Monday October 09, 2006
Gastrointestinal Complications in Patients Undergoing Heart Operation

An important article published last year in Annals of Surgery 1 and should be read by intensivists working particularly in cardiothoracic units (CT-CV-ICU).

8709 Consecutive Cardiac Surgical Patients were analyzed for gastrointestinal complications. Though GI complications are rare (n = 46 - 0.53%) but need great vigilance of intensivist as these are life saving if identify early. Intensivist should not get deceived if surgery is off-pump 2 or minimally invasive (MIDCAB) 3.


Preoperative predictors of complication were

• Prior cerebrovascular accident (CVA),
• Chronic obstructive pulmonary disease (COPD),
• Heparin-induced thrombocytopenia (Type II),
• Atrial fibrillation,
• Prior myocardial infarction,
• Renal insufficiency,
• Hypertension, and
• need for intra-aortic balloon counter-pulsation (IABP).
  

The most frequent serious GI complication were

• Mesenteric ischemia (n = 31/46 or 67% of patients). 22 Twenty-two were explored and 14 died within 2 days of heart operation. Of the 9 patients with mesenteric ischemia who were not explored, 7 died within 3 days of heart operation.
• Diverticulitis (5/46),
• Pancreatitis (4/46),
• Peptic ulcer disease (4/46), and
• Cholecystitis (2/46).
  

Predictors of death from GI complication included

• New York Heart Association class III and IV heart failure,
• Smoking,
• Chronic obstructive pulmonary disease,
• History of syncope,
• AST more than 600U/L,
• Direct bilirubin more than 2.4mg/dL,
• PH less than 7.30, and
• The need for more than 2 pressors.
  
  Again! The biggest guard is high suspicion and constant vigilance.
  

References: click to get abstract or article

Gastrointestinal Complications in Patients Undergoing Heart Operation - Ann Surg. 2005 June; 241(6): 895–904.

Off-pump coronary artery bypass surgery does not reduce gastrointestinal complications. Eur J Cardiothorac Surg. 2003;23:170 --174

Acute Cholecystitis after Minimally Invasive Coronary Artery Bypass Grafting: A Report 2 Cases - The Heart Surgery Forum, Volume 9, Number 5 / October 2006

Sunday October 08, 2006
Topics you can't afford to miss for Critical Care Board exams - Part 3

Since last 2 weeks we are posting important topics to prepare for our fellows to prepare for Internal Medicine's Critical Care Board exam. Click for Part 1 and Part 2. Here are few more topics.

1. Indication of digibind in Dig toxicity
2. Management of pulmonary artery rupture (one lung ventilation)
3. Atrial fibrillation - Management in stable as well as hemodynamic shock
4. Amiodarone induced 'acute' lung toxicity
5. Identify pneumothorax in CXR
6. Identify central line in arterial system - CXR
7. CT scan picture in late stage ARDS
8. Calculation / formula of required calorie in ICU patient
9. C-diff colitis - identification
10. Identification / risk of DVT and PE in ICU patients
11. Diagnosis of TTP
12. Hepato-toxicity of Quinolones
13. Adjustment of Lovenox in renal failure
14. Hypophosphatemia in TPN
15. Tretment of organophophate poisioning
16. Management of acalculous cholycystitis after CABG.
17. Not to get deceive by mildly elevated BNP.
18. Antibiotic choice in neutropenic fever.
19. Need of Iron in Erythropoetin treatment.
20. Diagnosis of Abdominal compartment syndrome