Working Group on Arrhythmia Surgery and Cardiac Pacing of the Spanish Society for Cardiovascular and Thoracic Surgery (SECTCV). A multicentre Spanish study for multivariate prediction of perioperative in-hospital cerebrovascular accident after coronary bypass surgery: The PACK2 score

Servicio de Cirugía Cardiaca, Instituto Cardiovascular, Hospital General Universitario, Valencia, Spain.
Interactive Cardiovascular and Thoracic Surgery (Impact Factor: 1.16). 04/2013; 17(2). DOI: 10.1093/icvts/ivt102
Source: PubMed


To develop a multivariate predictive risk score of perioperative in-hospital stroke after coronary artery bypass grafting (CABG) surgery.METHODA total of 26 347 patients were enrolled from 21 Spanish hospital databases. Logistic regression analysis was used to predict the risk of perioperative stroke (ictus or transient ischaemic attack). The predictive scale was developed from a training set of data and validated by an independent test set, both selected randomly. The assessment of the accuracy of prediction was related to the area under the ROC curve. The variables considered were: preoperative (age, gender, diabetes mellitus, arterial hypertension, previous stroke, cardiac failure and/or left ventricular ejection fraction <40%, non-elective priority of surgery, extracardiac arteriopathy, chronic kidney failure and/or creatininemia ≥2 mg/dl and atrial fibrillation) and intraoperative (on/off-pump).RESULTSGlobal perioperative stroke incidence was 1.38%. Non-elective priority of surgery (priority; OR = 2.32), vascular disease (arteriopathy; OR = 1.37), cardiac failure (cardiac; OR = 3.64) and chronic kidney failure (kidney; OR = 6.78) were found to be independent risk factors for perioperative stroke in uni- and multivariate models in the training set of data; P < 0.0001; AUC = 0.77, 95% CI 0.73-0.82. The PACK2 stroke CABG score was established with 1 point for each item, except for chronic kidney failure with 2 points (range 0-5 points); AUC = 0.76, 95% CI 0.72-0.80. In patients with PACK2 score ≥2 points, off-pump reduced perioperative stoke incidence by 2.3% when compared with on-pump CABG.CONCLUSIONSPACK2 risk scale shows good predictive accuracy in the data analysed and could be useful in clinical practice for decision making and patient selection.

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    • "Glycemic management is an important predictor of outcomes in patients undergoing CABG.[4567891011121314] Presence of diabetes is a risk factor for deep sternal wound infections DSWI[45] Although, earlier studies showed an association of diabetes with short-term morbidity and mortality in patients undergoing CABG, with improved hyperglycemia management, the immediate outcome in patients with diabetes is similar to those without diabetes.[67] "
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    ABSTRACT: Hyperglycemia is common in patients undergoing cardiac surgery and is associated with poor outcomes. This is a review of the perioperative insulin protocol being used at Medanta, the Medicity, which has a large volume cardiac surgery setup. Preoperatively, patients are usually continued on their preoperative outpatient medications. Intravenous insulin infusion is intiated postoperatively and titrated using a column method with a choice of 7 scales. Insulin dose is calculated as a factor of blood glucose and patient’s estimated insulin sensitivity. A comparison of this protocol is presented with other commonly used protocols. Since arterial blood gas analysis is done every 4 hours for first two days after cardiac surgery, automatic data collection from blood gas analyzer to a central database enables collection of glucose data and generating glucometrics. Data auditing has helped in improving performance through protocol modification.
    07/2014; 18(4):455. DOI:10.4103/2230-8210.137486

  • Interactive Cardiovascular and Thoracic Surgery 08/2013; 17(2):358. DOI:10.1093/icvts/ivt246 · 1.16 Impact Factor
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    ABSTRACT: Aim: Inpatient hyperglycemia management is essential, but difficult to achieve especially in a large volume cardiac surgery setup, thus necessitating use of nurse‐led insulin protocols. A rapid flux of nurses dealing with a huge workload has been a cause for traditionally not using nurse-led protocols in most Indian institutes. The challenges we faced were to have a simple protocol for the nurses to accept it without compromising on glycemic control. Therefore, this observational study was planned to measure the efficacy and safety of the insulin infusion protocol in cardiac surgery patients. Materials and Methods: Insulin protocol was implemented, using seven fixed columns of infusion with the nurse making decisions to initiate and titrate doses based on simple rules. Blood glucose (BG) data captured from blood gas analyzers (glucometrics) in the intervention group (i.e., after protocol implementation) were compared to control group (i.e., before the protocol implementation). Results: The mean BG for the first 48 h was lower in the intervention group as compared to control group, without an increase in the episodes of hypoglycemia. The nurses found the protocol easy to understand, less time-consuming and there was no protocol deviation over 8 months after implementation. Conclusion: A small change in the process, allowing nurses to titrate insulin doses based on some rules and having seven fixed columns of insulin infusion rates, improved glycemic control and efficiency.
    01/2015; 19(1):45. DOI:10.4103/2230-8210.146864