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but have focused on mortality and ICU LOS&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">12&#8211;14</span></a> Few studies have paid attention to the ratio of successful extubations and no one has tried to demonstrate the reasons for extubation failure in adult cardiac surgical patients&#46; The aim of this study was to assess whether an intensivist-directed care delivery model could improve the ratio of successful extubation after cardiac surgery and decrease ICU LOS and in-hospital mortality&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Study design</span><p id="par0015" class="elsevierStylePara elsevierViewall">This single-center&#44; retrospective&#44; historical-control study was performed in a cohort of adult patients who underwent cardiac surgery at the Zhongshan Hospital of the Fudan University from March 2015 to June 2016&#46; This is an academic teaching hospital with more than 3000 cardiac surgical procedures per year&#46; In September 2015&#44; the management of CSICU in our hospital was transferred from the department of cardiac surgery to the department of critical care medicine for quality improvement&#46; Thus&#44; a different care delivery model directed by intensivists was adopted&#46; Accordingly&#44; we collected clinical data of patients in the CSICU from March to August 2015 for a phase I group and from September 2015 to June 2016 for a phase II group&#46; In phase I&#44; cardiac surgeons who spent most of their time in the operating room directed the care delivery&#46; Therapy decisions including extubation and discharges from the CSICU were often made before they got into the operation room&#46; The cardiac surgeons managed the patients principally according to their personal experience&#44; with consultant physicians from other departments including radiology&#44; ultrasonography&#44; and respiratory departments&#46; In phase II&#44; intensivists directed the care delivery and were 24<span class="elsevierStyleHsp" style=""></span>h&#47;7 days on duty in the CSICU&#46; Physicians from other departments supported the intensivists and specialized techniques &#40;point of care &#91;POC&#93; ultrasound&#44; fiberoptic scope&#44; and advanced hemodynamic monitoring&#41; were available to them&#46; All intensivists extubated the patients according to the same criteria&#58; clear consciousness&#44; stable hemodynamics&#44; adequate oxygenation&#44; and successful spontaneous breathing trial&#46; The spontaneous breathing trial was carried out using a continuous positive airway pressure or pressure support model&#44; with pressure support at 5<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O and positive end expiratory pressures at 5<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#44; lasting 30&#8211;60<span class="elsevierStyleHsp" style=""></span>min&#46; The patients passed the spontaneous breathing trial if none of the following criteria were present&#58; breathing frequency &#62;35<span class="elsevierStyleHsp" style=""></span>breaths&#47;min&#44; SpO<span class="elsevierStyleInf">2</span> &#60;90&#37;&#44; rapid shallow breathing index &#40;respiratory rate&#47;tidal volume&#41; &#62;105 breaths&#47;min&#47;L&#44; 20&#37; increase or decrease from the baseline heart rate or blood pressure&#44; use of accessory muscles&#44; abdominal paradox movement&#44; substantial agitation&#44; anxiety&#44; and&#47;or diaphoresis&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">15&#44;16</span></a> If the patient was not able to pass the spontaneous breathing trial&#44; the intensivists tried to detect the reason for the failure using disciplinary related practices&#46; The intensivists followed the directive protocol strictly regarding the timing of patient transferring to the ward&#58; &#40;1&#41; weaning from various life support techniques&#59; &#40;2&#41; respiratory and hemodynamic stabilities&#59; &#40;3&#41; lack of severe discomfort feelings&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The primary outcome of this study was the improvement in successful extubations defined as not requiring reintubation within the first 48<span class="elsevierStyleHsp" style=""></span>h after the extubation&#46; The secondary outcomes were the improvement of in-hospital mortality and the reduced ICU LOS&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Population</span><p id="par0025" class="elsevierStylePara elsevierViewall">All consecutive patients older than 18 years&#44; who underwent cardiac surgery between March 2015 and June 2016&#44; were enrolled in this study&#46; We excluded patients who did not undergo surgical treatment&#44; those who died within 24<span class="elsevierStyleHsp" style=""></span>h after surgery&#44; and those readmitted to the CSICU&#46; The Ethical Committee of Zhongshan hospital affiliated to the Fudan University approved this study &#40;NO&#46; B2018-011&#41;&#46; Informed consent forms were not required because this retrospective study did not modify existing diagnostic or therapeutic strategies&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Definitions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Extubation failure was asserted in cases needing reintubation within 48<span class="elsevierStyleHsp" style=""></span>h after extubation&#46; Physicians identified atelectasis and pulmonary edema based on clinical manifestations&#44; chest radiographies and&#47;or ultrasound examinations&#46; Stroke was defined as brain hemorrhage or infarction confirmed by radiographic examinations&#46; CO<span class="elsevierStyleInf">2</span> retention was identified in cases with high arterial blood CO<span class="elsevierStyleInf">2</span> partial pressure and lethargy&#46; The MV duration was defined as the time between ICU admission and the first extubation&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Data collection</span><p id="par0035" class="elsevierStylePara elsevierViewall">The following data were recorded&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Baseline demographic data &#40;age&#44; gender&#44; body mass index&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Patients&#8217; degree of disease severity &#40;Acute Physiology and Chronic Health Evaluation II &#91;APACHE II&#93; score and EuroSCORE&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Type of surgery &#40;valve&#44; coronary artery bypass graft &#91;CABG&#93;&#44; valve and CABG&#44; aortic&#44; congenital and others&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;4&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Postoperative characteristics &#40;renal replacement therapy &#91;RRT&#93;&#44; intra-aortic balloon pump &#91;IABP&#93;&#44; extracorporeal membrane oxygenation &#91;ECMO&#93;&#44; POC ultrasound&#44; fiberoptic scope examination&#44; computed tomography &#91;CT&#93; scan&#44; and Pulse Contour Cardiac Output monitoring system &#91;PiCCO&#93;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#40;5&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Outcome &#40;MV duration&#44; tracheotomy&#44; noninvasive ventilation&#44; successful extubation&#44; ICU LOS&#44; readmission&#44; and in-hospital mortality&#41;&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Statistical methods</span><p id="par0065" class="elsevierStylePara elsevierViewall">Continuous variables were presented as means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD or medians &#40;25&#37;&#8211;75&#37; interquartile ranges&#44; IQRs&#41;&#44; while categorical variables were reported as adjusted proportions&#46; Continuous data were compared using student <span class="elsevierStyleItalic">t</span>-test or the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test as appropriate&#44; while differences between categorical variables were compared using the chi-square test or Fisher&#39;s exact test when necessary&#46; A <span class="elsevierStyleItalic">p</span> value &#60;0&#46;05 was considered statistically significant&#46; Statistical analyses were performed using the stata13&#46;0 and SPSS 22&#46;0 software &#40;IBM Corporation&#44; NY&#44; USA&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Demographic and clinical characteristics of enrolled patients</span><p id="par0070" class="elsevierStylePara elsevierViewall">A total of 4799 patients were enrolled in this study&#46; A patient flowchart was shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; The patients enrolled in the phase I and phase II groups were 1792 and 3007&#44; respectively&#46; Demographic characteristics&#44; APACHE II score&#44; EuroSCORE&#44; surgery type&#44; postoperative characteristics&#44; and outcomes were shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; We found no significant differences between the two phases in terms of age&#44; APACHE II score&#44; EuroSCORE or type of surgery &#40;5 subgroups&#58; valve only&#44; CABG only&#44; valve and CABG&#44; aortic&#44; congenital and others&#41;&#46; The cardiac surgeons did not perform POC ultrasound and fiberoptic scope examinations themselves&#44; nor did they perform advanced hemodynamic monitoring&#46; In phase I&#44; the cardiac surgeons took 33 out of 1792 &#40;1&#46;8&#37;&#41; patients for CT scans&#59; while in phase II&#44; the intensivists took 118 out of 3007 &#40;3&#46;9&#37;&#41; patients for CT scans&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Outcome of enrolled patients</span><p id="par0075" class="elsevierStylePara elsevierViewall">In phase II&#44; patients had a higher ratio of successful extubation &#40;99&#46;2&#37;&#41; than in phase I &#40;98&#46;6&#37;&#41;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;043&#44; together with a shorter median MV time &#40;18 vs&#46; 19<span class="elsevierStyleHsp" style=""></span>h&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The differences in in-hospital mortality between the phase II &#40;1&#46;4&#37;&#41; and phase I &#40;2&#46;1&#37;&#41; and ICU LOS &#40;39 vs&#46; 38<span class="elsevierStyleHsp" style=""></span>h&#41; were not significant&#46; However&#44; the readmission rate in phase II was lower &#40;3&#46;2&#37;&#41; than in phase I &#40;4&#46;7&#37;&#41;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#46; ECMO&#44; RRT or IABP therapies were occasionally used in both phases&#46; Tracheotomy &#40;0&#46;9&#37; vs&#46; 1&#46;1&#37;&#41; and noninvasive ventilation &#40;4&#46;8&#37; vs&#46; 4&#46;5&#37;&#41; were comparable in the two phases as well &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Characteristics of the patients with extubation failure</span><p id="par0080" class="elsevierStylePara elsevierViewall">In phase I&#44; 26 out of 1792 patients were reintubated within 48<span class="elsevierStyleHsp" style=""></span>h after extubation&#44; and in phase II&#44; 25 out of 3007 patients were reintubated within 48<span class="elsevierStyleHsp" style=""></span>h after extubation&#46; Demographic characteristics were comparable between the two phases&#46; There were also no significant differences in terms of the type of surgery&#44; tracheotomy and mortality between the two phases &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; We found significant differences between the two phases concerning the causes of extubation failure &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Characteristics of the patients with MV duration longer than 48<span class="elsevierStyleHsp" style=""></span>h</span><p id="par0085" class="elsevierStylePara elsevierViewall">In phase I&#44; 141 out of 1792 patients &#40;7&#46;9&#37;&#41; received MV for more than 48<span class="elsevierStyleHsp" style=""></span>h whilst in phase II&#44; 245 out of 3007 patients &#40;8&#46;1&#37;&#41; underwent MV for longer than 48<span class="elsevierStyleHsp" style=""></span>h&#46; We found no significant differences in the two phases in terms of age&#44; APACHE II&#44; EuroSCORE and type of surgery&#46; The two phases had patients undergoing similar life support techniques such as RRT&#44; IABP and ECMO&#46; In phase II&#44; the intensivists performed more POC ultrasound and fiberoptic scope examinations&#44; and they also took more patients for CT scans&#46; We found no significant differences between the two phases in terms of MV durations&#44; NIV or tracheotomy&#46; Compared with phase I&#44; phase II had a significantly higher ratio of successful extubations&#44; decreasing in-hospital mortality&#44; readmission rate&#44; and lower ICU LOS &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">In this historical cohort study comparing two different care delivery models in our dedicated CSICU&#44; we found a significant improvement in the ratio of successful extubations in the intensivist-directed care delivery model&#46; Additionally&#44; the MV duration was shorter compared with that in the cardiac surgeon-directed model&#46; The main reason for extubation failure in the phase I group was the presence of adverse respiratory variables such as secretions and atelectasis&#44; while in phase II it was the presence of adverse cardiac variables&#46; Other important clinical outcomes such as ICU LOS and in-hospital mortality were similar between the two groups&#46; However&#44; for the patients whose MV lasted &#62;48<span class="elsevierStyleHsp" style=""></span>h&#44; the ICU LOS and in-hospital mortality were both significantly better in the intensivist-directed care delivery model&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The rate of successful extubations is an important index to evaluate the quality of an ICU&#46; This is especially true in the CSICU because almost all the cardiac surgical patients are admitted with mechanical ventilation postoperatively&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">17&#8211;19</span></a> To successfully extubate a patient&#44; the physicians need to assess not only the pulmonary function but also other organ performances&#46; The main training processes for intensivists and cardiac surgeons are quite different&#46; The intensivists focus mainly on organ support techniques&#44; while the cardiac surgeons care more about surgical related issues&#46; Aging populations present more complicated situations and cardiothoracic critical care has become a new subspecialty requiring a specific curriculum and ICU experience&#44; which is not a specialty of surgical trainees&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">20&#8211;22</span></a> Intensivists perform a more thorough systematic evaluation of the patients and&#44; thus&#44; monitor important variables affecting successful extubation&#46; Studies have shown that systematically evaluating risk factors other than pulmonary mechanics may reduce extubation failure&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">23</span></a> To the best of our knowledge&#44; this is the first study to assess the influence of different care delivery models on the ratio of successful extubation in adult cardiac surgical patients&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In this study&#44; the intensivist-directed care delivery model not only improved the rate of successful extubations but also reduced the MV duration&#46; This may be attributed to the different care delivery models&#46; Although the reason for shorter mechanical ventilation periods during the phase II remained undetermined&#44; our findings were consistent with those of previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">24&#8211;26</span></a> We hypothesize that perhaps it was the intensivists&#8217; presence at the bedside being able to diagnose and treat patients more quickly&#46; And&#44; we suggest that the intensivist-directed care delivery model may facilitate earlier extubations&#46; Patients in phase II received more advanced hemodynamic monitoring and POC examinations&#44; such as bedside ultrasound examination&#46; POC ultrasound can help to quickly identify the causes of weaning failure such as pulmonary edema&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">27</span></a> pneumothorax&#44; pulmonary atelectasis&#44; and even diaphragmatic dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">28</span></a> And&#44; advanced hemodynamical monitoring such as PiCCO also helps in guiding fluid resuscitation&#44; and may lead to earlier extubations in hemodynamic compromised patients&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">29</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The differences of other major clinical outcomes such as in-hospital mortality and ICU LOS were not significant between phase I and phase II patients&#46; This is consistent with studies regarding the influence of transition to a 24&#47;7 in-house intensivist care delivery model on postoperative outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">13&#44;26</span></a> However&#44; other studies have shown that staffing ICUs with intensivists may improve clinical outcomes such as mortality and ICU LOS&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">30&#8211;32</span></a> The mortality and ICU LOS are influenced by many factors&#44; including the population enrolled&#46; More than 90&#37; of our patients were extubated within 48<span class="elsevierStyleHsp" style=""></span>h after the operation&#46; This group of patients displayed very low mortality and were often discharged within 24<span class="elsevierStyleHsp" style=""></span>h after extubation&#44; so their short ICU stay may not have provided enough time to show differences or benefits associated with the type of care received&#46; Additionally&#44; the shorter median MV duration in phase I among all patients was not clinically meaningful&#59; and therefore&#44; we reanalyzed our data in patients whose MV lasted &#62;48<span class="elsevierStyleHsp" style=""></span>h after the operation&#44; and found that reintubations&#44; mortality and ICU LOS were significantly reduced in those in the phase II&#46; Additionally&#44; our data showed that patients with prolonged mechanical ventilation had higher APACHE II scores&#44; and higher frequencies of IABP&#44; RRT&#44; PiCCO or ECMO usage&#46; The predictors of prolonged mechanical ventilation after cardiac surgery include older age&#44; cardiac dysfunction&#44; chronic renal failure&#44; chronic obstructive pulmonary disease&#44; repeated surgery&#44; emergency surgery&#44; higher New York Heart Association&#47;Canadian Cardiovascular Society class&#44; longer cardiopulmonary bypass time&#44; blood product transfusions&#44;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">33</span></a> early postoperative hemodynamic status&#44; and events such as stroke and bacteremia&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">34</span></a> In this study&#44; the possible causes for prolonged mechanical ventilation were the presence of underlying chronic diseases before surgery&#44; hemodynamic instability and surgery related complications&#46; Management of these patients often required a broad view of both cardiac and other organ functions&#46; The more comprehensive management offered by the intensivists may have resulted in the improved outcomes of the patients with prolonged mechanical ventilation in the second phase&#46; Collectively&#44; our results indicate that patients with prolonged mechanical ventilation may get more benefits from the intensivist-directed care delivery model&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The extubation failure may cause increased morbidity and longer ICU LOS&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">35&#44;36</span></a> The main causes of extubation failure include respiratory&#44; cardiac and neurological variables&#44; with respiratory failure being the most common cause&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">37&#8211;39</span></a> However&#44; Forouzan et al&#46; demonstrated that cardiac variables prompt more reintubations after cardiac surgery in adult patients than the respiratory variables&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a> We found significant differences on the causes of extubation failure between the two phase-groups&#46; In phase I&#44; 15 out of the 26 extubation failure cases &#40;57&#46;7&#37;&#41; were reintubated for respiratory reasons&#46; But&#44; respiratory variables such as secretions&#44; bronchospasm&#44; and atelectasis are reversible if managed properly&#46; In phase II&#44; only 6 out of the 25 &#40;24&#37;&#41; extubation failure cases were reintubated for respiratory reasons&#46; The majority of the reintubations were due to life-threatening arrhythmias and cardiac arrest&#44; which typically cannot be prevented and are less amenable to treatment&#46; We propose that intensivists are more skillful in airway management&#46; Intensivists addressed most of the respiratory causes for extubation failure&#44; and thus cardiac variables &#40;56&#37;&#41; became the main cause of extubation failure&#46; Our results indirectly indicate that the intensivist-directed care delivery model in our CSICU was superior to the cardiac surgeon-directed model in terms of patient extubation management&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">We are aware of the limitations of our study&#46; First&#44; this was a retrospective study&#44; so we could not collect and analyze all clinical data details&#44; such as results of POC ultrasound&#44; hemodynamic monitoring and fiberoptic scope examinations&#46; Second&#44; whether the difference in care delivery models and the improved outcomes &#40;reduced MV duration and higher ratio of successful extubation&#41; had a cause-effect relationship remains to be confirmed&#46; Finally&#44; this was a single center study&#44; and the results may not be applicable to other ICUs&#46; Further prospective&#44; multicenter trials are necessary to confirm the conclusions of this study&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">Compared with the cardiac surgeon-directed care delivery model&#44; the intensivist-directed model led to an improved successful extubation rate as well as a shorter duration of MV after cardiac surgery&#46; The intensivist-directed care delivery model is superior and feasible in our CSICU&#44; and should be considered for other CSICUs&#46; Further research will be required before more definitive recommendations can be made&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Author&#39;s contributions</span><p id="par0125" class="elsevierStylePara elsevierViewall">Guang-Wei Hao&#44; Guo-Guang Ma and Bo-Fei Liu performed the literature search&#44; extracted the data and drafted the manuscript&#46; Xiao-Mei Yang&#44; Ying Zhang&#44; Lan Liu&#44; Hua Liu and Ya-Min Zhuang reviewed studies for inclusion and extracted data&#46; Guo-Wei Tu&#44; Du-Ming Zhu and Zhe Luo performed the analysis and helped draft the manuscript&#46; Guo-Wei Tu and Zhe Luo conceived the idea&#44; participated in manuscript writing and revision&#46; All authors have read and approved the final manuscript&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Funding</span><p id="par0130" class="elsevierStylePara elsevierViewall">This article was supported by grants from the <span class="elsevierStyleGrantSponsor" id="gs1">Natural Science Foundation of Shanghai</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs1">16ZR1405600</span>&#41;&#44; the <span class="elsevierStyleGrantSponsor" id="gs2">National Natural Science Foundation of China</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs2">81500067</span>&#41;&#44; the <span class="elsevierStyleGrantSponsor" id="gs3">Health and Family Planning Commission of Shanghai</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs3">20154Y011</span>&#41; and research funds of from the <span class="elsevierStyleGrantSponsor" id="gs4">Zhong Shan Hospital</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs4">2017ZSYXQN23</span> and <span class="elsevierStyleGrantNumber" refid="gs4">2017ZSQN16</span>&#41;&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Demographic and clinical characteristics of enrolled patients"
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              "titulo" => "Outcome of enrolled patients"
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              "titulo" => "Characteristics of the patients with extubation failure"
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              "titulo" => "Characteristics of the patients with MV duration longer than 48 h"
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    "fechaRecibido" => "2018-04-19"
    "fechaAceptado" => "2018-07-02"
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            0 => "Extubaci&#243;n"
            1 => "Cirug&#237;a card&#237;aca"
            2 => "Manejo m&#233;dico"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To compare outcomes between intensivist-directed and cardiac surgeon-directed care delivery models&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This retrospective&#44; historical-control study was performed in a cohort of adult cardiac surgical patients at Zhongshan Hospital &#40;Fudan University&#44; China&#41;&#46; During the first phase &#40;March to August 2015&#41;&#44; cardiac surgeons were in charge of postoperative care while intensivists were in charge during the second phase &#40;September 2015&#8211;June 2016&#41;&#46; Both phases were compared regarding successful extubation rate&#44; intensive care unit &#40;ICU&#41; length of stay &#40;LOS&#41;&#44; and in-hospital mortality&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Tertiary Zhongshan Hospital &#40;Fudan University&#44; China&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Consecutive adult patients admitted to the cardiac surgical ICU &#40;CSICU&#41; after heart surgery&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Interventions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Phase I patients treated by cardiac surgeons&#44; and phase II patients treated by intensivists&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Main variables of interest</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Successful extubation&#44; ICU LOS and in-hospital mortality&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 1792 &#40;phase I&#41; and 3007 patients &#40;phase II&#41; were enrolled&#46; Most variables did not differ significantly between the two phases&#46; However&#44; patients in phase II had a higher successful extubation rate &#40;99&#46;17&#37; vs&#46; 98&#46;55&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;043&#41; and a shorter median duration of mechanical ventilation &#40;MV&#41; &#40;18 vs&#46; 19<span class="elsevierStyleHsp" style=""></span>h&#59; <span class="elsevierStyleItalic">p<span class="elsevierStyleHsp" style=""></span></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; In relation to patients with MV duration &#62;48<span class="elsevierStyleHsp" style=""></span>h&#44; those in phase II had a comparatively higher successful extubation rate &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;033&#41;&#44; shorter ICU LOS &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;038&#41; and a significant decrease in in-hospital mortality &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;039&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The intensivist-directed care model showed improved rates of successful extubation and shorter MV durations after cardiac surgery&#46;</p></span>"
        "secciones" => array:8 [
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        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Comparar el manejo entre intensivistas y cirujanos de pacientes de cirug&#237;a card&#237;aca en la unidad de cuidados intensivos&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dise&#241;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Este estudio de control retrospectivo se llev&#243; a cabo con una cohorte de pacientes adultos de cirug&#237;a card&#237;aca&#46; Durante la primera fase &#40;de marzo a agosto de 2015&#41;&#44; los cirujanos card&#237;acos estuvieron a cargo del manejo m&#233;dico en la unidad&#59; y durante la segunda fase &#40;septiembre de 2015 a junio de 2016&#41;&#44; lo hicieron intensivistas&#46; Comparamos las fases en cuanto al n&#250;mero de extubaciones exitosas&#44; el tiempo de estancia y la mortalidad&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Lugar del estudio</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Hospital Zhongshan de la Universidad de Fudan&#44; China&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Adultos admitidos secuencialmente a la unidad de cuidados intensivos card&#237;acos despu&#233;s de intervenciones quir&#250;rgicas&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Manejo m&#233;dico por cirujanos en la primera fase&#44; y por intensivistas en la segunda fase&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables prioritarias</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Extubaci&#243;n exitosa&#44; tiempo de estancia en la unidad de cuidados intensivos y mortalidad&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Participaron 1&#46;792 pacientes en la fase <span class="elsevierStyleSmallCaps">i</span> y 3&#46;007 en la fase <span class="elsevierStyleSmallCaps">ii</span>&#46; Los pacientes de la fase <span class="elsevierStyleSmallCaps">ii</span> tuvieron m&#225;s extubaciones exitosas &#40;99&#44;17 frente al 98&#44;55&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;043&#41;&#44; y necesitaron menos tiempo de ventilaci&#243;n mec&#225;nica &#40;mediana de 18 frente a 19<span class="elsevierStyleHsp" style=""></span>h&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; De entre los pacientes con ventilaci&#243;n mec&#225;nica de m&#225;s de 48<span class="elsevierStyleHsp" style=""></span>h&#44; los de la fase <span class="elsevierStyleSmallCaps">ii</span>fueron extubados exitosamente m&#225;s veces&#44; tuvieron una estancia m&#225;s corta &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;038&#41;&#44; y una menor mortalidad &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;039&#41;&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">El manejo m&#233;dico por intensivistas aument&#243; significativamente el n&#250;mero de extubaciones exitosas y disminuy&#243; el tiempo de ventilaci&#243;n mec&#225;nica&#46;</p></span>"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; BMI&#44; body mass index&#59; APACHE&#44; Acute Physiology and Chronic Health Evaluation&#59; EuroSCORE&#44; European system for cardiac operative risk evaluation&#59; CABG&#44; coronary artery bypass graft&#59; RRT&#44; renal replacement therapy&#59; IABP&#44; intra-aortic balloon pump&#59; ECMO&#44; extracorporeal membrane oxygenation&#59; POC&#44; point of care&#59; CT&#44; computed tomography&#59; PiCCO&#44; Pulse Contour Cardiac Output monitoring system&#59; MV&#44; mechanical ventilation&#59; NIV&#44; non-invasive ventilation&#59; LOS&#44; length of stay&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">RRT&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">91 &#40;3&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;505&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;0&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14 &#40;0&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;355&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">POC ultrasound&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2368 &#40;78&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Fibreopticscopy&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">216 &#40;7&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">33 &#40;1&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">118 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">PiCCO&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;671&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Diabetes&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;26&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;24&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;811&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Hypertension&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13 &#40;50&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;48&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;886&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">History of cardiac surgery&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">2 &#40;7&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;16&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;357&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Preoperative Hb&#44; g&#47;L</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">131&#46;83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;19&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">123&#46;13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#46;49&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Preoperative SCr&#44; &#956;mol&#47;L</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">84&#46;06<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#46;16&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">104&#46;53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>37&#46;53&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;624&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Preoperative EF&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;832&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NYHA&#44; III&#8211;IV&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">10 &#40;38&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;36&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;856&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">APACHE II score</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">14<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;028&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">EuroSCORE</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;384&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Operative characteristics</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Type of surgery</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;915&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Valve only&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;34&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;32&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">CABG only&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">6 &#40;23&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;20&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Valve</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#43;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">CABG&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">4 &#40;15&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;28&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Aortic&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">3 &#40;11&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;8&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Congenital&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">2 &#40;7&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;4&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Others&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">In hospital mortality&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Atelectasis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cardiac&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">7 &#40;26&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;56&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;035&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pulmonary edema&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cardiac arrest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Life threatening arrhythmias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Neurological&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;15&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">5 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;666&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Stroke and seizure&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CO<span class="elsevierStyleInf">2</span> retention&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">RRT&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">39 &#40;27&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">55 &#40;22&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">IABP&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">4 &#40;2&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">11 &#40;4&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;418&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">ECMO&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;2&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;4&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;175&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">POC ultrasound&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">209 &#40;85&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Fibreopticscopy&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">135 &#40;55&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">CT scan&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">14 &#40;9&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">43 &#40;17&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;042&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">PiCCO&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">22 &#40;9&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">MV time&#44; h</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">84 &#40;66&#44;116&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Tracheotomy&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;9&#46;93&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;5&#46;31&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;086&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NIV&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;19&#46;15&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">62 &#40;25&#46;31&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;167&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Successful extubation&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">126 &#40;89&#46;36&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">233 &#40;95&#46;10&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;033&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">165 &#40;97&#44;391&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">145 &#40;100&#44;221&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;038&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Readmission&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">31 &#40;21&#46;99&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">In hospital mortality&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">21 &#40;14&#46;89&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20 &#40;10&#46;62&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;039&nbsp;\t\t\t\t\t\t\n
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                  """
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      "titulo" => "References"
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          "identificador" => "bibs0015"
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                      "titulo" => "A decade of change &#8211; risk profiles and outcomes for isolated coronary artery bypass grafting procedures&#44; 1990&#8211;1999&#58; a report from the STS National Database Committee and the Duke Clinical Research Institute Society of Thoracic Surgeons"
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