Hyperglycemia in adult cardiac surgery may result in post-operative sternal wound infections, pneumonia, renal failure, increased length of stay, and cost. The Surgical Care Improvement Project (SCIP) (2006) requires blood glucose control in cardiac surgery at 6:00 am on post-operative day one (POD1) and post-operative day two (POD2) to be 200mg/dL or less. Enhanced Recovery After Surgery (ERAS) guidelines use a Maltodextrin 12.5% carbohydrate beverage six hours and two hours pre-operative of general surgery to improve post-operative outcomes, cost, and length of stay. One study replicated ERAS guidelines in adult coronary artery bypass grafting surgery patients finding patients had decreased length of stay and improved glycemic control six hours postoperatively. The purpose of this quality improvement project is to outline a proactive approach to the modifiable risk factor of pre-operative fasting. This quality improvement project describes a pre-operative fasting carbohydrate protocol for non-emergent, adults, scheduled for cardiac surgery at 10:00am or later, with a hemoglobin A1C of 8.4% or less, and a body mass index of 35 or less. The protocol is named the Hungry Sweet Heart Protocol and an implementation plan is described for a community hospital located in Tucson, AZ. Updating practices of strict NPO status prior to cardiac surgery is a proactive measure to improve glycemic control and adherence to SCIP guidelines post-operatively. Interdisciplinary teams, including DNPs, are perfectly suited to guide this implementation.

A substantial number of patients undergoing cardiac surgery are on dual anti-platelet treatment with clopidogrel and aspirin. A disadvantage with this treatment is increased risk of bleeding. Bleeding is a complication of major concern associated with adverse outcome for the patient and increased hospital resource utilization. Great variability in individual response to clopidogrel has been reported. If in vitro measurements of platelet reactivity would correlate with clinical bleeding parameters, potential bleeders could be identified preoperatively. The aims of this thesis were: (1) to describe the degree of pre-operative platelet inhibition in patients scheduled for primary isolated coronary artery bypass graft surgery; (2) to prospectively investigate whether the pre-operative platelet inhibition correlated with intra- and postoperative bleeding and transfusion requirements; and (3) to test the ability of clinically relevant risk factors to predict re-exploration for bleeding. (4) In addition, a cost analysis was performed on patients re-explored for bleeding, to analyse the magnitude of added resource utilization and costs. Based on this, a cost model of prophylactic treatment with haemostatic drugs was calculated. Platelet function tests investigated were: (1) flow cytometry, (2) VASP, (3) VerifyNowSystem, (4) PlateletMapping (a modified TEG), and (5) PFA-100. Clinical risk factors for re-exploration and the influence of antiplatelet and antifibrinolytic therapy were evaluated in a retrospective analysis. Cost analysis at three cardiothoracic centres was performed in a case-control study. In conclusion, there was no clinically useful correlation between preoperative assessment of platelet inhibition and blood loss or transfusion requirements during coronary artery bypass surgery. Furthermore, there was only modest agreement between the methods evaluating ADP-receptor blockade. Pre-operative treatment with the P2Y12-receptor inhibitor clopidogrel was an essential risk factor for re-exploration due to bleeding. Except for clopidogrel, no strong clinical factor to predict the risk of re-exploration was identified. The resource utilisation costs were 47% higher in patients requiring re-exploration due to bleeding than in those not requiring re-exploration. Prolonged stay in the ICU and recovery ward accounted for half of the added cost, a third was due to the costs of surgery, one fifth due to increased cost of transfusions, and <2% was due to haemostatic drug treatment.

Patients undergoing elective surgery typically fast for 8-12 hours before surgery. However, oral preoperative carbohydrate ingestion may increase postoperative insulin sensitivity and reduce complications. To determine the effects of carbohydrate supplementation prior to CABG or spinal surgery, 38 patients were randomized to receive a carbohydrate supplement or to fast for 12 hours preoperatively. Baseline and postoperative measurements of insulin sensitivity were completed using the short insulin tolerance test and homeostasis model assessment (HOMA). Patient discomfort was measured immediately before surgery. Insulin sensitivity was not significantly different between groups. However, the supplemented group experienced a significantly smaller rise in glucose levels following surgery (p=0.03) and had higher postoperative HOMA-β scores (p=0.02). Fasted patients were significantly more thirsty (p=0.01), hungry (p=0.04) and anxious (p=0.01) before surgery and experienced a significantly longer hospital stay (p=0.008). Carbohydrate supplementation improved outcomes, warranting re-evaluation of fasting practices prior to major surgery.

Patients undergoing elective surgery typically fast for 8-12 hours before surgery. However, oral preoperative carbohydrate ingestion may increase postoperative insulin sensitivity and reduce complications. To determine the effects of carbohydrate supplementation prior to CABG or spinal surgery, 38 patients were randomized to receive a carbohydrate supplement or to fast for 12 hours preoperatively. Baseline and postoperative measurements of insulin sensitivity were completed using the short insulin tolerance test and homeostasis model assessment (HOMA). Patient discomfort was measured immediately before surgery. Insulin sensitivity was not significantly different between groups. However, the supplemented group experienced a significantly smaller rise in glucose levels following surgery (p=0.03) and had higher postoperative HOMA-β scores (p=0.02). Fasted patients were significantly more thirsty (p=0.01), hungry (p=0.04) and anxious (p=0.01) before surgery and experienced a significantly longer hospital stay (p=0.008). Carbohydrate supplementation improved outcomes, warranting re-evaluation of fasting practices prior to major surgery.

As infecções em cirurgia cardíaca ainda apresentam um cenário importante nas infecções associadas à assistência a saúde (IAAS), favorecendo ao paciente à aquisição de infecções por micro-organimos multirreristentes. Este trabalho teve como objetivo avaliar o perfil de resistência a antimicrobianos, verificar a presença de genes que codificam as enzimas dos tipos oxacilinases e metalo-beta-lactamases e descrever as características demográficas e clínicas dos pacientes colonziados/infectados por Acinetobacter spp. e P.aeruginosa internados no Centro de Terapia Intensiva Cardíaca do HUPE no período de 2005 a 2010. A maioria das 46 amostras de Acinetobacter spp e das 35 de P.aeruginosa foram de origem respiratória seguido de sangue. A maioria das amostras de A. baumannii apresentou altos percentuais de resistência a: ceftazidina, cefepime, piperacilina-sulbactam, ciprofloxacin, ceftriaxona e CIM &#8805;32 &#956;g/mL para os carbapenêmicos. Uma amostra foi resistente a Polimixina B. O gene blaOXA-23 foi detectado em 65% das amostras e uma amostra apresentou o gene blaOXA-24. Não foram detectados os genes blaOXA-58-like e blaOXA-143. Para P. aeruginosa os percentuais de resistência para todos os antimicrobianos foram inferiores a 32%. Quatro amostras apresentaram resistência intermediária a polimixina B e nenhum gene de resistência foi detectado. Os prontuários dos pacientes foram analisados a fim de associar as características clínicas com os processos infecciosos identificados e seu desfecho clínico. Na análise por tipo de micro-organismo associado ao processo infeccioso à idade acima de 70 anos, DM e uso da ventilação mecânica por tempo prolongado foi maior no grupo dos pacientes que apresentaram infecção por P.aeruginosa. O IAM, a ICC em internações anteriores e suas complicações (choque cardiogênico e arritmia) tiveram impacto na mortalidade na série de pacientes (p<0,05). A insuficiência renal entre todas as comorbidades foi à única que teve associação com a mortalidade (OR= 8,3). Não houve associação entre a mortalidade e o micro-organismo que causou a infecção (Acinetobacter spp. p=0,3 e P.aeruginosa p=0,2) ou a resistência a carbapenêmicos (p=0,5). Foram observados dois casos de mediastinte por Acinetobacter spp. e dois por P. aeruginosa sendo um achado inédito no Brasil até o momento. / Infections in cardiac surgery still have an important scenario infections associated with health assistance(IAHA), favoring acquisition of the patients to infection by microrganisms multiresistants. This work aimed to avaluate the profile of the resistance antimicrobial, to verify the presence of genes encoding enzymes of types oxacilinases and metallo-beta-lactamases and describe demographic and clinical caracteristics of inpatients colonized/infected by Acinetobacter spp. and P. aeruginosa in Cardiac Care Center the Pedro Ernesto University Hospital during the period 2005 to 2010. Most of 46 samples of Acinetobacter spp. and 35 the P. aeruginosa were the respiratory origen and and blood. Most sample A.baumannii showed higher percentages of resistance to: ceftazidime, piperacilin-sulbactam, ciprofloxacin, ceftriaxone and CIM &#8805;32 &#956;g/mL for carbapenems. A sample was resistant a polymyxin B. The gene blaOXA-23 was detected in 65% of the samples and a sample showed gene blaOXA-24.The genes blaOXA-58-like e blaOXA-143 not were detected. For P. aeruginosa the percentage of resistance to all antimicrobials was less than 32%. Four samples showed intermediate resistance to polymyxin B and no gene the resistance was detected.The charts of all patients were analyzed in order to associated the clinical caracteristics with infections processes identified and the clinical outcome. The analyses by type of microrganism associated with infections process over the age of 70 years, DM and use mechanical ventilation for prolonged was higer in the patients with infection by P. aeruginosa. The IAM and the ICC of previous hospitalizations and complications (cardiogenic shock and arrhythmia) had an impact on mortality in series of patients (p<0,05). The renal failure among all comorbitidies was the only one that was associated with mortality (OR=8,3). There was no association between mortality and the organism causing the infection (Acinetobacter spp. p=0,3 and P.aeruginosa p=0,2). Two cases of mediastinitis of Acinetobacter spp. and two cases of P. aeruginosa was observed. It was an umprecedented finding in Brazil at that moment.

Introdução: O ângulo de fase (AF), derivado da análise de bioimpedância elétrica (BIA), tem sido interpretado como indicador de integridade da membrana celular; e a dinamometria manual têm sido usados como indicadores de prognóstico em algumas situações clínicas. Objetivos: avaliar o comportamento do AF e da dinamometria manual em pacientes submetidos à cirurgia cardíaca e associá-los com EuroSCORE e desfechos clínicos. Métodos: Estudo de coorte prospectivo com 50 pacientes submetidos à cirurgia cardíaca, com idade ≥18 anos, entre janeiro de 2015 e outubro de 2015. O AF e a dinamometria manual foram aferidos em três momentos: pré-operatório, pré-alta hospitalar e três meses após à cirurgia. Também foram coletadas as seguintes variáveis: tempo de circulação extracorpórea (CEC), isquemia, ventilação mecânica (VM), tempo de internação na Unidade de Terapia Intensiva (UTI) e tempo de internação hospitalar após à cirurgia e foi calculado o EuroSCORE. Resultados: Os pacientes foram de predominância do sexo masculino 32 (64%) com idade média de 62,8 ± 10,2 anos, tempo de estadia na UTI de 3 dias (2 – 23), tempo de internação pré-operatória de 7 (5 – 61) dias e EuroSCORE 4 (0 – 10) dias. Houve redução do AF, com diferença entre o período pré-operatório e os dois momentos de avaliação no pós-operatório (p<0,001). Quando a dinamometria manual foi avaliada ao longo do tempo foi observada uma redução entre o préoperatório e a pré-alta hospitalar (p<0,001) e recuperação dessa nos três meses após à cirurgia (p<0,001). A VM e o EuroSCORE tiveram correlação inversa com o AF e a dinamometria manual nos três momentos. A correlação do AF no período pré-operatório do EuroScore p=0,007 e o segundo e o terceiro momento p<0,001, e para os três momentos da VM (p<0,001), respectivamente. Já a correlação da dinamometria manual no primeiro e no segundo momento com o EuroSCORE e a VM p <0,001 e no terceiro momento p=0,010 e p=0,018, respectivamente. Conclusões: O AF e a dinamometria manual parecem estar associados ao tempo de VM, tempo de internação na UTI e tempo de internação no pós-operatório em pacientes submetidos à cirurgia cardíaca. / Background and aims: The phase angle (PA), derived from bioelectrical impedance analysis (BIA), have been interpreted as cell membrane integrity indicator; and the handgrip strength (HGS) have been used as prognostic indicators in some clinical situations. This study aims to evaluate the PA and HGS behavior in patients undergoing cardiac surgery and associate these with clinical outcomes and prognostic. Methods: Cohort prospective study of consecutive recruited patients undergoing cardiac surgery aged ≥18 years. The PA and HGS were measured at three set points: preoperatively, hospital predischarge and three months after surgery. Were also collected: time of cardiopulmonary bypass (CPB), ischemia, mechanical ventilation (MV), length of stay (LOS) in Intensive Care Unit (ICU) and LOS after surgery and calculated the EuroSCORE. Results: A decrease in PA was observed between the preoperative and the two postoperative stages (p<0.001). When the HGS was evaluated over time was seen a reduction between preoperative and predischarge (p<0.001) and a recovery in three months after surgery (p<0.001). The MV and EuroSCORE had an inverse association with PA and HGS in three stages. PA correlation in the first stage of the EuroSCORE p=0.007 and the second and third stage p<0.001, and for the three stages of MV (p<0.001), respectively. In HGS correlation in the first and second stage of the EuroSCORE and MV p<0,001 and in the third stage p=0.010 and p=0.018, respectively. Conclusion: PA and HGS appears to be related to MV time, LOS in ICU and LOS after surgery in patients undergoing cardiac surgery.

Cardiac surgery is known to initiate a complex physiological response with the immune system activation (SIRS), neurohormonal response, metabolic changes, coagulopathies etc. SIRS is triggered by tissue injury, myocardial ischemia, reperfusion, use of anaesthesia, cardioplegia, extracorporeal circuit etc. Excessive immune system activation is associated with progression of SIRS, life-threatening multi-organ dysfunction (MOD), and increased morbidity/mortality in the postoperative period. The immune system response is regulated and terminated by both cellular and humoral regulatory and inhibitory mechanisms including changes in expression of in our study monitored molecules: CD200/CD200R, sCD200R and CD95/CD95L. Methods: The study included the measurement the expression of CD95, CD95L, CD200R, and sCD200R molecules in granulocyte and monocyte populations in blood samples of 30 patients who underwent heart surgery using CPB. Samples collected before surgery, after surgery, and in the postoperative period (1st , 3rd , 7th day) were analysed by flow cytometry and sCD200R by ELISA. Results: We discovered a significant increase in the percentage of granulocytes expressing inhibitory molecule CD200R (from 5% to 17.8%) instantly after surgery. It might be presumed that these cells are less susceptible to...

Introdução: O ângulo de fase (AF), derivado da análise de bioimpedância elétrica (BIA), tem sido interpretado como indicador de integridade da membrana celular; e a dinamometria manual têm sido usados como indicadores de prognóstico em algumas situações clínicas. Objetivos: avaliar o comportamento do AF e da dinamometria manual em pacientes submetidos à cirurgia cardíaca e associá-los com EuroSCORE e desfechos clínicos. Métodos: Estudo de coorte prospectivo com 50 pacientes submetidos à cirurgia cardíaca, com idade ≥18 anos, entre janeiro de 2015 e outubro de 2015. O AF e a dinamometria manual foram aferidos em três momentos: pré-operatório, pré-alta hospitalar e três meses após à cirurgia. Também foram coletadas as seguintes variáveis: tempo de circulação extracorpórea (CEC), isquemia, ventilação mecânica (VM), tempo de internação na Unidade de Terapia Intensiva (UTI) e tempo de internação hospitalar após à cirurgia e foi calculado o EuroSCORE. Resultados: Os pacientes foram de predominância do sexo masculino 32 (64%) com idade média de 62,8 ± 10,2 anos, tempo de estadia na UTI de 3 dias (2 – 23), tempo de internação pré-operatória de 7 (5 – 61) dias e EuroSCORE 4 (0 – 10) dias. Houve redução do AF, com diferença entre o período pré-operatório e os dois momentos de avaliação no pós-operatório (p<0,001). Quando a dinamometria manual foi avaliada ao longo do tempo foi observada uma redução entre o préoperatório e a pré-alta hospitalar (p<0,001) e recuperação dessa nos três meses após à cirurgia (p<0,001). A VM e o EuroSCORE tiveram correlação inversa com o AF e a dinamometria manual nos três momentos. A correlação do AF no período pré-operatório do EuroScore p=0,007 e o segundo e o terceiro momento p<0,001, e para os três momentos da VM (p<0,001), respectivamente. Já a correlação da dinamometria manual no primeiro e no segundo momento com o EuroSCORE e a VM p <0,001 e no terceiro momento p=0,010 e p=0,018, respectivamente. Conclusões: O AF e a dinamometria manual parecem estar associados ao tempo de VM, tempo de internação na UTI e tempo de internação no pós-operatório em pacientes submetidos à cirurgia cardíaca. / Background and aims: The phase angle (PA), derived from bioelectrical impedance analysis (BIA), have been interpreted as cell membrane integrity indicator; and the handgrip strength (HGS) have been used as prognostic indicators in some clinical situations. This study aims to evaluate the PA and HGS behavior in patients undergoing cardiac surgery and associate these with clinical outcomes and prognostic. Methods: Cohort prospective study of consecutive recruited patients undergoing cardiac surgery aged ≥18 years. The PA and HGS were measured at three set points: preoperatively, hospital predischarge and three months after surgery. Were also collected: time of cardiopulmonary bypass (CPB), ischemia, mechanical ventilation (MV), length of stay (LOS) in Intensive Care Unit (ICU) and LOS after surgery and calculated the EuroSCORE. Results: A decrease in PA was observed between the preoperative and the two postoperative stages (p<0.001). When the HGS was evaluated over time was seen a reduction between preoperative and predischarge (p<0.001) and a recovery in three months after surgery (p<0.001). The MV and EuroSCORE had an inverse association with PA and HGS in three stages. PA correlation in the first stage of the EuroSCORE p=0.007 and the second and third stage p<0.001, and for the three stages of MV (p<0.001), respectively. In HGS correlation in the first and second stage of the EuroSCORE and MV p<0,001 and in the third stage p=0.010 and p=0.018, respectively. Conclusion: PA and HGS appears to be related to MV time, LOS in ICU and LOS after surgery in patients undergoing cardiac surgery.

Esta dissertação refere-se `a simulação de um sistema de controle em um manipulador robótico para compensação dos movimentos do coração em cirurgias cardíacas minimamente invasivas. No intuito de compensar os movimentos do batimento cardíaco utilizam-se técnicas de controle híbrido de posição/força e dados dos movimentos do coração obtidos in vivo, utilizadas como elementos básicos para a constituição deste sistema. Tópicos de modelagem de manipuladores robóticos e, em especial, a modelagem da relação entre as forças e deslocamentos na superfície do coração compõe a base estrutural. Focalizou-se, ainda, o papel do controle de força em relação `a posição da ferramenta do manipulador na superfície do coração. Pretende-se que a principal contribuição deste trabalho seja demonstrar que o controlador híbrido segue as restrições impostas pela dinâmica do sistema coração-pulmão. / This paper refers to the simulation of a control system for a robotic manipulator to compensate the movements of the heart in minimally invasive cardiac surgery. In order to compensate the motion of the beating heart techniques are used to implement a hybrid position/force controller based on data and the movements of the heart obtained in vivo, used as references to the input of the system. Topics modeling robotic manipulators, and in particular, modeling the relationship between forces and displacements on the surface of the heart comprises the structural basis. The role of power control over the position of the manipulator tool on the surface of the heart. It is intended that the main contribution of this study is to show that the hybrid controller follows the restrictions imposed by the dynamics of the heart-lung system.

Cardivascular diseases are still the major cause of mortality and morbidity in developped countries. From the available demographic datas ageing of population connected with increased number of patients is evident. These cardiovascular patients are treated conservative, interventional and surgical way. In the theoretical part of this work characteristics and patophysiology of ageing is described regarding particular body systems. Then there are mentioned individual diseases of heart which are currently being treated in a surgical way. It mainly deals with ischemic heart disease, disease of aortic, mitral and tricuspid valve and supraventricular arrythmia. There is also a desrciption of pre-operative preparation, course of the surgery and early postoperative period as well as pharmacological and interventionist therapy. Attention is paid to the differences in surgical care about seniors ? determination of operation risk, pre-operative course, operative course and postoperative rehabilitation. Quality of life is also mentioned as the important aspect while evaluating the success rate of treatment of the particular disease. The work gives information about its definition, possibilities of its observing and evaluation during the postoperative period. Last but not least social issues of senior patients are mentioned in the work as well. The research part is focused on the evaluation of the patients´ state during the pre-operative, perioperative and postoperative period. Particular associated diseases, data from the surgery and postoperative complications are also recorded. The research part then deals with the confirmation of individual hypothesis which were performed through the questionnaires before and one year after the surgery. It was answered by 310 patients.