Safeguarding anaesthesia research from spin

Leucoglycemic index predicts post-operative vasopressor-inotropic requirement after adult cardiac surgery (LEUCOGLYPTICS): A retrospective single-center study

Background and Aims

Cardiac surgery often necessitates considerable post-operative vasoactive-inotropic support. Given an encouraging literature on the prognostic potential of leucoglycemic index (LGI) [serum glucose (mg/dl) × total leucocytes count (cells/mm3)/1000], we aimed to evaluate whether intensive care unit (ICU)-admission LGI can predict post-operative vasopressor-inotropic requirements following cardiac surgery on cardio-pulmonary bypass (CPB).

Material and Methods

The data of patients undergoing cardiac surgery at our tertiary care center between January 2015 and December 2020 was retrospectively reviewed. The vasopressor-inotropic requirement was estimated using the VIS (vasoactive-inotropic score) values over the first post-operative 72 hrs. Subsequently, VISi (indexed VIS) was computed as maxVIS[0-24hrs] + maxVIS[24-48hrs] +2 × maxVIS[48-72hrs]/10), and the study participants were divided into h-VISi (VISi ≥3) and l-VISi (VISi <3).

Results

Out of 2138 patients, 479 (22.40%) patients categorized as h-VISi. On univariate analysis: LGI, age, European System for Cardiac Operative Risk Evaluation score (EuroSCORE II), left-ventricle ejection fraction, prior congestive heart failure (CHF), chronic renal failure, angiotensin-converting enzyme inhibitors, combined surgeries, CPB and aortic cross-clamp (ACC) duration, blood transfusion, and immediate post-operative glucose were significant h-VISi predictors. Subsequent to multi-variate analysis, the predictive performance of LGI (OR: 1.09; 95% CI: 1.03-1.14; P = 0.002) prior CHF (OR: 2.35; 95% CI: 1.44-3.82; P = 0.001), CPB time (OR: 1.08; 95% CI: 1.02-1.14; P = 0.019), ACC time (OR: 1.03; 95% CI: 1.02-1.04; P = 0.008), and EuroSCORE II (OR: 1.14; 95% CI: 1.06-1.21; P < 0.001) remained significant. With 1484.75 emerging as the h-VISi predictive cut-off, patients with LGI ≥ 1484.75 also had a higher incidence of vasoplegia, low-cardiac output syndrome, new-onset atrial fibrillation, acute kidney injury, and mortality. LGI additionally exhibited a significant positive correlation with duration of mechanical ventilation and ICU stay (R = 0.495 and 0.564, P value < 0.001).

Conclusion

An elevated LGI of greater than 1484.75 independently predicted a VISindex ≥3 following adult cardiac surgery on CPB.

Atrial Fibrillation and Perioperative Inflammation (FIBRILLAMMED Study): A Retrospective Analysis of the Predictive Role of Preoperative Albumin-Adjusted Platelet-Leukocytic Indices in OPCABG

Objective

New-onset atrial fibrillation (NOAF), an important postoperative complication, has pertinent inflammatory links. Motivated by the encouraging literature on the prognostic role of hypoalbuminemia, leukocytic indices [LIs: neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR)], systemic inflammation response index (SIRI=NLR×monocyte) and platelet-leukocytic indices [PLIs: platelet-to-lymphocyte ratio (PLR)], systemic immune inflammation index (SII=NLR×platelet), aggregate index of systemic inflammation (AISI=NLR×platelet×monocyte), we sought to investigate the NOAF-predictive value of preoperative albumin-adjusted indices (aa-LIs and aa-PLIs) in an off-pump coronary artery bypass grafting (OPCABG) setting.

Methods

Of 899 patients, 151 patients (16.79%) developed the primary outcome i.e. NOAF that was analyzed further retrospectively for its predictors instead of the highlighted text perioperative data of 899 patients undergoing elective OPCABG, were retrospectively analyzed. The study participants were categorized into non-NOAF and NOAF groups (defined as new-onset atrial arrhythmia with irregular RR interval with indistinct P wave in the first week postoperatively).

Results

One hundred and fifty-one patients (16.79%) developed NOAF. On univariate analysis: age, smoker status, The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, systemic hypertension, diabetes mellitus, prior congestive heart failure (CHF), and a higher preoperative NLR, PLR, SII, and albumin were significant predictors of NOAF. While age, CHF, and EuroSCORE II retained predictive significance in multivariate analysis, LI-PLIs and albumin did not emerge as independent NOAF predictors. Notably, aa-NLR, aa-PLR, and aa-SII independently predicted NOAF on the computation of model-estimates in the regression analysis (Odds ratio; 95% confidence interval: 31.05;15.75-70.61, 1.04;1.02-1.05, 1.12;1.10-1.14, respectively, P < 0.001). aa-NLR ≥1.32, aa-PLR ≥52.64, and aa-SII ≥344.38 predicted NOAF with the respective AUC;sensitivity;specificity of 0.66;63.6%;73.3%, 0.63;66.2%;59.0%, and 0.65;58.3%;78.2%. Preoperative aa-NLR, aa-PLR and aa-SII also positively correlated with CHA2DS2-VASc score (R=0.40, 0.45 and 0.42; P < 0.001).

Conclusion

The independent NOAF predictive value of aa-NLR, aa-PLR, and aa-SII reiterates the inflammatory relationship of the arrhythmic complication following OPCABG.

Spin and fragility in randomised controlled trials in the anaesthesia literature: a systematic review

BACKGROUND

Given variable frequency of misleading reports and the potential for spin (a way of describing results that can mislead readers) to influence interpretation of randomised controlled trials (RCTs), we have undertaken a spin reassessment. We evaluated the quality of recent literature in anaesthesia journals by assessing the presence of spin and calculating the fragility index.

METHODS

This systematic review of randomised trials was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We searched via PubMed® from January 1, 2019 to January 1, 2021 to identify all RCTs published in one of the 20 anaesthesia journals with the highest journal impact factors during this time. Four pairs of reviewers assessed articles independently for eligibility using a piloted electronic data extraction form. They assessed the presence of spin in statistically negative RCTs and calculated the fragility index for statistically positive RCTs.

RESULTS

Of the 802 screened records, 162 (20%) articles were analysed for spin, and 65 (8%) trials were analysed for fragility index. For the statistically negative studies, 66 articles (40%) presented spin; 89% of these occurrences of spin were described in the conclusion of the abstract. The primary type of spin was the highlight of secondary outcomes (67%). For statistically positive trials, the median fragility index was 4 [1-8].

CONCLUSIONS

This systematic review showed that 40% of statistically negative trials in high-impact anaesthesia journals could mislead readers. For statistically positive RCTs, the results relied on few subjects, with a median fragility index of 4 [1-8]. Efforts must be continued to reduce spin and fragility in the medical literature.

VASOplegia is Predicted by Preoperative Platelet-LEucocyte conGlomerate Indices in Cardiac Surgery (VASOPLEGICS): A retrospective single-center study

Background

Post-cardiotomy vasoplegia syndrome (VS) is often linked to an exaggerated inflammatory response to cardiopulmonary bypass (CPB). At the same time, the prognostic role of platelet-leucocyte indices (PLIs) and leucocyte indices (LIs), (platelet-lymphocyte ratio [PLR], systemic immune-inflammation index [SII = platelet × neutrophil/lymphocyte], aggregate index of systemic inflammation [AISI = platelet × monocyte × neutrophil/lymphocyte], and neutrophil-lymphocyte ratio [NLR], systemic inflammation response index [SIRI = monocyte × neutrophil/lymphocyte), respectively] has been recently described in diverse inflammatory settings.

Methods

The retrospective study was conducted to evaluate the VS predictive performance of PLIs and LIs in 1,045 adult patients undergoing elective cardiac surgery at a tertiary care center. VS was defined by mean blood pressure <60 mmHg, low systemic vascular resistance (SVRI <1,500 dynes.s/cm 5/m2), a normal or high CI (>2.5 L/min/m2), and a normal or reduced central filling pressure despite high-dose vasopressors.

Results

About 205 (19.61%) patients developed VS postoperatively. On univariate analysis, age, diabetes, dialysis-dependent renal failure, preoperative congestive heart failure (CHF), the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, ejection fraction, NLR, PLR, SII, SIRI, AISI, CPB, and aortic cross clamp (ACC) duration, packed red blood cell (PRBC) transfusion, and time-weighted average blood glucose predicted VS. Subsequent to the multivariate analysis, the predictive performance of EuroSCORE II (OR: 3.236; 95% CI: 2.345-4.468; P < 0.001), CHF (OR: 1.04; 95% CI: 1.02-1.06; P = 0.011), SII (OR: 1.09; 95% CI: 1.02-1.18; P = 0.001), AISI (OR: 1.11; 95% CI: 1.05-1.17; P < 0.001), PRBC (OR: 4.747; 95% CI: 2.443-9.223; P < 0.001), ACC time (OR: 1.003; 95% CI: 1.001-1.005; P = 0.004), and CPB time (OR: 1.016; 95% CI: 1.004-1.028; P = 0.001) remained significant. VS predictive cut-offs of SII and AISI were 1,045 1045×109 /mm3 and 137532×109/mm3, respectively. AISI positively correlated with the postoperative vasoactive-inotropic score (R = 0.718), lactate (R = 0.655), mechanical ventilation duration (R = 0.837), and ICU stay (R = 0.757).

Conclusions

Preoperative elevated SII and AISI emerged as independent predictors of post-cardiotomy VS.

Spin within systematic review abstracts on antiplatelet therapies after acute coronary syndrome: a cross-sectional study

OBJECTIVES

Spin is a reporting practice in which study results are misrepresented by overestimating efficacy or underestimating harm. Prevalence of spin varies between clinical specialties, and estimates are based almost entirely on clinical trials. Little is known about spin in systematic reviews.

DESIGN

We performed a cross-sectional analysis searching MEDLINE and Embase for systematic reviews and meta-analyses pertaining to antiplatelet therapies following acute coronary syndrome on 2 June 2020. Data were extracted evaluating the presence of spin and study characteristics, including methodological quality as rated by A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2). All data extraction was conducted in a masked, duplicate manner from 2 June 2020 to 26 June 2020.

PARTICIPANTS AND SETTING

Not applicable.

PRIMARY AND SECONDARY OUTCOME MEASURES

We assessed abstracts of systematic reviews on antiplatelet therapy following acute coronary syndrome and evaluated the prevalence of the nine most severe types of spin. We additionally explored associations between spin and certain study characteristics, including quality.

RESULTS

Our searches returned 15 263 articles, and 185 systematic reviews met inclusion criteria. Of these 185 reviews, 31.9% (59/185) contained some form of spin in the abstract. Seven forms of spin (1, 2, 3, 4, 5, 7 and 9) among the nine most severe were identified. No instances of types 6 or 8 were found. There were no statistically significant relationships between spin and the evaluated study characteristics or AMSTAR-2 appraisals.

CONCLUSIONS

Spin was present in abstracts for systematic reviews and meta-analyses; subsequent studies are needed to identify correlations between spin and specific study characteristics. There were no statistically significant associations between spin and study characteristics or AMSTAR-2 ratings; however, implementing changes will ensure that spin is reduced in the field of cardiology as well as other fields of medicine.

ICU Readmission in Cardiac Surgical Subset: A Problem Worth Pondering

Over the past decades, there have been noteworthy advancements in the cardiac surgical practice that have assisted fast-tracking and enhanced recovery after cardiac surgery (ERACS). With that said, intensive care unit (ICU) readmission in this high-risk patient cohort entails a significant morbidity–mortality burden. As an extension of the same, there has been a heightened emphasis on a comprehensive evaluation of the predisposition to readmission following a primary ICU discharge. However, the variability of the institutional perioperative practices and the research complexities compound our understanding of this heterogeneous outcome of readmission, which is intricately linked to both patient and organizational factors. Moreover, a discussion on ICU readmission in the recent times can only be rendered comprehensive when staged in close conjunction to the fast-tracking practices in cardiac surgery. From a more positive probing of the matter, a preventative outlook can likely mitigate a part of the larger problem of ICU readmission. Herein, focused cardiac prehabilitation programs can play a potential role given the emerging literature on the positive impact of the former on the most relevant readmission causes. Therefore, the index review article aims to address the subject of cardiac surgical ICU readmission, highlighting the magnitude and burden, the causes and risk-factors, and the research complexities alongside deliberating the topic in the present-day context of ERACS and cardiac prehabilitation.

Malnutrition-Inflammation Liaison in Predicting AKI following OPCABG in Diabetics: Role of a Novel Monocyte/High-Density Lipoprotein × Albumin Ratio

Background Monocyte/high-density lipoprotein ratio (MHR) has been recently proposed as a parsimonious inflammatory marker. Akin to MHR, hypoalbuminemia (a malnutrition marker) has a considerable proinflammatory potential and confers an accentuated risk of postcardiac surgery complications, like acute kidney injury (AKI). The present study evaluated the AKI-predictive value of the preoperative monocyte/high-density lipoprotein × albumin ratio (MHAR) in diabetic patients undergoing off-pump coronary artery bypass grafting (OPCABG).

Methods The retrospective study conducted at our tertiary cardiac care center included 687 diabetic OPCABG patients. Forty-eight hours postoperative data was evaluated for the occurrence of AKI, as defined by the Acute Kidney Injury Network criteria. The perioperative attributes of the AKI and non-AKI groups were compared to evaluate the predictors of AKI, by employing a regression analysis.

Results A total of 109 patients (15.87%) developed AKI postoperatively. On univariate analysis: age, EuroSCORE II, preoperative congestive heart failure, systemic hypertension, serum albumin, MHR, MHAR, intraoperative packed red blood cell transfusion, postoperative low cardiac output syndrome, and vasoactive-inotropic score (VIS) predicted AKI. AKI subsequent to multivariate analysis, age (odds ratio [OR]: 1.029), EuroSCORE II (OR: 1.264), MHAR (OR: 1.403), and VIS (OR: 1.07) were the independent predictors (p-values: 0.020, < 0.001, 0.013, 0.002, respectively). The AKI predictive cutoffs of albumin, MHR, and MHAR were ≤ 2.95, ≥ 15.25, and ≥ 4.08 (area under the curve:sensitivity:specificity of 0.761:84.86%:89.62%; 0.754:93.12%:86.68%; 0.798:89.63%:88.34%, respectively). MHAR ≥ 4.08 was also associated with a higher incidence of postoperative atrial fibrillation and major adverse cardiac events.

Conclusion Preoperative elevated MHAR independently predicts AKI following OPCABG in diabetics, implying a malnutrition-inflammation liaison at heart of the matter.

Preoperative Combined Adiposity–Nutritional Index Predicts Major aDverse Cardiac and Cerebral Events following Off-pump coRonary Artery Revascularization (PANDORA): A Retrospective Single-Center Study

Background The metabolic–nutritional profile of coronary artery disease (CAD) patients can be an important outcome determinant. A high visceral adiposity index (VAI) and a low prognostic nutritional index (PNI) have been described to predict major adverse cardiac and cerebral events (MACCE) in nonoperative settings and poor cardiac-surgical outcomes, respectively. The present study evaluated the MACCE-predictive value of the two indices, in isolation and as a combined adiposity–nutritional index (CANI = VAI/PNI) in patients undergoing off-pump coronary artery bypass grafting (OPCABG).

Methods The retrospective study was conducted in 1207 OPCABG patients at a tertiary cardiac care center. Thirty-day postoperative data was evaluated for the development of MACCE, defined by any of the following: cardiac arrest, ST-segment elevation myocardial ischemia (STEMI), repeat coronary revascularization, or stroke. The perioperative characteristics of the MACCE and no-MACCE groups were analyzed for the predictors of postoperative MACCE.

Results One-hundred thirty-two patients (10.93%) developed MACCE postoperatively. On univariate analysis, age, EuroSCORE II, ejection fraction, diabetes mellitus, asymptomatic carotid artery disease, left main (LM) disease, PNI, and VAI predicted MACCE. Subsequent to multivariate analysis, age, EuroSCORE II, and CANI were the independent predictors. The MACCE predictive cutoffs of VAI, PNI, and CANI were 3.2, 38.46, and 0.075 (area under the curve [AUC]; sensitivity; specificity: 0.64; 77%; 81.3%, 0.77; 92.6%, 65%, 0.78; 64.5%; 80.2%, respectively). CANI correlated positively with duration of mechanical ventilation, length of intensive care unit (ICU) stay, and mean postoperative vasoactive inotropic scores (VIS). CANI ≥ 0.075 was also associated with a higher incidence of postoperative atrial fibrillation, low cardiac output syndrome, and acute kidney injury.

Conclusions CANI emerged as an independent predictor of MACCE following OPCABG.

Feasibility of Opioid-Free Anesthesia for Cervical Rib Excision: A Case Series and Review of Literature

Background Perioperative pain management following cervical rib excision can be compounded in the background of chronic pain disorder caused by the neurovascular compression. The former mandates an enhanced analgesic requirement wherein the perioperative opioid use, in particular, can be associated with a peculiar adverse-effect profile and abuse potential. Appropriate to the context, an opioid-free anesthesia (OFA) protocol can be instrumental in minimizing the incidence of the aforementioned.

Case Series While two patients necessitated OFA owing to opioid contraindication, the formulated protocol was evaluated in another six consecutive patients posted for elective cervical rib excision. A combined paravertebral block and superficial cervical plexus block was employed alongside general anesthesia. Intravenous dexmedetomidine and lignocaine assisted the conduct of OFA, and paracetamol dosing was continued into the postoperative period. Intraoperative rescue analgesia was ensured by a ketofol bolus (1:1 mixture of ketamine and propofol) whereas intravenous diclofenac was used for postoperative rescue analgesia.

Results OFA could be successfully contemplated in all eight patients. A single bolus rescue dose of ketofol had to be administered in two patients intraoperatively and diclofenac had to be administered as postoperative rescue analgesic in two patients. There was no incidence of postoperative nausea/vomiting or any block-related complications. The postoperative stay was uneventful with an acceptable patient satisfaction.

Conclusion The index experience reiterates the fact that a prudent combination of nonopioid multimodal analgesics with case-based locoregional techniques can feature as a successful OFA protocol, albeit mandating future prospective studies in this novel area of clinical interest.

Haemodynamic predisposition to acute kidney injury: Shadow and light!

Acute kidney injury (AKI) could well be regarded as a sentinel complication given it is relatively common and associated with a substantial risk of subsequent morbidity and mortality. On the aegis of 'prevention is better than cure', there has been a wide interest in evaluating haemodynamic predisposition to AKI so as to provide a favourable renoprotective haemodynamic milieu to the subset of patients presenting a significant risk of developing AKI. In this context, the last decade has witnessed a series of evaluation of the hypotension value and duration cut-offs associated with risk of AKI across diverse non-operative and operative settings. Nevertheless, a holistic comprehension of the haemodynamic predisposition to AKI has been a laggard with only few reports highlighting the potential of elevated central venous pressure, intra-abdominal hypertension and high mean airway pressures in considerably attenuating the effective renal perfusion, particularly in scenarios where kidneys are highly sensitive to any untoward elevation in the afterload. Despite the inherent autoregulatory mechanisms, the effective renal perfusion pressure (RPP) can be modulated by a number of haemodynamic factors in addition to mean arterial pressure (MAP) as the escalation of renal interstitial pressure, in particular hampers kidney perfusion which in itself is a dynamic interplay of a number of innate pressures. The present article aims to review the subject of haemodynamic predisposition to AKI centralising the focus on effective RPP (over and above the conventional 'tunnel-vision' for MAP) and discuss the relevant literature accumulating in this area of ever-growing clinical interest.

A randomized comparative evaluation of C-MAC video-laryngoscope with Miller laryngoscope for neonatal endotracheal intubation

Background and Aims

An efficient neonatal airway management is peculiarly challenging even in the most experienced hands. Considering the recent interest in assessing the performance of various video-laryngoscopes (VL) in pediatric cohort, the prospective randomized study was contemplated to stage a comparative evaluation of C-MAC with Miller laryngoscope for neonatal endotracheal intubation.

Material and Methods

150 neonates were randomized to undergo intubation with either the C-MAC VL (n = 75) or the Miller laryngoscope (n = 75) performed by an experienced anesthesiologist in a tertiary care perioperative setting. The percentage of glottic opening (POGO), time to best glottic view (TTBGV), time to intubation (TTI), number of attempts, optimal external laryngeal manipulation (OELM) employed, and the complications were assessed and compared between the two groups.

Results

C-MAC group demonstrated a significantly higher POGO, compared to the Miller group (88 ± 26.7%;76.8 ± 32.1%, respectively, P = 0.022). TTBGV was significantly lower in the C-MAC (7.7 ± 0.1s) group as opposed to the Miller group (11.3 ± 1.1s). The C-MAC group displayed higher TTI values compared to the Miller group (25.4 ± 1.6s; 19.7 ± 1.2s, respectively, P < 0.01). The first-attempt intubation success rate and the number of attempts were comparable in both the groups. OELM was required in 24% of the patients in the Miller group as opposed to 10.7% in the C-MAC group (P = 0.031). Higher patient percentage in the C-MAC group required the need of stylet for assisting a successful intubation, although the difference between the two groups was not statistically significant.

Conclusion

Despite an improved view of the glottis, the TTI was higher for C-MAC compared to direct laryngoscopy with a comparable first-attempt success rate in the two techniques.