**3. Stratification of risk using data base**

4 Special Topics in Cardiac Surgery

**PREOPERATIVE EVALUATION OF CARDIAC SURGERY** 

1. History of bleeding: Use of antiplatelet and anticoagulant medication.

3. Vascular examination (carotid, abdominal aneurysm and peripheral pulses)

Patient with serious and incapacitated systemic disease, that constitutes a constant threat for

Dying patient, whose life expectancy does not exceed the 24 hours, is realized or not it to his

Patient with disease, with slight limitation ofordinary physical activity, fatigue, palpitations,

Patient with heart disease, with noticeable limitation of physical activity, less than the

Patient with heart disease, incapacity to walk and physical activity, symptoms of cardiac

There are over 100 studies of perioperatory risk-prognosis stratification that have tried to identify adverse predictive factors, the greater limitation of these studies is that they were realized in a single institution, small groups, or the cardiac experience of the anesthesiologistwas the one taken into account. Between the preoperative risk-prognosis

**History** 

2. Smoking (COPD, bronchospasm).

4. Diabetes (reactions to protamine, prior infection)

4. Heart / Lung (congestive heart failure, new murmur).

Patient with serious, but non incapacitated systemic disease.

Patient with heart disease, without limitations of physical activity.

ordinary physical activity, cause tires, palpitations design or pain angina.

1. Hematologic: PT, PTT, platelets, Hb, Time Ivy. 2. Chemistry: Electrolytes, BUN, QS, PFHS.

3. Alcoholism (cirrhosis)

8. Urologic symptoms.

**Physical Examination.**  1. Skin infection / rash. 2. Dental Caries (dental)

10. Infections (Urol) 11. Allergies

5. Varicose veins. **Laboratories** 

3. Urinalysis.

Chart 2.

the life.

surgery. **NYHA** 

4. Chest X-ray AP and lateral.

Patient with slight systemic disease.

5. Electrocradiogram.

designs or angina pain.

insufficiency, angina.

5. Neurological symptoms. 6. Venous insufficiency.

7. Distal vascular reconstruction.

9. Gastric ulcer or gastrointestinal bleeding.

The basic information of data is used to improve the clinical practice producing reports with validity and application, evaluating the results, optimizing and improving the cares of the patient, the high mortality is identified in a small and specific sub-group classified like of high risk. The obtained results are used to change institutional programs diminishing mortality in patients of high risk like of smaller risk, mainly in patient put under coronary revascularization diminishing the mortality from 4,5% to 1,5%.

The European for System Cardiac Operative Risk Evaluation (EuroSCORE) is a predicting logistic model of hospitable mortality in patients submissive cardiac intervention, starting off of 18 variables of risk and with a coefficient beta associated to each of them, it provides the probability of dying of each individual, this model was created and validated initially in across-sectional study of 19,030 European patients in 1999, and it has become, since then, in the used model more in the world in this type of patients. Most of the authors agree in raising that the Euroscore is a system simple additive that it provides to facultative a tool of easy handling to consider the death risk. A variant of the much more simple logistic model, denominated Euroscore additive, that awards a weight determined to each factor of risk that presents the patient, the sum of these weights exists provides the approximated probability to die.

The interesting exercise to compare logistic Euroscore with additive already has been realized, but in fact it contributes certain confusion, and the conclusions that are obtained are understood easily observing.

The preoperative surgical risk models are made on the basis of cardiac surgery using cardiopulmonary bypass (CPB). However, it can be applied to off-pump cardiac surgery, as evidenced by Vazquez Roque, in a study in 208 patients undergoing bypass surgery without cardiopulmonary bypass and found that the mean EuroSCORE was significantly higher in patients who died. When comparing patients with and without major complications can see that the mean EuroSCORE was also significantly higher in patients with major complications.

Without fatal perioperative morbidity results in an increase of stay in postoperative care unit and overall hospital stay, this increases resource consumption and costs per patient. The EuroSCORE proved to have a discriminating power and acceptable calibration in predicting these events, we can say that Euroscore, despite being designed a risk score based on patients who underwent cardiac surgery using CPB may be used to predict the risk of death and major complications in patients who are going to be revascularized without the use of cardiopulmonary bypass. This is a novel technique that still suffers from risk scores based on the preoperative characteristics of their own patients. The study uses databases Euroscore retrospective studies, to provide predictive models of morbidity, mortality and prolonged stay in the postoperative intensive care unit, which can be used to improve the quality of postoperative care in different institutions is a tool to categorize patients for cardiac surgery in several subgroups.

Intensive Care Management of Patients in the First 24 Hours After Cardiac Surgery 7

and compared with 3.548 patients with Parsonet, Tuman, and Tu, the CARE is a simple risk classification predicts morbidity and mortality on a scale which means ordinary CARE1 low risk, high risk means CARE5 and Care 2-4 as intermediate risk, based on clinical trial

Heart disease stable without other medical problems, surgery scheduled for a low

stable heart disease with one or more controlled medical problems, set to a low-risk

advanced or chronic heart disease, scheduled for cardiac surgery that delayed it can

On-pump bypass also known as cardiopulmonary bypass is a method used in coronary bypass surgery, this device has been used in cardiac surgery since 1960, due to the high incidence of perioperative mortality due to low spending, it is increasingly used in the last decade, increasing its survival up to 60%. Cardiac surgery and cardiopulmonary bypass activate the inflammatory response, characterized by cardiovascular and pulmonary disorders, this inflammatory response that occurs during cardiac surgery is presented by

The extent and duration of the inflammatory response depend on many factors including the composition of the solution pump, the presence of pulsatile perfusion, pharmacological agents used to reduce the response, the use of mechanical filtration, the type of extracorporeal circuit and temperature during cardiopulmonary bypass. During CPB flow decreased splenic occurs, which induces the crossing of endotoxins by the lumen, activating the inflammatory response, endotoxins are potent initiators of the inflammatory cascade,

A frequent complication of systemic inflammatory response is the evolution to multiple organ failure (MOF) including respiratory failure, shock and renal failure, development of FOM is the most important determinant for the postoperative increases those patients who have risk factors such as prolonged mechanical ventilation (intubation ≥ 48 hours), increased volumes of lower urinary nitrogenous and persistence of vasopressors, resulting in an increase in mortality to 41%. The inflammatory response and also condition FOM phenomena of hemolysis, thrombocytopenia and leukopenia, in the first 24 hours of the end of cardiopulmonary bypass can be seen that the total count of leukocytes undergoes an increase with significant changes in the differential count, the leukocytosis persisted in 72 hours, in the differential count reports a significant increase in neutrophils and monocytes and decreased lymphocyte counts during the first days. Postoperative fever in the second and third day in patients undergoing cardiac surgery is accompanied by an increase in neutrophils, two times the initial value during cardiopulmonary bypass activation of neutrophils is manifested by leukocyte sequestration in the pulmonary circulation at the

uncontrolled medical problem, or patient scheduled for surgery high risk.

uncontrolled medical problem, scheduled for surgery high risk.

Contact of blood with the cardiopulmonary bypass machine.

which in turn causes production of cytokines and complement activation.

Development of ischemia and reperfusion injury.

recognized three variables: 21.22

surgical risk.

surgery.

three processes:

Release of endotoxins.

**Scale of anesthetic Cardiac Risk Assessment (CARE).** 

complicate or improve their lives.

**Cardiopulmonary bypass (CBP)** 


Chart 3.

Due to differences in adult cardiac surgery in the countries of Europe the EuroSCORE is responsible for assessing the quality of surgical care, the analysis is performed for each individual to individual and predicting mortality among the countries of the study is were: Germany, England, Spain, Finland, France and Italy. The EuroSCORE model was satisfactory in all countries with a p <0.05, despite epidemiological differences between European countries the discriminative power of EuroSCORE was good in Spain and in other countries excellent. 14, 15,16,17, 18,19,20.
