Clinical benefit of steroid use in patients undergoing cardiopulmonary bypass: a meta-analysis of randomized trials

Steroids for surgery during cardiopulmonary bypass in adults: a meta-analysis

STUDY OBJECTIVE

To evaluate the effect of steroid administration on myocardial infarction (MI), stroke, renal insufficiency, death, intensive care (ICU) length of stay (LOS) and hospital LOS of patients undergoing cardiopulmonary bypass (CPB).

DESIGN

Meta-analysis of parallel randomized controlled trials.

SETTING

University hospital.

MEAUREMENTS

A search was conducted in PubMed, EMBASE, MEDLINE(R) and the Cochrane Central Register of Controlled Trials of studies on adults undergoing surgery with CPB who received steroid administration. Effect size (risk ratio or mean difference) for MI, stroke, renal insufficiency, death, ICU LOS, and hospital LOS were evaluated.

MAIN RESULTS

48 RCTs published between 1977 and 2012 were retained for analysis. Steroids had no effect on the MI risk ratio (RR) 0.91 (95% confidence interval [CI] 0.63, 1.32); death at 30 days RR 0.84 (0.59, 1.20); stroke RR 0.92 (0.60, 1.42) or renal insufficiency RR 0.83 (0.52, 1.32). Administration of steroids reduced ICU LOS (P = 0.00001; I(2) 87.5%) and hospital LOS (P = 0.03; I(2) 81.1%). Metaregressions showed that duration of steroid administration was correlated with the reduction in ICU LOS (P = 0.0004) and hospital LOS (P < 0.00001).

CONCLUSIONS

Increasing the duration of steroid administration may reduce ICU and hospital LOS greater than increasing the dose.

Is perioperative corticosteroid administration associated with a reduced incidence of postoperative atrial fibrillation in adult cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Is perioperative corticosteroid administration associated with a reduced incidence of postoperative atrial fibrillation (POAF) in adult cardiac surgery? A total of 70 papers were identified using the search as described below. Of these, eight were identified to provide best evidence to answer the clinical question. These papers consisted of well-designed, double-blinded randomized control trials (RCTs) or meta-analysis of RCTs that presented sufficient data to reach conclusions regarding the issues of interest for this review. Postoperative atrial fibrillation occurrence, outcomes and complications were included in the assessment. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the papers are tabulated. Literature search showed that the prophylactic use of hydrocortisone (100 mg/day, 4 days) can reduce the incidence of POAF to 30%, compared with 48% in the control group (P = 0.004). One gram of methylprednisolone before surgery followed by 4 mg of dexamethasone every 6 h for 1 day after surgery was also associated with a significant reduction in POAF (21 vs 51%; P = 0.003). Moreover, a single dose of dexamethasone (0.6 mg/kg) can significantly diminish POAF (18.95 vs 32.3%; P = 0.027). The changes in POAF appeared greatest in patients receiving intermediate doses of corticosteroid (50-210 mg of dexamethasone equivalent), while both lower (up to 8 mg) and higher (236-2850 mg) dosing resulted in blunted effects. Similarly, a moderate dose of hydrocortisone (200-1000 mg/day) is as effective as high (1001-10 000 mg/day) and very high doses (10 000 mg/day). Although the optimal dose, dosing interval and duration of therapy are unclear, meta-analysis suggests that a single dose can be as effective as multiple doses. No statistically significant complications associated with the use of corticosteroids were reported in any of the studies. We conclude that a single prophylactic moderate dose of corticosteroid (50-210 mg of dexamethasone equivalent or 200-1000 mg/day hydrocortisone) can significantly reduce the risk of POAF with no significant increase in morbidity or mortality.

Perioperative cardiovascular system failure in South Asians undergoing cardiopulmonary bypass is associated with prolonged inflammation and increased Toll-like receptor signaling in inflammatory monocytes

BACKGROUND

South Asian ethnicity is an independent risk factor for mortality after coronary artery bypass. We tested the hypothesis that this risk results from a greater inflammatory response to cardiopulmonary bypass (CPB).

METHODS

This was a single-site prospective cohort study. We compared the inflammatory response to CPB in 20 Caucasians and 17 South Asians undergoing isolated coronary artery bypass grafting surgery.

RESULTS

Plasma levels of proinflammatory cytokines (interleukin [IL]-6, IL-8, IL-12, interferon gamma, and tumor necrosis factor) and anti-inflammatory mediators (IL-10 and soluble TNF receptor I) were measured. The Toll-like receptor (TLR) signaling pathway was examined in peripheral blood monocytes by flow cytometry, measuring surface expression of TLR2, TLR4, and coreceptor CD14 and activation of downstream messenger molecules (interleukin-1 receptor-associated kinase 4, nuclear factor kappa from B cells (NF-κB), c-Jun amino-terminal kinase, p38 mitogen-activated protein kinase, and Protein Kinase B). South Asians had persistently higher plasma levels of IL-6 and exhibited increased TLR signaling through the p38 mitogen-activated protein kinase and Protein Kinase B pathways in inflammatory monocytes after CPB. This increased inflammatory response was paralleled clinically by a higher sequential organ failure assessment score (5.1 ± 1.4 versus 1.5 ± 1.6, P = 0.027) and prolonged cardiovascular system failure (23.5% versus 0%) 48 h after CPB.

CONCLUSIONS

South Asians develop an exacerbated systemic inflammatory response after CPB, which may contribute to the higher morbidity and mortality associated with coronary artery bypass in this population. These patients may benefit from targeted anti-inflammatory therapies designed to mitigate the adverse consequences resulting from this response.

Prostanoid therapy for pulmonary arterial hypertension: a meta-analysis of survival outcomes

BACKGROUND

Prostanoids have played an important role in the treatment of pulmonary arterial hypertension (PAH). However, whether prostanoid therapy provides a survival advantage is still not clear. The aim of this meta-analysis was to evaluate the efficacy and safety of prostanoids in PAH, focusing on the improvement in overall survival.

METHODS

Trials were identified from the Cochrane Library, EMBASE, and PUBMED databases. We calculated risk ratios (RR) for dichotomous data and weighted mean differences with 95 % confidence intervals (CI) for continuous data.

RESULTS

Fourteen trials with a total of 2,244 adult patients (1,189 patients in the prostanoid treatment group and 1,055 patients in the placebo group) were included in the meta-analysis. All-cause mortality rate in the control group was 4.17 %. In a 13.4-week follow-up, prostanoid treatment was associated with a 44 % reduction in mortality (RR 0.56; 95 % CI 0.35-0.88; P = 0.01).Subgroup analysis suggested that only treatment with intravenous prostanoids provided a survival benefit. Compared with placebo, prostanoids significantly reduced clinical worsening (RR 0.60; 95 % CI 0.46-0.80; P = 0.0003), increased the 6-min walk distance by 27.95 m, reduced mean pulmonary arterial pressure and pulmonary vascular resistance, and increased the cardiac index and mixed venous oxygen saturation. However, patients receiving prostanoid treatment showed a much higher incidence (RR 3.25; 95 % CI 2.07-5.10; P<0.00001) of withdrawal due to its adverse effects.

CONCLUSION

The results of this meta-analysis suggest that treatment with prostanoids improves the survival of patients with PAH.

Perioperative administration of enoximone and renal function after cardiac surgery: a propensity-matched analysis

BACKGROUND

Perioperative administration of enoximone has been shown to improve hemodynamics, organ function, and inflammatory response. Aim of the present study is to evaluate the impact of enoximone on postoperative renal function after on-pump cardiac surgery.

METHODS

A total of 3727 patients undergoing cardiac surgery at one Institution between May 2004 and November 2010 were reviewed. A propensity score was built and a 1:1 perfect matching was performed, providing two fairly comparable cohorts of 712 patients each, receiving or not enoximone after surgery. Renal function was evaluated by lower glomerular filtration rate (GFR) value reached postoperatively.

RESULTS

Overall 30-day mortality rate was 4.3% (62/1424). Cumulative incidence of postoperative renal failure (RF) was 157/1424(11%), of which 99/1424(7%) needed renal replacement therapy. Mean lower postoperative GFR in patients who received or not enoximone was 63 ± 30.1 and 53.5 ± 26.1 ml/min/1.73 m(2) (p<0.0001), respectively. At multivariable analysis age (OR2.75, p=0.0004), diabetes (OR1.82, p=0.006), preoperative GFR (OR3.81, p<0.0001), preoperative cardiogenic shock (OR1.65, p=0.004), previous cardiac surgery (OR2.12, p=0.0002), type of intervention (OR1.96, p=0.005), and enoximone (OR0.38, p=0.001) were found to be independently associated with postoperative RF. Logistic regression analysis showed that the administration of enoximone (OR0.41, p=0.0001), and of no inotropes (OR0.27, p<0.0001) were protective vs. the occurrence of postoperative RF.

CONCLUSION

Patients perioperatively receiving enoximone showed a statistically significant better renal function after cardiac surgery.

Perioperative glucocorticoids in hip and knee surgery - benefit vs. harm? A review of randomized clinical trials

Glucocorticoids are frequently used to prevent post-operative nausea and vomiting (PONV), and may be part of multimodal analgesic regimes. The objective of this review was to evaluate the overall benefit vs. harm of perioperative glucocorticoids in patients undergoing hip or knee surgery. A wide search was performed in PubMed, Embase, and Cochrane Central to identify relevant randomized clinical trials. A systematic approach was used, starting from the PRISMA recommendations. The Cochrane Collaboration's tool was used for risk of bias assessment. Studies were divided into three groups: systemic glucocorticoid administration analogous to > 10 mg or ≤ 10 mg dexamethasone, and local glucocorticoid administration. Seventeen studies with data from 1081 patients were included in the final qualitative synthesis. Benefit (of any kind) with glucocorticoid vs. placebo was reported in 15 studies. PONV was reduced with systemic glucocorticoid. Pain was reduced with high-dose systemic and local glucocorticoid, but not with low-dose systemic glucocorticoid. Systemic inflammatory markers were reduced with low-dose and high-dose systemic glucocorticoid, and with local glucocorticoid. Functional recovery was improved with local glucocorticoid. All studies were small-sized and none sufficiently powered to meaningfully evaluate uncommon adverse events. Most of the local administration studies had poor scientific quality (high risk of bias). Due to clinical heterogeneity and poor scientific quality, no meta-analysis was performed. In conclusion, in addition to PONV reduction with low-dose systemic glucocorticoid, this review supports high-dose systemic glucocorticoid to ameliorate post-operative pain after hip and knee surgery. However, large-scale safety and dose-finding studies are warranted before final recommendations.

Association between C-reactive protein and atrial fibrillation recurrence after catheter ablation: a meta-analysis

BACKGROUND

Atrial fibrillation (AF) is associated with inflammation. Increased serum C-reactive protein (CRP) levels are important representatives of an inflammatory state of AF. A variety of studies have evaluated whether increased CRP levels have an association with AF recurrence after catheter ablation. However, the results remain inconsistent, therefore, this meta-analysis was conducted to offer suggestions.

HYPOTHESIS

Increased baseline CRP have an association with AF recurrence after catheter ablation.

METHODS

Electronic databases including PubMed, Embase, Medline, ISI Web of Knowledge, and ScienceDirect were searched until December 31, 2012 for any CRP-associated studies. Overall and subgroup analyses were performed. Standardized mean difference (SMD) and 95% confidence interval (CI) were used to evaluate the associations between CRP levels and postablation AF recurrence. Statistical analysis was performed with Review Manager 5.2 and Stata 11.0.

RESULTS

Seven available studies were identified, which included 526 patients (179 recurrence vs 347 no recurrence). Overall, increased baseline CRP levels had significant positive association with postablation AF recurrence. The SMD in the CRP levels was 0.65 units (95% CI: 0.30-0.99), and the z-score for overall effect was 3.70 (P = 0.0002). The heterogeneity test showed that there were moderate differences between individual studies (P = 0.006, I(2) = 67%). Metaregression revealed that different sample sizes of studies possibly accounted for the heterogeneity. Positive associations were also found in subgroup analyses based on sample size. When stratifying for ethnicity, similarly significant associations were found in both European (Caucasian) and Asian populations.

CONCLUSIONS

Investigations demonstrate that baseline CRP levels are greater in patients with postablation AF recurrence. Further studies with larger sample size and delicate design for CRP should be conducted.

Risk Factors for Post-Coronary Artery Bypass Grafting (CABG) Atrial Fibrillation and the Role of Aspirin and Beta Blockers in its Prevention

Background: Atrial fibrillation/flutter (AF) is the most common arrhythmia following coronary artery bypass grafting (CABG) and it increases morbidity and mortality associated with this procedure. The purpose of this study was to evaluate the predictability of this arrhythmia using previously identified risk factors and to assess the efficacy of recommended prophylactic beta blocker (BB) therapy in the prevention of post CABG AF. Methods: We performed a retrospective chart analysis of consecutive patients undergoing elective CABG during 1 year period. Patients who developed new onset AF after the surgery were designated as cases and those who did not, as controls. 41 different variables were analyzed using Chi-square test and independent sample t-test. Multivariate analysis was carried out using logistic regression model. Results: 23% patients undergoing CABG developed AF during post-operative period. Statistically significant differences were observed between the two groups in terms of age, use of peri-operative Aspirin (ASA), current smoking, previous history of AF, left atrial size, history of congestive heart failure (CHF) and brain natriuretic peptide (BNP) levels. In terms of prophylactic therapy, preoperative BB did not independently protect against post CABG AF. On multivariate analysis, only age, use of ASA and previous history of AF remained as independent predictors of post CABG AF. Conclusion: In our study population, the use of preoperative BB did not independently decrease the risk of post-CABGAF. Age, peri-operative ASA use and previous history of AF remained strong independent predictors of post- operative AF.

Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery

BACKGROUND

Atrial fibrillation is a common post-operative complication of cardiac surgery and is associated with an increased risk of post-operative stroke, increased length of intensive care unit and hospital stays, healthcare costs and mortality. Numerous trials have evaluated various pharmacological and non-pharmacological prophylactic interventions for their efficacy in preventing post-operative atrial fibrillation. We conducted an update to a 2004 Cochrane systematic review and meta-analysis of the literature to gain a better understanding of the effectiveness of these interventions.

OBJECTIVES

The primary objective was to assess the effects of pharmacological and non-pharmacological interventions for preventing post-operative atrial fibrillation or supraventricular tachycardia after cardiac surgery. Secondary objectives were to determine the effects on post-operative stroke or cerebrovascular accident, mortality, cardiovascular mortality, length of hospital stay and cost of treatment during the hospital stay.

SEARCH METHODS

We searched the Cochrane Central Register of ControlLed Trials (CENTRAL) (Issue 8, 2011), MEDLINE (from 1946 to July 2011), EMBASE (from 1974 to July 2011) and CINAHL (from 1981 to July 2011).

SELECTION CRITERIA

We selected randomized controlled trials (RCTs) that included adult patients undergoing cardiac surgery who were allocated to pharmacological or non-pharmacological interventions for the prevention of post-operative atrial fibrillation or supraventricular tachycardia, except digoxin, potassium (K(+)), or steroids.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted study data and assessed trial quality.

MAIN RESULTS

One hundred and eighteen studies with 138 treatment groups and 17,364 participants were included in this review. Fifty-seven of these studies were included in the original version of this review while 61 were added, including 27 on interventions that were not considered in the original version. Interventions included amiodarone, beta-blockers, sotalol, magnesium, atrial pacing and posterior pericardiotomy. Each of the studied interventions significantly reduced the rate of post-operative atrial fibrillation after cardiac surgery compared with a control. Beta-blockers (odds ratio (OR) 0.33; 95% confidence interval) CI 0.26 to 0.43; I(2) = 55%) and sotalol (OR 0.34; 95% CI 0.26 to 0.43; I(2) = 3%) appear to have similar efficacy while magnesium's efficacy (OR 0.55; 95% CI 0.41 to 0.73; I(2) = 51%) may be slightly less. Amiodarone (OR 0.43; 95% CI 0.34 to 0.54; I(2) = 63%), atrial pacing (OR 0.47; 95% CI 0.36 to 0.61; I(2) = 50%) and posterior pericardiotomy (OR 0.35; 95% CI 0.18 to 0.67; I(2) = 66%) were all found to be effective. Prophylactic intervention decreased the hospital length of stay by approximately two-thirds of a day and decreased the cost of hospital treatment by roughly $1250 US. Intervention was also found to reduce the odds of post-operative stroke, though this reduction did not reach statistical significance (OR 0.69; 95% CI 0.47 to 1.01; I(2) = 0%). No significant effect on all-cause or cardiovascular mortality was demonstrated.

AUTHORS' CONCLUSIONS

Prophylaxis to prevent atrial fibrillation after cardiac surgery with any of the studied pharmacological or non-pharmacological interventions may be favored because of its reduction in the rate of atrial fibrillation, decrease in the length of stay and cost of hospital treatment and a possible decrease in the rate of stroke. However, this review is limited by the quality of the available data and heterogeneity between the included studies. Selection of appropriate interventions may depend on the individual patient situation and should take into consideration adverse effects and the cost associated with each approach.

Effect of dietary fiber on constipation: A meta analysis

AIM: To investigate the effect of dietary fiber intake on constipation by a meta-analysis of randomized controlled trials (RCTs).

METHODS: We searched Ovid MEDLINE (from 1946 to October 2011), Cochrane Library (2011), PubMed for articles on dietary fiber intake and constipation using the terms: constipation, fiber, cellulose, plant extracts, cereals, bran, psyllium, or plantago. References of important articles were searched manually for relevant studies. Articles were eligible for the meta-analysis if they were high-quality RCTs and reported data on stool frequency, stool consistency, treatment success, laxative use and gastrointestinal symptoms. The data were extracted independently by two researchers (Yang J and Wang HP) according to the described selection criteria. Review manager version 5 software was used for analysis and test. Weighted mean difference with 95%CI was used for quantitative data, odds ratio (OR) with 95%CI was used for dichotomous data. Both I² statistic with a cut-off of ≥ 50% and the χ² test with a P value < 0.10 were used to define a significant degree of heterogeneity.

RESULTS: We searched 1322 potential relevant articles, 19 of which were retrieved for further assessment, 14 studies were excluded for various reasons, five studies were included in the analysis. Dietary fiber showed significant advantage over placebo in stool frequency (OR = 1.19; 95%CI: 0.58-1.80, P < 0.05). There was no significant difference in stool consistency, treatment success, laxative use and painful defecation between the two groups. Stool frequency were reported by five RCTs, all results showed either a trend or a significant difference in favor of the treatment group, number of stools per week increased in treatment group than in placebo group (OR = 1.19; 95%CI: 0.58-1.80, P < 0.05), with no significant heterogeneity among studies (I²= 0, P = 0.77). Four studies evaluated stool consistency, one of them presented outcome in terms of percentage of hard stool, which was different from others, so we included the other three studies for analysis. Two studies reported treatment success. There was significant heterogeneity between the studies (P < 0.1, I² > 50%). Three studies reported laxative use, quantitative data was shown in one study, and the pooled analysis of the other two studies showed no significant difference between treatment and placebo groups in laxative use (OR = 1.07; 95%CI 0.51-2.25), and no heterogeneity was found (P = 0.84, I²= 0). Three studies evaluated painful defecation: one study presented both quantitative and dichotomous data, the other two studies reported quantitative and dichotomous data separately. We used dichotomous data for analysis.

CONCLUSION: Dietary fiber intake can obviously increase stool frequency in patients with constipation. It does not obviously improve stool consistency, treatment success, laxative use and painful defecation.

A comparative study of the immune modulating properties of antifibrinolytics in cardiac surgery

PURPOSE

Antifibrinolytics, used in cardiac surgery to abate postoperative blood loss, share anti-inflammatory properties by suppression of pro-inflammatory D-dimer and plasmin levels. Additional drug specific immune modulating qualities are often mentioned in the discussion on which antifibrinolytic can best be used. To determine the extent and relevance of these effects, we investigated cytokine and growth factor plasma levels in cardiac surgery patients randomized to receive either tranexamic acid, aprotinin, or placebo. Corticosteroid-treated patients served to put the effects in perspective.

METHODS

Using a biochip immunoassay, plasma of 36 cardiac surgery patients was quantified for 12 cytokines and growth factors, assessed preoperatively and 6, 12, 24, and 48 h after the start of cardiopulmonary bypass. Eight patients were treated with tranexamic acid, nine with aprotinin, and nine received placebo. Ten placebo-treated patients received corticosteroids.

RESULTS

IL-1ß, IL-6, IL-8, IL-10, IFN-γ, TNF-α, VEGF, MCP-1, and EGF plasma concentrations significantly changed over time across all patients. Aprotinin-treated patients showed decreased pro-inflammatory TNF-α and peak MCP-1 plasma levels when compared with placebo. However, corticosteroids attenuated the inflammatory response to a much larger extent, lowering postoperative IL-6, IL-10, IFN-γ, and VEGF concentrations also.

CONCLUSIONS

Aprotinin attenuates postoperative pro-inflammatory levels TNF-α and MCP-1 whereas tranexamic acid does not. The majority of plasma proteins studied, however, were not affected by the use of antifibrinolytics when compared with placebo. A clinically relevant common anti-inflammatory effect through inhibition of fibrinolysis seems therefore unlikely.

Perioperative care for the older outpatient undergoing ambulatory surgery

As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly will assume increased importance. Given the recent advances in anesthesia, surgery, and monitoring technology, the ambulatory setting offers potential advantages for elderly patients undergoing elective surgery. In this review article we summarize the physiologic and pharmacologic effects of aging and their influence on anesthetic drugs, the important considerations in the preoperative evaluation of elderly outpatients with coexisting diseases, the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and offer recommendations regarding the management of common postoperative side effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. We conclude with a discussion of future challenges related to the growth of ambulatory surgery practice in this segment of our surgical population. When information specifically for the elderly population was not available in the peer-reviewed literature, we drew from relevant information in other ambulatory surgery populations.

Integrating outcome benefit into anesthetic design: the promise of steroids and statins

Steroids and statins may facilitate the integration of anesthetic design with clinical outcome. Although steroids clearly benefit adult cardiac surgical patents, the evidence is weaker in pediatric cardiac surgery. Current large randomized trials of steroids likely will determine the future role of steroids in adult cardiac surgery. In the intensive care unit, steroid therapy is indicated in septic shock that is refractory to fluid and pressor therapy. Recent data, however, indicate that liberal steroid therapy for sepsis may have adverse outcome consequences. A 2nd concern in the intensive care unit is acute adrenal suppression secondary to bolus etomidate therapy because it may be deleterious in patients with septic shock. Possible clinical solutions include alternative induction agents, concomitant steroid therapy, and recent etomidate derivatives. Statins also reduce mortality and atrial fibrillation after cardiac surgery. Furthermore, they slow the progression of rheumatic valvular stenosis, an important consideration in the developing world. Statins also may reduce delirium, stroke, and acute renal injury after cardiac surgery, but further randomized trials are required before definitive recommendations can be formulated. Statins are essential in vascular surgery because they reduce mortality, myocardial ischemia, and acute renal injury. As a result, they have been recommended highly for outcome enhancement in recent perioperative guidelines. Although they may improve survival in sepsis, further investigation is indicated to define their therapeutic role.

Efficacy of methylprednisolone in preventing lung injury following pulmonary thromboendarterectomy

BACKGROUND

We sought to determine the efficacy and safety of perioperative treatment with methylprednisolone on the development of lung injury after pulmonary thromboendarterectomy.

METHODS

This was a randomized, prospective, double-blind, placebo-controlled study of 98 adult patients with chronic thromboembolic pulmonary hypertension who were undergoing pulmonary thromboendarterectomy at a single institution. The patients received either placebo (n = 47) or methylprednisolone (n = 51) (30 mg/kg in the cardiopulmonary bypass prime, 500 mg IV bolus following the final circulatory arrest, and 250 mg IV bolus 36 h after surgery). The primary end point was the presence of lung injury as determined by two independent, blinded physicians using prospectively defined criteria. The secondary end points included ventilator-free, ICU-free, and hospital-free days and selected levels of cytokines in the blood and in BAL fluid.

RESULTS

The incidence of lung injury was similar in both treatment groups (45% placebo, 41% steroid; P = .72). There were no statistical differences in the secondary clinical end points between treatment groups. Treatment with methylprednisolone, compared with placebo, was associated with a statistically significant reduction in plasma IL-6 and IL-8, a significant increase in plasma IL-10, and a significant reduction in postoperative IL-1ra and IL-6, but not IL-8 in BAL fluid obtained 1 day after surgery.

CONCLUSIONS

Perioperative methylprednisolone does not reduce the incidence of lung injury following pulmonary thromboendarterectomy surgery despite having an antiinflammatory effect on plasma and lavage cytokine levels.

Dexamethasone prophylaxis in pediatric open heart surgery is associated with increased blood long pentraxin PTX3: potential clinical implications

Glucocorticoid administration before cardiopulmonary bypass (CPB) can reduce the systemic inflammatory response and improve clinical outcome. Long pentraxin PTX3 is a novel inflammatory parameter that could play a protective cardiovascular role by regulating inflammation. Twenty-nine children undergoing open heart surgery were enrolled in the study. Fourteen received dexamethasone (1st dose 1.5 mg/Kg i.v. or i.m. the evening before surgery; 2nd dose 1.5 mg/kg i.v. before starting bypass) and fifteen children served as control. Blood PTX3, short pentraxin C-reactive protein (CRP), interleukin-1 receptor II (IL-1RII), fibrinogen and partial thromboplastin time (PTT) were assayed at different times. PTX3 levels significantly increased during CPB in dexamethasone-treated (+D) and dexamethasone-untreated (−D) subjects, but were significantly higher in +D than −D patients. CRP levels significantly increased both in +D and −D patients in the postoperative days, with values significantly higher in −D than +D patients. Fibrinogen and PTT values were significantly higher in −D than +D patients in the 1st postoperative day. IL-1RII plasma levels increased in the postoperative period in both groups. Dexamethasone prophylaxis in pediatric patients undergoing CPB for cardiac surgery is associated with a significant increase of blood PTX3 that could contribute to decreasing inflammatory parameters and improving patient clinical outcome.

Prophylactic corticosteroids for cardiopulmonary bypass in adults

BACKGROUND

High-dose prophylactic corticosteroids are often administered during cardiac surgery. Their use, however, remains controversial, as no trials are available that have been sufficiently powered to draw conclusions on their effect on major clinical outcomes.

OBJECTIVES

The objective of this meta-analysis was to estimate the effect of prophylactic corticosteroids in cardiac surgery on mortality, cardiac and pulmonary complications.

SEARCH STRATEGY

Major medical databases (CENTRAL, MEDLINE, EMBASE, CINAHL and Web of Science) were systematically searched for randomised studies assessing the effect of corticosteroids in adult cardiac surgery. Database were searched for the full period covered, up to December 2009. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials comparing corticosteroid treatment to either placebo treatment or no treatment in adult cardiac surgery were selected. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more end-points.

DATA COLLECTION AND ANALYSIS

The processes of searching and selection for inclusion eligibility were performed independently by two authors. Also, quality assessment and data-extraction of selected studies were independently performed by two authors. The primary endpoints were mortality, cardiac and pulmonary complications. The main effect measure was the Peto odds ratio comparing corticosteroids to no treatment/placebo.

MAIN RESULTS

Fifty-four randomised studies, mostly of limited quality, were included. Altogether, 3615 patients were included in these studies. The pooled odds ratio for mortality was 1.12 (95% CI 0.65 to 1.92), showing no mortality reduction in patients treated with corticosteroids. The odds ratios for myocardial and pulmonary complications were 0.95, (95% CI 0.57 to 1.60) and 0.83 (95% CI 0.49 to 1.40), respectively. The use of a random effects model did not substantially influence study results. Analyses of secondary endpoints showed a reduction of atrial fibrillation and an increase in gastrointestinal bleeding in the corticosteroids group.

AUTHORS' CONCLUSIONS

This meta-analysis showed no beneficial effect of corticosteroid use on mortality, cardiac and pulmonary complications in cardiac surgery patients.

Modulation of the cellular and humoral immune response to pediatric open heart surgery by methylprednisolone

BACKGROUND

With the intention to reduce overshooting immune response, glucocorticoids are frequently administered perioperatively in children undergoing open heart surgery. In a retrospective study we investigated extensively the modulation of the humoral and cellular immune response by methylprednisolone (MP).

METHODS

This study was carried out on blood samples from two groups of children who had undergone surgical correction of atrial or ventricular septal defects, either without (MP⁻, n = 10), or with MP administration (MP+, n = 23, dose median 11 (IQR 10-16) mg kg⁻¹ body weight) before cardiopulmonary bypass (CPB, duration median 42 (IQR 36-65) min). EDTA blood was obtained 24 h preoperatively, after anesthesia, at CPB begin and end, 4, 24, and 48 h after surgery, at discharge and at out-patient follow-up (median 8.2 (IQR 3.3-12.2) months after surgery). Complex blood analysis including clinical chemistry and flow cytometry were performed to monitor humoral immune response, differential blood count, lymphocyte subsets, and the degree of activation of various leukocyte subpopulations.

RESULTS

The patients' postoperative courses and follow-up were uneventful. Release of IL-6 and IL8 was reduced and that of the anti-inflammatory cytokine IL-10 upregulated by MP. Significant increase of circulating neutrophils and monocytes as inflammatory reaction to surgery and CPB contact was detected in both groups. However, invasion of monocytes to the periphery was delayed with MP. CD4+ and CD8+ T-lymphocyte counts were lower with MP treatment. B-lymphocyte count increased significantly after surgery in MP+ but remained constant in MP⁻ group.

CONCLUSIONS

MP treatment partially decreased the pro-inflammatory effect of CPB surgery and induced anti-inflammatory effect on the cellular and humoral level.

Pathophysiological mechanisms of atrial fibrillation: a translational appraisal

Atrial fibrillation (AF) is an arrhythmia that can occur as the result of numerous different pathophysiological processes in the atria. Some aspects of the morphological and electrophysiological alterations promoting AF have been studied extensively in animal models. Atrial tachycardia or AF itself shortens atrial refractoriness and causes loss of atrial contractility. Aging, neurohumoral activation, and chronic atrial stretch due to structural heart disease activate a variety of signaling pathways leading to histological changes in the atria including myocyte hypertrophy, fibroblast proliferation, and complex alterations of the extracellular matrix including tissue fibrosis. These changes in electrical, contractile, and structural properties of the atria have been called "atrial remodeling." The resulting electrophysiological substrate is characterized by shortening of atrial refractoriness and reentrant wavelength or by local conduction heterogeneities caused by disruption of electrical interconnections between muscle bundles. Under these conditions, ectopic activity originating from the pulmonary veins or other sites is more likely to occur and to trigger longer episodes of AF. Many of these alterations also occur in patients with or at risk for AF, although the direct demonstration of these mechanisms is sometimes challenging. The diversity of etiological factors and electrophysiological mechanisms promoting AF in humans hampers the development of more effective therapy of AF. This review aims to give a translational overview on the biological basis of atrial remodeling and the proarrhythmic mechanisms involved in the fibrillation process. We pay attention to translation of pathophysiological insights gained from in vitro experiments and animal models to patients. Also, suggestions for future research objectives and therapeutical implications are discussed.

Review: Beyond the Guidelines: New and Novel Agents for the Prevention of Atrial Fibrillation After Cardiothoracic Surgery

Postoperative atrial fibrillation (POAF), a common complication of cardiac surgery, can increase the morbidity and mortality, as well as the costs of the surgery being preformed. Guidelines recommend the use of β-blockers, amiodarone, or sotalol to decrease the risk of experiencing POAF. However, none of these agents fully protect the patient from POAF, thus newer agents are needed to be used in combination with them. Many different agents have been studied to fit this role and may be grouped into 2 categories: agents with antiarrhythmic activity such as magnesium and polyunsaturated fatty acids and agents with anti-inflammatory activity such as statins and free radical scavengers. Most of these novel agents have been studied in a wide variety of trials; however, some clearly have more effect than others. Although none of these newer agents have the data required to make blanket recommendations for use at this point, given the safety profile and low costs of some, many continue to be evaluated in randomized-controlled trials.

Corticosteroids and outcome in children undergoing congenital heart surgery: analysis of the Pediatric Health Information Systems database

BACKGROUND

Children undergoing congenital heart surgery often receive corticosteroids with the aim of reducing the inflammatory response after cardiopulmonary bypass; however, the value of this approach is unclear.

METHODS AND RESULTS

The Pediatric Health Information Systems Database was used to evaluate outcomes associated with corticosteroids in children (0 to 18 years of age) undergoing congenital heart surgery at 38 US centers from 2003 to 2008. Propensity scores were constructed to account for potential confounders: age, sex, race, prematurity, genetic syndrome, type of surgery (Risk Adjustment in Congenital Heart Surgery [RACHS-1] category), center, and center volume. Multivariable analysis, adjusting for propensity score and individual covariates, was performed to evaluate in-hospital mortality, postoperative length of stay, duration of ventilation, infection, and use of insulin. A total of 46 730 children were included; 54% received corticosteroids. In multivariable analysis, there was no difference in mortality among corticosteroid recipients and nonrecipients (odds ratio, 1.13; 95% confidence interval, 0.98 to 1.30). Corticosteroids were associated with longer length of stay (least square mean difference, 2.18 days; 95% confidence interval, 1.62 to 2.74 days), greater infection (odds ratio, 1.27; 95% confidence interval, 1.10 to 1.46), and greater use of insulin (odds ratio, 2.45; 95% confidence interval, 2.24 to 2.67). There was no difference in duration of ventilation. In analysis stratified by RACHS-1 category, no significant benefit was seen in any group, and the association of corticosteroids with increased morbidity was most prominent in RACHS-1 categories 1 through 3.

CONCLUSION

In this observational analysis of children undergoing congenital heart surgery, we were unable to demonstrate a significant benefit associated with corticosteroids and found that corticosteroids may be associated with increased morbidity, particularly in lower-risk patients.

Upstream effect for atrial fibrillation: still a dilemma?

Atrial fibrillation is the most common arrhythmia in clinical practice. Ion channel blocking agents are often characterized by limited long-term efficacy and several side effects. In addition, ablative invasive procedures are neither easily accessible nor always efficacious. The "upstream therapy," which includes angiotensin-converting enzyme inhibitors, aldosterone receptor antagonists, statins, glucocorticoids, and ω-3 poly-unsaturated fatty acids, targets arrhythmia substrate, influencing atrial structural and electrical remodeling that play an essential role in atrial fibrillation induction and maintenance. The mechanisms involved and the most important clinical evidence regarding the upstream therapy influence on atrial fibrillation are presented in this review. Some open questions are also proposed.

Protective effects of steroids in cardiac surgery: a meta-analysis of randomized double-blind trials

OBJECTIVE

Cardiac surgery and cardiopulmonary bypass (CPB) induce an acute inflammatory response contributing to postoperative morbidity. The use of steroids as anti-inflammatory agents in surgery using CPB has been tested in many trials and has been shown to have good anti-inflammatory effects but no clear clinical advantages for the lack of an adequately powered sample size. The aim of this study was to evaluate the effects of steroid treatment on mortality and morbidity after cardiac surgery.

DESIGN

A systematic meta-analysis of randomized double-blind trials (RDBs).

SETTING

A university hospital.

PARTICIPANTS

Adult patients who underwent cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

A trial search was performed through PubMed and Cochrane databases from 1966 to January 2009. Among 104 clinical trials reviewed, 31 RDB trials (1,974 patients) were considered suitable to be analyzed. A quality assessment of the trials was performed using the Jadad score. The types of steroid used in these trials were methylprednisolone (51.4%), dexamethasone (34.3%), hydrocortisone (5.7%), prednisolone (2.9%), or a combination of methylprednisolone and dexamethasone (5.7%). Steroid prophylaxis provided a protective effect preventing postoperative atrial fibrillation (odds ratio = 0.56; confidence interval [CI] 0.44-0.72, p < 0.0001), reducing postoperative blood loss (mean difference = -204.2 mL; CI from -287.4 to -121 mL; p < 0.0001), and reducing intensive care unit (mean difference = -6.6 hours; CI from -10.5 to -2.7 hours, p = 0.0007) and overall hospital stay (mean difference = -0.8 days; CI from -1.4 to -0.2 days, p = 0.01). Steroid prophylaxis had no effect on postoperative mortality, mechanical ventilation duration, re-exploration for bleeding, and postoperative infection.

CONCLUSIONS

A systematic review of RDB trials reveals that steroid prophylaxis may reduce morbidity after cardiac surgery and does not increase the risk of postoperative infections.

Hemofiltration during cardiopulmonary bypass does not decrease the incidence of atrial fibrillation after cardiac surgery

BACKGROUND

Atrial fibrillation (AF) occurs in 20%-50% of patients after cardiac surgery and is associated with increased morbidity and mortality. Corticosteroids are reported to decrease the incidence of postoperative AF, presumably by attenuating inflammation caused by surgery and cardiopulmonary bypass (CPB). We hypothesized that hemofiltration during CPB, which may attenuate inflammation, might decrease the incidence of AF after cardiac surgery.

METHODS

This was a retrospective review of patients previously enrolled in a double-blind, placebo-controlled trial evaluating the effects of perioperative steroid therapy and hemofiltration during CPB on duration of postoperative mechanical ventilation. In that study, 192 patients undergoing cardiac surgery were randomized to 1 of 3 groups: controls (placebo), hemofiltration during CPB, or perioperative steroid therapy. Patient records were reviewed to determine the incidence of new onset AF defined as any electrocardiogram evidence of AF or AF diagnosed by the patients' clinicians.

RESULTS

Of the 192 enrolled patients, 3 were excluded for protocol violations and 4 were excluded for history of chronic AF. Data from 185 patients from the original study were available for review. Sixty patients (32%) had new onset AF after cardiac surgery. There was no difference among groups in the incidence of AF (control group, 21%; steroid group, 41%; hemofiltration group, 36%; P = 0.057 among groups). The only risk factor for the development of AF was age (mean age of patients with AF, 65.4 +/- 10.1 yr vs patients without AF, 61.4 +/- 11.5 yr; P = 0.024). When age, procedure type, and presence or absence of chronic obstructive pulmonary disease were controlled for in multivariate analysis, the difference among study groups remained nonsignificant (P = 0.108).

CONCLUSIONS

Perioperative corticosteroids or the use of hemofiltration during CPB did not decrease the incidence of AF after cardiac surgery. Further studies evaluating the efficacy and safety of perioperative corticosteroids for prevention of postoperative AF are warranted before their routine use can be recommended.

Recent advances in perioperative medicine: highlights from the literature for the cardiothoracic and vascular anesthesiologist

There have been major advances in perioperative cardiothoracic and vascular medicine. Because of promising data, steroids, statins, and endothelin antagonists are being clinically tested in randomized trials with adult cardiac surgical patients. In vascular surgical patients, recent meta-analysis has revealed that interventions such as beta-blockade or endovascular stenting for peripheral vascular lesions may not improve outcome overall. Furthermore, a landmark trial has shown that anesthetic technique does not affect outcome after carotid endarterectomy. The surgical Apgar score may become part of routine clinical care of the vascular surgical patient because it predicts outcome and can be calculated at the bedside. Recent studies confirm that the serious perioperative risks of hyperglycemia also apply to nondiabetic and pediatric cardiac surgical patients. This has been highlighted in the new guidelines from the Society of Thoracic Surgeons. Perioperative myocardial protection is possible with ischemic preconditioning and omega-3 fatty acids. Pneumonia after lung resection may be reduced significantly by broadening antibiotic prophylaxis. Transfusion-related acute lung injury has immediate and delayed presentations that highlight the dangers of blood transfusion. Perioperative renal dysfunction after adult cardiac surgery is significantly reduced by the infusion of sodium bicarbonate. Although promising, further trials are required. Taken together, these recent advances will have significant influence on the future practice of cardiovascular and thoracic anesthesia as the ongoing search for perioperative outcome improvement achieves results.

Benefits and Risks of Corticosteroid Prophylaxis in Adult Cardiac Surgery

Background— Cardiopulmonary bypass and cardiac surgery are associated with a significant systemic inflammatory response that may increase postoperative complications. This meta-analysis assessed whether the benefits and risks of corticosteroid use were dose dependent in adult cardiac surgery.

Methods and Results— Randomized controlled trials of the use of corticosteroid prophylaxis in adult cardiac surgery (>18 years of age) requiring cardiopulmonary bypass were selected from MEDLINE (1966 to August 1, 2008), EMBASE (1988 to August 1, 2008), and the Cochrane controlled trials register without any language restrictions. A total of 3323 patients from 50 randomized controlled trials were identified and subject to meta-analysis. Corticosteroid prophylaxis reduced the risk of atrial fibrillation (25.1% versus 35.1%; number needed to treat, 10; relative risk, 0.74; 95% confidence interval [CI], 0.63 to 0.86; P <0.01) and length of stay in the intensive care unit (weighted mean difference, −0.37 days; 95% CI, −0.21 to −0.52; P <0.01) and hospital (weighted mean difference, −0.66 days; 95% CI, −0.77 to −1.25; P =0.03) compared with placebo. The use of corticosteroid was not associated with an increased risk of all-cause infection (relative risk, 0.93; 95% CI, 0.61 to 1.41; P =0.73), but hyperglycemia requiring insulin infusion after corticosteroid prophylaxis was common (28.2%; relative risk, 1.49; 95% CI, 1.11 to 2.01; P <0.01). No additional benefits were found on all outcomes beyond a total dose of 1000 mg hydrocortisone, and very high doses of corticosteroid were associated with prolonged mechanical ventilation.

Conclusions— Evidence suggests that low-dose corticosteroid is as effective as high-dose corticosteroid in reducing the risk of atrial fibrillation and duration of mechanical ventilation but with fewer potential side effects in adult cardiac surgery.