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Chin K, Jiang H, Steinberg BE, Goldenberg NM, Desjardins JF, Kabir G, Liu E, Vanama R, Baker AJ, Deschamps A, Simpson JA, Maynes JT, Vinogradov SA, Connelly KA, Mazer CD, Hare GMT. Bilateral nephrectomy impairs cardiovascular function and cerebral perfusion in a rat model of acute hemodilutional anemia. J Appl Physiol (1985) 2024; 136:1245-1259. [PMID: 38385183 DOI: 10.1152/japplphysiol.00858.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/30/2024] [Accepted: 02/15/2024] [Indexed: 02/23/2024] Open
Abstract
Anemia and renal failure are independent risk factors for perioperative stroke, prompting us to assess the combined impact of acute hemodilutional anemia and bilateral nephrectomy (2Nx) on microvascular brain Po2 (PBro2) in a rat model. Changes in PBro2 (phosphorescence quenching) and cardiac output (CO, echocardiography) were measured in different groups of anesthetized Sprague-Dawley rats (1.5% isoflurane, n = 5-8/group) randomized to Sham 2Nx or 2Nx and subsequently exposed to acute hemodilutional anemia (50% estimated blood volume exchange with 6% hydroxyethyl starch) or time-based controls (no hemodilution). Outcomes were assessed by ANOVA with significance assigned at P < 0.05. At baseline, 2Nx rats demonstrated reduced CO (49.9 ± 9.4 vs. 66.3 ± 19.3 mL/min; P = 0.014) and PBro2 (21.1 ± 2.9 vs. 32.4 ± 3.1 mmHg; P < 0.001) relative to Sham 2Nx rats. Following hemodilution, 2Nx rats demonstrated a further decrease in PBro2 (15.0 ± 6.3 mmHg, P = 0.022). Hemodiluted 2Nx rats did not demonstrate a comparable increase in CO after hemodilution compared with Sham 2Nx (74.8 ± 22.4 vs. 108.9 ± 18.8 mL/min, P = 0.003) that likely contributed to the observed reduction in PBro2. This impaired CO response was associated with reduced fractional shortening (33 ± 9 vs. 51 ± 5%) and increased left ventricular end-systolic volume (156 ± 51 vs. 72 ± 15 µL, P < 0.001) suggestive of systolic dysfunction. By contrast, hemodiluted Sham 2Nx animals demonstrated a robust increase in CO and preserved PBro2. These data support the hypothesis that the kidney plays a central role in maintaining cerebral perfusion and initiating the adaptive increase in CO required to optimize PBro2 during acute anemia.NEW & NOTEWORTHY This study has demonstrated that bilateral nephrectomy acutely impaired cardiac output (CO) and microvascular brain Po2 (PBro2), at baseline. Following acute hemodilution, nephrectomy prevented the adaptive increase in CO associated with acute hemodilution leading to a further reduction in PBro2, accentuating the degree of cerebral tissue hypoxia. These data support a role for the kidney in maintaining PBro2 and initiating the increase in CO that optimized brain perfusion during acute anemia.
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Affiliation(s)
- Kyle Chin
- Department of Anesthesiology and Pain Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Helen Jiang
- Department of Anesthesiology and Pain Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin E Steinberg
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Neil M Goldenberg
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jean-Francois Desjardins
- Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Golam Kabir
- Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elaine Liu
- Department of Anesthesiology and Pain Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Ramesh Vanama
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada
| | - Andrew J Baker
- Department of Anesthesiology and Pain Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Alain Deschamps
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal Quebec, Canada
| | - Jeremy A Simpson
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada
- IMPART investigator team Canada (https://impart.team/), Saint John, New Brunswick, Canada
| | - Jason T Maynes
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Program in Molecular Medicine, Hospital for Sick Children's Research Institute, Toronto, Ontario, Canada
| | - Sergei A Vinogradov
- Department of Biochemistry and Biophysics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Kim A Connelly
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- Department of Anesthesiology and Pain Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Gregory M T Hare
- Department of Anesthesiology and Pain Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- IMPART investigator team Canada (https://impart.team/), Saint John, New Brunswick, Canada
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Arynov A, Kaidarova D, Kabon B. Alternative blood transfusion triggers: a narrative review. BMC Anesthesiol 2024; 24:71. [PMID: 38395758 PMCID: PMC10885388 DOI: 10.1186/s12871-024-02447-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Anemia, characterized by low hemoglobin levels, is a global public health concern. Anemia is an independent factor worsening outcomes in various patient groups. Blood transfusion has been the traditional treatment for anemia; its triggers, primarily based on hemoglobin levels; however, hemoglobin level is not always an ideal trigger for blood transfusion. Additionally, blood transfusion worsens clinical outcomes in certain patient groups. This narrative review explores alternative triggers for red blood cell transfusion and their physiological basis. MAIN TEXT The review delves into the physiology of oxygen transport and highlights the limitations of using hemoglobin levels alone as transfusion trigger. The main aim of blood transfusion is to optimize oxygen delivery, necessitating an individualized approach based on clinical signs of anemia and the balance between oxygen delivery and consumption, reflected by the oxygen extraction rate. The narrative review covers different alternative triggers. It presents insights into their diagnostic value and clinical applications, emphasizing the need for personalized transfusion strategies. CONCLUSION Anemia and blood transfusion are significant factors affecting patient outcomes. While restrictive transfusion strategies are widely recommended, they may not account for the nuances of specific patient populations. The search for alternative transfusion triggers is essential to tailor transfusion therapy effectively, especially in patients with comorbidities or unique clinical profiles. Investigating alternative triggers not only enhances patient care by identifying more precise indicators but also minimizes transfusion-related risks, optimizes blood product utilization, and ensures availability when needed. Personalized transfusion strategies based on alternative triggers hold the potential to improve outcomes in various clinical scenarios, addressing anemia's complex challenges in healthcare. Further research and evidence are needed to refine these alternative triggers and guide their implementation in clinical practice.
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Affiliation(s)
- Ardak Arynov
- Department of Anesthesiology and Intensive Care, Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan.
| | - Dilyara Kaidarova
- Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan
| | - Barbara Kabon
- Department of Anaesthesia, General Intensive Medicine and Pain Medicine Medical, University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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Min L, Linyi Y, Chen L, Jiang S, Chen C. Preoperative moderate to severe anemia is associated with increased postoperative major adverse cardiac and cerebral events and pulmonary complications: a propensity score-matched analysis in hip fracture surgery patients over 80 years old. Perioper Med (Lond) 2023; 12:56. [PMID: 37950304 PMCID: PMC10636975 DOI: 10.1186/s13741-023-00349-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 11/03/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Anemia is a common health problem in the elderly. Preoperative anemia is a risk factor for postoperative outcomes in the elderly for hip fracture. The objective of the study was to explore the relationship between preoperative moderate to severe anemia and postoperative morbidity and mortality in hip fracture patients over 80 years old. METHODS We performed a retrospective cohort study exploring preoperative moderate to severe anemia and postoperative morbidity and mortality. Patients over 80 years old undergoing hip fracture surgery were included in the study. Data were collected for major adverse cardiac and cerebral events (MACCE), postoperative pulmonary complications (PPCs), in-hospital mortality, delirium, gastrointestinal complication, deep venous thrombus (DVT), acute renal failure, ICU admission, and perioperative transfusion > 2 units rate. RESULTS A total of 912 eligible patients were included for unmatched cohort analysis, and 512 patients were included for matched cohort analysis after propensity score matching. Baseline characteristics between the normal to mild anemia and moderate to severe anemia groups were significantly different. More patients in the moderate to severe cohort had a higher ASA classification grade III and female ratio. Patients in the moderate and severe anemia cohorts had more MACCE (unadjusted: odds ratio [OR] 1.968, 96% CI 1.090-3.555, P 0.023; adjusted: OR 1.929, 95% CI 1.014-3.668, P 0.045) and PPCs (unadjusted: OR 2.616, 95% CI 1.442-4.748, P 0.001; adjusted: OR 2.352, 95% CI 1.225-4.516, P 0.010) than patients with normal or mild anemia. However, the transfusion > 2 units rate was not significantly different between the two cohorts (unadjusted: OR 0.967, 95% CI 0.737-1.270, P 0.811; adjusted: OR 0.941, 95% CI 0.693-1.278, P 0.697). The in-hospital mortality, delirium rate, gastrointestinal complication, ICU admission, and DVT were similar. However, the in-hospital mortality was much higher (3.6%, 21/591 vs 1.6%, 5/321) in the moderate to severe anemia cohort. Furthermore, after propensity score-matched analysis, MACCE and PPCs were also significantly increased in the moderate to severe anemia cohort (OR 2.196 & 3.171, 95% CI 1.0794.470 & 1.563-6.436, P 0.027 & 0.001), which were in accordance with the unadjusted and adjusted results in the unmatched cohorts. CONCLUSIONS Moderate to severe preoperative anemia (< 11 g/dl) is associated with increased postoperative major adverse cardiac and cerebral events and pulmonary complications. Additionally, in-hospital mortality was not significant but was higher in the preoperative moderate to severe anemia cohort. Preoperative assessment and correction of hemoglobin level to above 11 g/dl might reduce MACCE, PPCs, and in-hospital mortality in hip fracture patients over 80 years old.
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Affiliation(s)
- Li Min
- Department of Anesthesiology, The First People's Hospital of Changzhou, Changzhou, Jiangsu, 213003, China
| | - Yang Linyi
- Department of Anesthesiology, The First People's Hospital of Changzhou, Changzhou, Jiangsu, 213003, China
| | - Li Chen
- Department of Anesthesiology, The First People's Hospital of Changzhou, Changzhou, Jiangsu, 213003, China
| | - Shen Jiang
- Department of Anesthesiology, The First People's Hospital of Changzhou, Changzhou, Jiangsu, 213003, China
| | - Chen Chen
- Department of Anesthesiology, The First People's Hospital of Changzhou, Changzhou, Jiangsu, 213003, China.
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Mistry N, Jiang H, Chin K, Hare GMT, Verma S, Mazer CD. Transfusion thresholds in acute coronary syndromes. Curr Opin Cardiol 2023; 38:533-538. [PMID: 37610413 DOI: 10.1097/hco.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
PURPOSE OF REVIEW Anemia is prevalent in patients with acute coronary syndromes. In this setting, there is uncertainty and controversy surrounding the optimal transfusion strategy for managing anemia. The goal of this review is to summarize the current clinical evidence, guidelines, and future directions for managing transfusion in acute coronary syndromes. RECENT FINDINGS There is limited evidence from randomized trials evaluating restrictive versus liberal transfusion in patients hospitalized with and/or for acute coronary syndromes. The results from these studies suggest clinical equipoise between transfusion strategies for short term outcomes, and a trend toward favoring a liberal strategy for long term major adverse cardiac events. There is inconsistency across clinical practice guidelines with respect to the optimal strategy for managing anemia and transfusion in acute coronary syndromes due to insufficient evidence. SUMMARY More evidence is urgently needed to conclusively establish the optimal strategy for transfusion management in the setting of acute coronary syndromes. These data will directly inform harmonization of clinical practice guidelines. Future investigations should explore alternative strategies to hemoglobin for quantifying the degree of anemic stress for personalizing transfusion therapy, the effects on functional outcomes, and managing anemia following hospital discharge.
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Affiliation(s)
- Nikhil Mistry
- Department of Anesthesia, St. Michael's Hospital, Unity Health Toronto
| | - Helen Jiang
- Department of Anesthesia, St. Michael's Hospital, Unity Health Toronto
| | - Kyle Chin
- Department of Anesthesia, St. Michael's Hospital, Unity Health Toronto
| | - Gregory M T Hare
- Department of Anesthesia, St. Michael's Hospital, Unity Health Toronto
- Department of Anesthesiology and Pain Medicine
- Department of Physiology, University of Toronto
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto
| | - Subodh Verma
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto
- Division of Cardiac Surgery, St. Michael's Hospital, Department of Surgery
- Department of Pharmacology and Toxicology
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, Unity Health Toronto
- Department of Anesthesiology and Pain Medicine
- Department of Physiology, University of Toronto
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto
- Department of Pharmacology and Toxicology
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
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5
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Mistry N, Hare GM, Shehata N, Kramer RS, Fawzy HF, Baker RA, Carmona P, Saczkowski R, Filipescu D, Alphonsus CS, Rochon A, Gregory AJ, Khanykin B, Leff JD, Mateo E, Karangelis D, Tellez JC, Saha T, Ko DT, Wijeysundera DN, Verma S, Mazer CD. Methemoglobin as a marker of acute anemic stress in cardiac surgery. iScience 2023; 26:107429. [PMID: 37575193 PMCID: PMC10415918 DOI: 10.1016/j.isci.2023.107429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/01/2023] [Accepted: 07/17/2023] [Indexed: 08/15/2023] Open
Abstract
Biological evidence supports plasma methemoglobin as a biomarker for anemia-induced tissue hypoxia. In this translational planned substudy of the multinational randomized controlled transfusion thresholds in cardiac surgery (TRICS-III) trial, which included adults undergoing cardiac surgery requiring cardiopulmonary bypass with a moderate-to-high risk of death, we investigated the relationship between perioperative hemoglobin concentration (Hb) and methemoglobin; and evaluated its association with postoperative outcomes. The primary endpoint was a composite of death, myocardial infarction, stroke, and severe acute kidney injury at 28 days. We observe weak non-linear associations between decreasing Hb and increasing methemoglobin, which were strongest in magnitude at the post-surgical time point. Increased levels of post-surgical methemoglobin were associated with a trend toward an elevated risk for stroke and exploratory neurological outcomes. Our generalizable study demonstrates post-surgical methemoglobin may be a marker of anemia-induced organ injury/dysfunction, and may have utility for guiding personalized approaches to anemia management. Clinicaltrials.gov registration NCT02042898.
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Affiliation(s)
- Nikhil Mistry
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Gregory M.T. Hare
- Department of Anesthesia, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Nadine Shehata
- Division of Hematology, Sinai Health System, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Robert S. Kramer
- Maine Medical Center Cardiovascular Institute, Portland, ME, USA
| | - Hosam F. Fawzy
- Department of Cardiothoracic Surgery, Faculty of Medicine, University of Tanta, Tanta, Egypt
| | - Robert A. Baker
- Cardiac Surgery Research and Perfusion, Flinders University and Flinders Medical Centre, Adelaide, SA, Australia
| | - Paula Carmona
- Cardiovascular-Anesthesia and Intensive Care. University Hospital La Fe, Valencia, Spain
| | - Richard Saczkowski
- Department of Cardiac Sciences, Perfusion Services, Kelowna General Hospital, Kelowna, BC, Canada
| | - Daniela Filipescu
- University of Medicine and Pharmacy Carol Davila, Emergency Institute for Cardiovascular Diseases “Prof. Dr. C.C. Iliescu”, Bucharest, Romania
| | - Christella S. Alphonsus
- Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | | | - Alexander J. Gregory
- Department of Anesthesiology, Perioperative and Pain Medicine and Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Boris Khanykin
- Cardiothoracic Anesthesiology Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jonathan D. Leff
- Montefiore-Einstein Center for Heart and Vascular Care, New York City, NY, USA
| | - Eva Mateo
- Hospital General Universitario de València, València, Spain
| | - Dimos Karangelis
- Department of Cardiothoracic Surgery, Democritus University of Thrace, Alexandroupolis, Greece
| | | | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Kingston, ON, Canada
| | - Dennis T. Ko
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Duminda N. Wijeysundera
- Department of Anesthesia, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Subodh Verma
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Division of Cardiac Surgery, St. Michael’s Hospital, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - C. David Mazer
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
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6
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Li M, Chen C, Shen J, Yang L. Preoperative Hemoglobin <10 g/DL Predicts an Increase in Major Adverse Cardiac Events in Patients With Hip Fracture Over 80 Years: A Retrospective Cohort Study. Geriatr Orthop Surg Rehabil 2023; 14:21514593231183611. [PMID: 37334252 PMCID: PMC10272637 DOI: 10.1177/21514593231183611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/22/2023] [Accepted: 06/02/2023] [Indexed: 06/20/2023] Open
Abstract
Background Preoperative anemia has been associated with perioperative morbidity and mortality in patients undergoing cardiac and non-cardiac surgery. Preoperative anemia is common in elderly hip fracture patients. The primary objective of the study was to explore the relationship between preoperative hemoglobin levels and postoperative major adverse cardiovascular events (MACEs) in hip fracture patients over 80 years. Methods The retrospective study enrolled hip fracture patients over 80 years from January 2015 to December 2021 in our center. The data were collected from the hospital's electronic database after approval by the ethics committee. The primary objective of the study was to investigate MACEs, and the secondary objectives included in-hospital mortality, delirium, acute renal failure, ICU admission rate, and transfusion (>2 U). Results 912 patients were entered for final analysis. Based on the restricted cubic spline, the risk of preoperative hemoglobin (<10 g/DL) was associated with an increased risk of postoperative complications. With univariable logistic analysis, a hemoglobin level <10 g/DL was associated with increased MACEs [OR 1.769, 95% CI (1.074, 2.914), P = .025], in-hospital mortality [OR 2.709, 95% CI (1.215, 6.039), P = .015] and transfusion >2 U risk [OR 2.049, 95% CI (1.56, 2.69), P < .001]. Even after adjustment for confounding factors, MACEs [OR 1.790, 95% CI (1.073, 2.985), P = .026], in-hospital mortality [OR 2.81, 95% CI (1.214, 6.514), P = .016] and transfusion >2 U rate [OR 2.002, 95% CI (1.516, 2.65), P < .001] were still higher in the lower hemoglobin level cohort. Moreover, a log-rank test showed increased in-hospital mortality in the cohort with a preoperative hemoglobin level of <10 g/DL. However, there was no difference in delirium, acute renal failure, and ICU admission rates. Conclusions In conclusion, for hip fracture patients over 80 years, preoperative hemoglobin levels <10 g/DL might be associated with increased postoperative MACEs, in-hospital mortality, and transfusion >2 U.
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Affiliation(s)
- Min Li
- Department of Anesthesiology, The First People’s Hospital of Changzhou, Changzhou, China
| | - Chen Chen
- Department of Anesthesiology, The First People’s Hospital of Changzhou, Changzhou, China
| | - Jiang Shen
- Department of Anesthesiology, The First People’s Hospital of Changzhou, Changzhou, China
| | - Linyi Yang
- Department of Anesthesiology, The First People’s Hospital of Changzhou, Changzhou, China
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7
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Persello A, Souab F, Dupas T, Aillerie V, Bigot E, Denis M, Erraud A, Pelé T, Blangy-Letheule A, Miniou P, Guedat P, De Waard M, Abgueguen E, Rozec B, Lauzier B. A Rat Model of Clinically Relevant Extracorporeal Circulation Develops Early Organ Dysfunctions. Int J Mol Sci 2023; 24:ijms24087338. [PMID: 37108501 PMCID: PMC10139167 DOI: 10.3390/ijms24087338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/24/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
In clinical practice, extracorporeal circulation (ECC) is associated with coagulopathy and inflammation, eventually leading to organ injuries without preventive systemic pharmacological treatment. Relevant models are needed to reproduce the pathophysiology observed in humans and preclinical tests. Rodent models are less expensive than large models but require adaptations and validated comparisons to clinics. This study aimed to develop a rat ECC model and to establish its clinical relevance. One hour of veno-arterial ECC or a sham procedure were achieved on mechanically ventilated rats after cannulations with a mean arterial pressure objective > 60 mmHg. Five hours post-surgery, the rats' behavior, plasmatic/blood biomarkers, and hemodynamics were measured. Blood biomarkers and transcriptomic changes were compared in 41 patients undergoing on-pump cardiac surgery. Five hours post-ECC, the rats presented hypotension, hyperlactatemia, and behavioral alterations. The same patterns of marker measurements (Lactate dehydrogenase, Creatinine kinase, ASAT, ALAT, and Troponin T) were observed in both rats and human patients. Transcriptome analyses showed similarity in both humans and rats in the biological processes involved in the ECC response. This new ECC rat model seems to resemble both ECC clinical procedures and the associated pathophysiology, but with early organ injury corresponding to a severe phenotype. Although the mechanisms at stake in the post-ECC pathophysiology of rats or humans need to be described, this new rat model appears to be a relevant and costless preclinical model of human ECC.
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Affiliation(s)
- Antoine Persello
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
- InFlectis BioScience, 44200 Nantes, France
| | - Fouzia Souab
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Thomas Dupas
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Virginie Aillerie
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Edith Bigot
- Department of Biochemistry, CHU de Nantes, 44800 Nantes, France
| | - Manon Denis
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Angélique Erraud
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Thomas Pelé
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | | | | | | | - Michel De Waard
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | | | - Bertrand Rozec
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Benjamin Lauzier
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
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8
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Chin K, Joo H, Jiang H, Lin C, Savinova I, Joo S, Alli A, Sklar MC, Papa F, Simpson J, Baker AJ, Mazer CD, Darrah W, Hare GMT. Importance of assessing biomarkers and physiological parameters of anemia-induced tissue hypoxia in the perioperative period. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:186-197. [PMID: 36377057 PMCID: PMC10068554 DOI: 10.1016/j.bjane.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
Anemia is associated with increased risk of Acute Kidney Injury (AKI), stroke and mortality in perioperative patients. We sought to understand the mechanism(s) by assessing the integrative physiological responses to anemia (kidney, brain), the degrees of anemia-induced tissue hypoxia, and associated biomarkers and physiological parameters. Experimental measurements demonstrate a linear relationship between blood Oxygen Content (CaO2) and renal microvascular PO2 (y = 0.30x + 6.9, r2 = 0.75), demonstrating that renal hypoxia is proportional to the degree of anemia. This defines the kidney as a potential oxygen sensor during anemia. Further evidence of renal oxygen sensing is demonstrated by proportional increase in serum Erythropoietin (EPO) during anemia (y = 93.806*10-0.02, r2 = 0.82). This data implicates systemic EPO levels as a biomarker of anemia-induced renal tissue hypoxia. By contrast, cerebral Oxygen Delivery (DO2) is defended by a profound proportional increase in Cerebral Blood Flow (CBF), minimizing tissue hypoxia in the brain, until more severe levels of anemia occur. We hypothesize that the kidney experiences profound early anemia-induced tissue hypoxia which contributes to adaptive mechanisms to preserve cerebral perfusion. At severe levels of anemia, renal hypoxia intensifies, and cerebral hypoxia occurs, possibly contributing to the mechanism(s) of AKI and stroke when adaptive mechanisms to preserve organ perfusion are overwhelmed. Clinical methods to detect renal tissue hypoxia (an early warning signal) and cerebral hypoxia (a later consequence of severe anemia) may inform clinical practice and support the assessment of clinical biomarkers (i.e., EPO) and physiological parameters (i.e., urinary PO2) of anemia-induced tissue hypoxia. This information may direct targeted treatment strategies to prevent adverse outcomes associated with anemia.
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Affiliation(s)
- Kyle Chin
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada; University of Toronto, Department of Physiology, Toronto, Canada
| | - Hannah Joo
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada
| | - Helen Jiang
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada
| | - Chloe Lin
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada
| | - Iryna Savinova
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Canada
| | - Sarah Joo
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada
| | - Ahmad Alli
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada
| | - Michael C Sklar
- St. Michael's Hospital, Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, Toronto, Canada; University of Toronto, Temerty Faculty of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto, Canada; University of Toronto, St. Michael's Hospital, Department of Critical Care, Toronto, Canada
| | - Fabio Papa
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada
| | - Jeremy Simpson
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Canada
| | - Andrew J Baker
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada; St. Michael's Hospital, Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, Toronto, Canada; University of Toronto, Temerty Faculty of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto, Canada; University of Toronto, St. Michael's Hospital, Department of Critical Care, Toronto, Canada
| | - C David Mazer
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada; University of Toronto, Department of Physiology, Toronto, Canada; St. Michael's Hospital, Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, Toronto, Canada; University of Toronto, Temerty Faculty of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto, Canada; University of Toronto, St. Michael's Hospital, Department of Critical Care, Toronto, Canada
| | - William Darrah
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada
| | - Gregory M T Hare
- University of Toronto, Temerty Faculty of Medicine, St. Michael's Hospital, Department of Anesthesia and Pain Medicine, Toronto, Canada; University of Toronto, Department of Physiology, Toronto, Canada; St. Michael's Hospital, Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, Toronto, Canada; St. Michael's Hospital Center of Excellence for Patient Blood Management, 30 Bond Street, Toronto, Canada.
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9
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Zhang L, Liu H, Huang S, Tong C, Wang Z, Qi H, Baker PN, Kilby MD. Alterations in Fetal Doppler Parameters Before and Twenty-Four Hours After Radiofrequency Ablation for Twin Reversed Arterial Perfusion Sequence. Front Med (Lausanne) 2022; 9:802666. [PMID: 35492315 PMCID: PMC9046669 DOI: 10.3389/fmed.2022.802666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 03/07/2022] [Indexed: 11/22/2022] Open
Abstract
Objective To evaluate alterations in the fetal Doppler parameters of pump fetuses before and 24 h after radiofrequency ablation surgery for twin reversed arterial perfusion sequence (TRAPs). Methods This is a retrospective study of 28 pump fetuses in TRAPs and 28 normal control twins between 2016 and 2021. The fetal Doppler parameters, including the umbilical artery pulsatility index (UA-PI), middle cerebral artery peak systolic velocity (MCA-PSV), middle cerebral artery pulsatility index (MCA-PI), and cerebroplacental ratio (CPR), of the controls, and pump fetuses before and 24 h after surgery were compared. Results An increasing trend and a further increase in the MCA-PSV, MCA-PI, MCA-PSV Z score, and MCA-PI Z score after surgery were observed in pump fetuses with gestational age (GA) ≥20 weeks; however, such changes were not observed in those with a GA of <20 weeks. The UA-PI and CPR before and after surgery were not different between control and pump fetuses, whether the GA was ≥20 or <20 weeks. Conclusion In the middle second trimester, the pump fetus might suffer from high cardiac output rather than hypoxemia before surgery and congestive heart failure, or hemodilutional anemia after surgery. This may provide some theoretical evidence in favor of early intervention, rather than waiting for a more advanced GA, to avoid unnecessary hemodynamic alterations.
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Affiliation(s)
- Lan Zhang
- State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Fetal Medicine Unit, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- International Collaborative Joint Laboratory of Reproduction and Development of Ministry of Education P.R.C., Chongqing Medical University, Chongqing, China
| | - Hongli Liu
- State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Fetal Medicine Unit, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- International Collaborative Joint Laboratory of Reproduction and Development of Ministry of Education P.R.C., Chongqing Medical University, Chongqing, China
| | - Shuai Huang
- State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Fetal Medicine Unit, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- International Collaborative Joint Laboratory of Reproduction and Development of Ministry of Education P.R.C., Chongqing Medical University, Chongqing, China
| | - Chao Tong
- State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- International Collaborative Joint Laboratory of Reproduction and Development of Ministry of Education P.R.C., Chongqing Medical University, Chongqing, China
- *Correspondence: Chao Tong,
| | - Zhigang Wang
- Institute of Ultrasound Imaging, Department of Ultrasound, Second Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ultrasound Molecular Imaging, Chongqing, China
- Zhigang Wang,
| | - Hongbo Qi
- State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Fetal Medicine Unit, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- International Collaborative Joint Laboratory of Reproduction and Development of Ministry of Education P.R.C., Chongqing Medical University, Chongqing, China
- Hongbo Qi,
| | - Philip N. Baker
- College of Life Sciences, University of Leicester, Leicester, United Kingdom
| | - Mark D. Kilby
- Institute of Metabolism and System Research, University of Birmingham, Birmingham, United Kingdom
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10
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Zhou XF, Yu RG, Chen Q, Xue YM, Chen H. Performance of Lactate and CO 2-Derived Parameters in Predicting Major Postoperative Complications After Cardiac Surgery With Cardiopulmonary Bypass: Protocol of a Diagnostic Accuracy Study. Front Cardiovasc Med 2021; 8:724713. [PMID: 34660725 PMCID: PMC8517114 DOI: 10.3389/fcvm.2021.724713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/08/2021] [Indexed: 12/12/2022] Open
Abstract
Background: CO2-derived parameters are increasingly used to identify either low-flow status or anaerobic metabolism in shock resuscitation. However, the performance of CO2-derived parameters in cardiac surgical patients is poorly understood. This study aims to compare the performance of lactate and CO2-derived parameters in predicting major postoperative complications after cardiac surgery with cardiopulmonary bypass. Methods: This is a prospective, single-center, diagnostic accuracy study. All patients who receive elective cardiac surgery involving cardiopulmonary bypass will be screened for study eligibility. Blood samples will be taken for the calculation of CO2-derived parameters, including the venous-arterial difference in CO2 partial pressure (PCO2 gap), venous-arterial difference in CO2 content to arterial-venous O2 content ratio (Cv-aCO2/Ca-vO2), and venous-arterial difference in CO2 partial pressure to arterial-venous O2 content ratio (Pv-aCO2/Ca-vO2) at ICU admission, and 3, 6, and 12 h later. Baseline, perioperative data will be collected daily for 7 days; patients will be followed up for 28 days to collect outcome data. The primary endpoint is the occurrence of major postoperative complications. Receiver-operating characteristics (ROC) curve analysis will be carried out to assess the predictive performance of lactate and CO2-derived parameters. The performance of the ROC curves will be compared. Discussion: The performance of lactate and CO2-derived parameters in predicting major postoperative complications will be investigated in the non-sepsis population, which has not been extensively investigated. Our study will compare the two surrogates of respiratory quotient directly, which is an important strength. Trial Registration: ChiCTR, ChiCTR2000029365. Registered January 26th, 2020, http://www.chictr.org.cn/showproj.aspx?proj=48744.
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Affiliation(s)
- Xiao-Fen Zhou
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Rong-Guo Yu
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Qian Chen
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Yi-Min Xue
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Han Chen
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
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11
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Ngo JP, Noe KM, Zhu MZL, Martin A, Ollason M, Cochrane AD, Smith JA, Thrift AG, Evans RG. Intraoperative renal hypoxia and risk of cardiac surgery-associated acute kidney injury. J Card Surg 2021; 36:3577-3585. [PMID: 34327740 DOI: 10.1111/jocs.15859] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/13/2021] [Accepted: 07/16/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is common after cardiac surgery requiring cardiopulmonary bypass. Renal hypoxia may precede clinically detectable AKI. We compared the efficacy of two indices of renal hypoxia, (i) intraoperative urinary oxygen tension (UPO2 ) and (ii) the change in plasma erythropoietin (pEPO) during surgery, in predicting AKI. We also investigated whether the performance of these prognostic markers varies with preoperative patient characteristics. METHODS In 82 patients undergoing on-pump cardiac surgery, blood samples were taken upon induction of anesthesia and upon entry into the intensive care unit. UPO2 was continuously measured throughout surgery. RESULTS Thirty-two (39%) patients developed postoperative AKI. pEPO increased during surgery, but this increase did not predict AKI, regardless of risk of postoperative mortality assessed by EuroSCORE-II. For patients categorized at higher risk by EuroSCORE-II >1.98 (median score for the cohort), UPO2 ≤10 mmHg at any time during surgery predicted a 4.04-fold excess risk of AKI (p = .04). However, UPO2 did not significantly predict AKI in lower-risk patients. UPO2 significantly predicted AKI in patients who were older, had previous myocardial infarction, diabetes, lower preoperative serum creatinine, or shorter bypass times. pEPO and UPO2 were only weakly correlated. CONCLUSIONS Intraoperative change in pEPO does not predict AKI. However, UPO2 shows promise, particularly in patients with higher risk of operative mortality. The disparity between these two markers of renal hypoxia may indicate that UPO2 reflects medullary oxygenation whereas pEPO reflects cortical oxygenation.
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Affiliation(s)
- Jennifer P Ngo
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia.,Department of Cardiac Physiology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Khin M Noe
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Michael Z L Zhu
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Australia
| | - Andrew Martin
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Australia
| | - Meg Ollason
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Andrew D Cochrane
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Australia
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Australia
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
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12
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13
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Evans RG, Cochrane AD, Hood SG, Iguchi N, Marino B, Bellomo R, McCall PR, Okazaki N, Smith JA, Zhu MZ, Ngo JP, Noe KM, Martin A, Thrift AG, Lankadeva YR, May CN. Dynamic responses of renal oxygenation at the onset of cardiopulmonary bypass in sheep and man. Perfusion 2021; 37:624-632. [PMID: 33977810 DOI: 10.1177/02676591211013640] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The renal medulla is susceptible to hypoxia during cardiopulmonary bypass (CPB), which may contribute to the development of acute kidney injury. But the speed of onset of renal medullary hypoxia remains unknown. METHODS We continuously measured renal medullary oxygen tension (MPO2) in 24 sheep, and urinary PO2 (UPO2) as an index of MPO2 in 92 patients, before and after induction of CPB. RESULTS In laterally recumbent sheep with a right thoracotomy (n = 20), even before CPB commenced MPO2 fell from (mean ± SEM) 52 ± 4 to 41 ±5 mmHg simultaneously with reduced arterial pressure (from 108 ± 5 to 88 ± 5 mmHg). In dorsally recumbent sheep with a medial sternotomy (n = 4), MPO2 was even more severely reduced (to 12 ± 12 mmHg) before CPB. In laterally recumbent sheep in which a crystalloid prime was used (n = 7), after commencing CPB, MPO2 fell abruptly to 24 ±6 mmHg within 20-30 minutes. MPO2 during CPB was not improved by adding donor blood to the prime (n = 13). In patients undergoing cardiac surgery, UPO2 fell by 4 ± 1 mmHg and mean arterial pressure fell by 7 ± 1 mmHg during the 30 minutes before CPB. UPO2 then fell by a further 12 ± 2 mmHg during the first 30 minutes of CPB but remained relatively stable for the remaining 24 minutes of observation. CONCLUSIONS Renal medullary hypoxia is an early event during CPB. It starts to develop even before CPB, presumably due to a pressure-dependent decrease in renal blood flow. Medullary hypoxia during CPB appears to be promoted by hypotension and is not ameliorated by increasing blood hemoglobin concentration.
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Affiliation(s)
- Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Sally G Hood
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Naoya Iguchi
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Bruno Marino
- Cellsaving and Perfusion Resources, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Peter R McCall
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Nobuki Okazaki
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Anesthesiology and Resuscitology, Okayama University, Okayama, Japan
| | - Julian A Smith
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Michael Zl Zhu
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Jennifer P Ngo
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Cardiac Physiology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Khin M Noe
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Andrew Martin
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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14
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Pajares MA, Margarit JA, García-Camacho C, García-Suarez J, Mateo E, Castaño M, López Forte C, López Menéndez J, Gómez M, Soto MJ, Veiras S, Martín E, Castaño B, López Palanca S, Gabaldón T, Acosta J, Fernández Cruz J, Fernández López AR, García M, Hernández Acuña C, Moreno J, Osseyran F, Vives M, Pradas C, Aguilar EM, Bel Mínguez AM, Bustamante-Munguira J, Gutiérrez E, Llorens R, Galán J, Blanco J, Vicente R. Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:183-231. [PMID: 33541733 DOI: 10.1016/j.redar.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 01/28/2023]
Abstract
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
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Affiliation(s)
- M A Pajares
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - J A Margarit
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - C García-Camacho
- Unidad de Perfusión del Servicio de Cirugía Cardiaca, Hospital Universitario Puerta del Mar,, Cádiz, España
| | - J García-Suarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro, Madrid, España
| | - E Mateo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - M Castaño
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - C López Forte
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J López Menéndez
- Servicio de Cirugía Cardiaca, Hospital Ramón y Cajal, Madrid, España
| | - M Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - M J Soto
- Unidad de Perfusión, Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - S Veiras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - E Martín
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - B Castaño
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Toledo, Toledo, España
| | - S López Palanca
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - J Acosta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Fernández Cruz
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - A R Fernández López
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Virgen Macarena, Sevilla, España
| | - M García
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Hernández Acuña
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - J Moreno
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - F Osseyran
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - M Vives
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - C Pradas
- Servicio de Cirugía Cardiaca, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E M Aguilar
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, España
| | - A M Bel Mínguez
- Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J Bustamante-Munguira
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Gutiérrez
- Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Llorens
- Servicio de Cirugía Cardiovascular, Hospiten Rambla, Santa Cruz de Tenerife, España
| | - J Galán
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Blanco
- Unidad de Perfusión, Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - R Vicente
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
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Margarit JA, Pajares MA, García-Camacho C, Castaño-Ruiz M, Gómez M, García-Suárez J, Soto-Viudez MJ, López-Menéndez J, Martín-Gutiérrez E, Blanco-Morillo J, Mateo E, Hernández-Acuña C, Vives M, Llorens R, Fernández-Cruz J, Acosta J, Pradas-Irún C, García M, Aguilar-Blanco EM, Castaño B, López S, Bel A, Gabaldón T, Fernández-López AR, Gutiérrez-Carretero E, López-Forte C, Moreno J, Galán J, Osseyran F, Bustamante-Munguira J, Veiras S, Vicente R. Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP). CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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16
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Zhu S, Sai X, Lin J, Deng G, Zhao M, Nasser MI, Zhu P. Mechanisms of perioperative brain damage in children with congenital heart disease. Biomed Pharmacother 2020; 132:110957. [PMID: 33254442 DOI: 10.1016/j.biopha.2020.110957] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/27/2020] [Accepted: 10/27/2020] [Indexed: 11/15/2022] Open
Abstract
Congenital heart disease, particularly cyanotic congenital heart disease (CCHD), may lead to a neurodevelopmental delay through central nervous system injury, more unstable central nervous system development, and increased vulnerability of the nervous system. Neurodevelopmental disease is the most serious disorder of childhood, affecting the quality of life of children and their families. Therefore, the monitoring and optimization of nerve damage treatments are important. The factors contributing to neurodevelopmental disease are primarily related to preoperative, intraoperative, postoperative, genetic, and environmental causes, with intraoperative causes being the most influential. Nevertheless, few studies have examined these factors, particularly the influencing factors during early postoperative care. Children with congenital heart disease may experience brain damage during early heart intensive care due to unstable haemodynamics and total body oxygen transfer, particularly early postoperative inflammatory reactions in the brain, blood glucose levels, and other factors that potentially influence long-term neural development. This study analyses the forms of structural and functional brain damage in the early postoperative period, along with the recent evolution of research on its contributing factors.
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Affiliation(s)
- Shuoji Zhu
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, Guangdong, 510100, China
| | - Xiyalatu Sai
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, Guangdong, 510100, China; The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Jianxin Lin
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, Guangdong, 510100, China
| | - Gang Deng
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, Guangdong, 510100, China
| | - Mingyi Zhao
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, Guangdong, 510100, China.
| | - M I Nasser
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, Guangdong, 510100, China.
| | - Ping Zhu
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, Guangdong, 510100, China.
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17
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Chin K, Cazorla-Bak MP, Liu E, Nghiem L, Zhang Y, Yu J, Wilson DF, Vinogradov SA, Gilbert RE, Connelly KA, Evans RG, Baker AJ, David Mazer C, Hare GMT. Renal microvascular oxygen tension during hyperoxia and acute hemodilution assessed by phosphorescence quenching and excitation with blue and red light. Can J Anaesth 2020; 68:214-225. [PMID: 33174162 DOI: 10.1007/s12630-020-01848-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 08/05/2020] [Accepted: 08/14/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE The kidney plays a central physiologic role as an oxygen sensor. Nevertheless, the direct mechanism by which this occurs is incompletely understood. We measured renal microvascular partial pressure of oxygen (PkO2) to determine the impact of clinically relevant conditions that acutely change PkO2 including hyperoxia and hemodilution. METHODS We utilized two-wavelength excitation (red and blue spectrum) of the intravascular phosphorescent oxygen sensitive probe Oxyphor PdG4 to measure renal tissue PO2 in anesthetized rats (2% isoflurane, n = 6) under two conditions of altered arterial blood oxygen content (CaO2): 1) hyperoxia (fractional inspired oxygen 21%, 30%, and 50%) and 2) acute hemodilutional anemia (baseline, 25% and 50% acute hemodilution). The mean arterial blood pressure (MAP), rectal temperature, arterial blood gases (ABGs), and chemistry (radiometer) were measured under each condition. Blue and red light enabled measurement of PkO2 in the superficial renal cortex and deeper cortical and medullary tissue, respectively. RESULTS PkO2 was higher in the superficial renal cortex (~ 60 mmHg, blue light) relative to the deeper renal cortex and outer medulla (~ 45 mmHg, red light). Hyperoxia resulted in a proportional increase in PkO2 values while hemodilution decreased microvascular PkO2 in a linear manner in both superficial and deeper regions of the kidney. In both cases (blue and red light), PkO2 correlated with CaO2 but not with MAP. CONCLUSION The observed linear relationship between CaO2 and PkO2 shows the biological function of the kidney as a quantitative sensor of anemic hypoxia and hyperoxia. A better understanding of the impact of changes in PkO2 may inform clinical practices to improve renal oxygen delivery and prevent acute kidney injury.
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Affiliation(s)
- Kyle Chin
- Department of Anesthesia, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Melina P Cazorla-Bak
- Department of Anesthesia, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Elaine Liu
- Department of Anesthesia, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Linda Nghiem
- Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Yanling Zhang
- Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Julie Yu
- Deaprtment of Anesthesia and Perioperative Medicine, Western University, London, ON, Canada
| | - David F Wilson
- Department of Biochemistry and Biophysics, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sergei A Vinogradov
- Department of Biochemistry and Biophysics, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Richard E Gilbert
- Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Division of Endocrinology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Kim A Connelly
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Division of Cardiology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Andrew J Baker
- Department of Anesthesia, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Department of Physiology, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Gregory M T Hare
- Department of Anesthesia, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. .,Department of Physiology, University of Toronto, Toronto, ON, Canada. .,Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
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18
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When to transfuse your acute care patient? A narrative review of the risk of anemia and red blood cell transfusion based on clinical trial outcomes. Can J Anaesth 2020; 67:1576-1594. [DOI: 10.1007/s12630-020-01763-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/07/2020] [Accepted: 05/07/2020] [Indexed: 12/14/2022] Open
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19
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Abrahamson JR, Read A, Chin K, Mistry N, Joo H, Desjardins JF, Liu E, Thai K, Wilson DF, Vinogradov SA, Maynes JT, Gilbert RE, Connelly KA, Baker AJ, Mazer CD, Hare GMT. Renal tissue Po2sensing during acute hemodilution is dependent on the diluent. Am J Physiol Regul Integr Comp Physiol 2020; 318:R799-R812. [DOI: 10.1152/ajpregu.00323.2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Sensing changes in blood oxygen content ([Formula: see text]) is an important physiological role of the kidney; however, the mechanism(s) by which the kidneys sense and respond to changes in [Formula: see text] are incompletely understood. Accurate measurements of kidney tissue oxygen tension ([Formula: see text]) may increase our understanding of renal oxygen-sensing mechanisms and could inform decisions regarding the optimal fluid for intravascular volume resuscitation to maintain renal perfusion. In some clinical settings, starch solution may be nephrotoxic, possibly due to inadequacy of tissue oxygen delivery. We hypothesized that hemodilution with starch colloid solutions would reduce [Formula: see text] to a more severe degree than other diluents. Anesthetized Sprague-Dawley rats ( n = 77) were randomized to undergo hemodilution with either colloid (6% hydroxyethyl starch or 5% albumin), crystalloid (0.9% saline), or a sham procedure (control) ( n = 13–18 rats/group). Data were analyzed by ANOVA with significance assigned at P < 0.05. After hemodilution, mean arterial pressure (MAP) decreased marginally in all groups, while hemoglobin (Hb) and [Formula: see text] decreased in proportion to the degree of hemodilution. Cardiac output was maintained in all groups after hemodilution. [Formula: see text] decreased in proportion to the reduction in Hb in all treatment groups. At comparably reduced Hb, and maintained arterial oxygen values, hemodilution with starch resulted in larger decreases in [Formula: see text] relative to animals hemodiluted with albumin or saline ( P < 0.008). Renal medullary erythropoietin (EPO) mRNA levels increased more prominently, relative to other hypoxia-regulated molecules (GLUT-1, GAPDH, and VEGF). Our data demonstrate that the kidney acts as a biosensor of reduced [Formula: see text] following hemodilution and that [Formula: see text] may provide a quantitative signal for renal cellular responsiveness to acute anemia. Evidence of a more severe reduction in [Formula: see text] following hemodilution with starch colloid solution suggests that tissue hypoxia may contribute to starch induced renal toxicity.
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Affiliation(s)
- Jessica R. Abrahamson
- Department of Anesthesia, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Austin Read
- Department of Anesthesia, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kyle Chin
- Department of Anesthesia, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nikhil Mistry
- Department of Anesthesia, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Ontario, Canada
| | - Hannah Joo
- Department of Anesthesia, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jean-Francois Desjardins
- Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Elaine Liu
- Department of Anesthesia, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kerri Thai
- Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - David F. Wilson
- Department of Biochemistry and Biophysics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sergei A. Vinogradov
- Department of Biochemistry and Biophysics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason T. Maynes
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Richard E. Gilbert
- Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, Division of Endocrinology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kim A. Connelly
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrew J. Baker
- Department of Anesthesia, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Ontario, Canada
| | - C. David Mazer
- Department of Anesthesia, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Ontario, Canada
| | - Gregory M. T. Hare
- Department of Anesthesia, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
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20
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Hare GMT. Cellular oxygen sensing and the anesthesiologist: the Nobel-worthy discovery of hypoxia inducible factor and its implications in clinical practice. Can J Anaesth 2020; 67:174-176. [PMID: 31712964 DOI: 10.1007/s12630-019-01526-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- Gregory M T Hare
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
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21
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Evans RG, Iguchi N, Cochrane AD, Marino B, Hood SG, Bellomo R, McCall PR, May CN, Lankadeva YR. Renal hemodynamics and oxygenation during experimental cardiopulmonary bypass in sheep under total intravenous anesthesia. Am J Physiol Regul Integr Comp Physiol 2019; 318:R206-R213. [PMID: 31823674 DOI: 10.1152/ajpregu.00290.2019] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Renal medullary hypoxia may contribute to the pathophysiology of acute kidney injury, including that associated with cardiac surgery requiring cardiopulmonary bypass (CPB). When performed under volatile (isoflurane) anesthesia in sheep, CPB causes renal medullary hypoxia. There is evidence that total intravenous anesthesia (TIVA) may preserve renal perfusion and renal oxygen delivery better than volatile anesthesia. Therefore, we assessed the effects of CPB on renal perfusion and oxygenation in sheep under propofol/fentanyl-based TIVA. Sheep (n = 5) were chronically instrumented for measurement of whole renal blood flow and cortical and medullary perfusion and oxygenation. Five days later, these variables were monitored under TIVA using propofol and fentanyl and then on CPB at a pump flow of 80 mL·kg-1·min-1 and target mean arterial pressure of 70 mmHg. Under anesthesia, before CPB, renal blood flow was preserved under TIVA (mean difference ± SD from conscious state: -16 ± 14%). However, during CPB renal blood flow was reduced (-55 ± 13%) and renal medullary tissue became hypoxic (-20 ± 13 mmHg versus conscious sheep). We conclude that renal perfusion and medullary oxygenation are well preserved during TIVA before CPB. However, CPB under TIVA leads to renal medullary hypoxia, of a similar magnitude to that we observed previously under volatile (isoflurane) anesthesia. Thus use of propofol/fentanyl-based TIVA may not be a useful strategy to avoid renal medullary hypoxia during CPB.
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Affiliation(s)
- Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Naoya Iguchi
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources, Melbourne, Victoria, Australia
| | - Sally G Hood
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Peter R McCall
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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22
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Ngo JP, Lankadeva YR, Zhu MZL, Martin A, Kanki M, Cochrane AD, Smith JA, Thrift AG, May CN, Evans RG. Factors that confound the prediction of renal medullary oxygenation and risk of acute kidney injury from measurement of bladder urine oxygen tension. Acta Physiol (Oxf) 2019; 227:e13294. [PMID: 31066975 DOI: 10.1111/apha.13294] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 04/07/2019] [Accepted: 05/02/2019] [Indexed: 02/01/2023]
Abstract
AIM Urinary oxygen tension (uPO2 ) may provide an estimate of renal medullary PO2 (mPO2 ) and thus risk of acute kidney injury (AKI). We assessed the potential for variations in urine flow and arterial PO2 (aPO2 ) to confound these estimates. METHODS In 28 sheep urine flow, uPO2 , aPO2 and mPO2 were measured during development of septic AKI. In 65 human patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) uPO2 and aPO2 were measured continuously during CPB, and in a subset of 20 patients, urine flow was estimated every 5 minutes. RESULTS In conscious sheep breathing room air, uPO2 was more closely correlated with mPO2 than with aPO2 or urine flow. The difference between mPO2 and uPO2 varied little with urine flow or aPO2 . In patients, urine flow increased abruptly from 3.42 ± 0.29 mL min-1 to 6.94 ± 0.26 mL min-1 upon commencement of CPB, usually coincident with reduced uPO2 . During hyperoxic CPB high values of uPO2 were often observed at low urine flow. Low urinary PO2 during CPB (<10 mm Hg at any time during CPB) was associated with greater (4.5-fold) risk of AKI. However, low urine flow during CPB was not significantly associated with risk of AKI. CONCLUSIONS uPO2 provides a robust estimate of mPO2 , but this relationship is confounded by the simultaneous presence of systemic hyperoxia and low urine flow. Urine flow increases and uPO2 decreases during CPB. Thus, CPB is probably the best time to use uPO2 to detect renal medullary hypoxia and risk of post-operative AKI.
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Affiliation(s)
- Jennifer P. Ngo
- Cardiovascular Disease Program, Biomedicine Discovery Institute Monash University Melbourne Australia
- Department of Physiology Monash University Melbourne Australia
| | - Yugeesh R. Lankadeva
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Australia
| | - Michael Z. L. Zhu
- Cardiovascular Disease Program, Biomedicine Discovery Institute Monash University Melbourne Australia
- Department of Physiology Monash University Melbourne Australia
- Department of Cardiothoracic Surgery Monash Health, Monash University Melbourne Australia
- Department of Surgery, School of Clinical Sciences at Monash Health Monash University Melbourne Australia
| | - Andrew Martin
- Cardiovascular Disease Program, Biomedicine Discovery Institute Monash University Melbourne Australia
- Department of Physiology Monash University Melbourne Australia
- Department of Cardiothoracic Surgery Monash Health, Monash University Melbourne Australia
- Department of Surgery, School of Clinical Sciences at Monash Health Monash University Melbourne Australia
| | - Monica Kanki
- Cardiovascular Disease Program, Biomedicine Discovery Institute Monash University Melbourne Australia
- Department of Physiology Monash University Melbourne Australia
| | - Andrew D. Cochrane
- Department of Cardiothoracic Surgery Monash Health, Monash University Melbourne Australia
- Department of Surgery, School of Clinical Sciences at Monash Health Monash University Melbourne Australia
| | - Julian A. Smith
- Department of Cardiothoracic Surgery Monash Health, Monash University Melbourne Australia
- Department of Surgery, School of Clinical Sciences at Monash Health Monash University Melbourne Australia
| | - Amanda G. Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health Monash University Melbourne Australia
| | - Clive N. May
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Australia
| | - Roger G. Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute Monash University Melbourne Australia
- Department of Physiology Monash University Melbourne Australia
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Swartz MF, Makhija P, Rubenstein J, Henrichs KF, Powers KS, Wang HY, Simon BV, Alfieris GM, Blumberg N, Cholette JM. Met-Hemoglobin Is a Biomarker for Poor Oxygen Delivery in Infants Following Surgical Palliation. World J Pediatr Congenit Heart Surg 2019; 10:485-491. [PMID: 31142197 DOI: 10.1177/2150135119852327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Infants with cyanotic congenital heart disease demonstrate wide fluctuations in hemoglobin (Hb), oxygen saturation, and cardiac output following palliation. Methemoglobin (Met-Hb), the product of Hb oxidation, may represent a compensatory mechanism during hypoxia and may be utilized as a biomarker. METHODS Arterial and venous Met-Hb levels were obtained from infants requiring palliation. The primary outcome was to describe the relationship between Met-Hb and other indices of tissue oxygenation (venous saturation, estimated arteriovenous oxygen difference [Est AV-Diff], and lactate). Secondary outcomes were to determine the impact of elevated Met-Hb levels ≥1.0% and the effect of red blood cell (RBC) transfusion on Met-Hb levels. RESULTS Fifty infants and 465 Met-Hb values were studied. Venous Met-Hb levels were significantly higher than arterial levels (venous: 0.84% ± 0.36% vs arterial: 0.45% ± 0.18%; P < .001). Venous Met-Hb demonstrated a significant inverse relationship with venous oxygen saturation (R = -0.6; P < .001) and Hb (R = -0.3, P < .001) and a direct relationship with the Est AV-Diff (R = 0.3, P < .001). A total of 129 (29.6%) venous Met-Hb values were elevated (≥1.0%) and were associated with significantly lower Hb and venous saturation levels and higher Est AV-Diff and lactate levels. Methemoglobin levels decreased significantly following 65 RBC transfusions (0.94 ± 0.40 vs 0.77 ± 0.34; P < .001). Linear mixed models demonstrated that higher venous Met-Hb levels were associated with lower measures of tissue oxygenation and not related to any preoperative clinical differences. CONCLUSION Methemoglobin may be a clinically useful marker of tissue oxygenation in infants following surgical palliation.
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Affiliation(s)
- Michael F Swartz
- 1 Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Pooja Makhija
- 2 Department of Pediatrics, University of Buffalo, Buffalo, NY, USA
| | | | - Kelly F Henrichs
- 4 Department of Pathology and Laboratory Medicine, University of Rochester, Rochester, NY, USA
| | - Karen S Powers
- 3 Department of Pediatrics, University of Rochester, Rochester, NY, USA
| | - Hong Yue Wang
- 5 Department of Biostatistics, University of Rochester, Rochester, NY, USA
| | | | - George M Alfieris
- 1 Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Neil Blumberg
- 4 Department of Pathology and Laboratory Medicine, University of Rochester, Rochester, NY, USA
| | - Jill M Cholette
- 3 Department of Pediatrics, University of Rochester, Rochester, NY, USA
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24
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Lee CJ, Smith DW, Gardiner BS, Evans RG. Stimulation of erythropoietin release by hypoxia and hypoxemia: similar but different. Kidney Int 2019; 95:23-25. [DOI: 10.1016/j.kint.2018.09.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 09/26/2018] [Indexed: 11/24/2022]
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25
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Abstract
PURPOSE OF REVIEW Anemia can contribute negatively to a patient's morbidity and mortality. Which treatment options do exist and what role do anesthesiologists play in management of perioperative anemia treatment? This review gives an overview about recent findings. RECENT FINDINGS Patient Blood Management and standards for the management and treatment of anemia have been established worldwide. Various logistic settings and approaches are possible. With a special focus on cardiovascular anesthesia, intravenous iron is a therapeutic option in the preoperative setting. Autologous blood salvage is a standard procedure during surgery. Restrictive transfusion triggers in adult cardiac surgery have been shown to be beneficial in the majority of studies. Elderly patients and defined comorbidities might require higher transfusion triggers. Both, intravenous and oral iron increase hemoglobin values when given prior to surgery. Oral iron is effective when given several weeks prior to elective surgery. Erythropoietin is a treatment decision individualized to each patient. SUMMARY Within the previous 18 months, important publications have demonstrated the established role of anesthesiologists in managing perioperative anemia. A substantial pillar for anemia treatment is the implementation of Patient Blood Management worldwide.
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