencia fisioterapeutica por 24 horas (n=43), no Hospital Universitario da Universidade Federal do Maranhao. Para analise estatistica, foram utilizados os testes qui-quadrado, t de Student e G, sendo os dados considerados estatisticamente significantes quando p<0,05. A duracao da ventilacao mecânica foi menor quando ocorreu assistencia fisioterapeutica no periodo noturno (6,7±3,7 horas vs. 8,7±3,1 horas, p=0,02). Nesse mesmo periodo, o numero de pacientes extubados em tempo inferior a seis horas tambem foi significativamente maior (53,4% vs. 27,4%, p=0,0182), assim como o numero de extubacoes programadas (79% vs. 43,1%, p=0,009). A atuacao fisioterapeutica influenciou o processo de ventilacao mecânica de pacientes submetidos a cirurgia cardiaca nao complicada e admitidos na UTI no periodo noturno, reduzindo o tempo de ventilacao mecânica e aumentando o numero de extubacoes em tempo inferior a seis horas e o numero de extubacoes programadas durante a noite.ABSTRACT | The aim of this study was to verify the influence of physical therapists on the mechanical ventilation process of patients who underwent non-complicated cardiac surgery admitted to the Cardiac ICU overnight. Documentary and retrospective study with adult patients who underwent cardiac surgery admitted to the ICU overnight from November 2010 to October 2011 with physiotherapeutic care for 12 hours (n=51), and from November 2011 to October 2012 with physiotherapeutic care for 24 hours (n=43), at the University Hospital of the Federal University of Maranhao. For statistical analysis, we used Chi-square, Student’s t, and G tests; data were considered statistically significant when p<0.05. The duration of the mechanical ventilation was lower when physiotherapeutic care occurred at night (6.7±3.7 h vs. 8.7±3.1 h, p=0.02). In this same period, the number of patients extubated in less than 6 hours was also significantly higher (53.4% vs. 27.4%, p=0.0182), as well as the number of scheduled extubations (79% vs. 43.1%, p=0.009). The physiotherapeutic practice influenced the mechanical ventilation process of patients who underwent non-complicated cardiac surgery admitted to the ICU overnight, reducing the time of mechanical ventilation and increasing the number of extubations in less than 6 hours, as well as the number of extubations scheduled during the night.

Influência da atuação fisioterapêutica no processo de ventilação mecânica de pacientes admitidos em UTI no período noturno após cirurgia cardíaca não complicada

Este estudo pretendeu verificar se a presenca do fisioterapeuta influencia no processo de ventilacao mecânica de pacientes submetidos a cirurgia cardiaca nao complicada e admitidos em UTI cardiologica no periodo noturno. Trata-se de estudo documental retrospectivo com pacientes adultos submetidos a cirurgia cardiaca e admitidos na UTI no periodo noturno nos meses de novembro de 2010 a outubro de 2011, com assistencia fisioterapeutica por 12 horas (n=51) e entre novembro de 2011 e outubro de 2012, periodo com assistencia fisioterapeutica por 24 horas (n=43), no Hospital Universitario da Universidade Federal do Maranhao. Para analise estatistica, foram utilizados os testes qui-quadrado, t de Student e G, sendo os dados considerados estatisticamente significantes quando p<0,05. A duracao da ventilacao mecânica foi menor quando ocorreu assistencia fisioterapeutica no periodo noturno (6,7±3,7 horas vs. 8,7±3,1 horas, p=0,02). Nesse mesmo periodo, o numero de pacientes extubados em tempo inferior a seis horas tambem foi significativamente maior (53,4% vs. 27,4%, p=0,0182), assim como o numero de extubacoes programadas (79% vs. 43,1%, p=0,009). A atuacao fisioterapeutica influenciou o processo de ventilacao mecânica de pacientes submetidos a cirurgia cardiaca nao complicada e admitidos na UTI no periodo noturno, reduzindo o tempo de ventilacao mecânica e aumentando o numero de extubacoes em tempo inferior a seis horas e o numero de extubacoes programadas durante a noite.ABSTRACT | The aim of this study was to verify the influence of physical therapists on the mechanical ventilation process of patients who underwent non-complicated cardiac surgery admitted to the Cardiac ICU overnight. Documentary and retrospective study with adult patients who underwent cardiac surgery admitted to the ICU overnight from November 2010 to October 2011 with physiotherapeutic care for 12 hours (n=51), and from November 2011 to October 2012 with physiotherapeutic care for 24 hours (n=43), at the University Hospital of the Federal University of Maranhao. For statistical analysis, we used Chi-square, Student’s t, and G tests; data were considered statistically significant when p<0.05. The duration of the mechanical ventilation was lower when physiotherapeutic care occurred at night (6.7±3.7 h vs. 8.7±3.1 h, p=0.02). In this same period, the number of patients extubated in less than 6 hours was also significantly higher (53.4% vs. 27.4%, p=0.0182), as well as the number of scheduled extubations (79% vs. 43.1%, p=0.009). The physiotherapeutic practice influenced the mechanical ventilation process of patients who underwent non-complicated cardiac surgery admitted to the ICU overnight, reducing the time of mechanical ventilation and increasing the number of extubations in less than 6 hours, as well as the number of extubations scheduled during the night.

Mortality Risk After Cardiac Surgery: Application of Inscor in a University Hospital in Brazil's Northeast.

Objective To apply the InsCor in patients undergoing cardiac surgery in a university hospital in Brazils northeast. Methods It is a retrospective, quantitative and analytical study, carried out at the University Hospital of the Federal University of Maranhão. InsCor is a remodeling of two risk score models. It evaluates the prediction of mortality through variables such as gender, age, type of surgery or reoperation, exams, and preoperative events. Data from January to December 2015 were collected, using a Physical Therapy Evaluation Form and medical records. Quantitative variables were expressed as mean and standard deviation and qualitative variables as absolute and relative frequencies. Fishers exact and Kruskal-Wallis tests were applied, considering significant differences when P value was < 0.05. Calibration was performed by Hosmer-Lemeshow test. Results One hundred and forty-eight patients were included. Thirty-six percent were female, with mean age of 54.7±15.8 years and mean body mass index (BMI) equal to 25.6 kg/m2. The most frequent surgery was coronary artery bypass grafting (51.3%). According to InsCor, 73.6% of the patients had low risk, 20.3% medium risk, and only 6.1% high risk. In this sample, 11 (7.4%) patients died. The percentage of death in patients classified as low, medium and high risk was 6.3, 7.1% and 11.1%, respectively. Conclusion InsCor presented easy applicability due to the reduced number of variables analyzed and it showed satisfactory prediction of mortality in this sample of cardiac surgery patients.

Effects of Resistance Exercise Applied Early After Coronary Artery Bypass Grafting: a Randomized Controlled Trial

OBJECTIVE To evaluate the effects of resistance exercise applied early after coronary artery bypass grafting. METHODS It is a randomized controlled trial with 34 patients undergoing coronary artery bypass grafting between August 2013 and May 2014. Patients were randomized into two groups by simple draw: a control group (n=17), who received conventional physical therapy and an intervention group (n=17), who received, additionally, resistance exercise. Pulmonary function and functional capacity were evaluated in preoperative period and hospital discharge by spirometry and the six-minute walk test. For statistical analysis, we used the following tests: Shapiro-Wilk, Mann-Whitney, Students t and Fishers exact. Variables with P<0.05 were considered significant. RESULTS Groups were homogeneous in terms of demographic, clinical and surgical variables. Resistance exercise exerted no effect on pulmonary function of intervention group compared to control group. However, intervention group maintained functional capacity at hospital discharge measured by percentage of predict distance in 6MWT (54.122.7% vs. 52.515.5%, P=0.42), while control group had a significant decrease (59.211.1% vs. 50.69.9%, P<0.016). CONCLUSION Our results indicate that resistance exercise, applied early, may promote maintenance of functional capacity on coronary artery bypass grafting patients, having no impact on pulmonary function when compared to conventional physical therapy.