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Mohr NL, Krannich A, Jung H, Hulde N, von Dossow V. Intraoperative Blood Pressure Management and Its Effects on Postoperative Delirium After Cardiac Surgery: A Single-Center Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2024; 38:1127-1134. [PMID: 38369449 DOI: 10.1053/j.jvca.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/17/2024] [Accepted: 01/23/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVES There is accumulating evidence that blood pressure management might be associated with end-organ dysfunction after cardiac surgery. This study aimed to investigate the impact of intraoperative hypotension (IOH) on adverse neurologic outcomes and mortality. DESIGN A single-center retrospective cohort study. SETTING The Heart and Diabetes Centre Bad Oeynhausen NRW, Ruhr-University Bochum. PARTICIPANTS This retrospective cohort study included 31,315 adult patients who underwent elective cardiac surgery at the authors' institution between January 2009 and December 2018. INTERVENTIONS All cardiac surgery procedures except assist device implantation, organ transplantation, and emergency surgery. MEASUREMENTS AND MAIN RESULTS Adverse neurologic outcomes were defined as postoperative delirium and stroke. IOH was defined as mean arterial pressure below 60 mmHg for >2 minutes. The frequency of IOH episodes and the cumulative IOH duration were recorded. The association between IOH and adverse neurologic outcomes was examined with unadjusted statistical analysis and multiple logistic regression analysis. Eight hundred forty-nine (2.9%) patients developed postoperative stroke, and 2,401 (7.7%) patients developed postoperative delirium. The frequency of IOH episodes was independently associated with postoperative delirium in the multiple logistic regression analysis (odds ratio 1.02, 95% CI 1.003-1.03, p < 0.001), whereas there was no association between it and stroke. CONCLUSION This large retrospective monocentric cohort study revealed that increased episodes of IOH were associated with the risk of developing postoperative delirium after cardiac surgery. This might have important clinical implications with respect to careful and precise hemodynamic monitoring and proactive treatment, especially in patients with increased risk for postoperative delirium.
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Affiliation(s)
- Niklas L Mohr
- Institute of Anesthesiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | | | - Hilke Jung
- Institute of Congenital heart diseases, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Nikolai Hulde
- Institute of Anesthesiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Vera von Dossow
- Institute of Anesthesiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany.
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D'Amico F, Pruna A, Putowski Z, Dormio S, Ajello S, Scandroglio AM, Lee TC, Zangrillo A, Landoni G. Low Versus High Blood Pressure Targets in Critically Ill and Surgical Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2024:00003246-990000000-00330. [PMID: 38656245 DOI: 10.1097/ccm.0000000000006314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVES Hypotension is associated with adverse outcomes in critically ill and perioperative patients. However, these assumptions are supported by observational studies. This meta-analysis of randomized controlled trials aims to compare the impact of lower versus higher blood pressure targets on mortality. DATA SOURCES We searched PubMed, Cochrane, and Scholar from inception to February 10, 2024. STUDY SELECTION Randomized trials comparing lower versus higher blood pressure targets in the management of critically ill and perioperative settings. DATA EXTRACTION The primary outcome was all-cause mortality at the longest follow-up available. This review was registered in the Prospective International Register of Systematic Reviews, CRD42023452928. DATA SYNTHESIS Of 2940 studies identified by the search string, 28 (12 in critically ill and 16 in perioperative settings) were included totaling 15,672 patients. Patients in the low blood pressure target group had lower mortality (23 studies included: 1019/7679 [13.3%] vs. 1103/7649 [14.4%]; relative risk 0.93; 95% CI, 0.87-0.99; p = 0.03; I2 = 0%). This corresponded to a 97.4% probability of any increase in mortality with a Bayesian approach. These findings were mainly driven by studies performed in the ICU setting and with treatment lasting more than 24 hours; however, the magnitude and direction of the results were similar in the majority of sensitivity analyses including the analysis restricted to low risk of bias studies. We also observed a lower rate of atrial fibrillation and fewer patients requiring transfusion in low-pressure target groups. No differences were found in the other secondary outcomes. CONCLUSIONS Based on pooled randomized trial evidence, a lower compared with a higher blood pressure target results in a reduction of mortality, atrial fibrillation, and transfusion requirements. Lower blood pressure targets may be beneficial but there is ongoing uncertainty. However, the present meta-analysis does not confirm previous findings and recommendations. These results might inform future guidelines and promote the study of the concept of protective hemodynamics.
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Affiliation(s)
- Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Zbigniew Putowski
- Department of Intensive Care and Perioperative Medicine, Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Sara Dormio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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3
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Evans RG, Cochrane AD, Hood SG, Marino B, Iguchi N, Bellomo R, McCall PR, Okazaki N, Jufar AH, Miles LF, Furukawa T, Ow CPC, Raman J, May CN, Lankadeva YR. Differential responses of cerebral and renal oxygenation to altered perfusion conditions during experimental cardiopulmonary bypass in sheep. Clin Exp Pharmacol Physiol 2024; 51:e13852. [PMID: 38452756 DOI: 10.1111/1440-1681.13852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/23/2024] [Accepted: 02/13/2024] [Indexed: 03/09/2024]
Abstract
We tested whether the brain and kidney respond differently to cardiopulmonary bypass (CPB) and to changes in perfusion conditions during CPB. Therefore, in ovine CPB, we assessed regional cerebral oxygen saturation (rSO2 ) by near-infrared spectroscopy and renal cortical and medullary tissue oxygen tension (PO2 ), and, in some protocols, brain tissue PO2 , by phosphorescence lifetime oximetry. During CPB, rSO2 correlated with mixed venous SO2 (r = 0.78) and brain tissue PO2 (r = 0.49) when arterial PO2 was varied. During the first 30 min of CPB, brain tissue PO2 , rSO2 and renal cortical tissue PO2 did not fall, but renal medullary tissue PO2 did. Nevertheless, compared with stable anaesthesia, during stable CPB, rSO2 (66.8 decreasing to 61.3%) and both renal cortical (90.8 decreasing to 43.5 mm Hg) and medullary (44.3 decreasing to 19.2 mm Hg) tissue PO2 were lower. Both rSO2 and renal PO2 increased when pump flow was increased from 60 to 100 mL kg-1 min-1 at a target arterial pressure of 70 mm Hg. They also both increased when pump flow and arterial pressure were increased simultaneously. Neither was significantly altered by partially pulsatile flow. The vasopressor, metaraminol, dose-dependently decreased rSO2 , but increased renal cortical and medullary PO2 . Increasing blood haemoglobin concentration increased rSO2 , but not renal PO2 . We conclude that both the brain and kidney are susceptible to hypoxia during CPB, which can be alleviated by increasing pump flow, even without increasing arterial pressure. However, increasing blood haemoglobin concentration increases brain, but not kidney oxygenation, whereas vasopressor support with metaraminol increases kidney, but not brain oxygenation.
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Affiliation(s)
- Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
- 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
| | - Sally G Hood
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources, 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
| | - Rinaldo Bellomo
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Peter R McCall
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
- 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
| | - Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Lachlan F Miles
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Taku Furukawa
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Connie P C Ow
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Jaishankar Raman
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Clive N May
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
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4
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Wen P, Luo P, Yang M, Huang J, Long Y, Liu L, Xu P. Knowledge mapping and research trends on perioperative neurocognitive disorder from 1990 to 2022: a bibliometric analysis. Ann Med Surg (Lond) 2024; 86:2058-2066. [PMID: 38576958 PMCID: PMC10990356 DOI: 10.1097/ms9.0000000000001872] [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: 12/05/2023] [Accepted: 02/16/2024] [Indexed: 04/06/2024] Open
Abstract
Introduction Perioperative neurocognitive disorder (PND) has attracted consistently increasing attention worldwide. However, there are few bibliometric studies that systematically evaluate this field. This study aimed to visualize the knowledge structure and research trends in PND through bibliometrics to help understand the future development of basic and clinical research. Methods Literature related to PND in Web of Science and PubMed from 1990 to 2022 were collected through keywords retrospectively. Additionally, the source information, citation information, etc. of these publications were extracted. Finally, bibliometric analysis was performed by visualization software and statistical software. Results There were 2837 articles and reviews in total. An exponential rise in PND-related publications was observed. China had the most publication, followed by the US and Germany. The institution with the most output and citations was Harvard University (149 papers, 8966 citations). The most prominent author was Marcantonio Edward R with 66 publications and 5721 citations. The journal with the highest productivity for PND research was Frontiers in Aging Neuroscience followed by Anesthesia and Analgesia. Keywords were identified as six topics, including postoperative delirium, postoperative neurocognitive disorder, cardiac surgery, anaesthesia, orthopedic surgery, and dementia. According to keyword analysis, the most recent popular keywords in PND research were prevention, older patients, emergence delirium, orthopedic surgery, and dexmedetomidine. Conclusions Publications on PND are increasing at an alarming rate from 1990 to 2022. Current research and future trends will concentrate on the prevention and treatment of PND, as well as PND associated with orthopedic surgery in older adults.
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Affiliation(s)
| | - Pan Luo
- Department of Auricular Reconstruction, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
| | | | - Jingyuan Huang
- Anesthesiology, Honghui Hospital, Xi’an Jiaotong University, Shaanxi
| | - Yunfei Long
- Department of Neurology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Lin Liu
- Departments of Joint Surgery
| | - Peng Xu
- Departments of Joint Surgery
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5
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Udzik J, Pacholewicz J, Biskupski A, Safranow K, Wojciechowska-Koszko I, Kwiatkowski P, Roszkowska P, Rogulska K, Dziedziejko V, Marcinowska Z, Kwiatkowski S, Kwiatkowska E. Higher perfusion pressure and pump flow during cardiopulmonary bypass are beneficial for kidney function-a single-centre prospective study. Front Physiol 2024; 15:1257631. [PMID: 38420620 PMCID: PMC10899324 DOI: 10.3389/fphys.2024.1257631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Background: Kidneys play an essential role in the circulatory system, regulating blood pressure and intravascular volume. They are also set on maintaining an adequate filtration pressure in the glomerulus. During the CPB, a decrease in systemic blood pressure and hemoglobin concentration may lead to renal ischemia and subsequent acute kidney injury. Methods: One hundred nine adult patients were prospectively enrolled in this study. The intervention in this study was increasing the flow of the CPB pump to reach the target MAP of > 90 mmHg during the procedure. The control group had a standard pump flow of 2.4 L/min/m2. Results: Standard pump flow of 2.4 L/min/m2 resulted in mean MAP < 90 mmHg during the CPB in most patients in the control group. Maintaining a higher MAP during CPB in this study population did not affect CSA-AKI incidence. However, it increased the intraoperative and postoperative diuresis and decreased renin release associated with CPB. Higher MAP during the CPB did not increase the incidence of cerebrovascular complications after the operation; patients in the highest MAP group had the lowest incidence of postoperative delirium, but the result did not obtain statistical significance. Conclusion: Maintaining MAP > 90 mmHg during the CPB positively impacts intraoperative and postoperative kidney function. It significantly reduces renal hypoperfusion during the procedure compared to MAP < 70 mmHg. MAP > 90 mmHg is safe for the central nervous system, and preliminary results suggest that it may have a beneficial impact on the incidence of postoperative delirium.
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Affiliation(s)
- Jakub Udzik
- Cardiac Surgery Department, Pomeranian Medical University, Szczecin, Poland
| | - Jerzy Pacholewicz
- Cardiac Surgery Department, Pomeranian Medical University, Szczecin, Poland
| | - Andrzej Biskupski
- Cardiac Surgery Department, Pomeranian Medical University, Szczecin, Poland
| | - Krzysztof Safranow
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Szczecin, Poland
| | | | - Paweł Kwiatkowski
- Department of Diagnostic Immunology, Pomeranian Medical University, Szczecin, Poland
| | - Paulina Roszkowska
- Department of Diagnostic Immunology, Pomeranian Medical University, Szczecin, Poland
| | - Karolina Rogulska
- Department of Diagnostic Immunology, Pomeranian Medical University, Szczecin, Poland
| | - Violetta Dziedziejko
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Szczecin, Poland
| | - Zuzanna Marcinowska
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Szczecin, Poland
| | - Sebastian Kwiatkowski
- Department of Obstetrics and Gynecology, Pomeranian Medical University, Szczecin, Poland
| | - Ewa Kwiatkowska
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
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Zulauf FN, Sikora N. CON: There Should be an Individualized Optimal Perfusion Pressure on CPB. J Cardiothorac Vasc Anesth 2024; 38:566-568. [PMID: 37648612 DOI: 10.1053/j.jvca.2023.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/30/2023] [Indexed: 09/01/2023]
Affiliation(s)
- Fabio Nicolas Zulauf
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Bern, Switzerland.
| | - Normunds Sikora
- Children's Clinical University Hospital, Department of Paediatric Cardiology and Cardiac Surgery, Riga Stradins University, Department of Surgery, Riga, Latvia
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Payne T, Moran B. Intraoperative hypotension is not associated with reduced atrial fibrillation or hospital length of stay. Comment on Br J Anaesth 2023; 131: 823-31. Br J Anaesth 2024; 132:181-183. [PMID: 37996276 DOI: 10.1016/j.bja.2023.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 11/25/2023] Open
Affiliation(s)
- Thomas Payne
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
| | - Benjamin Moran
- Critical Care Program, The George Institute of Global Health, Sydney, NSW, Australia; Department of Intensive Care, Gosford Hospital, Gosford, NSW, Australia; Department of Anaesthesia and Pain Medicine, Gosford Hospital, Gosford, NSW, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
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Wang F, Zhu Y. Intraoperative hypotension and postoperative outcomes. Comment on Br J Anaesth 2023; 131: 823-831. Br J Anaesth 2024; 132:178-180. [PMID: 37923583 DOI: 10.1016/j.bja.2023.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/05/2023] [Indexed: 11/07/2023] Open
Affiliation(s)
- Fei Wang
- Department of Anesthesiology, Sichuan Academy of Medical Science and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yihao Zhu
- Department of Anesthesiology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China.
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Chang H, Chen E, Zhu T, Liu J, Chen C. Communication Regarding the Myocardial Ischemia/Reperfusion and Cognitive Impairment: A Narrative Literature Review. J Alzheimers Dis 2024; 97:1545-1570. [PMID: 38277294 PMCID: PMC10894588 DOI: 10.3233/jad-230886] [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] [Accepted: 12/07/2023] [Indexed: 01/28/2024]
Abstract
Coronary artery disease is a prevalent ischemic disease that results in insufficient blood supply to the heart muscle due to narrowing or occlusion of the coronary arteries. Various reperfusion strategies, including pharmacological thrombolysis and percutaneous coronary intervention, have been developed to enhance blood flow restoration. However, these interventions can lead to myocardial ischemia/reperfusion injury (MI/RI), which can cause unpredictable complications. Recent research has highlighted a compelling association between MI/RI and cognitive function, revealing pathophysiological mechanisms that may explain altered brain cognition. Manifestations in the brain following MI/RI exhibit pathological features resembling those observed in Alzheimer's disease (AD), implying a potential link between MI/RI and the development of AD. The pro-inflammatory state following MI/RI may induce neuroinflammation via systemic inflammation, while impaired cardiac function can result in cerebral under-perfusion. This review delves into the role of extracellular vesicles in transporting deleterious substances from the heart to the brain during conditions of MI/RI, potentially contributing to impaired cognition. Addressing the cognitive consequence of MI/RI, the review also emphasizes potential neuroprotective interventions and pharmacological treatments within the MI/RI model. In conclusion, the review underscores the significant impact of MI/RI on cognitive function, summarizes potential mechanisms of cardio-cerebral communication in the context of MI/RI, and offers ideas and insights for the prevention and treatment of cognitive dysfunction following MI/RI.
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Affiliation(s)
- Haiqing Chang
- Department of Anesthesiology, West China Hospital, Sichuan University, Sichuan, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Erya Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Sichuan, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Sichuan, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Sichuan, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chan Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Sichuan, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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D'Amico F, Fominskiy EV, Turi S, Pruna A, Fresilli S, Triulzi M, Zangrillo A, Landoni G. Intraoperative hypotension and postoperative outcomes: a meta-analysis of randomised trials. Br J Anaesth 2023; 131:823-831. [PMID: 37739903 DOI: 10.1016/j.bja.2023.08.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 09/24/2023] Open
Abstract
INTRODUCTION Intraoperative hypotension is associated with adverse postoperative outcomes; however these findings are supported only by observational studies. The aim of this meta-analysis of randomised trials was to compare the postoperative effects permissive management with targeted management of intraoperative blood pressure. METHODS We searched PubMed, Cochrane, and Embase up to June 2023 for studies comparing permissive (mean arterial pressure ≤60 mm Hg) with targeted (mean arterial pressure >60 mm Hg) intraoperative blood pressure management. Primary outcome was all-cause mortality at the longest follow-up available. Secondary outcomes were atrial fibrillation, myocardial infarction, acute kidney injury, delirium, stroke, number of patients requiring transfusion, time on mechanical ventilation, and length of hospital stay. RESULTS We included 10 randomised trials including a total of 9359 patients. Mortality was similar between permissive and targeted blood pressure management groups (89/4644 [1.9%] vs 99/4643 [2.1%], odds ratio 0.88, 95% confidence interval [CI], 0.65-1.18, P=0.38, I2=0% with nine studies included). Atrial fibrillation (102/3896 [2.6%] vs 130/3887 [3.3%] odds ratio 0.71, 95% CI 0.53-0.96, P=0.03, I2=0%), and length of hospital stay (mean difference -0.20 days, 95% CI -0.26 to -0.13, P<0.001, I2=0%) were reduced in the permissive management group. No significant differences were found in subgroup analysis for cardiac and noncardiac surgery. CONCLUSION Pooled randomised evidence shows that a target intraoperative mean arterial pressure ≤60 mm Hg is not associated with increased mortality; nevertheless it is surprisingly associated with a reduced rate of atrial fibrillation and of length of hospital stay. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42023393725.
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Affiliation(s)
- Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evgeny V Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Fresilli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Margherita Triulzi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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11
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Luo Y, Liu J, Hong Y, Peng S, Meng S. Sevoflurane-induced hypotension causes cognitive dysfunction and hippocampal inflammation in mice. Behav Brain Res 2023; 455:114672. [PMID: 37716552 DOI: 10.1016/j.bbr.2023.114672] [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: 05/24/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 09/18/2023]
Abstract
Sevoflurane commonly adopted for anesthetic in clinical practice, however, its influences on cerebral blood flow and cognitive function remain controversial. Herein, the sevoflurane-induced hypotension on arterial blood pressure, cerebral blood flow, cognitive function, and hippocampal inflammation was investigated in mice. A significant decrease in arterial blood pressure and cerebral blood flow was indicated by the sevoflurane anesthesia treatment. Moreover, sevoflurane-induced hypotension was associated with the impaired cognitive function and the increased levels of NLRP3 inflammasome activation and oxidative stress in hippocampus. These findings suggest that sevoflurane-induced hypotension may lead to the cognitive dysfunction and hippocampal inflammation.
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Affiliation(s)
- Yuelian Luo
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang West Road, Guangzhou 510120, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, China
| | - Jiayi Liu
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang West Road, Guangzhou 510120, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, China
| | - Yu Hong
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang West Road, Guangzhou 510120, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, China
| | - Shuling Peng
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang West Road, Guangzhou 510120, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, China.
| | - Shiyu Meng
- Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang West Road, Guangzhou 510120, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, China.
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12
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Müller-Wirtz LM, Ruetzler K, Rössler J. Intraoperative hypotension and delirium. J Clin Anesth 2023; 89:111153. [PMID: 37245475 DOI: 10.1016/j.jclinane.2023.111153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 05/17/2023] [Indexed: 05/30/2023]
Affiliation(s)
- Lukas M Müller-Wirtz
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Mulkey MA, Smith AB, Wion RK, House SL, Wierenga KL. Nonpharmacological Cognitive Impairment Prevention Interventions in Older Adults Undergoing Cardiac Surgery: A Systematic Review. J Cardiovasc Nurs 2023; 38:E165-E177. [PMID: 35953076 PMCID: PMC9899292 DOI: 10.1097/jcn.0000000000000936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND More than 1 million individuals undergo cardiothoracic surgery for coronary artery bypass graft or valve repair/replacement annually in the United States. There is an increased risk of developing serious cognitive impairment post cardiothoracic surgery. Pharmacological interventions and surgical techniques were associated with improvements in cognitive function in previous systematic reviews. However, a gap in the literature exists regarding how nonpharmacological interventions can mitigate cognitive impairment in adults undergoing cardiac surgery. OBJECTIVE The aim of this study was to explore the effectiveness of nonpharmacological interventions to reduce the detrimental effects of cardiac surgery on cognitive function in patients after cardiothoracic surgery. METHODS CINAHL, MEDLINE, PubMed, EMBASE, PsycINFO, and Web of Science databases were searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines from January 2011 to February 2022. RESULTS Nineteen studies were included in this review. Researchers defined cognitive impairment differently across studies. Various interventions were used to reduce cognitive impairment post cardiothoracic surgery, with the most common being remote ischemic limb conditioning. The interventions used to reduce cognitive impairment were heterogeneous in outcomes, measurements, and time of assessment, but only 2 interventions were associated with a reduction in cognitive impairment. CONCLUSIONS This review is a unique synthesis of the quality of interventions that address broader components of cognition. Researchers used various interventions to reduce cognitive impairment; the outcomes, instruments, and time interval for measurements were heterogeneous. Researchers should conduct future studies at multiple time intervals, using a comprehensive measure of cognitive impairment to better understand the impact of cognitive impairment interventions postoperatively.
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Hui V, Ho KM, Hahn R, Wright B, Larbalestier R, Pavey W. The association between intraoperative cardiopulmonary bypass power and complications after cardiac surgery. Perfusion 2023:2676591231187958. [PMID: 37442644 DOI: 10.1177/02676591231187958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
BACKGROUND Low cardiac power (product of flow and pressure) has been shown to be associated with mortality in patients with cardiogenic shock after acute myocardial infarction, but has not been studied in cardiac surgical patients. This study's hypothesis was that cardiac power during cardiopulmonary bypass for cardiac surgery would have a greater association with adverse events than either flow or MAP (mean arterial pressure) alone. METHODS We undertook a retrospective observational study using patient data from February 2015 to March 2022 undergoing cardiac surgery at Fiona Stanley Hospital in Perth Australia. Excluded were patient age less than 18 years old, patients undergoing thoracic transplantation, ventricular assist devices, off pump cardiac surgery and aortic surgery. The primary outcome was a composite outcome of 30-days mortality, stroke or new-onset renal insufficiency. RESULTS Overall, 1984 cardiac surgeries were included in the analysis. Neither duration nor area below thresholds tested for power, MAP or flow was associated with the primary composite outcome. However, we found that an area below MAP thresholds 35-50 mmHg was associated with new renal insufficiency (adjusted odds ratio 1.17 [95% CI 1.02 to 1.35] for patients spending 10 min at 10 mmHg below 50 mmHg MAP compared to those who did not). CONCLUSIONS This study suggests that MAP during cardiopulmonary bypass, but not power or flow, was an independent risk factor for adverse renal outcomes for cardiac surgical patients.
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Affiliation(s)
- Victor Hui
- Department of Anaesthesia and Pain Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Heart Lung Research Institute of Western Australia, WA, Australia
| | - Kwok M Ho
- Medical School, University of Western Australia, Perth, WA, Australia
- School of Veterinary and Life Sciences, Murdoch University, Perth, WA, Australia
| | - Rebecca Hahn
- Heart Lung Research Institute of Western Australia, WA, Australia
| | - Brian Wright
- Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Robert Larbalestier
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, WA, Australia
| | - Warren Pavey
- Heart Lung Research Institute of Western Australia, WA, Australia
- Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley Hospital, Perth, WA, Australia
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15
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Descamps R, Amour J, Besnier E, Bougle A, Charbonneau H, Charvin M, Cholley B, Desebbe O, Fellahi JL, Frasca D, Labaste F, Lena D, Mahjoub Y, Mertes PM, Molliex S, Moury PH, Moussa MD, Oilleau JF, Ouattara A, Provenchere S, Rozec B, Parienti JJ, Fischer MO. Perioperative individualized hemodynamic optimization according to baseline mean arterial pressure in cardiac surgery patients: Rationale and design of the OPTIPAM randomized trial. Am Heart J 2023; 261:10-20. [PMID: 36934980 DOI: 10.1016/j.ahj.2023.03.005] [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] [Received: 11/04/2022] [Revised: 03/02/2023] [Accepted: 03/11/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Postoperative morbidity and mortality after cardiac surgery with cardiopulmonary bypass (CPB) remain high despite recent advances in both anesthesia and perioperative management. Among modifiable risk factors for postoperative complications, optimal arterial pressure during and after surgery has been under debate for years. Recent data suggest that optimizing arterial pressure to the baseline of the patient may improve outcomes. We hypothesize that optimizing the mean arterial pressure (MAP) to the baseline MAP of the patient during cardiac surgery with CPB and during the first 24 hours postoperatively may improve outcomes. STUDY DESIGN The OPTIPAM trial (NCT05403697) will be a multicenter, randomized, open-label controlled trial testing the superiority of optimized MAP management as compared with a MAP of 65 mm Hg or more during both the intraoperative and postoperative periods in 1,100 patients scheduled for cardiac surgery with CPB. The primary composite end point is the occurrence of acute kidney injury, neurological complications including stroke or postoperative delirium, and death. The secondary end points are hospital and intensive care unit lengths of stay, Day 7 and Day 90 mortality, postoperative cognitive dysfunction on Day 7 and Day 90, and quality of life at Day 7 and Day 90. Two interim analyses will assess the safety of the intervention. CONCLUSION The OPTIPAM trial will assess the effectiveness of an individualized target of mean arterial pressure in cardiac surgery with CPB in reducing postoperative morbidity. CLINICAL TRIAL REGISTRATION NCT05403697.
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Affiliation(s)
- Richard Descamps
- Department of Anesthesiology and Critical Care Medicine, Caen University Hospital, Caen, France.
| | - Julien Amour
- Institute of Perfusion, Critical Care Medicine and Anesthesiology in Cardiac Surgery (IPRA), Hôpital Privé Jacques Cartier, Massy, France
| | - Emmanuel Besnier
- Normandie Univ, UNIROUEN, INSERM U1096, CHU Rouen, Department of Anesthesiology and Critical Care, Rouen, France
| | - Adrien Bougle
- Sorbonne Université, GRC 29, Assistance Publique - Hôpitaux de Paris, DMU DREAM, Département d'Anesthésie et Réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Hélène Charbonneau
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, France
| | - Martin Charvin
- CHU Clermont-Ferrand, Médecine Péri-Opératoire (MC, FL, PJ, A-LC, EF); Université Clermont-Auvergne (EF), France
| | | | - Olivier Desebbe
- Department of Anesthesiology and Intensive Care, Ramsay Sante Sauvegarde Clinic, Lyon, France
| | - Jean-Luc Fellahi
- Service d'anesthésie-Réanimation, Hôpital Louis Pradel, Boulevard Pinel, Bron Cedex, France
| | - Denis Frasca
- Department of Anaesthesia and Intensive Care, University Hospital of Poitiers, France
| | - François Labaste
- Anesthesiology and Intensive Care Department, University Hospital of Toulouse, Toulouse, France
| | - Diane Lena
- Institut Arnault Tzanck, Cardiologie Médico-chirurgicale, Saint Laurent du Var, France
| | - Yazine Mahjoub
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, Amiens, France
| | - Paul-Michel Mertes
- Service d'Anesthésie-Réanimation, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Serge Molliex
- Department of Anaesthesiology and Critical Care Medicine, Hôpital Nord, Saint Etienne, France
| | | | | | - Jean-Ferreol Oilleau
- Department of Anaesthesia and Critical Care, Brest University Hospital, Brest, France
| | - Alexandre Ouattara
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medical Surgical Centre, Bordeaux, France
| | - Sophie Provenchere
- Anesthesiology and surgical critical care department, DMU PARABOL, AP-HP, Bichat Hospital, Paris, France
| | - Bertand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Nantes France
| | - Jean-Jacques Parienti
- Department of Biostatistics and Clinical Research, Caen University Hospital, Caen, France
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Ma J, Wang F, Wang J, Wang P, Dou X, Yao S, Lin Y. The Effect of Low-Dose Esketamine on Postoperative Neurocognitive Dysfunction in Elderly Patients Undergoing General Anesthesia for Gastrointestinal Tumors: A Randomized Controlled Trial. Drug Des Devel Ther 2023; 17:1945-1957. [PMID: 37408867 PMCID: PMC10318106 DOI: 10.2147/dddt.s406568] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/07/2023] [Indexed: 07/07/2023] Open
Abstract
Purpose This study aims to evaluate the effects of the intraoperative application of low-dose esketamine on postoperative neurocognitive dysfunction (PND) in elderly patients undergoing general anesthesia for gastrointestinal tumors. Methods Sixty-eight elderly patients were randomly allocated to two groups: the esketamine group (group Es) (0.25 mg/kg loading, 0.125mg/kg/h infusion) and the control group (group C) (received normal saline). The primary outcome was the incidence of delayed neurocognitive recovery (DNR). The secondary outcomes were intraoperative blood loss, the total amount of fluid given during surgery, propofol and remifentanil consumption, cardiovascular adverse events, use of vasoactive drugs, operating and anesthesia time, the number of cases of sufentanil remedial analgesia, the incidence of postoperative delirium (POD), the intraoperative hemodynamics, bispectral index (BIS) value at 0, 1, 2 h after operation and numeric rating scale (NRS) pain scores within 3 d after surgery. Results The incidence of DNR in group Es (16.13%) was lower than in group C (38.71%) (P <0.05). The intraoperative remifentanil dosage and the number of cases of dopamine used in group Es were lower than in group C (P <0.05). Compared with group C, DBP was higher at 3 min after intubation, and MAP was lower at 30 min after extubation in group Es (P<0.05). The incidence of hypotension and tachycardia in group Es was lower than in group C (P <0.05). The NRS pain score at 3 d after surgery in group Es was lower than in group C (P <0.05). Conclusion Low-dose esketamine infusion reduced to some extent the incidence of DNR in elderly patients undergoing general anesthesia for gastrointestinal tumors, improved intraoperative hemodynamics and BIS value, decreased the incidence of cardiovascular adverse events and the intraoperative consumption of opioids, and relieved postoperative pain.
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Affiliation(s)
- Jiamin Ma
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, 201620, People’s Republic of China
| | - Fuquan Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Jingxu Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Pengcheng Wang
- Department of Anesthesiology, Zhumadian Central Hospital, Zhumadian, 463000, People’s Republic of China
| | - Xiaoke Dou
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Shanglong Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Yun Lin
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
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Li T, Han W, Yang X, Wang Y, Peng L, He L, Hu L, Liu J, Xia M, Wang S. Effects of Different Injection Rates of Propofol on Postoperative Cognition in Elderly Patients Undergoing Laparoscopic Inguinal Hernia Repair. Drug Des Devel Ther 2023; 17:1741-1752. [PMID: 37333962 PMCID: PMC10276595 DOI: 10.2147/dddt.s407905] [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] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/06/2023] [Indexed: 06/20/2023] Open
Abstract
Purpose This study aimed to explore the effects of different injection rates of propofol on postoperative cognition in elderly patients undergoing laparoscopic inguinal hernia repair. Methods A total of 180 elderly patients who planned to undergo laparoscopic inguinal hernia repair were randomly divided into three groups: slow injection of propofol (VS-Group, 30 mg kg-1 h-1); medium injection of propofol (VM-Group, 100 mg kg-1 h-1) or fast injection of propofol (VF-Group, 300 mg kg-1 h-1). Propofol was induced by microinfusion pump, and the depth of anesthesia was monitored by bispectral index (BIS). Propofol and remifentanil were continuously infused during anesthesia maintenance and adjusted according to BIS. The primary outcome was the use of the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) to measure the incidence of postoperative cognitive decline (POCD) in elderly patients on the first and seventh postoperative day. Secondary outcomes included induced dose of propofol, incidence of burst suppression and maximum electroencephalographic (EEG) effect of propofol (BIS-min) during induction. Results The incidence of POCD on the first and seventh day postoperatively was similar among the three groups (P > 0.05). However, with the increase of propofol injection rate, induced dose of propofol, incidence of burst suppression and BIS-min during induction, the number of patients requiring vasoactive agents were significantly increased (P < 0.001). Multivariate regression analysis showed that the brief duration of burst suppression during induction did not affect the occurrence of POCD, while age and duration of hospitalization were risk factors for POCD. Conclusion For elderly patients undergoing laparoscopic inguinal hernia repair, lowering the injection rate of propofol (such as 30 mg kg-1 h-1) cannot decrease the incidence of early POCD, but reduces induction dose of propofol and use of vasoactive drugs, making the patient's hemodynamics more stable.
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Affiliation(s)
- Tingting Li
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
- Department of Anesthesiology, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, People’s Republic of China
| | - Wenjing Han
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
- Department of Anesthesiology, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, People’s Republic of China
| | - Xinlu Yang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Yu Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Li Peng
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Lingwei He
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Lianjia Hu
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Jiayuan Liu
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Min Xia
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Sheng Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
- Department of Anesthesiology, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, People’s Republic of China
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Hypotension and Cardiac Surgical Outcomes: Reply. Anesthesiology 2023; 138:336-337. [PMID: 36652594 DOI: 10.1097/aln.0000000000004417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Karan N, Bansal S, Mehta UM, Chakrabarti D, Reddy M. Postoperative delayed neurocognitive recovery: Evaluation of its incidence and correlation with intraoperative cerebral desaturation - A prospective observational study. Clin Neurol Neurosurg 2023; 227:107642. [PMID: 36871389 DOI: 10.1016/j.clineuro.2023.107642] [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: 12/28/2022] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND Delayed neurocognitive recovery (DNR) is commonly seen in patients in the postoperative period. Literature has shown that monitoring cerebral desaturation intraoperatively can predict the development of DNR in elderly patients undergoing surgery in prone position. This prospective observational study was conducted in patients of all ages, with the primary objective to determine the incidence of DNR and its correlation with cerebral oximetry. The secondary objectives were to determine if intraoperative cerebral desaturation influenced the neuropsychometric variables from preoperative to postoperative period. METHODS This study included 61 patients, aged > 18 years undergoing spinal surgery in prone position. An evening before surgery and at 48 h postoperatively, patients were subjected to neuropsychological examination; Hindi Mental State Examination, Colour Trail Test 1 (CTT 1), CTT 2, Auditory Verbal Learning (AVLT) tests conducted by principal investigator (PI). DNR was defined as a 20% change in any of the test scores from the baseline. rSO2 was recorded bilaterally every 10 min throughout surgery by an independent person. Cerebral desaturation was defined as a 20% drop in rSO2 from the control value. RESULTS The incidence of DNR was 24.6%. The duration of anesthesia and cerebral desaturation were found to be independently predictive of DNR, with each hour of anesthesia causing a two-fold increase in the chances of development DNR (P = 0.019) and presence of cerebral desaturation causing a 6-fold increase (P = 0.039). CTT 1 and CTT 2 tests had significantly larger increase in test scores in the postoperative period, in patients with cerebral desaturation. CONCLUSION Duration of anesthesia and cerebral desaturation were factors predictive of the development of DNR in patients undergoing spine surgery in prone position.
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Affiliation(s)
- Nupur Karan
- Department of Neuroanaesthesia and Neurocritical care, National Institute of Mental Health and Neurosciences, Bengaluru 560029, India
| | - Sonia Bansal
- Department of Neuroanaesthesia and Neurocritical care, National Institute of Mental Health and Neurosciences, Bengaluru 560029, India.
| | - Urvakhsh Meherwan Mehta
- Department of Neuroanaesthesia and Neurocritical care, National Institute of Mental Health and Neurosciences, Bengaluru 560029, India; Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru 560029, India
| | - Dhritiman Chakrabarti
- Department of Neuroanaesthesia and Neurocritical care, National Institute of Mental Health and Neurosciences, Bengaluru 560029, India; Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru 560029, India
| | - Madhusudan Reddy
- Department of Neuroanaesthesia and Neurocritical care, National Institute of Mental Health and Neurosciences, Bengaluru 560029, India
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Predictive Value of Multimodality Intraoperative Neurophysiological Monitoring During Cardiac Surgery. J Clin Neurophysiol 2023; 40:180-186. [PMID: 34510090 DOI: 10.1097/wnp.0000000000000875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION This study aimed to determine the ability of multimodality intraoperative neurophysiologic monitoring, including somatosensory evoked potentials (SSEP) and EEG, to predict perioperative clinical stroke and stroke-related mortality after open-heart surgery in high-risk patients. METHODS The records of all consecutive patients who underwent coronary artery bypass grafting, and cardiac valve repair/replacement with high risk for stroke who underwent both SSEP and EEG recording at the University of Pittsburgh Medical Center between 2009 and 2015 were reviewed. Sensitivity and specificity of these modalities to predict in-hospital clinical strokes and stroke-related mortality were calculated. RESULTS A total of 531 patients underwent open cardiac procedures monitored using SSEP and EEG. One hundred thirty-one patients (24.67%) experienced significant changes in either modality. Fourteen patients (2.64%) suffered clinical strokes within 24 hours after surgery, and eight patients (1.50%) died during their hospitalization. The incidence of in-hospital clinical stroke and stroke-related mortality among patients who experienced a significant change in monitoring compared with those with no significant change was 11.45% versus 1.75%. The sensitivity and specificity of significant changes in either SSEP or EEG to predict in-hospital major stroke and stroke-related mortality were 0.93 and 0.77, respectively. CONCLUSIONS Intraoperative neurophysiologic monitoring with SSEP and EEG has high sensitivity and specificity in predicting perioperative stroke and stroke-related mortality after open cardiac procedures. These results support the benefits of multimodality neuromonitoring during cardiac surgery.
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Ranucci M, Cotza M, Di Dedda U. The Conundrum of Systemic Arterial Pressure Management on Cardiopulmonary Bypass. J Clin Med 2023; 12:jcm12030806. [PMID: 36769463 PMCID: PMC9918189 DOI: 10.3390/jcm12030806] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
The recently released EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass (CPB) in adult cardiac surgery [...].
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Moore CC, Yu S, Aljure O. A comprehensive review of cerebral oximetry in cardiac surgery. J Card Surg 2022; 37:5418-5433. [PMID: 36423259 DOI: 10.1111/jocs.17232] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 09/03/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients who undergo cardiac surgery are at increased risk of stroke, postoperative cognitive decline, and delirium. These neurocognitive complications have led to increased costs, intensive care unit stays, morbidity, and mortality. As a result, there is a significant push to mitigate any neurological complications in cardiac surgery patients. Near-infrared spectroscopy to measure regional cerebral oxygen saturations has gained consideration due to its noninvasive and user-friendly nature. Cerebral oximetry desaturations during cardiac surgery have been linked to an array of adverse clinical outcomes. However, the most effective intraoperative interventions to protect this vulnerable patient population have yet to be ascertained. AIM OF STUDY To provide a comprehensive summary of the intraoperative management for cerebral oximetry desaturations during cardiac surgery. The review highlights clinical outcomes from cerebral oximetry use to quantify the importance of identifying cerebral desaturations during cardiac surgery. The review then interrogates possible interventions for cerebral oximetry desaturations in an effort to determine which interventions are most efficacious and to enlighten possible areas for further research. METHODS A narrative review of randomized controlled trials, observational studies, and systematic reviews with metanalyses was performed through August 2021. RESULTS There is significant heterogeneity among patient populations for which cerebral oximetry monitoring has been studied in cardiac surgery. Further, the definition of a clinically significant cerebral desaturation and the assessment of neurocognitive outcomes varied substantially across studies. As a result, metanalysis is challenging and few conclusions can be drawn. Cerebral oximetry use during cardiac surgery has not been associated with improvements in neurocognitive outcomes, morbidity, or mortality to date. The evidence to support a particular intervention for an acute desaturation is equivocal. CONCLUSIONS Future research is needed to quantify a clinically significant cerebral desaturation and to determine which interventions for an acute desaturation effectively improve clinical outcomes.
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Affiliation(s)
- Christina C Moore
- Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Oscar Aljure
- Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
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Kotani Y, Kataoka Y, Izawa J, Fujioka S, Yoshida T, Kumasawa J, Kwong JS. High versus low blood pressure targets for cardiac surgery while on cardiopulmonary bypass. Cochrane Database Syst Rev 2022; 11:CD013494. [PMID: 36448514 PMCID: PMC9709767 DOI: 10.1002/14651858.cd013494.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Cardiac surgery is performed worldwide. Most types of cardiac surgery are performed using cardiopulmonary bypass (CPB). Cardiac surgery performed with CPB is associated with morbidities. CPB needs an extracorporeal circulation that replaces the heart and lungs, and performs circulation, ventilation, and oxygenation of the blood. The lower limit of mean blood pressure to maintain blood flow to vital organs increases in people with chronic hypertension. Because people undergoing cardiac surgery commonly have chronic hypertension, we hypothesised that maintaining a relatively high blood pressure improves desirable outcomes among the people undergoing cardiac surgery with CPB. OBJECTIVES To evaluate the benefits and harms of higher versus lower blood pressure targets during cardiac surgery with CPB. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search of databases was November 2021 and trials registries in January 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing a higher blood pressure target (mean arterial pressure 65 mmHg or greater) with a lower blood pressure target (mean arterial pressure less than 65 mmHg) in adults undergoing cardiac surgery with CPB. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Primary outcomes were 1. acute kidney injury, 2. cognitive deterioration, and 3. all-cause mortality. Secondary outcomes were 4. quality of life, 5. acute ischaemic stroke, 6. haemorrhagic stroke, 7. length of hospital stay, 8. renal replacement therapy, 9. delirium, 10. perioperative transfusion of blood products, and 11. perioperative myocardial infarction. We used GRADE to assess certainty of evidence. MAIN RESULTS We included three RCTs with 737 people compared a higher blood pressure target with a lower blood pressure target during cardiac surgery with CPB. A high blood pressure target may result in little to no difference in acute kidney injury (risk ratio (RR) 1.30, 95% confidence interval (CI) 0.81 to 2.08; I² = 72%; 2 studies, 487 participants; low-certainty evidence), cognitive deterioration (RR 0.82, 95% CI 0.45 to 1.50; I² = 0%; 2 studies, 389 participants; low-certainty evidence), and all-cause mortality (RR 1.33, 95% CI 0.30 to 5.90; I² = 49%; 3 studies, 737 participants; low-certainty evidence). No study reported haemorrhagic stroke. Although a high blood pressure target may increase the length of hospital stay slightly, we found no differences between a higher and a lower blood pressure target for the other secondary outcomes. We also identified one ongoing RCT which is comparing a higher versus a lower blood pressure target among the people who undergo cardiac surgery with CPB. AUTHORS' CONCLUSIONS A high blood pressure target may result in little to no difference in patient outcomes including acute kidney injury and mortality. Given the wide CIs, further studies are needed to confirm the efficacy of a higher blood pressure target among those who undergo cardiac surgery with CPB.
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Affiliation(s)
- Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Yuki Kataoka
- Department of Internal Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, Japan
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Junichi Izawa
- Division of Critical Care Medicine, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Okinawa, Japan
- Department of Preventive Services, Kyoto University Graduate School of Public Health, Kyoto, Japan
| | - Shoko Fujioka
- Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Jikei University Kashiwa Hospital, Department of Emergency Medicine, Jikei University School of Medicine, Tokyo, Japan
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Japan
| | - Junji Kumasawa
- Department of Critical Care Medicine, Sakai City Medical Center, Sakai City, Japan
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Joey Sw Kwong
- Global Health Nursing, Graduate School of Nursing Science, St Luke's International University, Tokyo, Japan
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Tran PNT, Kusirisin P, Kaewdoungtien P, Phannajit J, Srisawat N. Higher blood pressure versus normotension targets to prevent acute kidney injury: a systematic review and meta-regression of randomized controlled trials. Crit Care 2022; 26:364. [PMID: 36434726 PMCID: PMC9700976 DOI: 10.1186/s13054-022-04236-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/10/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Renal hypoperfusion is one of the most common causes of acute kidney injury (AKI), especially in shock and perioperative patients. An optimal blood pressure (BP) target to prevent AKI remains undetermined. We conducted a systematic review and meta-analysis of available randomized clinical trial (RCT) results to address this knowledge gap. METHODS From inception to May 13, 2022, we searched Ovid Medline, EMBASE, Cochrane Library, SCOPUS, clinicaltrials.gov, and WHO ICTRP for RCTs comparing higher BP target versus normotension in hemodynamically unstable patients (shock, post-cardiac arrest, or surgery patients). The outcomes of interest were post-intervention AKI rate and renal replacement therapy (RRT) rate. Two investigators independently screened the citations and reviewed the full texts for eligible studies according to a predefined form. RESULTS Twelve trials were included, enrolling a total of 5759 participants, with shock, non-cardiac, and cardiac surgery patients accounting for 3282 (57.0%), 1687 (29.3%) and 790 (13.7%) patients, respectively. Compared to lower mean arterial blood pressure (MAP) targets that served as normotension, targeting higher MAP had no significant effect on AKI rates in shock (RR [95% CI] = 1.10 [0.93, 1.29]), in cardiac-surgery (RR [95% CI] = 0.87 [0.73, 1.03]) and non-cardiac surgery patients (RR [95% CI] = 1.25 [0.98, 1.60]) using random-effects meta-analyses. In shock patients with premorbid hypertension, however, targeting MAP above 70 mmHg resulted in significantly lower RRT risks, RR [95%CI] = 1.20 [1.03, 1.41], p < 0.05. CONCLUSIONS Targeting a higher MAP in shock or perioperative patients may not be superior to normotension, except in shock patients with premorbid hypertension. Further studies are needed to assess the effects of a high MAP target to preventing AKI in hypertensive patients across common settings of hemodynamic instability. Trial registration This systematic review has been registered on PROSPERO ( CRD42021286203 ) on November 19, 2021, prior to data extraction and analysis.
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Affiliation(s)
- Phu Nguyen Trong Tran
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.413054.70000 0004 0468 9247Department of Internal Medicine, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Cantho, Vietnam
| | - Prit Kusirisin
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.7132.70000 0000 9039 7662Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Piyanut Kaewdoungtien
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.415092.b0000 0004 0576 2645Division of Nephrology, Police General Hospital, Royal Thai Police Headquarters, Bangkok, Thailand
| | - Jeerath Phannajit
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Division of Clinical Epidemiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nattachai Srisawat
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.512985.2Academy of Science, Royal Society of Thailand, Bangkok, Thailand
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25
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Ushio M, Egi M, Fujimoto D, Obata N, Mizobuchi S. Timing, Threshold, and Duration of Intraoperative Hypotension in Cardiac Surgery: Their Associations With Postoperative Delirium. J Cardiothorac Vasc Anesth 2022; 36:4062-4069. [PMID: 35915006 DOI: 10.1053/j.jvca.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/04/2022] [Accepted: 06/15/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To study the timing, threshold, and duration of intraoperative hypotension (IOH) associated with the risk of postoperative delirium (POD). DESIGN A single-center retrospective observational study. SETTING University teaching hospital. PARTICIPANTS A total of 503 adult patients who underwent cardiac valvular surgery that required cardiopulmonary bypass (CPB). MEASUREMENTS AND MAIN RESULTS The authors predefined the following 4 periods: (1) during surgery, (2) pre-CPB, (3) during CPB, and (4) post-CPB, and 8 thresholds of mean arterial pressure for IOH according to every 5 mmHg between 50 mmHg and 85 mmHg. The authors calculated the cumulative duration below the 8 thresholds in each period. The primary outcome was delirium defined as a score of ≥4 for at least one Intensive Care Delirium Screening Checklist assessment during 48 h after the surgery. Among 503 patients, POD occurred in 95 patients (18.9%). There was no significant association of POD with all of the thresholds of IOH in the periods of pre-CPB, during CPB, and during surgery. However, in the post-CPB period, the patients with POD had a significantly longer cumulative duration of IOH according to all of the thresholds of mean arterial pressure. In multivariate analyses, 4 IOH thresholds in the post-CPB period were associated independently with POD: <60 mmHg (odds ratio [OR] =1.84 [95% CI 1.10-3.10]), <65 mmHg (OR = 1.72 [1.01-2.92]), <70 mmHg (OR = 1.83 [1.03-3.26]), and <75 mmHg (OR = 1.94 [1.02-3.69]). CONCLUSIONS A longer cumulative duration of IOH with the threshold between <60 and <75 mmHg that occurred after CPB was independently associated with the risk of POD.
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Affiliation(s)
- Masahiro Ushio
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan.
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan
| | - Daichi Fujimoto
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan
| | - Norihiko Obata
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan
| | - Satoshi Mizobuchi
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan
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26
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Olesen ND, Egesborg AH, Frederiksen HJ, Kitchen CC, Svendsen LB, Olsen NV, Secher NH. Influence of blood pressure on internal carotid artery blood flow during combined propofol-remifentanil and thoracic epidural anesthesia. J Anaesthesiol Clin Pharmacol 2022; 38:580-587. [PMID: 36778814 PMCID: PMC9912875 DOI: 10.4103/joacp.joacp_575_20] [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: 09/29/2020] [Revised: 04/14/2021] [Accepted: 05/14/2021] [Indexed: 12/31/2022] Open
Abstract
Background and Aims Anesthesia often reduces mean arterial pressure (MAP) to a level that may compromise cerebral blood flow. We evaluated whether phenylephrine treatment of anesthesia-induced hypotension affects internal carotid artery (ICA) blood flow and whether anesthesia affects ICA flow and CO2 reactivity. Material and Methods The study included twenty-seven patients (65 ± 11 years; mean ± SD) undergoing esophageal resection (n = 14), stomach resection (n = 12), or a gastroentero anastomosis (n = 1) during combined propofol-remifentanil and thoracic epidural anesthesia. Duplex ultrasound evaluated ICA blood flow. Evaluations were before and after induction of anesthesia, before and after the administration of phenylephrine as part of standard care to treat anesthesia-induced hypotension at a MAP below 60 mmHg, and the hypocapnic reactivity of ICA flow was determined before and during anesthesia. Results Induction of anesthesia reduced MAP from 108 ± 12 to 66 ± 16 mmHg (P < 0.0001) and ICA flow from 340 ± 92 to 196 ± 52 mL/min (P < 0.0001). Phenylephrine was administered to 24 patients (0.1-0.2 mg) and elevated MAP from 53 ± 8 to 73 ± 8 mmHg (P = 0.0001) and ICA flow from 191 ± 43 to 218 ± 50 mL/min (P = 0.0276). Furthermore, anesthesia reduced the hypocapnic reactivity of ICA flow from 23 (18-33) to 14%/kPa (10-22; P = 0.0068). Conclusion Combined propofol-remifentanil and thoracic epidural anesthesia affect ICA flow and CO2 reactivity. Phenylephrine partly restored ICA flow indicating that anesthesia-induced hypotension contributes to the reduction in ICA flow.
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Affiliation(s)
- Niels D. Olesen
- Department of Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen N, Denmark
| | - Astrid H. Egesborg
- Department of Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark
| | - Hans-Jørgen Frederiksen
- Department of Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark
| | - Carl-Christian Kitchen
- Department of Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark
| | - Lars B. Svendsen
- Department of Surgical Gastroenterology, Rigshospitalet, University of Copenhagen, Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark
| | - Niels V. Olsen
- Department of Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen N, Denmark
| | - Niels H. Secher
- Department of Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark
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27
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Intraoperative Blood Pressure and Long-Term Neurodevelopmental Function in Children Undergoing Ambulatory Surgery. Anesth Analg 2022; 135:787-797. [DOI: 10.1213/ane.0000000000005853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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28
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Li X, Cheng W, Zhang J, Li D, Wang F, Cui N. Early alteration of peripheral blood lymphocyte subsets as a risk factor for delirium in critically ill patients after cardiac surgery: A prospective observational study. Front Aging Neurosci 2022; 14:950188. [PMID: 36118695 PMCID: PMC9477480 DOI: 10.3389/fnagi.2022.950188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/10/2022] [Indexed: 12/01/2022] Open
Abstract
Objective There is a high incidence of delirium among patients with organ dysfunction undergoing cardiac surgery who need critical care. This study aimed to explore the risk factors for delirium in critically ill patients undergoing cardiac surgery and the predictive value of related risk factors. Methods We conducted a prospective observational study on adult critically ill patients who underwent cardiac surgery between January 2019 and August 2021. Patients were consecutively assigned to delirium and non-delirium groups. Univariate analysis and multivariate logistic analysis were used to determine the risk factors for delirium. Receiver operating characteristic curves and a nomogram were used to identify the predictive value of related risk factors. Results Delirium developed in 242 of 379 (63.9%) participants. Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores were 14.2 ± 5.6 and 18 ± 8.4, respectively. Patients with delirium had longer cardiopulmonary bypass time (149.6 ± 59.1 vs. 126.7 ± 48.5 min, p < 0.001) and aortic cross-clamp time (98.7 ± 51.5 vs. 86.1 ± 41.6 min, p = 0.010) compared with the non-delirium group. The area under the curve was 0.824 for CD4+ T cell count and 0.862 for CD4/CD8 ratio. Multivariate analysis demonstrated that age [odds ratio (OR) 1.030, p = 0.038], duration of physical restraint (OR 1.030, p < 0.001), interleukin-6 (OR 1.001, p = 0.025), CD19+ B cell count (OR 0.996, p = 0.016), CD4+ T cell count (OR 1.005, p < 0.001) and CD4/CD8 ratio (OR 5.314, p < 0.001) were independent risk factors for delirium. A nomogram revealed that age, cardiopulmonary bypass duration, CD4+ T cell count and CD4/CD8 ratio were independent predictors of delirium. Conclusion Age, duration of physical restraint, CD4+ T cell count and CD4/CD8 ratio were reliable factors for predicting delirium in critically ill patients after cardiac surgery. The receiver operating characteristic curves and nomogram suggested a potential role for CD4+ T cells in mediating potential neuroinflammation of delirium.
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Affiliation(s)
- Xiao Li
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences (CAMS), Beijing, China
| | - Wei Cheng
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences (CAMS), Beijing, China
| | - Jiahui Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences (CAMS), Beijing, China
| | - Dongkai Li
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences (CAMS), Beijing, China
| | - Fei Wang
- Department of Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences (CAMS), Beijing, China
| | - Na Cui
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences (CAMS), Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
- *Correspondence: Na Cui,
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29
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Yang X, Huang X, Li M, Jiang Y, Zhang H. Identification of individuals at risk for postoperative cognitive dysfunction (POCD). Ther Adv Neurol Disord 2022; 15:17562864221114356. [PMID: 35992893 PMCID: PMC9386869 DOI: 10.1177/17562864221114356] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 06/29/2022] [Indexed: 11/23/2022] Open
Abstract
Postoperative cognitive dysfunction (POCD) is common, occurring in around 10-54% of individuals within first few weeks after surgery. Although the majority of POCD is less commonly persistent later than 3 months following surgery, the condition increases length of stay (LOS), mortality and long-term cognitive decline, raising the need for a broad screening to identify individuals at risk for POCD during the perioperative period. In this narrative review, we summarize preoperative, intraoperative and postoperative risk factors for POCD reported in last 5 years and discuss neuropsychological tools and potential biomarkers and time points for assessment that might be suitable for clinical use. We aim to provide crucial information for developing a strategy of routine screening for POCD, which may assist with better identification of at-risk individuals for early interventions. Very importantly, the utilization of a standardized strategy may also allow higher consistency and comparability across different studies.
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Affiliation(s)
| | | | - Min Li
- Department of Rehabilitation Medicine, Shanghai Fourth People’s Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Yuan Jiang
- Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, No.278, Baoguang Avenue Middle Section, Xindu District, Chengdu 610599, China
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30
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Song Q, Li J, Jiang Z. Provisional Decision-Making for Perioperative Blood Pressure Management: A Narrative Review. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:5916040. [PMID: 35860431 PMCID: PMC9293529 DOI: 10.1155/2022/5916040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
Blood pressure (BP) is a basic determinant for organ blood flow supply. Insufficient blood supply will cause tissue hypoxia, provoke cellular oxidative stress, and to some extent lead to organ injury. Perioperative BP is labile and dynamic, and intraoperative hypotension is common. It is unclear whether there is a causal relationship between intraoperative hypotension and organ injury. However, hypotension surely compromises perfusion and causes harm to some extent. Because the harm threshold remains unknown, various guidelines for intraoperative BP management have been proposed. With the pending definitions from robust randomized trials, it is reasonable to consider observational analyses suggesting that mean arterial pressures below 65 mmHg sustained for more than 15 minutes are associated with myocardial and renal injury. Advances in machine learning and artificial intelligence may facilitate the management of hemodynamics globally, including fluid administration, rather than BP alone. The previous mounting studies concentrated on associations between BP targets and adverse complications, whereas few studies were concerned about how to treat and multiple factors for decision-making. Hence, in this narrative review, we discussed the way of BP measurement and current knowledge about baseline BP extracting for surgical patients, highlighted the decision-making process for BP management with a view to providing pragmatic guidance for BP treatment in the clinical settings, and evaluated the merits of an automated blood control system in predicting hypotension.
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Affiliation(s)
- Qiliang Song
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Jipeng Li
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Zongming Jiang
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
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31
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Vacas S, Canales C, Deiner SG, Cole DJ. Perioperative Brain Health in the Older Adult: A Patient Safety Imperative. Anesth Analg 2022; 135:316-328. [PMID: 35584550 PMCID: PMC9288500 DOI: 10.1213/ane.0000000000006090] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
While people 65 years of age and older represent 16% of the population in the United States, they account for >40% of surgical procedures performed each year. Maintaining brain health after anesthesia and surgery is not only important to our patients, but it is also an increasingly important patient safety imperative for the specialty of anesthesiology. Aging is a complex process that diminishes the reserve of every organ system and often results in a patient who is vulnerable to the stress of surgery. The brain is no exception, and many older patients present with preoperative cognitive impairment that is undiagnosed. As we age, a number of changes occur in the human brain, resulting in a patient who is less resilient to perioperative stress, making older adults more susceptible to the phenotypic expression of perioperative neurocognitive disorders. This review summarizes the current scientific and clinical understanding of perioperative neurocognitive disorders and recommends patient-centered, age-focused interventions that can better mitigate risk, prevent harm, and improve outcomes for our patients. Finally, it discusses the emerging topic of sleep and cognitive health and other future frontiers of scientific inquiry that might inform clinical best practices.
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Affiliation(s)
- Susana Vacas
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Cecilia Canales
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Stacie G Deiner
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Daniel J Cole
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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32
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McEwen CC, Amir T, Qiu Y, Young J, Kennedy K, Grocott HP, Kessani H, Mazer D, Brudney S, Kavosh M, Jacobsohn E, Vedel A, Wang E, Whitlock RP, Belley-Coté EP, Spence J. Morbidity and mortality in patients managed with high compared with low blood pressure targets during on-pump cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 2022; 69:374-386. [PMID: 35014001 DOI: 10.1007/s12630-021-02171-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Many believe that blood pressure management during cardiac surgery is associated with postoperative outcomes. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the impact of high compared with low intraoperative blood pressure targets on postoperative morbidity and mortality in adults undergoing cardiac surgery on cardiopulmonary bypass (CPB). Our primary objective was to inform the design of a future large RCT. SOURCE We searched MEDLINE, EMBASE, Web of Science, CINAHL, and CENTRAL for RCTs comparing high with low intraoperative blood pressure targets in adult patients undergoing any cardiac surgical procedure on CPB. We screened reference lists, grey literature, and conference proceedings. PRINCIPAL FINDINGS We included eight RCTs (N =1,116 participants); all examined the effect of blood pressure management only during the CPB. Trial definitions of high compared with low blood pressure varied and, in some, there was a discrepancy between the target and achieved mean arterial pressure. We observed no difference in delirium, cognitive decline, stroke, acute kidney injury, or mortality between high and low blood pressure targets (very-low to low quality evidence). Higher blood pressure targets may have increased the risk of requiring a blood transfusion (three trials; n = 456 participants; relative risk, 1.4; 95% confidence interval, 1.1 to 1.9; P = 0.01; moderate quality evidence) but this finding was based on a small number of trials. CONCLUSION Individual trial definitions of high and low blood pressure targets varied, limiting inferences. The effect of high (compared with low) blood pressure targets on other morbidity and mortality after cardiac surgery remains unclear because of limitations with the body of existing evidence. Research to determine the optimal management of blood pressure during cardiac surgery is required. STUDY REGISTRATION PROSPERO (CRD42020177376); registered: 5 July 2020.
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Affiliation(s)
- Charlotte C McEwen
- Department of Surgery (Cardiac Surgery), McMaster University, Hamilton, ON, Canada
| | - Takhliq Amir
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Yuan Qiu
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Jack Young
- Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | - Kevin Kennedy
- Department of Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Hilary P Grocott
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Hesham Kessani
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Scott Brudney
- Departments of Medicine (Critical Care) and Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Morvarid Kavosh
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Eric Jacobsohn
- Departments of Medicine (Critical Care) and Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Anne Vedel
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eugene Wang
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada.,Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada
| | - Emilie P Belley-Coté
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada.,Departments of Medicine (Cardiology and Critical Care) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jessica Spence
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada. .,Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada.
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Augoustides JG. Protecting the Central Nervous System During Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Vu T, Smith JA. An Update on Postoperative Cognitive Dysfunction Following Cardiac Surgery. Front Psychiatry 2022; 13:884907. [PMID: 35782418 PMCID: PMC9240195 DOI: 10.3389/fpsyt.2022.884907] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/23/2022] [Indexed: 12/14/2022] Open
Abstract
Postoperative cognitive dysfunction is extremely prevalent following cardiac surgery. The increasing patient age and comorbidity profile increases their susceptibility to cognitive impairment. The underlying pathophysiological mechanisms leading to cognitive impairment are not clearly elucidated. Using the contemporary literature (2015-present), this narrative review has three aims. Firstly, to provide an overview of postoperative cognitive impairment. Secondly, to analyse the predominant pathophysiological mechanisms leading to cognitive dysfunction following cardiac surgery such as inflammation, cerebral hypoperfusion, cerebral microemboli, glycaemic control and anaesthesia induced neurotoxicity. Lastly, to assess the current therapeutic strategies of interest to address these pathophysiological mechanisms, including the administration of dexamethasone, the prevention of prolonged cerebral desaturations and the monitoring of cerebral perfusion using near-infrared spectroscopy, surgical management strategies to reduce the neurological effects of microemboli, intraoperative glycaemic control strategies, the effect of volatile vs. intravenous anaesthesia, and the efficacy of dexmedetomidine.
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Affiliation(s)
- Tony Vu
- Department of Cardiothoracic Surgery, Monash Health, Melbourne, VIC, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Julian A Smith
- Department of Cardiothoracic Surgery, Monash Health, Melbourne, VIC, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
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Newman MF, Berger M, Mathew JP. Postoperative Cognitive Dysfunction and Delirium. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00042-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Miao Q, Wu DJ, Chen X, Xu M, Sun L, Guo Z, He B, Wu J. Target blood pressure management during cardiopulmonary bypass improves lactate levels after cardiac surgery: a randomized controlled trial. BMC Anesthesiol 2021; 21:309. [PMID: 34879822 PMCID: PMC8653567 DOI: 10.1186/s12871-021-01537-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 12/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background Hyperlactatemia is associated with a poor prognosis in cardiac surgery patients. This study explored the impact of target blood pressure management during cardiopulmonary bypass (CPB) on blood lactate levels after cardiac surgery. Methods Adult patients undergoing cardiac valve surgery between 20/1/2020 and 30/6/2020 at Shanghai Chest Hospital were enrolled. The patients were randomized into a low mean arterial pressure (L-MAP) group (target MAP between 50 and 60 mmHg) or a high mean arterial pressure (H-MAP) group (target MAP between 70 and 80 mmHg), n = 20 for each. Norepinephrine was titrated only during CPB to maintain MAP at the target level. Blood lactate levels in the two groups were detected before the operation (T0), at the end of CPB (T1), at the end of the operation (T2), 1 h after the operation (T3), 6 h after the operation (T4) and 24 h after the operation (T5). The primary outcome was the blood lactate level at the end of the operation (T2). The secondary outcomes included the blood lactate level at T1, T3, T4, and T5 and the dose of epinephrine and dopamine within 24 h after the operation, time to extubation, length of stay in the ICU, incidence of readmission within 30 days, and mortality within 1 year. Results Forty patents were enrolled and analyzed in the study. The lactate level in the H-MAP group was significantly lower than that in the L-MAP group at the end of the operation (3.1 [IQR 2.1, 5.0] vs. 2.1 [IQR 1.7, 2.9], P = 0.008) and at the end of CPB and 1 hour after surgery. The dose of epinephrine within 24 h after the operation, time to extubation and length of stay in the ICU in the L-MAP group were significantly higher than those in the H-MAP group. Conclusions Maintaining a relatively higher MAP during CPB deceased the blood lactate level at the end of surgery, reduced epinephrine consumption, and shortened the time to extubation and length of stay in the ICU after surgery. Trial registration This single-center, prospective, RCT has completed the registration of the Chinese Clinical Trial Center at 8/1/2020 with the registration number ChiCTR2000028941. It was conducted from 20/1/2020 to 30/6/2020 as a single, blinded trial in Shanghai Chest Hospital.
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Affiliation(s)
- Qing Miao
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China
| | - Dong Jin Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China
| | - Xu Chen
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China
| | - Meiying Xu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China
| | - Lin Sun
- Department of Cardiopulmonary Bypass, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhen Guo
- Department of Cardiopulmonary Bypass, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Bin He
- Department of Intensive Care Unit, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China.
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Targeted temperature management in cardiac surgery: a systematic review and meta-analysis on postoperative cognitive outcomes. Br J Anaesth 2021; 128:11-25. [PMID: 34862000 DOI: 10.1016/j.bja.2021.09.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Postoperative cognitive decline occurs commonly after cardiac surgery. The available literature is inconclusive on the role of intraoperative causal or protective factors. METHODS We systematically reviewed studies evaluating delayed neurocognitive recovery (DNR), postoperative neurocognitive disorder (NCD), stroke, and the mortality rates among patients undergoing hypothermic or normothermic cardiopulmonary bypass (CPB). We further performed a subgroup analysis for age, surgery type (coronary artery bypass grafting [CABG], valve surgery, or combined), and the mean arterial blood pressure (MAP) during CPB, and conducted a proportion meta-analysis after calculation of single proportions and confidence intervals (CIs). RESULTS We included a total of 58 studies with 9609 patients in our analysis. Among these, 1906 of 4010 patients (47.5%) had DNR, and 2071 of 7160 (28.9%) had postoperative NCD. Ninety of 4625 patients (2.0%) had a stroke, and 174 of 7589 (2.3%) died. There was no statistically significant relationship between the considered variables and DNR, NCD, stroke, and mortality. In the subgroup analysis comparing hypothermic with normothermic CPB, we found higher NCD rates after combined surgery; for normothermic CPB cases only, the rates of DNR and NCD were lower after combined surgery compared with CABG surgery. A MAP >70 mm Hg compared with MAP=50-70 mm Hg during CPB was associated with a lower rate of DNR. CONCLUSIONS Temperature, MAP during cardiopulmonary bypass age, and surgery type were not associated with neurocognitive disorders, stroke, and mortality in cardiac surgery. Normothermic cardiopulmonary bypass, particularly when performed with MAP >70 mm Hg, may reduce the risk of postoperative neurocognitive decline after cardiac surgery. PROSPERO REGISTRATION NUMBER CRD42019140844.
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Association between perioperative hypotension and postoperative delirium and atrial fibrillation after cardiac surgery: A post-hoc analysis of the DECADE trial. J Clin Anesth 2021; 76:110584. [PMID: 34784557 DOI: 10.1016/j.jclinane.2021.110584] [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: 05/19/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To test the hypotheses that in adults having cardiac surgery with cardio-pulmonary bypass, perioperative hypotension increases the risk of delirium and atrial fibrillation during the initial five postoperative days. DESIGN Sub-analysis of the DECADE multi-center randomized trial. SETTING Patients who had cardiac surgery with cardiopulmonary bypass at the Cleveland Clinic. INTERVENTIONS In the underlying trial, patients were randomly assigned 1:1 to dexmedetomidine or normal saline placebo. MEASUREMENTS Intraoperative mean arterial pressures were recorded at 1-min intervals from arterial catheters or at 1-5-min intervals oscillometrically. Postoperative blood pressures were recorded every half-hour or more often. The co-primary outcomes were atrial fibrillation and delirium occurring between intensive care unit admission and the earlier of postoperative day 5 or hospital discharge. Delirium was assessed twice daily during the initial 5 postoperative days while patients remained hospitalized with the Confusion Assessment Method for the intensive care unit. Assessments were made by trained research fellows who were blinded to the dexmedetomidine administration. MAIN RESULTS There was no significant association between intraoperative hypotension and delirium, with an adjusted odds ratio of 0.94 (95% CI: 0.81, 1.09; P = 0.419) for a doubling in AUC of mean arterial pressure (MAP) <60 mmHg. An increase in intraoperative AUC of MAP <60 mmHg was not significantly associated with the odds of atrial fibrillation (adjusted odds ratio = 0.99; 95% CI: 0.87, 1.11; P = 0.819). Postoperative MAP <70 mmHg per hour 1.14 (97.5% CI: 1.04,1.26; P = 0.002) and MAP <80 mmHg per hour 1.05 (97.5%: 1.01, 1.10; P = 0.010) were significantly associated with atrial fibrillation. CONCLUSIONS In patients having cardiac surgery with cardio-pulmonary bypass, neither intraoperative nor postoperative hypotension were associated with delirium. Postoperative hypotension was associated with atrial fibrillation, although intraoperative hypotension was not.
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Heterogeneous impact of hypotension on organ perfusion and outcomes: a narrative review. Br J Anaesth 2021; 127:845-861. [PMID: 34392972 DOI: 10.1016/j.bja.2021.06.048] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/08/2021] [Accepted: 06/25/2021] [Indexed: 12/20/2022] Open
Abstract
Arterial blood pressure is the driving force for organ perfusion. Although hypotension is common in acute care, there is a lack of accepted criteria for its definition. Most practitioners regard hypotension as undesirable even in situations that pose no immediate threat to life, but hypotension does not always lead to unfavourable outcomes based on experience and evidence. Thus efforts are needed to better understand the causes, consequences, and treatments of hypotension. This narrative review focuses on the heterogeneous underlying pathophysiological bases of hypotension and their impact on organ perfusion and patient outcomes. We propose the iso-pressure curve with hypotension and hypertension zones as a way to visualize changes in blood pressure. We also propose a haemodynamic pyramid and a pressure-output-resistance triangle to facilitate understanding of why hypotension can have different pathophysiological mechanisms and end-organ effects. We emphasise that hypotension does not always lead to organ hypoperfusion; to the contrary, hypotension may preserve or even increase organ perfusion depending on the relative changes in perfusion pressure and regional vascular resistance and the status of blood pressure autoregulation. Evidence from RCTs does not support the notion that a higher arterial blood pressure target always leads to improved outcomes. Management of blood pressure is not about maintaining a prespecified value, but rather involves ensuring organ perfusion without undue stress on the cardiovascular system.
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Lappalainen L, Rajamaki B, Tolppanen AM, Hartikainen S. Coronary artery revascularizations and cognitive decline - A systematic review. Curr Probl Cardiol 2021; 47:100960. [PMID: 34363848 DOI: 10.1016/j.cpcardiol.2021.100960] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 07/30/2021] [Indexed: 12/19/2022]
Abstract
Coronary artery disease (CAD) is a risk factor for cognitive decline. The aim of this study was to systematically review recent literature on whether coronary artery revascularizations are associated to cognitive decline and dementia. Pubmed, Scopus, and CINAHL (EBSCO) were searched systematically from January 2009 till September 2020. Studies were conducted on persons with CAD undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) procedure compared to other coronary artery disease treatments, and the outcome was cognitive decline or dementia. Altogether four of the 680 reviewed articles met inclusion criteria. Results were inconsistent, and the outcome measurements heterogeneous between studies. Our findings indicate an evidence gap in the current understanding of long-term outcomes following coronary artery revascularization. However, evidence of long-term effects on cognition would complement our understanding of their benefits. There is a need for more studies on long-term cognitive outcomes after coronary artery revascularizations.
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Affiliation(s)
- Laura Lappalainen
- School of Pharmacy, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland.
| | - Blair Rajamaki
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland; School of Pharmacy, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland
| | - Anna-Maija Tolppanen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland; School of Pharmacy, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland
| | - Sirpa Hartikainen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland; School of Pharmacy, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland
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Miniksar ÖH, Çiçekçioğlu F, Kılıç M, Honca M, Miniksar DY, Gocmen AY, Kaçmaz O, Öz H. Decreased brain-derived neurotrophic factor levels may predict early perioperative neurocognitive disorder in patients undergoing coronary artery bypass surgery: A prospective observational pilot study. J Clin Anesth 2021; 71:110235. [PMID: 33774438 DOI: 10.1016/j.jclinane.2021.110235] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE To determine the prognostic value of the change in intraoperative BDNF (Brain-derived neurotrophic factor) levels during cardiac surgery with cardiopulmonary bypass (CPB) on early perioperative neurocognitive disorder (PND). DESIGN Prospective observational pilot study. SETTING The study was performed in the Medical Faculty Hospital, from January 2020 to August 2020. PATIENTS 45 adult patients undergoing elective coronary artery bypass surgery (CABG) with CPB. INTERVENTIONS None. MEASUREMENTS Cognitive function was evaluated 1 day before and 4 days after the surgery. Serum BDNF levels were measured at four time points (T1: after induction; T2: with aortic cross-clamp; T3: without aortic cross-clamp; T4: 4 days after surgery) by enzyme-linked immunosorbent assay. MAIN RESULTS The incidence of PND was 37.8% four days after surgery. Serum BDNF (T2 and T4) levels were significantly lower in PND group compared to non- PND group (p = 0.003 and p = 0.016, respectively). Moreover, lactate, rSO2 (regional cerebral oxygen saturation), aortic cross-clamp time, CPB duration, and the amount of blood transfusion differed between the groups. Logistic regression analysis identified serum BDNF-T2, age, cross-clamp time, and rSO2-T2 as independent risk factors for PND. Based on the ROC analysis, the area under curve (AUC) of BDNF-T2 concentration for prediction of PND was 0.759 with sensitivity of 71.4% and specificity of 64.7% (p < 0.01). CONCLUSION Intraoperative BDNF serum levels may be a useful biomarker in predicting PND in patients undergoing CABG surgery. More comprehensive studies is needed in order to confirm the effect of decreasing intraoperative BDNF serum levels on the development of PND. TRIAL REGISTRATION NUMBER NCT04250935 www.clinicaltrials.gov.
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Affiliation(s)
- Ökkeş Hakan Miniksar
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey.
| | - Ferit Çiçekçioğlu
- Department of Cardiovascular Surgery, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Mahmut Kılıç
- Department of Public Health, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Mehtap Honca
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Dilşad Yıldız Miniksar
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Ayse Yesim Gocmen
- Department of Biochemistry, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Osman Kaçmaz
- Department of Anesthesiology and Reanimation, Malatya Training and Research Hospital, Turgut Ozal University, Malatya, Turkey
| | - Hakan Öz
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
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Xu N, Li LX, Wang TL, Jiao LQ, Hua Y, Yao DX, Wu J, Ma YH, Tian T, Sun XL. Processed Multiparameter Electroencephalogram-Guided General Anesthesia Management Can Reduce Postoperative Delirium Following Carotid Endarterectomy: A Randomized Clinical Trial. Front Neurol 2021; 12:666814. [PMID: 34322079 PMCID: PMC8311024 DOI: 10.3389/fneur.2021.666814] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 06/09/2021] [Indexed: 12/17/2022] Open
Abstract
Background: Patients undergoing carotid endarterectomy (CEA) for severe carotid stenosis are vulnerable to postoperative delirium, a complication frequently associated with poor outcome. This study investigated the impact of processed electroencephalogram (EEG)-guided anesthesia management on the incidence of postoperative delirium in patients undergoing CEA. Methods: This single-center, prospective, randomized clinical trial on 255 patients receiving CEA under general anesthesia compared the outcomes of patient state index (PSI) monitoring [SEDLine Brain Function Monitor (Masimo, Inc, Irvine, CA)] (standard group, n = 128) with PSI combined with density spectral array(DSA) -guided monitoring (intervention group, n = 127) to reduce the risk of intraoperative EEG burst suppression. All patients were monitored by continuous transcranial Doppler ultrasound (TCD) and near-infrared spectroscopy (NIRS) to avoid perioperative cerebral hypoperfusion or hyperperfusion. According to the surgical process, EEG suppression time was calculated separately for three stages: S1 (from anesthesia induction to carotid artery clamping), S2 (from clamping to declamping), and S3 (from declamping to the end of surgery). The primary outcome was incidence of postoperative delirium according to the Confusion Assessment Method algorithm during the first 3 days post-surgery, and secondary outcomes were other neurologic complications and length of hospital stay. Results: There were no episodes of cerebral hypoperfusion or hyperperfusion according to TCD and NIRS monitoring in either group during surgery. The incidence of postoperative delirium within 3 days post-surgery was significantly lower in the intervention group than the standard group (7.87 vs. 28.91%, P < 0.01). In the intervention group, the total EEG suppression time and the EEG suppression time during S2 and S3 were shorter (Total, 0 “0” vs. 0 “1.17” min, P = 0.04; S2, 0 “0” vs. 0 “0.1” min, P < 0.01; S3, 0 “0” vs. 0 “0” min, P = 0.02). There were no group differences in incidence of neurologic complications and length of postoperative hospital stay. Conclusion: Processed electroencephalogram-guided general anesthesia management, consisting of PSI combined with DSA monitoring, can significantly reduce the risk of postoperative delirium in patients undergoing CEA. Patients, especially those exhibiting hemodynamic fluctuations or receiving surgical procedures that disrupt cerebral perfusion, may benefit from the monitoring of multiple EEG parameters during surgery. Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT03622515.
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Affiliation(s)
- Na Xu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Li-Xia Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tian-Long Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Li-Qun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasound, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Dong-Xu Yao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Wu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan-Hui Ma
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tian Tian
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xue-Li Sun
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Semrau JS, Motamed M, Ross-White A, Boyd JG. Cerebral oximetry and preventing neurological complication post-cardiac surgery: a systematic review. Eur J Cardiothorac Surg 2021; 59:1144-1154. [PMID: 33517375 DOI: 10.1093/ejcts/ezaa485] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/02/2020] [Accepted: 12/09/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES This systematic review aims to provide an up-to-date summary of the current literature examining the relationship between intraoperative regional cerebral oxygen saturation and neurological complications after cardiac surgery. METHODS Observational and interventional studies investigating the link between regional cerebral oxygen saturation and postoperative delirium, cognitive dysfunction and stroke were included. After database searching and study screening, study characteristics and major findings were extracted. RESULTS Twenty-seven studies were identified. Of the observational studies (n = 17), 8 reported that regional cerebral oxygen desaturations were significantly associated with neurological complications after cardiac surgery. Of the interventional studies (n = 10), 3 provided evidence for monitoring cerebral oximetry during cardiac surgery as a means of reducing incidence of postoperative cognitive dysfunction or stroke. There was significant heterogeneity in the tools and rigor used to diagnose neurological complications. CONCLUSIONS Studies to date show an inconsistent relationship between regional cerebral oxygen saturation and neurological outcomes after cardiac surgery, and lack of clear benefit of targeting cerebral oximetry to minimize neurological complications. Standardized assessments, definitions of impairment and desaturation thresholds will help determine the benefits of cerebral oximetry monitoring during cardiac surgery.
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Affiliation(s)
- Joanna S Semrau
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Mehras Motamed
- School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | | | - J Gordon Boyd
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,Kingston Health Sciences Centre, Kingston, ON, Canada.,Department of Critical Care, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
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McIlroy DR, Roman B, Billings FT, Bollen BA, Fox A, Geube M, Liu H, Shore-Lesserson L, Zarbock A, Shaw AD. Potential Renoprotective Strategies in Adult Cardiac Surgery: A Survey of Society of Cardiovascular Anesthesiologists Members to Explore the Rationale and Beliefs Driving Current Clinical Decision-Making. J Cardiothorac Vasc Anesth 2021; 35:2043-2051. [PMID: 33674203 PMCID: PMC9933995 DOI: 10.1053/j.jvca.2021.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The authors sought to (1) characterize the rationale underpinning anesthesiologists' use of various perioperative strategies hypothesized to affect renal function in adult patients undergoing cardiac surgery, (2) characterize existing belief about the quality of evidence addressing the renal impact of these strategies, and (3) identify potentially renoprotective strategies for which anesthesiologists would most value a detailed, evidence-based review. DESIGN Survey of perioperative practice in adult patients undergoing cardiac surgery. SETTING Online survey. PARTICIPANTS Members of the Society of Cardiovascular Anesthesiologists (SCA). INTERVENTIONS None. MEASUREMENTS & MAIN RESULTS The survey was distributed to more than 2,000 SCA members and completed in whole or in part by 202 respondents. Selection of target intraoperative blood pressure (and relative hypotension avoidance) was the strategy most frequently reported to reflect belief about its potential renal effect (79%; 95% CI: 72-85). Most respondents believed the evidence supporting an effect on renal injury of intraoperative target blood pressure during cardiac surgery was of high or moderate quality. Other factors, including a specific nonrenal rationale, surgeon preference, department- or institution-level decisions, tradition, or habit, also frequently were reported to affect decision making across queried strategies. Potential renoprotective strategies most frequently requested for inclusion in a subsequent detailed, evidence-based review were intraoperative target blood pressure and choice of vasopressor agent to achieve target pressure. CONCLUSIONS A large number of perioperative strategies are believed to variably affect renal injury in adult patients undergoing cardiac surgery, with wide variation in perceived quality of evidence for a renal effect of these strategies.
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Affiliation(s)
- David R McIlroy
- Vanderbilt University Medical Center, Nashville, TN; Monash University, Commercial Road, Melbourne, Victoria, Australia.
| | - Bennett Roman
- Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121
| | | | - Bruce A Bollen
- Missoula Anesthesiology and The International Heart Institute of Montana, 500 W Broadway St, Missoula, MT 59802
| | - Amanda Fox
- UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, Tx, 75390
| | - Mariya Geube
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44122
| | - Hong Liu
- University of California Davis Health, 4150 V Street, Sacramento, CA, 95817
| | - Linda Shore-Lesserson
- Zucker School of Medicine at Hofstra Northwell, 300 Community Drive, Manhasset, NY, 11030
| | | | - Andrew D Shaw
- University of Alberta, 8440-112 Street NW, Edmonton, AB, T6G 2G3, Canada
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Wahba A, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Puis L. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Eur J Cardiothorac Surg 2021; 57:210-251. [PMID: 31576396 DOI: 10.1093/ejcts/ezz267] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav's University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
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Vedel AG, Holmgaard F, Danielsen ER, Langkilde A, Paulson OB, Ravn HB, Rasmussen LS, Nilsson JC. Blood pressure and brain injury in cardiac surgery: a secondary analysis of a randomized trial. Eur J Cardiothorac Surg 2021; 58:1035-1044. [PMID: 32840297 DOI: 10.1093/ejcts/ezaa216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/27/2020] [Accepted: 05/14/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Brain dysfunction is a serious complication after cardiac surgery. In the Perfusion Pressure Cerebral Infarcts trial, we allocated cardiac surgery patients to a mean arterial pressure of either 70-80 or 40-50 mmHg during cardiopulmonary bypass (CPB). In this secondary analysis, we compared selected cerebral metabolites using magnetic resonance spectroscopy hypothesizing that a postoperative decrease in occipital grey matter (GM) N-acetylaspartate-to-total-creatine ratio, indicative of ischaemic injury, would be found in the high-target group. METHODS Of the 197 patients randomized in the Perfusion Pressure Cerebral Infarcts trial, 55 and 42 patients had complete and useful data from GM and white matter (WM), respectively. Spectroscopies were done preoperatively and on postoperative days 3-6. Cognitive function was assessed prior to surgery, at discharge and at 3 months. We predefined the statistical significance level to be 0.01. RESULTS A postoperative decrease was found in GM N-acetylaspartate-to-total-creatine ratio in the high-target group [mean difference -0.09 (95% confidence interval -0.14 to -0.04), P = 0.014]. No significant differences were found in other metabolite ratios investigated in GM or WM. No significant association was found between changes in metabolite ratios and new cerebral infarcts, WM lesion score or cognitive dysfunction. CONCLUSIONS A higher mean arterial pressure during CPB was associated with signs of impaired cerebral metabolism, though not at the predefined significance level of 0.01. No significant association was found between metabolite ratio changes and neuroradiological pathology or change in cognitive function. CLINICAL TRIAL REGISTRATION NUMBER Clinicaltrials.gov: NCT02185885.
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Affiliation(s)
- Anne G Vedel
- D epartment of Cardiothoracic Anaesthesiology, Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,D epartment of Anaesthesia, Center of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Frederik Holmgaard
- D epartment of Cardiothoracic Anaesthesiology, Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Else R Danielsen
- D epartment of Radiology, Diagnostic Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Annika Langkilde
- D epartment of Radiology, Diagnostic Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Olaf B Paulson
- Neurobiology Research Unit, Neuroscience Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hanne B Ravn
- D epartment of Cardiothoracic Anaesthesiology, Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars S Rasmussen
- D epartment of Anaesthesia, Center of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens C Nilsson
- D epartment of Cardiothoracic Anaesthesiology, Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Abstract
Neurological complications after cardiac surgery and percutaneous cardiac interventions are not uncommon. These include periprocedural stroke, postoperative cognitive dysfunction after cardiac surgery, contrast-induced encephalopathy after percutaneous interventions, and seizures. In this article, we review the incidence, pathophysiology, diagnosis, and management of these complications. Improved understanding of these complications could lead to their prevention, faster detection, and facilitation of diagnostic workup and appropriate treatment.
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Affiliation(s)
| | - Jeffrey Wang
- Division of Neurology, Department of Medicine, University of Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Magdy Selim
- Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Lomivorotov VV, Moroz G, Abubakirov M, Osinsky R, Landoni G. Volatile and Intravenous Anesthetics for Brain Protection in Cardiac Surgery: Does the Choice of Anesthesia Matter? J Cardiothorac Vasc Anesth 2021; 36:567-576. [PMID: 33766470 DOI: 10.1053/j.jvca.2021.02.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/11/2022]
Abstract
Postoperative neurologic complications have a significant effect on morbidity, mortality, and long-term disability in patients undergoing cardiac surgery. The etiology of brain injury in patients undergoing cardiac surgery is multifactorial and remains unclear. There are several perioperative causative factors for neurologic complications, including microembolization, hypoperfusion, and systemic inflammatory response syndrome. Despite technologic advances and the development of new anesthetic drugs, there remains a high rate of postoperative neurologic complications. Moreover, despite the strong evidence that volatile anesthesia exerts cardioprotective effects in patients undergoing cardiac surgery, the neuroprotective effects of volatile agents remain unclear. Several studies have reported an association of using volatile anesthetics with improvement of biochemical markers of brain injury and postoperative neurocognitive function. However, there is a need for additional studies to define the optimal anesthetic drug for protecting the brain in patients undergoing cardiac surgery.
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Affiliation(s)
- Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia; Department of Anesthesiology and Intensive Care, Novosibirsk State University, Novosibirsk, Russia.
| | - Gleb Moroz
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Marat Abubakirov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Roman Osinsky
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Giovanni Landoni
- Anesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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Wiberg S, Holmgaard F, Blennow K, Nilsson JC, Kjaergaard J, Wanscher M, Langkilde AR, Hassager C, Rasmussen LS, Zetterberg H, Vedel AG. Associations between mean arterial pressure during cardiopulmonary bypass and biomarkers of cerebral injury in patients undergoing cardiac surgery: secondary results from a randomized controlled trial. Interact Cardiovasc Thorac Surg 2021; 32:229-235. [PMID: 33221914 PMCID: PMC8906782 DOI: 10.1093/icvts/ivaa264] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/15/2020] [Accepted: 10/04/2020] [Indexed: 08/26/2023] Open
Abstract
OBJECTIVES Cardiac surgery is associated with risk of cerebral injury and mean arterial pressure (MAP) during cardiopulmonary bypass (CPB) is suggested to be associated with cerebral injury. The 'Perfusion Pressure Cerebral Infarcts' (PPCI) trial randomized patients undergoing coronary artery bypass grafting (CABG) and/or aortic valve replacement to a MAP of 40-50 or 70-80 mmHg during CPB and found no difference in clinical or imaging outcomes between the groups. We here present PPCI trial predefined secondary end points, consisting of biomarkers of brain injury. METHODS Blood was collected from PPCI trial patients at baseline, 24 and 48 h after induction of anaesthesia and at discharge from the surgical ward. Blood was analysed for neuron-specific enolase, tau, neurofilament light and the glial marker glial fibrillary acidic protein. Linear mixed models were used to analyse differences in biomarker value changes from baseline between the 2 MAP allocation groups. RESULTS A total of 193 (98%) patients were included. We found no differences in biomarker levels over time from baseline to discharge between the 2 MAP allocation groups (PNSE = 0.14, PTau = 0.46, PNFL = 0.21, PGFAP = 0.13) and the result did not change after adjustment for age, sex and type of surgery. CONCLUSIONS We found no significant differences in levels of biomarkers of neurological injury in patients undergoing elective or subacute CABG and/or aortic valve replacement randomized to either a target MAP of 40-50 mmHg or a target MAP of 70-80 mmHg during CBP.
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Affiliation(s)
- Sebastian Wiberg
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Frederik Holmgaard
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Jens C Nilsson
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Michael Wanscher
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Annika R Langkilde
- Department of Radiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars S Rasmussen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anesthesia, Center of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
- UK Dementia Research Institute at UCL, London, UK
| | - Anne Grønborg Vedel
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Postoperative Neurocognitive Disorders in Cardiac Surgery: Investigating the Role of Intraoperative Hypotension. A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18020786. [PMID: 33477713 PMCID: PMC7831914 DOI: 10.3390/ijerph18020786] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/09/2021] [Accepted: 01/15/2021] [Indexed: 12/19/2022]
Abstract
Perioperative neurocognitive disorders remain a challenging obstacle in patients after cardiac surgery, as they significantly contribute to postoperative morbidity and mortality. Identifying the modifiable risk factors and mechanisms for postoperative cognitive decline (POCD) and delirium (POD) would be an important step forward in preventing such adverse events and thus improving patients’ outcome. Intraoperative hypotension is frequently discussed as a potential risk factor for neurocognitive decline, due to its significant impact on blood flow and tissue perfusion, however the studies exploring its association with POCD and POD are very heterogeneous and present divergent results. This review demonstrates 13 studies found after structured systematic search strategy and discusses the possible relationship between intraoperative hypotension and postoperative neuropsychiatric dysfunction.
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