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Abstract
Clinicians make frequent treatment decisions regarding acute blood pressure reduction for the critically ill. Key to the decision making process is a balance between reducing arterial wall stress and maintaining perfusion to vital organs. In this article, we review the physiological considerations underlying acute blood pressure management, including the concept of cerebral autoregulation and its adaptations to chronic hypertension. We then discuss available pharmacological interventions suited for reducing blood pressure acutely. We also discuss specific blood pressure targets in common critical illnesses and consider future directions in this therapeutic area.
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102
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MacEwen C, Sutherland S, Daly J, Pugh C, Tarassenko L. Relationship between Hypotension and Cerebral Ischemia during Hemodialysis. J Am Soc Nephrol 2017; 28:2511-2520. [PMID: 28270412 DOI: 10.1681/asn.2016060704] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 01/23/2017] [Indexed: 12/18/2022] Open
Abstract
The relationship between BP and downstream ischemia during hemodialysis has not been characterized. We studied the dynamic relationship between BP, real-time symptoms, and cerebral oxygenation during hemodialysis, using continuous BP and cerebral oxygenation measurements prospectively gathered from 635 real-world hemodialysis sessions in 58 prevalent patients. We examined the relationship between BP and cerebral ischemia (relative drop in cerebral saturation >15%) and explored the lower limit of cerebral autoregulation at patient and population levels. Furthermore, we estimated intradialytic exposure to cerebral ischemia and hypotension for each patient, and entered these values into multivariate models predicting change in cognitive function. In all, 23.5% of hemodialysis sessions featured cerebral ischemia; 31.9% of these events were symptomatic. Episodes of hypotension were common, with mean arterial pressure falling by a median of 22 mmHg (interquartile range, 14.3-31.9 mmHg) and dropping below 60 mmHg in 24% of sessions. Every 10 mmHg drop from baseline in mean arterial pressure associated with a 3% increase in ischemic events (P<0.001), and the incidence of ischemic events rose rapidly below an absolute mean arterial pressure of 60 mmHg. Overall, however, BP poorly predicted downstream ischemia. The lower limit of cerebral autoregulation varied substantially (mean 74.1 mmHg, SD 17.6 mmHg). Intradialytic cerebral ischemia, but not hypotension, correlated with decreased executive cognitive function at 12 months (P=0.03). This pilot study demonstrates that intradialytic cerebral ischemia occurs frequently, is not easily predicted from BP, and may be clinically significant.
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Affiliation(s)
- Clare MacEwen
- Oxford Kidney Unit, Oxford University Hospitals National Health Service Trust, Oxford, United Kingdom; .,Institute of Biomedical Engineering, Department of Engineering Science, and
| | - Sheera Sutherland
- Oxford Kidney Unit, Oxford University Hospitals National Health Service Trust, Oxford, United Kingdom
| | - Jonathan Daly
- Institute of Biomedical Engineering, Department of Engineering Science, and
| | - Christopher Pugh
- Oxford Kidney Unit, Oxford University Hospitals National Health Service Trust, Oxford, United Kingdom.,Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Lionel Tarassenko
- Institute of Biomedical Engineering, Department of Engineering Science, and
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103
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Experimental assessment of oxygen homeostasis during acute hemodilution: the integrated role of hemoglobin concentration and blood pressure. Intensive Care Med Exp 2017; 5:12. [PMID: 28251580 PMCID: PMC5332316 DOI: 10.1186/s40635-017-0125-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 02/21/2017] [Indexed: 11/12/2022] Open
Abstract
Background Low hemoglobin concentration (Hb) and low mean arterial blood pressure (MAP) impact outcomes in critically ill patients. We utilized an experimental model of “normotensive” vs. “hypotensive” acute hemodilutional anemia to test whether optimal tissue perfusion is dependent on both Hb and MAP during acute blood loss and fluid resuscitation, and to assess the value of direct measurements of the partial pressure of oxygen in tissue (PtO2). Methods Twenty-nine anesthetized rats underwent 40% isovolemic hemodilution (1:1) (or sham-hemodilution control, n = 4) with either hydroxyethyl starch (HES) (n = 14, normotensive anemia) or saline (n = 11, hypotensive anemia) to reach a target Hb value near 70 g/L. The partial pressure of oxygen in the brain and skeletal muscle tissue (PtO2) were measured by phosphorescence quenching of oxygen using G4 Oxyphor. Mean arterial pressure (MAP), heart rate, temperature, arterial and venous co-oximetry, blood gases, and lactate were assessed at baseline and for 60 min after hemodilution. Cardiac output (CO) was measured at baseline and immediately after hemodilution. Data were analyzed by repeated measures two-way ANOVA. Results Following “normotensive” hemodilution with HES, Hb was reduced to 66 ± 6 g/L, CO increased (p < 0.05), and MAP was maintained. These conditions resulted in a reduction in brain PtO2 (22.1 ± 5.6 mmHg to 17.5 ± 4.4 mmHg, p < 0.05), unchanged muscle PO2, and an increase in venous oxygen extraction. Following “hypotensive” hemodilution with saline, Hb was reduced to 79 ± 5 g/L and both CO and MAP were decreased (P < 0.05). These conditions resulted in a more severe reduction in brain PtO2 (23.2 ± 8.2 to 10.7 ± 3.6 mmHg (p < 0.05), a reduction in muscle PtO2 (44.5 ± 11.0 to 19.9 ± 12.4 mmHg, p < 0.05), a further increase in venous oxygen extraction, and a threefold increase in systemic lactate levels (p < 0.05). Conclusions Acute normotensive anemia (HES hemodilution) was associated with a subtle decrease in brain tissue PtO2 without clear evidence of global tissue hypoperfusion. By contrast, acute hypotensive anemia (saline hemodilution) resulted in a profound decrease in both brain and muscle tissue PtO2 and evidence of inadequate global perfusion (lactic acidosis). These data emphasize the importance of maintaining CO and MAP to ensure adequacy of vital organ oxygen delivery during acute anemia. Improved methods of assessing PtO2 may provide an earlier warning signal of vital organ hypoperfusion.
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104
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Amini S, Abbaspour H, Morovatdar N, Robabi HN, Soltani G, Tashnizi MA. Risk Factors and Outcome of Acute Kidney Injury after Congenital Heart Surgery: A Prospective Observational Study. Indian J Crit Care Med 2017; 21:847-851. [PMID: 29307966 PMCID: PMC5752794 DOI: 10.4103/ijccm.ijccm_459_16] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Backgrounds and Aims: Acute kidney injury (AKI) is a frequent event after congenital heart surgery with increased mortality and morbidity. We investigated frequency, risk factors, and associated morbidity and mortality of AKI after pediatric cardiac surgery at a single institution. Methods: Children undergoing congenital heart surgery from March 2013 to February 2016 were assessed for development of AKI based on modified pediatric Risk, Injury, Failure, Loss, and End-stage renal disease criteria. They were also investigated for predictive risk factors, associated mortality, and morbidity including duration of mechanical ventilation, Intensive Care Unit (ICU), and hospital length of stay. Results: Five hundred and nineteen patients were recruited during the study period including 259 (49.9%) males and 260 (50.1%) females. AKI was seen in 150 (28.9%) patients including 101 (67.3%), 42 (28%), and 7 (4.7%) cases with risk, injury, and failure stages, respectively. Patients with AKI had longer ventilation time (P = 0.002), ICU (P = 0.05), and hospital (P = 0.56) stay. Mortality was seen in 31 (2.7%) and 44 (11.9%) patients with and without AKI, respectively (P = 0.01). After multivariable logistic regression, there was an association between AKI and preoperative abnormal levels of creatinine (adjusted odds ratio [aOR] = 0.47, 95% confidence interval [CI] 0.22–1.01; P = 0.05), presence of cyanotic heart disease (aOR = 1.97, 95% CI = 1.15–3.2; P = 0.01), duration of surgery (aOR = 1.05/10 min, 95% CI = 1.01–1.08; P = 0.007), and elevated lactate level (aOR = 1.14, 95% CI = 1.03–1.3; P = 0.01). Conclusion: The presence of cyanotic heart disease, duration of surgery, elevated postoperative lactate level, and likely preoperative creatinine level were independent risk factors for the development of AKI after congenital heart surgery.
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Affiliation(s)
- Shahram Amini
- Department of Anesthesiology and Critical Care, Cardiac Anesthesia Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hasan Abbaspour
- Department of Anesthesiology and Critical Care, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Negar Morovatdar
- Department of Community Medicine, Clinical Research Unit, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hojat Naghavi Robabi
- Department of Anesthesiology and Critical Care, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ghasem Soltani
- Department of Anesthesiology and Critical Care, Cardiac Anesthesia Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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105
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Miyazawa H, Ookawara S, Ito K, Yanai K, Ishii H, Kitano T, Shindo M, Ueda Y, Kaku Y, Hirai K, Hoshino T, Tabei K, Morishita Y. Factors associating with oxygenation of lower-limb muscle tissue in hemodialysis patients. World J Nephrol 2016; 5:524-530. [PMID: 27872834 PMCID: PMC5099598 DOI: 10.5527/wjn.v5.i6.524] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/18/2016] [Accepted: 09/08/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the lower-limb muscle oxygenation in hemodialysis (HD) patients and identify the factors associating with muscle oxygenation.
METHODS Sixty-seven HD patients (53 men and 14 women; mean age, 67.1 ± 1.2 years; mean HD duration, 5.6 ± 0.9 years) were recruited. In addition, 15 healthy individuals (nine men and six women; mean age, 38.2 ± 4.6 years) were recruited as the control group. Lower-limb muscle regional saturation of oxygen (rSO2) was monitored on the lateral side of the gastrocnemius muscle before HD using an INVOS 5100C (Covidien Japan, Tokyo, Japan), which utilizes near-infrared spectroscopy. Here, we evaluated the association between lower-limb muscle rSO2 and clinical parameters.
RESULTS The rSO2 values were significantly lower in patients undergoing HD than in healthy individuals (50.0% ± 1.7% vs 76.8% ± 2.5%, P < 0.001). Lower-limb muscle rSO2 showed significant positive correlations with diastolic blood pressure, blood urea nitrogen concentration, serum creatinine concentration, serum potassium concentration, serum inorganic phosphate concentration, and serum albumin concentration as well as negative correlation with HD duration. We conducted a multiple linear regression analysis using parameters that were significantly correlated with the lower-limb muscle rSO2 in a simple linear regression analysis. Multiple regression analysis demonstrated that lower-limb muscle rSO2 was independently associated with serum inorganic phosphate (standardized coefficient: 0.27) and serum albumin concentrations (standardized coefficient: 0.24). In addition, there were no differences in lower-limb muscle rSO2 between diabetic and non-diabetic HD patients. This study has several limitations. Firstly, its sample size was relatively small. Secondly, we could not evaluate the association between lower-limb muscle rSO2 and calculated nutritional markers, including normalized protein catabolic rate and body mass index, anthropometric measurements representing nutritional status, and the severity of protein-energy wasting. Finally, we did not routinely examine the arterial vascular status of HD patients without symptoms of peripheral artery disease. As such, it is possible that some HD patients with subclinical peripheral artery disease may have been included in this study.
CONCLUSION In HD patients, the oxygenation of lower-limb muscle tissue was associated with serum inorganic phosphate and albumin concentrations, both of which represent nutritional status.
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Goodson CM, Rosenblatt K, Rivera-Lara L, Nyquist P, Hogue CW. Cerebral Blood Flow Autoregulation in Sepsis for the Intensivist: Why Its Monitoring May Be the Future of Individualized Care. J Intensive Care Med 2016; 33:63-73. [PMID: 27798314 DOI: 10.1177/0885066616673973] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cerebral blood flow (CBF) autoregulation maintains consistent blood flow across a range of blood pressures (BPs). Sepsis is a common cause of systemic hypotension and cerebral dysfunction. Guidelines for BP management in sepsis are based on historical concepts of CBF autoregulation that have now evolved with the availability of more precise technology for its measurement. In this article, we provide a narrative review of methods of monitoring CBF autoregulation, the cerebral effects of sepsis, and the current knowledge of CBF autoregulation in sepsis. Current guidelines for BP management in sepsis are based on a goal of maintaining mean arterial pressure (MAP) above the lower limit of CBF autoregulation. Bedside tools are now available to monitor CBF autoregulation continuously. These data reveal that individual BP goals determined from CBF autoregulation monitoring are more variable than previously expected. In patients undergoing cardiac surgery with cardiopulmonary bypass, for example, the lower limit of autoregulation varied between a MAP of 40 to 90 mm Hg. Studies of CBF autoregulation in sepsis suggest patients frequently manifest impaired CBF autoregulation, possibly a result of BP below the lower limit of autoregulation, particularly in early sepsis or with sepsis-associated encephalopathy. This suggests that the present consensus guidelines for BP management in sepsis may expose some patients to both cerebral hypoperfusion and cerebral hyperperfusion, potentially resulting in damage to brain parenchyma. The future use of novel techniques to study and clinically monitor CBF autoregulation could provide insight into the cerebral pathophysiology of sepsis and offer more precise treatments that may improve functional and cognitive outcomes for survivors of sepsis.
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Affiliation(s)
- Carrie M Goodson
- 1 Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathryn Rosenblatt
- 2 Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lucia Rivera-Lara
- 2 Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul Nyquist
- 2 Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles W Hogue
- 4 Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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107
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Balzer F, Aronson S, Campagna JA, Ding L, Treskatsch S, Spies C, Sander M. High Postoperative Blood Pressure After Cardiac Surgery Is Associated With Acute Kidney Injury and Death. J Cardiothorac Vasc Anesth 2016; 30:1562-1570. [PMID: 27554236 DOI: 10.1053/j.jvca.2016.05.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Gaps and uncertainty exist regarding the understanding of optimal clinical goals for perioperative (ie, preoperative, intraoperative, and postoperative) blood pressure (BP) management in patients undergoing cardiac surgery and the consequences of achieving or failing to achieve those goals. In this setting, it is understood that preoperative hypertension is predictive of poor postoperative outcomes, with a growing appreciation that current, clinically acceptable changes in intraoperative BP also may be associated independently with adverse short- and long-term outcomes. In contrast, the impact of postoperative BP on outcomes after cardiac surgery remains less clear. DESIGN This study was a retrospective outcome analysis. SETTING The study included all cardiac surgery patients cared for at a single institution over a 7-year period. Consequences of the success or failure of meeting postoperative BP targets on medical outcomes and health resource utilization were evaluated. RESULTS The study comprised 5,225 patients. Hypertensive postoperative patients experienced a higher in-hospital mortality rate compared with matched-case normotensive patients (4.97% v 1.32%, p<0.001) and a longer hospital stay (p = 0.024). In hypertensive patients, serum creatinine levels from postoperative day 1 through postoperative day 7 were increased compared with baseline and postoperative renal dysfunction according to the Kidney Disease: Improving Global Outcomes criteria occurred significantly more often (25.3% v 19.7%, p = 0.027). CONCLUSIONS Postoperative hypertension is associated with compromised outcome as reflected by higher mortality, longer length of stay, and higher incidence of renal dysfunction.
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Affiliation(s)
- Felix Balzer
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Li Ding
- The Medicines Company, Inc, Parsippany, NJ
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Sander
- Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Giessen und Marburg GmbH, Giessen, Germany.
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108
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Affiliation(s)
- Eun-Ho Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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109
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Prediction and Prevention of Acute Kidney Injury after Cardiac Surgery. BIOMED RESEARCH INTERNATIONAL 2016; 2016:2985148. [PMID: 27419130 PMCID: PMC4935903 DOI: 10.1155/2016/2985148] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/25/2016] [Accepted: 05/29/2016] [Indexed: 12/17/2022]
Abstract
The incidence of acute kidney injury after cardiac surgery (CS-AKI) ranges from 33% to 94% and is associated with a high incidence of morbidity and mortality. The etiology is suggested to be multifactorial and related to almost all aspects of perioperative management. Numerous studies have reported the risk factors and risk scores and novel biomarkers of AKI have been investigated to facilitate the subclinical diagnosis of AKI. Based on the known independent risk factors, many preventive interventions to reduce the risk of CS-AKI have been tested. However, any single preventive intervention did not show a definite and persistent benefit to reduce the incidence of CS-AKI. Goal-directed therapy has been considered to be a preventive strategy with a substantial level of efficacy. Many pharmacologic agents were tested for any benefit to treat or prevent CS-AKI but the results were conflicting and evidences are still lacking. The present review will summarize the current updated evidences about the risk factors and preventive strategies for CS-AKI.
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110
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Grams ME, Sang Y, Coresh J, Ballew S, Matsushita K, Molnar MZ, Szabo Z, Kalantar-Zadeh K, Kovesdy CP. Acute Kidney Injury After Major Surgery: A Retrospective Analysis of Veterans Health Administration Data. Am J Kidney Dis 2016; 67:872-80. [PMID: 26337133 PMCID: PMC4775458 DOI: 10.1053/j.ajkd.2015.07.022] [Citation(s) in RCA: 221] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/11/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Few trials of acute kidney injury (AKI) prevention after surgery have been conducted, and most observational studies focus on AKI following cardiac surgery. The frequency of, risk factors for, and outcomes after AKI following other types of major surgery have not been well characterized and may present additional opportunities for trials in AKI. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS 3.6 million US veterans followed up from 2004 to 2011 for the receipt of major surgery (cardiac; general; ear, nose, and throat; thoracic; vascular; urologic; and orthopedic) and postoperative outcomes. FACTORS Demographics, health characteristics, and type of surgery. OUTCOMES Postoperative AKI defined by the KDIGO creatinine criteria, postoperative length of stay, end-stage renal disease, and mortality. RESULTS Postoperative AKI occurred in 11.8% of the 161,185 major surgery hospitalizations (stage 1, 76%; stage 2, 15%, stage 3 [without dialysis], 7%; and AKI requiring dialysis, 2%). Cardiac surgery had the highest postoperative AKI risk (relative risk [RR], 1.22; 95% CI, 1.17-1.27), followed by general (reference), thoracic (RR, 0.92; 95% CI, 0.87-0.98), orthopedic (RR, 0.70; 95% CI, 0.67-0.73), vascular (RR, 0.68; 95% CI, 0.64-0.71), urologic (RR, 0.65; 95% CI, 0.61-0.69), and ear, nose, and throat (RR, 0.32; 95% CI, 0.28-0.37) surgery. Risk factors for postoperative AKI included older age, African American race, hypertension, diabetes mellitus, and, for estimated glomerular filtration rate < 90mL/min/1.73m(2), lower estimated glomerular filtration rate. Participants with postoperative AKI had longer lengths of stay (15.8 vs 8.6 days) and higher rates of 30-day hospital readmission (21% vs 13%), 1-year end-stage renal disease (0.94% vs 0.05%), and mortality (19% vs 8%), with similar associations by type of surgery and more severe stage of AKI relating to poorer outcomes. LIMITATIONS Urine output was not available to classify AKI; cohort included mostly men. CONCLUSIONS AKI was common after major surgery, with similar risk factor and outcome associations across surgery type. These results can inform the design of clinical trials in postoperative AKI to the noncardiac surgery setting.
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Affiliation(s)
- Morgan E Grams
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Josef Coresh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Shoshana Ballew
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Zoltan Szabo
- Department of Cardiothoracic Surgery and Cardiothoracic Anesthesia, Linköping University Hospital, Linköping, Sweden; Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research & Epidemiology, University of California Irvine Medical Center, Irvine, CA; Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN
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Donnelly J, Budohoski KP, Smielewski P, Czosnyka M. Regulation of the cerebral circulation: bedside assessment and clinical implications. Crit Care 2016; 20:129. [PMID: 27145751 PMCID: PMC4857376 DOI: 10.1186/s13054-016-1293-6] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Regulation of the cerebral circulation relies on the complex interplay between cardiovascular, respiratory, and neural physiology. In health, these physiologic systems act to maintain an adequate cerebral blood flow (CBF) through modulation of hydrodynamic parameters; the resistance of cerebral vessels, and the arterial, intracranial, and venous pressures. In critical illness, however, one or more of these parameters can be compromised, raising the possibility of disturbed CBF regulation and its pathophysiologic sequelae. Rigorous assessment of the cerebral circulation requires not only measuring CBF and its hydrodynamic determinants but also assessing the stability of CBF in response to changes in arterial pressure (cerebral autoregulation), the reactivity of CBF to a vasodilator (carbon dioxide reactivity, for example), and the dynamic regulation of arterial pressure (baroreceptor sensitivity). Ideally, cerebral circulation monitors in critical care should be continuous, physically robust, allow for both regional and global CBF assessment, and be conducive to application at the bedside. Regulation of the cerebral circulation is impaired not only in primary neurologic conditions that affect the vasculature such as subarachnoid haemorrhage and stroke, but also in conditions that affect the regulation of intracranial pressure (such as traumatic brain injury and hydrocephalus) or arterial blood pressure (sepsis or cardiac dysfunction). Importantly, this impairment is often associated with poor patient outcome. At present, assessment of the cerebral circulation is primarily used as a research tool to elucidate pathophysiology or prognosis. However, when combined with other physiologic signals and online analytical techniques, cerebral circulation monitoring has the appealing potential to not only prognosticate patients, but also direct critical care management.
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Affiliation(s)
- Joseph Donnelly
- />Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Hills Road, Cambridge, CB2 0QQ UK
| | - Karol P. Budohoski
- />Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Hills Road, Cambridge, CB2 0QQ UK
| | - Peter Smielewski
- />Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Hills Road, Cambridge, CB2 0QQ UK
| | - Marek Czosnyka
- />Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Hills Road, Cambridge, CB2 0QQ UK
- />Institute of Electronic Systems, Warsaw University of Technology, ul. Nowowiejska 15/19, 00-665 Warsaw, Poland
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Saito S, Uchino S, Takinami M, Uezono S, Bellomo R. Postoperative blood pressure deficit and acute kidney injury progression in vasopressor-dependent cardiovascular surgery patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:74. [PMID: 27013056 PMCID: PMC4806486 DOI: 10.1186/s13054-016-1253-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 02/23/2016] [Indexed: 12/29/2022]
Abstract
Background In vasopressor-dependent patients who had undergone cardiovascular surgery, we examined whether those with progression of acute kidney injury (AKI) had a greater difference (deficit) between premorbid and within-ICU hemodynamic pressure-related parameters compared to those without AKI progression. Methods We assessed consecutive adults who underwent cardiovascular surgery and who stayed in our ICU for at least 48 hours and received vasopressor support for more than 4 hours. We obtained premorbid and vasopressor-associated, time-weighted average values for hemodynamic pressure-related parameters (systolic [SAP], diastolic [DAP], and mean arterial pressure [MAP]; central venous pressure [CVP], mean perfusion pressure [MPP], and diastolic perfusion pressure [DPP]) and calculated deficits in those values. We defined AKI progression as an increase of at least one Kidney Disease: Improving Global Outcomes stage. Results We screened 159 patients who satisfied the inclusion criteria and identified 76 eligible patients. Thirty-six patients (47 %) had AKI progression. All achieved pressure-related values were similar between patients with or without AKI progression. However, deficits in DAP (P = 0.027), MPP (P = 0.023), and DPP (P = 0.002) were significantly greater in patients with AKI progression. Conclusions Patients with AKI progression had greater DAP, MPP, and DPP deficits compared to patients without AKI progression. Such deficits might be modifiable risk factors for the prevention of AKI progression.
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Affiliation(s)
- Shinjiro Saito
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan.
| | - Shigehiko Uchino
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Masanori Takinami
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Shoichi Uezono
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Melbourne, VIC, 3084, Australia
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Perioperative risk factors and cumulative duration of “triple-low” state associated with worse 30-day mortality of cardiac valvular surgery. J Clin Monit Comput 2016; 31:387-395. [DOI: 10.1007/s10877-016-9856-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 03/01/2016] [Indexed: 10/22/2022]
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114
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Alpha-stat, beach chair, cerebral autoregulation… But who is at risk? Can J Anaesth 2016; 63:513-8. [DOI: 10.1007/s12630-016-0605-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/14/2015] [Accepted: 01/27/2016] [Indexed: 11/27/2022] Open
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Cerebral Autoregulation Monitoring with Ultrasound-Tagged Near-Infrared Spectroscopy in Cardiac Surgery Patients. Anesth Analg 2016; 121:1187-93. [PMID: 26334746 DOI: 10.1213/ane.0000000000000930] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Individualizing mean arterial blood pressure (MAP) based on cerebral blood flow (CBF) autoregulation monitoring during cardiopulmonary bypass (CPB) holds promise as a strategy to optimize organ perfusion. The purpose of this study was to evaluate the accuracy of cerebral autoregulation monitoring using microcirculatory flow measured with innovative ultrasound-tagged near-infrared spectroscopy (UT-NIRS) noninvasive technology compared with transcranial Doppler (TCD). METHODS Sixty-four patients undergoing CPB were monitored with TCD and UT-NIRS (CerOx™). The mean velocity index (Mx) was calculated as a moving, linear correlation coefficient between slow waves of TCD-measured CBF velocity and MAP. The cerebral flow velocity index (CFVx) was calculated as a similar coefficient between slow waves of cerebral flow index measured using UT-NIRS and MAP. When MAP is outside the autoregulation range, Mx is progressively more positive. Optimal blood pressure was defined as the MAP with the lowest Mx and CFVx. The right- and left-sided optimal MAP values were averaged to define the individual optimal MAP and were the variables used for analysis. RESULTS The Mx for the left side was 0.31 ± 0.17 and for the right side was 0.32 ± 0.17. The mean CFVx for the left side was 0.33 ± 0.19 and for the right side was 0.35 ± 0.19. Time-averaged Mx and CFVx during CPB had a statistically significant "among-subject" correlation (r = 0.39; 95% confidence interval [CI], 0.22-0.53; P < 0.001) but had only a modest agreement within subjects (bias 0.03 ± 0.20; 95% prediction interval for the difference between Mx and CFVx, -0.37 to 0.42). The MAP with the lowest Mx and CFVx ("optimal blood pressure") was correlated (r = 0.71; 95% CI, 0.56-0.81; P < 0.0001) and was in modest within-subject agreement (bias -2.85 ± 8.54; 95% limits of agreement for MAP predicted by Mx and CFVx, -19.60 to 13.89). Coherence between ipsilateral middle CBF velocity and cerebral flow index values averaged 0.61 ± 0.07 (95% CI, 0.59-0.63). CONCLUSIONS There was a statistically significant correlation and agreement between CBF autoregulation monitored by CerOx compared with TCD-based Mx.
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LaPar DJ, Rich JB, Isbell JM, Brooks CH, Crosby IK, Yarboro LT, Ghanta RK, Kern JA, Brown M, Quader MA, Speir AM, Ailawadi G. Preoperative Renal Function Predicts Hospital Costs and Length of Stay in Coronary Artery Bypass Grafting. Ann Thorac Surg 2016; 101:606-12; discussion 612. [DOI: 10.1016/j.athoracsur.2015.07.079] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Revised: 06/24/2015] [Accepted: 07/28/2015] [Indexed: 10/22/2022]
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Katz N, Ronco C. Acute kidney stress--a useful term based on evolution in the understanding of acute kidney injury. Crit Care 2016; 20:23. [PMID: 26796793 PMCID: PMC4722620 DOI: 10.1186/s13054-016-1184-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Critical care physicians have debated an appropriate term for the clinical phase preceding acute kidney injury (AKI). The recent development of cell cycle arrest biomarkers that signal the potential development of AKI is part of an evolution in the molecular diagnosis and understanding of AKI. It is proposed that the pre-injury phase that leads to AKI can be described as “acute kidney stress”. This term has the potential to expand horizons in regard to the early detection of situations that will lead to AKI and the early implementation of corrective measures.
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Affiliation(s)
- Nevin Katz
- Division of Cardiac Surgery, Johns Hopkins University, 1800 Orleans Street, Suite 7107, Baltimore, MD, 21287, USA. .,Foundation for the Advancement of Cardiothoracic Surgical Care (FACTS-Care), 1912 Foxhall Road, McLean, VA, 22101, USA.
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Renal Transplantation, International Renal Research Institute Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy
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Hori D, Hogue C, Adachi H, Max L, Price J, Sciortino C, Zehr K, Conte J, Cameron D, Mandal K. Perioperative optimal blood pressure as determined by ultrasound tagged near infrared spectroscopy and its association with postoperative acute kidney injury in cardiac surgery patients. Interact Cardiovasc Thorac Surg 2016; 22:445-51. [PMID: 26763042 DOI: 10.1093/icvts/ivv371] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 11/16/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Perioperative blood pressure management by targeting individualized optimal blood pressure, determined by cerebral blood flow autoregulation monitoring, may ensure sufficient renal perfusion. The purpose of this study was to evaluate changes in the optimal blood pressure for individual patients, determined during cardiopulmonary bypass (CPB) and during early postoperative period in intensive care unit (ICU). A secondary aim was to examine if excursions below optimal blood pressure in the ICU are associated with risk of cardiac surgery-associated acute kidney injury (CSA-AKI). METHODS One hundred and ten patients undergoing cardiac surgery had cerebral blood flow monitored with a novel technology using ultrasound tagged near infrared spectroscopy (UT-NIRS) during CPB and in the first 3 h after surgery in the ICU. The correlation flow index (CFx) was calculated as a moving, linear correlation coefficient between cerebral flow index measured using UT-NIRS and mean arterial pressure (MAP). Optimal blood pressure was defined as the MAP with the lowest CFx. Changes in optimal blood pressure in the perioperative period were observed and the association of blood pressure excursions (magnitude and duration) below the optimal blood pressure [area under the curve (AUC) < OptMAP mmHgxh] with incidence of CSA-AKI (defined using Kidney Disease: Improving Global Outcomes criteria) was examined. RESULTS Optimal blood pressure during early ICU stay and CPB was correlated (r = 0.46, P < 0.0001), but was significantly higher in the ICU compared with during CPB (75 ± 8.7 vs 71 ± 10.3 mmHg, P = 0.0002). Thirty patients (27.3%) developed CSA-AKI within 48 h after the surgery. AUC < OptMAP was associated with CSA-AKI during CPB [median, 13.27 mmHgxh, interquartile range (IQR), 4.63-20.14 vs median, 6.05 mmHgxh, IQR 3.03-12.40, P = 0.008], and in the ICU (13.72 mmHgxh, IQR 5.09-25.54 vs 5.65 mmHgxh, IQR 1.71-13.07, P = 0.022). CONCLUSIONS Optimal blood pressure during CPB and in the ICU was correlated. Excursions below optimal blood pressure (AUC < OptMAP mmHgXh) during perioperative period are associated with CSA-AKI. Individualized blood pressure management based on cerebral autoregulation monitoring during the perioperative period may help improve CSA-AKI-related outcomes.
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Affiliation(s)
- Daijiro Hori
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles Hogue
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hideo Adachi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Laura Max
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joel Price
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher Sciortino
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kenton Zehr
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John Conte
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Duke Cameron
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kaushik Mandal
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hori D, Max L, Laflam A, Brown C, Neufeld KJ, Adachi H, Sciortino C, Conte JV, Cameron DE, Hogue CW, Mandal K. Blood Pressure Deviations From Optimal Mean Arterial Pressure During Cardiac Surgery Measured With a Novel Monitor of Cerebral Blood Flow and Risk for Perioperative Delirium: A Pilot Study. J Cardiothorac Vasc Anesth 2016; 30:606-12. [PMID: 27321787 DOI: 10.1053/j.jvca.2016.01.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate whether excursions of blood pressure from the optimal mean arterial pressure during and after cardiac surgery are associated with postoperative delirium identified using a structured examination. DESIGN Prospective, observational study. SETTING University hospital. PARTICIPANTS The study included 110 patients undergoing cardiac surgery. INTERVENTIONS Patients were monitored using ultrasound-tagged near-infrared spectroscopy to assess optimal mean arterial pressure by cerebral blood flow autoregulation monitoring during cardiopulmonary bypass and the first 3 hours in the intensive care unit. MEASUREMENTS AND MAIN RESULTS The patients were tested preoperatively and on postoperative days 1 to 3 with the Confusion Assessment Method or Confusion Assessment Method for the Intensive Care Unit, the Delirium Rating Scale-Revised-98, and the Mini Mental State Examination. Summative presence of delirium on postoperative days 1 through 3, as defined by the consensus panel following Diagnostic and Statistical Manual of Mental Disorders-IV-TR criteria, was the primary outcome. Delirium occurred in 47 (42.7%) patients. There were no differences in blood pressure excursions above and below optimal mean arterial pressure between patients with and without summative presence of delirium. Secondary analysis showed blood pressure excursions above the optimal mean arterial pressure to be higher in patients with delirium (mean±SD, 33.2±26.51 mmHgxh v 23.4±16.13 mmHgxh; p = 0.031) and positively correlated with the Delirium Rating Scale score on postoperative day 2 (r = 0.27, p = 0.011). CONCLUSIONS Summative presence of delirium was not associated with perioperative blood pressure excursions; but on secondary exploratory analysis, excursions above the optimal mean arterial pressure were associated with the incidence and severity of delirium on postoperative day 2.
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Affiliation(s)
- Daijiro Hori
- Division of Cardiac Surgery, Department of Surgery
| | - Laura Max
- Department of Anesthesiology & Critical Care Medicine
| | - Andrew Laflam
- Department of Anesthesiology & Critical Care Medicine
| | - Charles Brown
- Department of Anesthesiology & Critical Care Medicine
| | - Karin J Neufeld
- Department of Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hideo Adachi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | | | - John V Conte
- Division of Cardiac Surgery, Department of Surgery
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Freeman WD, Wadei HM. A brain-kidney connection: the delicate interplay of brain and kidney physiology. Neurocrit Care 2016; 22:173-5. [PMID: 25672972 DOI: 10.1007/s12028-015-0119-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- William D Freeman
- Departments of Neurosurgery, Neurology and Critical Care, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA,
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Dias C, Gaio AR, Monteiro E, Barbosa S, Cerejo A, Donnelly J, Felgueiras Ó, Smielewski P, Paiva JA, Czosnyka M. Kidney-brain link in traumatic brain injury patients? A preliminary report. Neurocrit Care 2016; 22:192-201. [PMID: 25273515 DOI: 10.1007/s12028-014-0045-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Kidney hyperfiltration with augmented renal clearance is frequently observed in patients with traumatic brain injury. The aim of this study is to report preliminary findings about the relationship between brain autoregulation impairment, estimated kidney glomerular filtration rate and outcome in critically ill patients after severe traumatic brain injury. METHODS Data collected from a cohort of 18 consecutive patients with severe traumatic brain injury managed with ICP monitoring in a Neurocritical Care Unit, were retrospectively analyzed. Early morning blood tests were performed for routine chemistry assessments and we analyzed creatinine and estimated creatinine clearance, osmolarity, and sodium. Daily norepinephrine dose, protein intake, and water balance were documented. Time average of brain monitoring data (intracranial pressure, cerebral perfusion pressure, and cerebrovascular reactivity pressure index--PRx) were calculated for 6 h before blood sample tests. Patient outcome was evaluated using Glasgow outcome scale at 6-month follow-up, considering nonfatal outcome if GOS ≥ 3 and fatal outcome if GOS < 3. Multiple linear regression models were used to study the crude and adjusted effects of the above variables on PRx throughout time. RESULTS A total of 199 complete daily observations from 18 adult consecutive multiple trauma patients with severe traumatic brain injury were analyzed. At hospital admission, the median post-resuscitation Glasgow coma score was 6 (range 3-12), mean SAPSII score was 44.65 with predicted mortality of 36 %. Hospital mortality rate was 27 % and median GOS at 6 month after discharge was 3. Creatinine clearance (CrCl) was found to have a negative correlation with PRx (Pearson correlation--0.82), with statistically significant crude (p < 0.001) and adjusted (p = 0.001) effects. For each increase of 10 ml/min in CrCl (estimated either by the Cockcroft-Gault or by Modification of Diet in Renal Disease Study equations) a mean decrease in PRx of approximately 0.01 was expected. Amongst possible confounders only norepinephrine was shown to have a significant effect. Mean PRx value for outcome fatal status was greater than mean PRx for nonfatal status (p < 0.05), regardless of the model used for the CrCl estimation. CONCLUSIONS Better cerebral autoregulation evaluated with cerebrovascular PRx is significantly correlated with augmented renal clearance in TBI patients and associates with better outcome.
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Affiliation(s)
- Celeste Dias
- Intensive Care Department, Neurocritical Care Unit, Hospital Sao Joao, Porto, Portugal,
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Cheng H, Sun JZ, Ji FH, Liu H. Prevention and Treatment of Cardiac Surgery Associated Acute Kidney Injury. JOURNAL OF ANESTHESIA AND PERIOPERATIVE MEDICINE 2016; 3:42-51. [PMID: 31598583 PMCID: PMC6785192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
AIM OF REVIEW Acute kidney injury (AKI) after cardiac surgery is a relatively common postoperative complication and is independently related to increased mortality and morbidity. METHOD In this review, we will focus on risk factors of developing AKI, early detection by biomarkers and preventive strategies for AKI after adult cardiac surgery. RECENT FINDINGS Many perioperative factors affect renal function and acute AKI following cardiac surgery. Novel biomarkers of kidney injury such as neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18), cystatin C (CysC), have the potential to facilitate the early diagnosis of cardiac surgery associated AKI (CSA-AKI). Pharmacological interventions have been inconsistent to their efficacy, and to date, there is no compelling pharmacologic agent known to reduce the risk of AKI or treat established AKI. SUMMARY Preventive strategies of AKI focus on optimal perioperative management.
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Affiliation(s)
- Hao Cheng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China,Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, USA
| | - Jian-Zhong Sun
- Department of Anesthesiology, Thomas Jefferson University and Hospitals, Philadelphia, USA
| | - Fu-Hai Ji
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, USA
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Brown C, Faigle R, Klinker L, Bahouth M, Max L, LaFlam A, Neufeld KJ, Mandal K, Gottesman R, Hogue C. The Association of Brain MRI Characteristics and Postoperative Delirium in Cardiac Surgery Patients. Clin Ther 2015; 37:2686-2699.e9. [PMID: 26621626 PMCID: PMC5384473 DOI: 10.1016/j.clinthera.2015.10.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 10/15/2015] [Accepted: 10/27/2015] [Indexed: 12/17/2022]
Abstract
PURPOSE Delirium is common after cardiac surgery and is associated with adverse consequences, including cognitive decline. Identification of vulnerable older adults might allow for early implementation of delirium-prevention strategies. Brain MRI findings provide insight into structural brain changes that may identify vulnerable patients. The purpose of this study was to examine the association between brain MRI characteristics potentially associated with delirium vulnerability and the development of postoperative delirium in a nested cohort of patients undergoing cardiac surgery. METHODS We identified 79 cardiac surgery patients who had brain MRI imaging after cardiac surgery, as part of an ongoing randomized trial evaluating the efficacy of blood pressure management based on cerebral autoregulation monitoring versus standard management for improving neurological outcomes. Cerebral lateral ventricular size, cortical sulcal width, and white matter hyperintensities (WMH) on brain MRI scans were graded on a validated 0 to 9 scale, and categorized into tertiles. New ischemic lesions were characterized as present or absent. Delirium was assessed using a validated chart-review. Neuropsychological testing performed before surgery was used to establish preoperative cognitive baseline. Multivariable logistic regression was used to assess the independent association between MRI characteristics and postoperative delirium. FINDINGS The average age of patients was 70.1 ± 7.8 years old, and 72% were male. Twenty-eight of 79 (35.4%) patients developed postoperative delirium. Patients with delirium had higher unadjusted ventricular size (median 4 vs. 3, P = 0.003), and there was a trend towards higher sulcal sizes and WMH grades. Increasing tertiles of ventricular size (Odds Ratio [OR] 3.59; 95% Confidence Interval [CI] 1.59-8.12; P = 0.002) and sulcal size (OR 2.15; 95%CI 1.13-4.12; P = 0.02) were associated with postoperative delirium, with a trend for tertiles of WMH grade (OR 1.91; 95%CI 0.99-3.68; P = 0.05). In multivariable models adjusted for logistic EuroSCORE, baseline cognitive status, bypass time, and any postoperative complication, each tertile of ventricular size was associated with increased odds of postoperative delirium (OR 3.23 per tertile increase in ventricular size; 95%CI 1.21-8.60; P = 0.02). There were no differences in odds of delirium by tertiles of sulcal grade, tertiles of white matter grade, or presence of new ischemic lesions, in adjusted models. IMPLICATIONS Increased brain ventricular size was independently associated with delirium after cardiac surgery. These results suggest that cerebral atrophy may contribute to increased vulnerability for postoperative delirium. Baseline brain MRIs may be useful in identifying cardiac surgery patients at high risk for postoperative delirium, who might benefit from targeted perioperative approaches to prevent delirium. ClinicalTrials.gov identifier: NCT00981474.
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Affiliation(s)
- Charles Brown
- Zayed 6208, 1800 Orleans St., Baltimore MD 21287, United States of America, , 410 955 7519
| | - Roland Faigle
- Phipps 484, 600 N Wolfe Street, Baltimore MD 21287, United States of America,
| | - Lauren Klinker
- Zayed 6208, 1800 Orleans St., Baltimore MD 21287, United States of America,
| | - Mona Bahouth
- 466 Phipps, 600 N. Wolfe St., Baltimore MD 21205, United States of America,
| | - Laura Max
- Zayed 6208, 1800 Orleans St., Baltimore MD 21287, United States of America,
| | - Andrew LaFlam
- Zayed 6208, 1800 Orleans St., Baltimore MD 21287, United States of America,
| | - Karin J. Neufeld
- Osler 320, 600 N. Wolfe St., Baltimore MD 21287, United States of America,
| | - Kaushik Mandal
- Zayed 7107, 1800 Orleans St., Baltimore MD 21287, United States of America,
| | | | - Charles Hogue
- Zayed 6208, 1800 Orleans St., Baltimore MD 21287, United States of America,
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Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery. Anesthesiology 2015; 123:515-23. [PMID: 26181335 DOI: 10.1097/aln.0000000000000765] [Citation(s) in RCA: 456] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Intraoperative hypotension (IOH) may be associated with postoperative acute kidney injury (AKI), but the duration of hypotension for triggering harm is unclear. The authors investigated the association between varying periods of IOH with mean arterial pressure (MAP) less than 55, less than 60, and less than 65 mmHg with AKI. METHODS The authors conducted a retrospective cohort study of 5,127 patients undergoing noncardiac surgery (2009 to 2012) with invasive MAP monitoring and length of stay of 1 or more days. Exclusion criteria were preoperative MAP less than 65 mmHg, dialysis dependence, urologic surgery, and surgical duration less than 30 min. The primary exposure was IOH. The primary outcome was AKI (50% or 0.3 mg/dl increase in creatinine) during the first 2 postoperative days. Multivariable logistic regression was used to model the exposure-outcome relationship. RESULTS AKI occurred in 324 (6.3%) patients and was associated with MAP less than 60 mmHg for 11 to 20 min and MAP less than 55 mmHg for more than 10 min in a graded fashion. The adjusted odds ratio of AKI for MAP less than 55 mmHg was 2.34 (1.35 to 4.05) for 11- to 20-min exposure and 3.53 (1.51 to 8.25) for more than 20 min. For MAP less than 60 mmHg, the adjusted odds ratio for AKI was 1.84 (1.11 to 3.06) for 11- to 20-min exposure. CONCLUSIONS In this analysis, postoperative AKI is associated with sustained intraoperative periods of MAP less than 55 and less than 60 mmHg. This study provides an impetus for clinical trials to determine whether interventions that promptly treat IOH and are tailored to individual patient physiology could help reduce the risk of AKI.
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Gautam SC, Brooks CH, Balogun RA, Xin W, Ma JZ, Abdel-Rahman EM. Predictors and Outcomes of Post-Hospitalization Dialysis Dependent Acute Kidney Injury. Nephron Clin Pract 2015; 131:185-90. [PMID: 26524288 DOI: 10.1159/000441607] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 10/06/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a frequent complication of hospitalized patients and is associated with poor outcomes. Hospitalized patients with AKI may need prolonged dialysis, necessitating post-hospitalization dialysis (PHD-AKI). Scarce information is available to stratify the risks and predict outcomes. This study aims to assess outcomes and identify predictors of outcomes of PHD-AKI within 90 days. METHODS All adult AKI patients initiating hemodialysis (HD) at the University of Virginia (UVA) between June 1, 2012, and September 30, 2013 were retrospectively studied. PHD-AKI patients continued treatment at a specifically designated unit. They were followed until an outcome (end-stage renal disease [ESRD], death or dialysis-independence) was achieved. RESULTS During the study period, 108 patients required outpatient dialysis out of 365 AKI patients initiating in-patient HD at UVA. An additional 11 patients who developed dialysis-requiring AKI at referring hospitals but underwent HD at our unit were included for a total of 119 patients studied. ESRD was declared in 48.7%, while 9.2% expired and 42.0% achieved dialysis independence. Congestive heart failure, baseline renal function and a prior episode of AKI within the preceding 6 months were statistically significant predictors of renal outcomes. CONCLUSION Dialysis independence of PHD-AKI patients is not uncommon. Certain clinical parameters may help predict renal outcome. Identifying predictors of renal recovery will guide further interventions, especially with the Centers for Medicare and Medicaid Services soon to allow AKI patients to be dialyzed at outpatient ESRD facilities. Ongoing biomarkers research may add further knowledge for optimum diagnosis and prognosis of AKI.
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Murkin JM, Kamar M, Silman Z, Balberg M, Adams SJ. Intraoperative Cerebral Autoregulation Assessment Using Ultrasound-Tagged Near-Infrared-Based Cerebral Blood Flow in Comparison to Transcranial Doppler Cerebral Flow Velocity: A Pilot Study. J Cardiothorac Vasc Anesth 2015; 29:1187-93. [DOI: 10.1053/j.jvca.2015.05.201] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Indexed: 11/11/2022]
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Donnelly J, Aries MJ, Czosnyka M. Further understanding of cerebral autoregulation at the bedside: possible implications for future therapy. Expert Rev Neurother 2015; 15:169-85. [PMID: 25614952 DOI: 10.1586/14737175.2015.996552] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cerebral autoregulation reflects the ability of the brain to keep the cerebral blood flow (CBF) relatively constant despite changes in cerebral perfusion pressure. It is an intrinsic neuroprotective physiological phenomenon often suggested as part of pathophysiological pathways in brain research. However, despite increasing knowledge of this phenomenon for over 50 years, harnessing cerebral autoregulation as a basis for therapy remains an elegant concept rather than a practical reality. This raises the question is it useful to measure at the bedside or is it merely a scientific curiosity that is too complex and has little pragmatic relevance. In this article, we attempt to answer this question by demonstrating how cerebral autoregulation assessment can have prognostic value, indicate pathological states, and potentially even influence therapy with the use of the 'optimal cerebral perfusion pressure' paradigm. Evidence from the literature is combined with bedside clinical examples to address the following fundamental questions about cerebral autoregulation: What is it? How do we measure it? Why is it important? Can we use it as a basis for therapy?
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Affiliation(s)
- Joseph Donnelly
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK
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Assessment of Cerebral Autoregulation Patterns with Near-infrared Spectroscopy during Pharmacological-induced Pressure Changes. Anesthesiology 2015; 123:327-35. [DOI: 10.1097/aln.0000000000000715] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Abstract
Background:
Previous work has demonstrated paradoxical increases in cerebral oxygen saturation (ScO2) as blood pressure decreases and paradoxical decreases in ScO2 as blood pressure increases. It has been suggested that these paradoxical responses indicate a functional cerebral autoregulation mechanism. Accordingly, the authors hypothesized that if this suggestion is correct, paradoxical responses will occur exclusively in patients with intact cerebral autoregulation.
Methods:
Thirty-four patients undergoing elective cardiac surgery were included. Cerebral autoregulation was assessed with the near-infrared spectroscopy–derived cerebral oximetry index (COx), computed by calculating the Spearman correlation coefficient between mean arterial pressure and ScO2. COx less than 0.30 was previously defined as functional autoregulation. During cardiopulmonary bypass, 20% change in blood pressure was accomplished with the use of nitroprusside for decreasing pressure and phenylephrine for increasing pressure. Effects on COx were assessed. Data were analyzed using two-way ANOVA, Kruskal–Wallis test, and Wilcoxon and Mann–Whitney U test.
Results:
Sixty-five percent of patients had a baseline COx less than 0.30, indicating functional baseline autoregulation. In 50% of these patients (n = 10), COx became highly negative after vasoactive drug administration (from −0.04 [−0.25 to 0.16] to −0.63 [−0.83 to −0.26] after administration of phenylephrine, and from −0.05 [−0.19 to 0.17] to −0.55 [−0.94 to −0.35] after administration of nitroprusside). A negative COx implies a decrease in ScO2 with increase in pressure and, conversely, an increase in ScO2 with decrease in pressure.
Conclusions:
In this study, paradoxical changes in ScO2 after pharmacological-induced pressure changes occurred exclusively in patients with intact cerebral autoregulation, corroborating the hypothesis that these paradoxical responses might be attributable to a functional cerebral autoregulation.
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Hypotension After Cardiac Operations Based on Autoregulation Monitoring Leads to Brain Cellular Injury. Ann Thorac Surg 2015; 100:487-93. [PMID: 26089226 DOI: 10.1016/j.athoracsur.2015.03.036] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/28/2015] [Accepted: 03/06/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Individualizing blood pressure targets could improve organ perfusion compared with current practices. In this study we assess whether hypotension defined by cerebral autoregulation monitoring vs standard definitions is associated with elevation in the brain-specific injury biomarker glial fibrillary acidic protein plasma levels (GFAP). METHODS Plasma GFAP levels were measured in 121 patients undergoing cardiac operations after anesthesia induction, at the conclusion of the operation, and on postoperative day 1. Cerebral autoregulation was monitored during the operation with the cerebral oximetry index, which correlates low-frequency changes in mean arterial pressure (MAP) and regional cerebral oxygen saturation. Blood pressure was recorded every 15 minutes in the intensive care unit. Hypotension was defined based on autoregulation data as an MAP below the optimal MAP (MAP at the lowest cerebral oximetry index) and based on standard definitions (systolic blood pressure decrement >20%, >30% from baseline, or <100 mm Hg, or both). RESULTS MAP (mean ± standard deviation) in the intensive care unit was 74 ± 7.3 mm Hg; optimal MAP was 78 ± 12.8 mm Hg (p = 0.008). The incidence of hypotension varied from 22% to 37% based on standard definitions but occurred in 54% of patients based on the cerebral oximetry index (p < 0.001). There was no relationship between standard definitions of hypotension and plasma GFAP levels, but MAP of less than optimal was positively related with postoperative day 1 GFAP levels (coefficient, 1.77; 95% confidence interval, 1.27 to 2.48; p = 0.001) after adjusting for GFAP levels at the conclusion of the operation and low cardiac output syndrome. CONCLUSIONS Individualizing blood pressure management using cerebral autoregulation monitoring may better ensure brain perfusion than current practice.
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Should Cerebral Near-infrared Spectroscopy be Standard of Care in Adult Cardiac Surgery? Heart Lung Circ 2015; 24:544-50. [DOI: 10.1016/j.hlc.2015.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 01/19/2015] [Indexed: 11/18/2022]
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Sørensen H, Grocott HP, Secher NH. Near infrared spectroscopy for frontal lobe oxygenation during non-vascular abdominal surgery. Clin Physiol Funct Imaging 2015; 36:427-435. [DOI: 10.1111/cpf.12244] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 02/20/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Henrik Sørensen
- Department of Anesthesia, Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - Hilary P. Grocott
- Department of Anesthesia & Perioperative Medicine; University of Manitoba; Winnipeg MB Canada
| | - Niels H. Secher
- Department of Anesthesia, Rigshospitalet; University of Copenhagen; Copenhagen Denmark
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Shoulder surgery in the beach chair position is associated with diminished cerebral autoregulation but no differences in postoperative cognition or brain injury biomarker levels compared with supine positioning: the anesthesia patient safety foundation beach chair study. Anesth Analg 2015; 120:176-185. [PMID: 25268397 DOI: 10.1213/ane.0000000000000455] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although controversial, failing to consider the gravitational effects of head elevation on cerebral perfusion is speculated to increase susceptibility to rare, but devastating, neurologic complications after shoulder surgery in the beach chair position (BCP). We hypothesized that patients in the BCP have diminished cerebral blood flow autoregulation than those who undergo surgery in the lateral decubitus position (LDP). A secondary aim was to examine whether there is a relationship between patient positioning during surgery and postoperative cognition or serum brain injury biomarker levels. METHODS Patients undergoing shoulder surgery in the BCP (n = 109) or LDP (n = 109) had mean arterial blood pressure (MAP) and regional cerebral oxygen saturation (rScO2) monitored with near-infrared spectroscopy. A continuous, moving Pearson correlation coefficient was calculated between MAP and rScO2, generating the variable cerebral oximetry index (COx). When MAP is in the autoregulated range, COx approaches zero because there is no correlation between cerebral blood flow and arterial blood pressure. In contrast, when MAP is below the limit of autoregulation, COx is higher because there is a direct relationship between lower arterial blood pressure and lower cerebral blood flow. Thus, diminished autoregulation would be manifest as higher COx. Psychometric testing was performed before surgery and then 7 to 10 days and 4 to 6 weeks after surgery. A composite cognitive outcome was determined as the Z-score. Serum S100β, neuron-specific enolase, and glial fibrillary acidic protein were measured at baseline, after surgery, and on postoperative day 1. RESULTS After adjusting for age and history of hypertension, COx (P = 0.035) was higher and rScO2 lower (P < 0.0001) in the BCP group than in the LDP group. After adjusting for baseline composite cognitive outcome, there was no difference in Z-score 7 to 10 days (P = 0.530) or 4 to 6 weeks (P = 0.202) after surgery between the BCP and the LDP groups. There was no difference in serum biomarker levels between the 2 position groups CONCLUSIONS : Compared with patients in the LDP, patients undergoing shoulder surgery in the BCP are more likely to have higher COx indicating diminished cerebral autoregulation and lower rScO2. There were no differences in the composite cognitive outcome between the BCP and the LDP groups after surgery after accounting for baseline Z-score.
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Kramer RS, Herron CR, Groom RC, Brown JR. Acute Kidney Injury Subsequent to Cardiac Surgery. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2015; 47:16-28. [PMID: 26390675 PMCID: PMC4566816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 02/17/2015] [Indexed: 06/05/2023]
Abstract
Acute kidney injury (AKI) after cardiac surgery is a common and underappreciated syndrome that is associated with poor shortand long-term outcomes. AKI after cardiac surgery may be epiphenomenon, a signal for adverse outcomes by virtue of other affected organ systems, and a consequence of multiple factors. Subtle increases in serum creatinine (SCr) postoperatively, once considered inconsequential, have been shown to reflect a kidney injury that likely occurred in the operating room during cardiopulmonary bypass (CPB) and more often in susceptible individuals. The postoperative elevation in SCr is a delayed signal reflecting the intraoperative injury. Preoperative checklists and the conduct of CPB represent opportunities for prevention of AKI. Newer definitions of AKI provide us with an opportunity to scrutinize perioperative processes of care and determine strategies to decrease the incidence of AKI subsequent to cardiac surgery. Recognizing and mitigating risk factors preoperatively and optimizing intraoperative practices may, in the aggregate, decrease the incidence of AKI. This review explores the pathophysiology of AKI and addresses the features of patients who are the most vulnerable to AKI. Preoperative strategies are discussed with particular attention to a readiness for surgery checklist. Intraoperative strategies include minimizing hemodilution and maximizing oxygen delivery with specific suggestions regarding fluid management and plasma preservation.
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Affiliation(s)
- Robert S. Kramer
- Division of Cardiothoracic Surgery, Maine Medical Center, Portland, Maine
| | - Crystal R. Herron
- Division of Cardiothoracic Surgery, Maine Medical Center, Portland, Maine
| | - Robert C. Groom
- Division of Cardiothoracic Surgery, Maine Medical Center, Portland, Maine
| | - Jeremiah R. Brown
- Departments of Medicine and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice and Section of Cardiology, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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Ito K, Ookawara S, Ueda Y, Goto S, Miyazawa H, Yamada H, Kitano T, Shindo M, Kaku Y, Hirai K, Yoshida M, Hoshino T, Nabata A, Mori H, Yoshida I, Kakei M, Tabei K. Factors affecting cerebral oxygenation in hemodialysis patients: cerebral oxygenation associates with pH, hemodialysis duration, serum albumin concentration, and diabetes mellitus. PLoS One 2015; 10:e0117474. [PMID: 25706868 PMCID: PMC4338103 DOI: 10.1371/journal.pone.0117474] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 12/24/2014] [Indexed: 01/13/2023] Open
Abstract
Background Patients undergoing hemodialysis (HD) often develop cerebral disease complications. Furthermore, cerebral regional saturation of oxygen (rSO2) was previously reported to be significantly lower in HD patients than in healthy subjects. We aimed to identify the factors affecting the cerebral rSO2 in HD patients. Methods Fifty-four HD patients (38 men and 16 women; mean age, 67.7 ± 1.2 years, HD duration, 6.5 ± 1.9 years) were recruited. Cerebral rSO2 was monitored at the forehead before HD using an INVOS 5100C (Covidien Japan, Tokyo, Japan). Results The rSO2 levels were significantly lower in HD patients compared with healthy controls (49.5 ± 1.7% vs. 68.9 ± 1.6%, p <0.001). Multiple regression analysis showed that cerebral rSO2 independently associated with pH (standardized coefficient: -0.35), HD duration (standardized coefficient: -0.33), and serum albumin concentration (standardized coefficient: 0.28). Furthermore, the rSO2 was significantly lower in HD patients with diabetes mellitus (DM), compared with patients without DM (46.8 ± 1.7% vs. 52.1 ± 1.8%, p <0.05). Conclusions In HD patients, cerebral rSO2 was affected by multiple factors, including pH, HD duration, and serum albumin concentration. Furthermore, this is the first report describing significantly lower levels of rSO2 in HD patients with DM than in those without DM.
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Affiliation(s)
- Kiyonori Ito
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Susumu Ookawara
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
- Department of Internal Medicine, Nishikawa Town Hospital, Yamagata, Japan
- * E-mail:
| | - Yuichiro Ueda
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Sawako Goto
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Haruhisa Miyazawa
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hodaka Yamada
- Division of Endocrinology and Metabolism, Department of Integrated Medicine Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taisuke Kitano
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Mitsunobu Shindo
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yoshio Kaku
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Keiji Hirai
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Masashi Yoshida
- Division of Endocrinology and Metabolism, Department of Integrated Medicine Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taro Hoshino
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Aoi Nabata
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Honami Mori
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Izumi Yoshida
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Masafumi Kakei
- Division of Endocrinology and Metabolism, Department of Integrated Medicine Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kaoru Tabei
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Hori D, Ono M, Adachi H, Hogue CW. Effect of carotid revascularization on cerebral autoregulation in combined cardiac surgery†. Eur J Cardiothorac Surg 2015; 49:281-7. [PMID: 25646403 DOI: 10.1093/ejcts/ezv018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 12/22/2014] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Combined carotid artery endarterectomy (CEA) and coronary artery bypass grafting surgery is considered to reduce long-term stroke risk for patients with severe carotid artery stenosis. The benefits of CEA for improving cerebral perfusion during subsequent cardiopulmonary bypass (CPB) are unclear. The purpose of this pilot study was to assess cerebral autoregulation and cerebral oximetry in patients undergoing combined CEA and cardiac surgery with those undergoing cardiac surgery without significant carotid artery stenosis or with uncorrected stenosis. METHODS Cerebral autoregulation was monitored continuously in 257 patients with the cerebral oximetry index (COx). COx represents a moving Pearson's correlation coefficient between low-frequency changes in regional cerebral oxygen saturation (rScO2) and mean arterial pressure that has been validated in previous investigations. Impaired autoregulation was defined as a value of COx ≥0.3. RESULTS Nineteen patients had prior CEA, 8 underwent combined CEA and cardiac surgery, 8 had uncorrected stenosis >70% and 197 had stenosis <50%. Combined, patients with stenosis >70% had a higher COx before CPB compared with those with stenosis <50% (median, 0.26, 25th percentile and 75th percentile [p25-p75], 0.18-0.33 vs 0.18, p25-p75, 0.07-0.27, respectively, P = 0.054). Patients who underwent combined CEA and cardiac surgery had a higher COx before surgery compared with those with prior CEA (P = 0.027) and stenosis <50% (P = 0.026). There were no differences in average COx or rScO2 during CPB in patients undergoing combined CEA and cardiac surgery compared with those with prior CEA (P = 0.53, 0.27) and those with stenosis <50% (P = 0.71, 0.19), respectively. During CPB, patients with uncorrected stenosis had an average COx of 0.36 (p25-p75, 0.28-0.56) indicating cerebral autoregulation impairment, and lower rScO2 compared with patients with prior CEA (P = 0.006) and stenosis <50% (P = 0.005). CONCLUSIONS While higher at baseline, patients undergoing CEA immediately before cardiac surgery had COx and rScO2 measurements during CPB similar to those with non-significant stenosis in contrast to those patients with uncorrected stenosis who had evidence of impaired autoregulation and lower rScO2. These preliminary results suggest the potential utility of COx, possibly for complimenting patient selection for CEA as well as for individual patient management during surgery.
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Affiliation(s)
- Daijiro Hori
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Masahiro Ono
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hideo Adachi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Charles W Hogue
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Asymmetric Brain Edema After Cardiac Transplantation: Cerebroautoregulatory Failure and Relative Hyperperfusion. Transplant Proc 2015; 47:194-7. [DOI: 10.1016/j.transproceed.2014.06.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 06/17/2014] [Indexed: 11/21/2022]
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139
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Brown CH, Morrissey C, Ono M, Yenokyan G, Selnes OA, Walston J, Max L, LaFlam A, Neufeld K, Gottesman RF, Hogue CW. Impaired olfaction and risk of delirium or cognitive decline after cardiac surgery. J Am Geriatr Soc 2015; 63:16-23. [PMID: 25597555 PMCID: PMC4299936 DOI: 10.1111/jgs.13198] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the prevalence of impaired olfaction in individuals presenting for cardiac surgery and the independent association between impaired olfaction and postoperative delirium and cognitive decline. DESIGN Nested prospective cohort study. SETTING Academic hospital. PARTICIPANTS Individuals undergoing coronary artery bypass, valve surgery, or both (n = 165). MEASUREMENTS Olfaction was measured using the Brief Smell Identification Test, with impaired olfaction defined as an olfactory score below the fifth percentile of normative data. Delirium was assessed using a validated chart review method. Cognitive performance was assessed using a neuropsychological testing battery at baseline and 4 to 6 weeks after surgery. RESULTS Impaired olfaction was identified in 54 of 165 participants (33%) before surgery. Impaired olfaction was associated with greater adjusted risk of postoperative delirium (relative risk = 1.90, 95% confidence interval = 1.17-3.09, P = .009). There was no association between impaired olfaction and change in composite cognitive score in the overall study population. CONCLUSION Impaired olfaction is prevalent in individuals undergoing cardiac surgery and is associated with greater adjusted risk of postoperative delirium but not cognitive decline. Impaired olfaction may identify unrecognized vulnerability to postoperative delirium in individuals undergoing cardiac surgery.
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Affiliation(s)
- Charles H. Brown
- Assistant Professor, Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University School of Medicine; Baltimore, MD, 21287
| | - Candice Morrissey
- Fellow, Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University School of Medicine; Baltimore, MD, 21287
| | - Masahiro Ono
- Fellow, Department of Cardiac Surgery, Texas Heart Institute; Houston, TX 77030
| | - Gayane Yenokyan
- Assistant Scientist, Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, The Johns Hopkins University School of Medicine; Baltimore, MD, 21287
| | - Ola A. Selnes
- Professor, Department of Neurology, The Johns Hopkins University School of Medicine; Baltimore, MD, 21287
| | - Jeremy Walston
- Professor, Department of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine; Baltimore, MD, 21287
| | - Laura Max
- Research Assistant, Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University School of Medicine; Baltimore, MD, 21287
| | - Andrew LaFlam
- Research Assistant, Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University School of Medicine; Baltimore, MD, 21287
| | - Karin Neufeld
- Associate Professor, Department of Psychiatry, The Johns Hopkins University School of Medicine; Baltimore, MD, 21287
| | - Rebecca F. Gottesman
- Associate Professor, Department of Neurology, The Johns Hopkins University School of Medicine; Baltimore, MD, 21287
| | - Charles W. Hogue
- Professor, Department of Anesthesiology & Critical Care Medicine; The Johns Hopkins University School of Medicine; Baltimore, MD, 21287
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Naik BI, Durieux ME. Hemodynamic monitoring devices: Putting it all together. Best Pract Res Clin Anaesthesiol 2014; 28:477-88. [DOI: 10.1016/j.bpa.2014.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 09/05/2014] [Accepted: 09/17/2014] [Indexed: 10/24/2022]
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141
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Steppan J, Hogue CW. Cerebral and tissue oximetry. Best Pract Res Clin Anaesthesiol 2014; 28:429-39. [PMID: 25480772 DOI: 10.1016/j.bpa.2014.09.002] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 09/10/2014] [Accepted: 09/16/2014] [Indexed: 01/20/2023]
Abstract
The use of near-infrared spectroscopy (NIRS) has been increasingly adopted in cardiac surgery to measure regional cerebral oxygen saturation. This method takes advantage of the fact that light in the near-infrared spectrum penetrates tissue, including bone and muscle. Sensors are placed at fixed distances from a light emitter, and algorithms subtract superficial light absorption from deep absorption to provide an index of tissue oxygenation. Although the popularity of NIRS monitoring is growing, definitive data that prove outcome benefits with its use remain sparse. Therefore, widespread, routine use of NIRS as a standard-of-care monitor cannot be recommended at present. Recent investigations have focused on the use of NIRS in subgroups that may benefit from NIRS monitoring, such as pediatric patients. Furthermore, a novel application of processed NIRS information for monitoring cerebral autoregulation and tissue oxygenation (e.g., kidneys and the gut) is promising.
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Affiliation(s)
- Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Charles W Hogue
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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Hori D, Brown C, Ono M, Rappold T, Sieber F, Gottschalk A, Neufeld KJ, Gottesman R, Adachi H, Hogue CW. Arterial pressure above the upper cerebral autoregulation limit during cardiopulmonary bypass is associated with postoperative delirium. Br J Anaesth 2014; 113:1009-17. [PMID: 25256545 DOI: 10.1093/bja/aeu319] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Mean arterial pressure (MAP) below the lower limit of cerebral autoregulation during cardiopulmonary bypass (CPB) is associated with complications after cardiac surgery. However, simply raising empiric MAP targets during CPB might result in MAP above the upper limit of autoregulation (ULA), causing cerebral hyperperfusion in some patients and predisposing them to cerebral dysfunction after surgery. We hypothesized that MAP above an ULA during CPB is associated with postoperative delirium. METHODS Autoregulation during CPB was monitored continuously in 491 patients with the cerebral oximetry index (COx) in this prospective observational study. COx represents Pearson's correlation coefficient between low-frequency changes in regional cerebral oxygen saturation (measured with near-infrared spectroscopy) and MAP. Delirium was defined throughout the postoperative hospitalization based on clinical detection with prospectively defined methods. RESULTS Delirium was observed in 45 (9.2%) patients. Mechanical ventilation for >48 h [odds ratio (OR), 3.94; 95% confidence interval (CI), 1.72-9.03], preoperative antidepressant use (OR, 3.0; 95% CI, 1.29-6.96), prior stroke (OR, 2.79; 95% CI, 1.12-6.96), congestive heart failure (OR, 2.68; 95% CI, 1.28-5.62), the product of the magnitude and duration of MAP above an ULA (mm Hg h; OR, 1.09; 95% CI, 1.03-1.15), and age (per year of age; OR, 1.01; 95% CI, 1.01-1.07) were independently associated with postoperative delirium. CONCLUSIONS Excursions of MAP above the upper limit of cerebral autoregulation during CPB are associated with risk for delirium. Optimizing MAP during CPB to remain within the cerebral autoregulation range might reduce risk of delirium. CLINICAL TRIAL REGISTRATION clinicaltrials.gov NCT00769691 and NCT00981474.
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Affiliation(s)
- D Hori
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, 1800 Orleans Ave, Zayed 6208B, Baltimore, MD 21287, USA
| | - C Brown
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, 1800 Orleans Ave, Zayed 6208B, Baltimore, MD 21287, USA
| | - M Ono
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, 1800 Orleans Ave, Zayed 6208B, Baltimore, MD 21287, USA
| | - T Rappold
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, 1800 Orleans Ave, Zayed 6208B, Baltimore, MD 21287, USA
| | - F Sieber
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, 1800 Orleans Ave, Zayed 6208B, Baltimore, MD 21287, USA
| | - A Gottschalk
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, 1800 Orleans Ave, Zayed 6208B, Baltimore, MD 21287, USA
| | - K J Neufeld
- Department of Psychiatry, The Johns Hopkins Hospital, 1800 Orleans Ave, Zayed 6208B, Baltimore, MD 21287, USA
| | - R Gottesman
- Department of Neurology, The Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, 1800 Orleans Ave, Zayed 6208B, Baltimore, MD 21287, USA
| | - H Adachi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - C W Hogue
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, 1800 Orleans Ave, Zayed 6208B, Baltimore, MD 21287, USA
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Sørensen H, Grocott HP, Niemann M, Rasmussen A, Hillingsø JG, Frederiksen HJ, Secher NH. Ventilatory strategy during liver transplantation: implications for near-infrared spectroscopy-determined frontal lobe oxygenation. Front Physiol 2014; 5:321. [PMID: 25202281 PMCID: PMC4142416 DOI: 10.3389/fphys.2014.00321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 08/04/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND As measured by near infrared spectroscopy (NIRS), cerebral oxygenation (ScO2) may be reduced by hyperventilation in the anhepatic phase of liver transplantation surgery (LTx). Conversely, the brain may be subjected to hyperperfusion during reperfusion of the grafted liver. We investigated the relationship between ScO2 and end-tidal CO2 tension (EtCO2) during the various phases of LTx. METHODS In this retrospective study, 49 patients undergoing LTx were studied. Forehead ScO2, EtCO2, minute ventilation (VE), and hemodynamic variables were recorded from the beginning of surgery through to the anhepatic and reperfusion phases during LTx. RESULTS In the anhepatic phase, ScO2 was reduced by 4.3% (95% confidence interval: 2.5-6.0%; P < 0.0001), EtCO2 by 0.3 kPa (0.2-0.4 kPa; P < 0.0001), and VE by 0.4 L/min (0.1-0.7 L/min; P = 0.0018). Conversely, during reperfusion of the donated liver, ScO2 increased by 5.5% (3.8-7.3%), EtCO2 by 0.7 kPa (0.5-0.8 kPa), and VE by 0.6 L/min (0.3-0.9 L/min; all P < 0.0001). Changes in ScO2 were correlated to those in EtCO2 (Pearson r = 0.74; P < 0.0001). CONCLUSION During LTx, changes in ScO2 are closely correlated to those of EtCO2. Thus, this retrospective analysis suggests that attention to maintain a targeted EtCO2 would result in a more stable ScO2 during the operation.
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Affiliation(s)
- Henrik Sørensen
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Hilary P. Grocott
- Department of Anesthesia and Perioperative Medicine, St. Boniface Hospital, University of ManitobaWinnipeg, MB, Canada
| | - Mads Niemann
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Allan Rasmussen
- Department of Surgery and Transplantation, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Jens G. Hillingsø
- Department of Surgery and Transplantation, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Hans J. Frederiksen
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Niels H. Secher
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
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Williams M, Lee JK. Intraoperative blood pressure and cerebral perfusion: strategies to clarify hemodynamic goals. Paediatr Anaesth 2014; 24:657-67. [PMID: 24725244 PMCID: PMC4154320 DOI: 10.1111/pan.12401] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2014] [Indexed: 01/24/2023]
Abstract
Blood pressure can vary considerably during anesthesia. If blood pressure falls outside the limits of cerebrovascular autoregulation, children can become at risk of cerebral ischemic or hyperemic injury. However, the blood pressure limits of autoregulation are unclear in infants and children, and these limits can shift after brain injury. This article will review autoregulation, considerations for the hemodynamic management of children with brain injuries, and research on autoregulation monitoring techniques.
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Affiliation(s)
- Monica Williams
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, USA
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, USA
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145
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Affiliation(s)
- R. D. Sanders
- Surgical Outcomes Research Centre; University College London Hospital; London UK
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146
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Larsen SL, Lyngeraa TS, Maschmann CP, Van Lieshout JJ, Pott FC. Cardiovascular consequence of reclining vs. sitting beach-chair body position for induction of anesthesia. Front Physiol 2014; 5:187. [PMID: 24904427 PMCID: PMC4032912 DOI: 10.3389/fphys.2014.00187] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 04/26/2014] [Indexed: 11/13/2022] Open
Abstract
The sitting beach-chair position is regularly used for shoulder surgery and anesthesia may be induced in that position. We tested the hypothesis that the cardiovascular challenge induced by induction of anesthesia is attenuated if the patient is placed in a reclining beach-chair position. Anesthesia was induced with propofol in the sitting beach-chair (n = 15) or with the beach-chair tilted backwards to a reclining beach-chair position (n = 15). The last group was stepwise tilted to the sitting beach-chair position prior to surgery. Hypotension was treated with ephedrine. Continuous hemodynamic variables were recorded by photoplethysmography and frontal cerebral oxygenation (ScO2) by near infrared spectroscopy. Significant differences were only observed immediately after the induction when patients induced in a reclining beach-chair position had higher mean arterial pressure (MAP) (35 ± 12 vs. 45 ± 15 % reduction from baseline, p = 0.04) and ScO2 (7 ± 6 vs. 1 ± 8% increase from baseline, p = 0.02) and received less ephedrine (mean: 4 vs. 13 mg, p = 0.048). The higher blood pressure and lower need of vasopressor following induction of anesthesia in the reclining compared to the sitting beach-chair position indicate more stable hemodynamics with the clinical implication that anesthesia should not be induced with the patient in the sitting position.
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Affiliation(s)
- Søren L Larsen
- Department of Anesthesiology, Bispebjerg Hospital, University of Copenhagen Denmark
| | - Tobias S Lyngeraa
- Department of Anesthesiology, Bispebjerg Hospital, University of Copenhagen Denmark
| | | | - Johannes J Van Lieshout
- Acute Admissions Unit, Laboratory for Clinical Cardiovascular Physiology, Department of Internal Medicine, AMC Center for Heart Failure University of Amsterdam, Netherlands ; Queen's Medical Centre, School of Life Sciences, University of Nottingham Medical School Nottingham, UK
| | - Frank C Pott
- Department of Anesthesiology, Bispebjerg Hospital, University of Copenhagen Denmark
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147
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Aronson S, Levy JH, Lumb PD, Fontes M, Wang Y, Crothers TA, Sulham KA, Navetta MS. Impact of perioperative blood pressure variability on health resource utilization after cardiac surgery: an analysis of the ECLIPSE trials. J Cardiothorac Vasc Anesth 2014; 28:579-85. [PMID: 24726635 DOI: 10.1053/j.jvca.2014.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine the impact of blood pressure control on hospital health resource utilization using data from the ECLIPSE trials. DESIGN Post-hoc analysis of data from 3 prospective, open-label, randomized clinical trials (ECLIPSE trials). SETTING Sixty-one medical centers in the United States. PARTICIPANTS Patients 18 years or older undergoing cardiac surgery. INTERVENTIONS Clevidipine was compared with nitroglycerin, sodium nitroprusside, and nicardipine. MEASUREMENTS AND MAIN RESULTS The ECLIPSE trials included 3 individual randomized open-label studies comparing clevidipine to nitroglycerin, sodium nitroprusside, and nicardipine. Blood pressure control was assessed as the integral of the cumulative area under the curve (AUC) outside specified systolic blood pressure ranges, such that lower AUC represents less variability. This analysis examined surgery duration, time to extubation, as well as intensive care unit (ICU) and hospital length of stay (LOS) in patients with AUC≤10 mmHg×min/h compared to patients with AUC>10 mmHg×min/h. One thousand four hundred ten patients were included for analysis; 736 patients (52%) had an AUC≤10 mmHg×min/h, and 674 (48%) had an AUC>10 mmHg×min/h. The duration of surgery and ICU LOS were similar between groups. Time to extubation and postoperative LOS were both significantly shorter (p = 0.05 and p<0.0001, respectively) in patients with AUC≤10. Multivariate analysis demonstrates AUC≤10 was significantly and independently associated with decreased time to extubation (hazard ratio 1.132, p = 0.0261) and postoperative LOS (hazard ratio 1.221, p = 0.0006). CONCLUSIONS Based on data derived from the ECLIPSE studies, increased perioperative BP variability is associated with delayed time to extubation and increased postoperative LOS.
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Affiliation(s)
- Solomon Aronson
- Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Jerrold H Levy
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Philip D Lumb
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Manuel Fontes
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Sickeler R, Phillips-Bute B, Kertai MD, Schroder J, Mathew JP, Swaminathan M, Stafford-Smith M. The Risk of Acute Kidney Injury With Co-Occurrence of Anemia and Hypotension During Cardiopulmonary Bypass Relative to Anemia Alone. Ann Thorac Surg 2014; 97:865-71. [DOI: 10.1016/j.athoracsur.2013.09.060] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 09/12/2013] [Accepted: 09/16/2013] [Indexed: 11/26/2022]
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149
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Vives M, Wijeysundera D, Marczin N, Monedero P, Rao V. Cardiac surgery-associated acute kidney injury. Interact Cardiovasc Thorac Surg 2014; 18:637-45. [DOI: 10.1093/icvts/ivu014] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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