Is continued aggressive care justified in patients requiring mechanical ventilation after a stroke following cardiovascular surgery?

Background and purpose

Ischemic stroke after cardiovascular surgery is a major postoperative event that further complicates ICU care. In many disabled patients who remain ventilated the need for aggressive care is reconsidered. However, the prognosis of patients who survive the acute postoperative phase but require extended ventilatory support due to a stroke is unknown.

Methods

We identified 44 patients with acute ischemic stroke diagnosed after cardiovascular surgery resulting in prolonged endotracheal intubation (>14 days). We collected data on surgical indication, presurgical comorbid conditions, stroke mechanism and location, reason for prolonged intubation, pulmonary complications requiring therapeutic intervention, and duration of ventilatory support and ICU stay. Clinical outcome was defined using the Glasgow outcome scale (GOS). Proportions were compared using the Fisher exact test and continuous variables using the paired t-test.

Results

Coronary revascularization, valvular replacement/repair, and aortic surgery accounted for nearly one-third of the interventions each. Sixty-four percent of the strokes had purely embolic features and 29% had a combination of embolic and hemodynamic features. Most patients (75%) remained intubated due to inability to protect the airway, whereas weaning failure was less common (25%). Thirty-seven failed extubation attempts were recorded and 35% of them resulted in serious complications. Pulmonary complications occurred in 59% of patients, including pneumonia in 52% and ARDS in 12%. In-hospital mortality was 46% and only 9% of patients were functionally independent (GOS 4–5) upon discharge. History of lung disease and smoking was associated with poor functional recovery (P = 0.04). The presence of pulmonary complications was associated with longer ICU stay (34 ± 17 days versus 26 ± 11 days; P = 0.02) and a trend towards longer duration of mechanical ventilation (38 ± 39 days versus 22 ± 11 days; P = 0.16).

Conclusion

Prolonged mechanical ventilation is an important poor prognostic factor in patients who suffer a stroke after cardiovascular surgery. Patients with perioperative stroke who cannot be extubated within the first 2 weeks have a very poor outcome, especially those with pre-existing lung disease. Almost half of the patients die in the hospital and less than one in 10 patients achieve meaningful functional recovery.