الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Cardiovascular disease is a major health problem throughout the world and a growing health problem in developing nations. It can be treated by non surgical or surgical interventions. The most common surgical procedures performed in Egypt include coronary artery bypass grafting surgery for coronary arteries diseases and valve repair or replacement surgery for valvular diseases.
Technological advances during the last decades in intensive care medicine made it possible to treat an increasing number of high risk surgical patients. In order to build and maintain cardiac surgery programs, clinicians are faced not only with maximizing clinical efficiency, but also with critically assessing individual patient’s risk and finding ways to more effectively manage high risk patients. Early identifications of patients at risk for negative clinical outcomes will help health team in planning prophylactic measures to reduce ICU stay, minimize complications and mortality after cardiac surgery.
The unique challenge for the critical care nurse is to integrate theoretical knowledge, assessment skills, and problem- solving ability to provide optimal nursing care and maintain high-quality outcomes while decreasing resources consumption. Moreover, identifications of preoperative, intraoperative, and postoperative factors indicating patients clinical outcomes will enable critical care nurses to provide an effective and safe care plan, preventing complications and providing accurate information to patients and their families.
The aim of this study is to identify interdependent perioperative factors affecting the clinical outcome for cardiac surgical patients. A descriptive correlation research design was used to conduct this research. The present study setting included the open-heart intensive care units of Alexandria main university hospital and Shark El Madina hospital. The sample of the current study was included 60 cardiac patients of both sexes aged from 18 to 75 years, who had either coronary artery bypass graft (CABG) or valve replacement surgeries. Two tools were developed and used in this study. Tool one was developed to identify preoperative, intra-operative, and postoperative factors that may affect surgical outcomes. Moreover, the Parsonnet mortality risk score that consisted of 14 preoperative risk factors and categorized studied sample into groups of increasing risk and poor outcome. Patients in the “good outcome” group (Parsonnet score of 0 to 4) had an average mortality of 1%, patients in the “elevated risk” group (Parsonnet score of 5 to 9) had an average mortality of 5%, patients in the “poor outcome ” group (Parsonnet score of 10to 15) had an average mortality of 10%, and patients in the “ very poor outcome and extremely high risk ” group (Parsonnet score of 15to >20) had an average mortality 15% and more. Tool two that was used to assess patients clinical outcomes (length of stay, increase morbidity, and mortality).
The most common results encountered by this research are:
The major characteristics of studied patients were male (63.3%), their mean age were 44.7±15.99 years, 51.7% were single, 63.3% obtained preparatory grade, 43.3% were manual workers, and 51.7% had CABG surgery.
The preoperative factor; the Parsonnet mortality risk score >10 is significantly concomitant with the increase risk for prolonged ICU length of stay >48 hours postoperatively and ICU mortality.
In relation to intraoperative factors and patients outcomes, the current study found significant effect between the number of CABG vessels and cardiac surgery outcome.
A significant relationship was found between nine independent postoperative variables and patients outcomes ; dysrhythmia, hemodynamic changes, the need of intropic support for 48 hours, the number of blood units transfused, the use of antifibrinolytic drug (aprotinin), a depressed level of consciousness(GCS < 7), the intubation period and duration on mechanical ventilations more than 24 hours postoperatively, and fluid balance/ hour.
The postoperative complications were found to be adversely affecting the clinical outcomes; cardiac complications, renal complications, infectious manifestations, pulmonary complications, gastrointestinal complications, and postoperative bleeding.
It can be concluded that several perioperative factors may affect the clinical outcome of cardiac surgical patients (those with prolonged ICU length of stay, increased incidence of morbidity, and mortality) had the preoperative Parsonnet mortality risk score more than 10.Morover, they had CABG surgeries, with postoperative prolonged intubation period, prolonged duration on mechanical ventilation more than 24 hours, and experienced postoperative hemodynamic instability. Furthermore, they experienced depressed level of consciousness (GCS < 7), increased number of blood transfusion units, had negative fluid balance during the second postoperative day, and experienced postoperative supraventricular &ventricular tachyarrthmia. In addition the postoperative use of inotropes >48 hours, and patients received antifibriolytics medication (aprotinin).All these factors may affect the clinical outcome of cardiac surgical patients.
Atrial dysrhythmias, low cardiac output syndrome, neurological deficits, postoperative bleeding, reoperation were the most postoperative complications associated with a prolonged ICU length of stay. On the other hand, pulmonary insufficiency, acute renal failure, gastric bleeding, acute cholecystitis, and postoperative bleeding were the postoperative complications associated with the mortality incidence.
Knowledge of the factors influencing length of ICU stay, increase morbidity, and mortality will enable critical care nurses to develop care plan, anticipate postoperative problems in the high-risk patients, and proportional consumption of hospital resources.
The most important recommendations of this research are:
- Assessment of patients surgical risk for adverse clinical outcomes should be given priority in nursing care plan.
- Providing information for health care providers, patients and families of patients at risk for prolonged ICU length of stay, complications, and deaths following coronary artery bypass and/or heart valve surgery.
- Training programs for critical care nurses for the assessment of perioperative risk factors.
- Establishment of guidelines and policies for nursing assessment & management in cooperation with hospital leaders to prepare high risk patients for early discharge.
- Further research is needed to identify factors affecting surgical outcomes.