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Gilbey T, Milne B, de Somer F, Kunst G. Neurologic complications after cardiopulmonary bypass - A narrative review. Perfusion 2023; 38:1545-1559. [PMID: 35986553 PMCID: PMC10612382 DOI: 10.1177/02676591221119312] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
Neurologic complications, associated with cardiac surgery and cardiopulmonary bypass (CPB) in adults, are common and can be devastating in some cases. This comprehensive review will not only consider the broad categories of stroke and neurocognitive dysfunction, but it also summarises other neurological complications associated with CPB, and it provides an update about risks, prevention and treatment. Where appropriate, we consider the impact of off-pump techniques upon our understanding of the contribution of CPB to adverse outcomes.
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Affiliation(s)
- Tom Gilbey
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Benjamin Milne
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Filip de Somer
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Gudrun Kunst
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, Faculty of Life Sciences and Medicine, King’s College London British Heart Foundation Centre of Excellence, London, UK
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Wu H, Zhuang Y, Wu W, Huang J, Huang H, Wang L. Post-operative cognitive dysfunction in patients following gastrointestinal endoscopic treatment. APPLIED NEUROPSYCHOLOGY. ADULT 2023:1-6. [PMID: 36657421 DOI: 10.1080/23279095.2023.2168543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
We aimed to explore the changes in post-operative cognitive dysfunction (POCD) after gastrointestinal endoscopic treatment using detailed neuropsychological assessments. Patients hospitalized for gastrointestinal endoscopic polypectomy were recruited for neuropsychological evaluations, which included the Chinese version of the Mini-Mental State Examination (MMSE), Auditory-Verbal Learning Test, Digit Span Test (DST), Trail Making Task (TMT), Verbal Fluency Test, Clock Drawing Test, and Stroop test. Cognitive assessments were performed twice: one day before and 24 h after treatment. Healthy control subjects participated in the neuropsychological assessment during the same intervals. Detailed cognitive assessments were performed for 40 patients and 60 control subjects. Based on the Z scores, the incidence of POCD 24 h after gastrointestinal endoscopic treatment was 20%. Patients with POCD had significant impairment in the post-operative MMSE, forward DST, TMT, and Stroop interference effect correct count tests (all p < 0.05). Our preliminary results showed that patients were not fully recovered, and 20% had impairment in multiple cognitive assessments 24 h after a gastrointestinal endoscopy. As attention was affected, safety while discharging those patients should be a concern.
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Affiliation(s)
- Haining Wu
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
- Department of Neurology, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, Fujian, China
| | - Yingying Zhuang
- Department of Gastroenterology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Weiqi Wu
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Junying Huang
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Honghong Huang
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Lingxing Wang
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
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3
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Réhabilitation améliorée après chirurgie cardiaque adulte sous CEC ou à cœur battant 2021. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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4
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Mertes PM, Kindo M, Amour J, Baufreton C, Camilleri L, Caus T, Chatel D, Cholley B, Curtil A, Grimaud JP, Houel R, Kattou F, Fellahi JL, Guidon C, Guinot PG, Lebreton G, Marguerite S, Ouattara A, Provenchère Fruithiot S, Rozec B, Verhoye JP, Vincentelli A, Charbonneau H. Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump. Anaesth Crit Care Pain Med 2022; 41:101059. [PMID: 35504126 DOI: 10.1016/j.accpm.2022.101059] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay. DESIGN A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence. METHODS Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method. RESULTS The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions. CONCLUSIONS Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.
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Affiliation(s)
- Paul-Michel Mertes
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Michel Kindo
- Department of Cardiac Surgery, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Julien Amour
- Institut de Perfusion, de Réanimation, d'Anesthésie de Chirurgie Cardiaque Paris Sud, IPRA, Hôpital Privé Jacques Cartier, Massy, France
| | - Christophe Baufreton
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France; MITOVASC Institute CNRS UMR 6214, INSERM U1083, University, Angers, France
| | - Lionel Camilleri
- Department of Cardiovascular Surgery, CHU Clermont-Ferrand, T.G.I, I.P., CNRS, SIGMA, UCA, UMR 6602, Clermont-Ferrand, France
| | - Thierry Caus
- Department of Cardiac Surgery, UPJV, Amiens University Hospital, Amiens Picardy University Hospital, Amiens, France
| | - Didier Chatel
- Department of Cardiac Surgery (D.C.), Institut du Coeur Saint-Gatien, Nouvelle Clinique Tours Plus, Tours, France
| | - Bernard Cholley
- Anaesthesiology and Intensive Care Medicine, Hôpital Européen Georges-Pompidou, AP-HP, Université de Paris, INSERM, IThEM, Paris, France
| | - Alain Curtil
- Department of Cardiac Surgery, Clinique de la Sauvegarde, Lyon, France
| | | | - Rémi Houel
- Department of Cardiac Surgery, Saint Joseph Hospital, Marseille, France
| | - Fehmi Kattou
- Department of Anaesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, Lyon, France; Faculté de Médecine Lyon Est, Université Claude-Bernard Lyon 1, Lyon, France
| | - Catherine Guidon
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Intensive Care, Dijon University Hospital, Dijon, France; University of Bourgogne and Franche-Comté, LNC UMR1231, Dijon, France; INSERM, LNC UMR1231, Dijon, France; FCS Bourgogne-Franche Comté, LipSTIC LabEx, Dijon, France
| | - Guillaume Lebreton
- Sorbonne Université, INSERM, Unité mixte de recherche CardioMetabolisme et Nutrition, ICAN, AP-HP, Hôpital Pitié-Salpétrière, Paris, France
| | - Sandrine Marguerite
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Alexandre Ouattara
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, F-33000 Bordeaux, France; Univ. Bordeaux, INSERM, UMR 1034, Biology of Cardiovascular Diseases, F-33600 Pessac, France
| | - Sophie Provenchère Fruithiot
- Department of Anaesthesia, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France; Centre d'Investigation Clinique 1425, INSERM, Université de Paris, Paris, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laennec, CHU Nantes, Nantes, France; Université de Nantes, CHU Nantes, CNRS, INSERM, Institut duDu Thorax, Nantes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - André Vincentelli
- Department of Cardiac Surgery, University of Lille, CHU Lille, Lille, France
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Effectiveness of Mild to Moderate Hypothermic Cardiopulmonary Bypass on Early Clinical Outcomes. J Cardiovasc Dev Dis 2022; 9:jcdd9050151. [PMID: 35621862 PMCID: PMC9145413 DOI: 10.3390/jcdd9050151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/20/2022] [Accepted: 05/06/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Intraoperative hypothermia is an integral part of cardiopulmonary bypass (CPB), and a precise degree of hypothermia may improve the early clinical outcomes of cardiac surgery. Presently, there is no agreement on an accurate, advantageous temperature range for routine use in CPB. To address this issue, we conducted a retrospective observational study to compare the effects of different hypothermic temperature ranges on primary (inotropic support, blood loss, and platelet count) and secondary (ventilation support and in-hospital stay) outcomes in patients undergoing elective cardiac surgery. Methods: Data were retrieved from the medical database of the Cardiovascular Surgery Department, King Edward Medical University, Lahore-Pakistan (a tertiary care hospital), dating from February 2015 to December 2017. Patients were divided into mild (34 °C to 36 °C), intermediate (31 °C to 33 °C), or moderate (28 °C to 30 °C) hypothermic groups. Results: Out of 275 patients, 245 (89.09%) fit the inclusion criteria. The cohort with mild hypothermic CPB temperatures presented better clinical outcomes in terms of requiring less inotropic support, less blood loss, fewer blood transfusions, improved platelet counts, shorter in-hospital stays, and required less ventilation support, when compared with other hypothermic groups. Conclusions: Mild hypothermic CPB (34 °C to 36 °C) may produce better clinical outcomes for cardiac surgery and improve the quality of health of cardiac patients.
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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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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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Tsaousi G, Tramontana A, Yamani F, Bilotta F. Cerebral Perfusion and Brain Oxygen Saturation Monitoring with: Jugular Venous Oxygen Saturation, Cerebral Oximetry, and Transcranial Doppler Ultrasonography. Anesthesiol Clin 2021; 39:507-523. [PMID: 34392882 DOI: 10.1016/j.anclin.2021.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Accumulating evidence indicates that cerebral desaturation in the perioperative period occurs more frequently than recognized. Combining monitoring modalities that reflect different aspects of cerebral perfusion status, such as near-infrared spectroscopy, jugular bulb saturation, and transcranial Doppler ultrasonography, may provide an extended window for prevention, early detection, and prompt intervention in ongoing hypoxic/ischemic neuronal injury and, thereby, improve neurologic outcome. Such an approach would minimize the impact of limitations of each monitoring modality, while individual components complement each other, enhancing the accuracy of acquired information. Current literature has failed to demonstrate any clear-cut clinical benefit of these modalities on outcome prognosis.
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Affiliation(s)
- Georgia Tsaousi
- Department of Anesthesiology and ICU, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece
| | - Alessio Tramontana
- Department of Anesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I, "Sapienza" University of Rome, viale del Policlinico 151, 00185 Rome, Italy
| | - Farouk Yamani
- Department of Anesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I, "Sapienza" University of Rome, viale del Policlinico 151, 00185 Rome, Italy
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I, "Sapienza" University of Rome, viale del Policlinico 151, 00185 Rome, Italy.
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Saczkowski R, Kuzak N, Grunau B, Schulze C. Extracorporeal life support rewarming rate is associated with survival with good neurological outcome in accidental hypothermia. Eur J Cardiothorac Surg 2021; 59:593-600. [PMID: 33230533 DOI: 10.1093/ejcts/ezaa385] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Favourable outcomes have been demonstrated after extracorporeal life support (ECLS) facilitated rewarming for severe accidental hypothermia. The clinical impact of varying rewarming rates however is unclear. We sought to quantify the change in the probability of good neurological outcome with ECLS rewarming rate and identify the optimal rewarming rate threshold. METHODS We performed a secondary analysis of the International ACcidental Hypothermia Extracorporeal Life Support Collaborators, an individual patient data data set (n = 658) for ECLS-assisted rewarming for accidental hypothermia. The independent variable of interest was rewarming rate. The primary outcome was survival with good neurological status. We applied an adjusted marginal effects model to quantify the probability of good neurological outcome over clinically observed rewarming rates. We examined strata defined by sex, initial potassium level and history of asphyxiation. RESULTS Of 658 cases, the median age and initial core temperature were 36 years (22-55) and 24.5°C (22.1-26.2) respectively; 190 (29%) were female, and 547 (83%) had a non-perfusing initial cardiac rhythm. The mean rewarming rate was 7.0°C/h. The median ECLS duration was 5.8 h (range: 0.5-158 h). The overall survival was 46% (n = 303/658), and good neurological outcome was 40% (n = 265/658). The median intensive care unit and hospital length of stay was 5 days (range: 1-35 days) and 18 days (range: 1-106 days), respectively. Marginal effects analysis demonstrated a 1.9% decrease in the probability of survival with good neurological outcome for each 1°C/h increase in rewarming. Across the reported range of rewarming rates (0.05-30.8°C/h), the probability of good neurological outcome declined from 49.6% to 4.1% for an average patient. The relationship was similar within various subgroups. The optimal cut-off threshold for the rate of rewarming to distinguish between a good and poor neurological outcome was ≤5.0°C/h. CONCLUSIONS Among cases with severe accidental hypothermia treated with ECLS, slower rewarming rates are associated with improved survival with good neurological outcomes. Slow rewarming, at rates ≤5.0°C/h, may improve clinical outcomes.
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Affiliation(s)
- Richard Saczkowski
- Department of Cardiac Sciences, Division of Cardiac Surgery, Kelowna General Hospital, Kelowna, British Columbia, Canada
| | - Nick Kuzak
- Division of Cardiac Anaesthesia, Kelowna General Hospital, Kelowna, BC, Canada.,University of British Columbia, Department of Anesthesiology, Kelowna, BC, Canada.,Department of Emergency Medicine, Kelowna General Hospital, Kelowna, BC, Canada
| | - Brian Grunau
- Department of Emergency Medicine, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Costas Schulze
- Department of Cardiac Sciences, Division of Cardiac Surgery, Kelowna General Hospital, Kelowna, British Columbia, Canada.,Department of Critical Care Medicine, Kelowna General Hospital, Kelowna, BC, Canada
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Observational study of long-term persistent elevation of neurodegeneration markers after cardiac surgery. Sci Rep 2019; 9:7177. [PMID: 31073130 PMCID: PMC6509119 DOI: 10.1038/s41598-019-42351-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/11/2019] [Indexed: 12/17/2022] Open
Abstract
Surgery and anesthesia induce inflammatory changes in the central nervous system, which ultimately lead to neuronal damage concomitant with an increase in the level of neurodegeneration markers. Despite some experimental data showing prolonged activation of the immune system post-surgery, no study has determined the extent of long-term elevation of neurodegeneration markers. The purpose of this study was to investigate the serum levels of tau protein, ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1), neurofilament light (NF-L), and glial fibrillary acidic protein (GFAP) after elective cardiac surgery with the implementation of cardiopulmonary bypass (CPB). The serum levels of these markers from 30 patients were compared longitudinally to the baseline (pre-surgery or t0), at 24 hours (t+24), at 7 days (t+7d), and at 3 months (t+3m). The secondary outcome was the production of macrophage-colony stimulating factor (M-CSF) and tumor necrosis factor-α (TNF-α) in vitro by isolated monocytes in response to lipopolysaccharide (LPS) as the measure of immune system activation. The tertiary outcome was the serum level of C-reactive protein (CRP), serum amyloid P (SAP), and α-2-macroglobulin (A2M). Serum levels of tau protein increased 24 hours after surgery (p = 0.0015) and remained elevated at 7 days (p = 0.0017) and three months (p = 0.036). Serum levels of UCH-L1 peaked at 24 hours (p = 0.00055) and normalized at 3 months. In vitro secretion of M-CSF by LPS-stimulated peripheral monocytes, but not TNFα, correlated highly (r = 0.58; p = 0.04) with persistent elevation of serum tau levels at 3 months. The serum CRP and SAP increases correlated with tau post-CPB levels significantly at 3 months. We demonstrated that elevation of serum tau levels at 24 hours, 7 days, and 3 months after heart surgery is concomitant with some traits of inflammation after CPB. The elevation of tau several weeks into recovery is significantly longer than expected.
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Shaban A, Leira EC. Neurological Complications of Cardiological Interventions. Curr Neurol Neurosci Rep 2019; 19:6. [DOI: 10.1007/s11910-019-0923-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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12
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The influence of prolonged intensive care stay on quality of life, recovery, and clinical outcomes following cardiac surgery: A prospective cohort study. J Thorac Cardiovasc Surg 2018; 156:1906-1915.e3. [DOI: 10.1016/j.jtcvs.2018.05.076] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 05/05/2018] [Accepted: 05/07/2018] [Indexed: 11/22/2022]
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Berger M, Terrando N, Smith SK, Browndyke JN, Newman MF, Mathew JP. Neurocognitive Function after Cardiac Surgery: From Phenotypes to Mechanisms. Anesthesiology 2018; 129:829-851. [PMID: 29621031 PMCID: PMC6148379 DOI: 10.1097/aln.0000000000002194] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
For half a century, it has been known that some patients experience neurocognitive dysfunction after cardiac surgery; however, defining its incidence, course, and causes remains challenging and controversial. Various terms have been used to describe neurocognitive dysfunction at different times after cardiac surgery, ranging from "postoperative delirium" to "postoperative cognitive dysfunction or decline." Delirium is a clinical diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Postoperative cognitive dysfunction is not included in the DSM-5 and has been heterogeneously defined, though a recent international nomenclature effort has proposed standardized definitions for it. Here, the authors discuss pathophysiologic mechanisms that may underlie these complications, review the literature on methods to prevent them, and discuss novel approaches to understand their etiology that may lead to novel treatment strategies. Future studies should measure both delirium and postoperative cognitive dysfunction to help clarify the relationship between these important postoperative complications.
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Affiliation(s)
- Miles Berger
- Assistant Professor, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Niccolò Terrando
- Assistant Professor, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - S. Kendall Smith
- Critical Care Fellow, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Jeffrey N. Browndyke
- Assistant Professor, Division of Geriatric Behavioral Health, Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Mark F. Newman
- Merel H. Harmel Professor of Anesthesiology, and President of the Private Diagnostic Clinic, Duke University Medical Center, Durham, NC
| | - Joseph P. Mathew
- Jerry Reves, MD Professor and Chair, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Bhamidipati D, Goldhammer JE, Sperling MR, Torjman MC, McCarey MM, Whellan DJ. Cognitive Outcomes After Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2017; 31:707-718. [DOI: 10.1053/j.jvca.2016.09.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Indexed: 12/17/2022]
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Bhalala US, Appachi E, Mumtaz MA. Neurologic Injury Associated with Rewarming from Hypothermia: Is Mild Hypothermia on Bypass Better than Deep Hypothermic Circulatory Arrest? Front Pediatr 2016; 4:104. [PMID: 27734011 PMCID: PMC5039167 DOI: 10.3389/fped.2016.00104] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 09/07/2016] [Indexed: 11/13/2022] Open
Abstract
Many known risk factors for adverse cardiovascular and neurological outcomes in children with congenital heart defects (CHD) are not modifiable; however, the temperature and blood flow during cardiopulmonary bypass (CPB), are two risk factors, which may be altered in an attempt to improve long-term neurological outcomes. Deep hypothermic circulatory arrest, traditionally used for aortic arch repair, has been associated with short-term and long-term neurologic sequelae. Therefore, there is a rising interest in using moderate hypothermia with selective antegrade cerebral blood flow on CPB during aortic arch repair. Rewarming from moderate-to-deep hypothermia has been shown to be associated with neuronal injury, neuroinflammation, and loss of cerebrovascular autoregulation. A significantly lesser degree of rewarming is required following mild (33-35°C) hypothermia as compared with moderate (28-32°C), deep (21-27°C), and profound (less than 20°C) hypothermia. Therefore, we believe that mild hypothermia is associated with a lower risk of rewarming-induced neurologic injury. We hypothesize that mild hypothermia with selective antegrade cerebral perfusion during CPB for neonatal aortic arch repair would be associated with improved neurologic outcome.
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Affiliation(s)
- Utpal S Bhalala
- Children's Hospital of San Antonio, Baylor College of Medicine , San Antonio, TX , USA
| | - Elumalai Appachi
- Children's Hospital of San Antonio, Baylor College of Medicine , San Antonio, TX , USA
| | - Muhammad Ali Mumtaz
- Children's Hospital of San Antonio, Baylor College of Medicine , San Antonio, TX , USA
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Wang CH, Chen NC, Tsai MS, Yu PH, Wang AY, Chang WT, Huang CH, Chen WJ. Therapeutic Hypothermia and the Risk of Hemorrhage: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Medicine (Baltimore) 2015; 94:e2152. [PMID: 26632746 PMCID: PMC5059015 DOI: 10.1097/md.0000000000002152] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Current guidelines recommend a period of moderate therapeutic hypothermia (TH) for comatose patients after cardiac arrest to improve clinical outcomes. However, in-vitro studies have reported platelet dysfunction, thrombocytopenia, and coagulopathy, results that might discourage clinicians from applying TH in clinical practice. We aimed to quantify the risks of hemorrhage observed in clinical studies.Medline and Embase were searched from inception to October 2015.Randomized controlled trials (RCTs) comparing patients undergoing TH with controls were selected, irrespective of the indications for TH. There were no restrictions for language, population, or publication year.Data on study characteristics, which included patients, details of intervention, and outcome measures, were extracted.Forty-three trials that included 7528 patients were identified from 2692 potentially relevant references. Any hemorrhage was designated as the primary outcome and was reported in 28 studies. The pooled results showed no significant increase in hemorrhage risk associated with TH (risk difference [RD] 0.005; 95% confidence interval [CI] -0.001-0.011; I, 0%). Among secondary outcomes, patients undergoing TH were found to have increased risk of thrombocytopenia (RD 0.109; 95% CI 0.038-0.179; I 57.3%) and transfusion requirements (RD 0.021; 95% CI 0.003-0.040; I 0%). The meta-regression analysis indicated that prolonged duration of cooling may be associated with increased risk of hemorrhage.TH was not associated with increased risk of hemorrhage despite the increased risk of thrombocytopenia and transfusion requirements. Clinicians should cautiously assess each patient's risk-benefit profile before applying TH.
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Affiliation(s)
- Chih-Hung Wang
- From the Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Douliu City, Yunlin County (C-HW), Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Zhongzheng Dist., Taipei City (C-HW), Department of Emergency Medicine, Tao Yuan General Hospital, Ministry of Health and Welfare, Taoyuan Dist, Taoyuan City (N-CC), Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Zhongzheng Dist., Taipei City (M-ST, A-YW, W-TC, C-HH, W-JC), Department of Emergency Medicine, Taipei Hospital, Ministry of Health and Welfare, Xinzhuang Dist., New Taipei City (P-HY); and Department of Emergency Medicine, Lotung Poh-Ai Hospital, Luodong Township, Yilan County, Taiwan (R.O.C.) (W-JC)
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Risk Factors Associated with Cognitive Decline after Cardiac Surgery: A Systematic Review. Cardiovasc Psychiatry Neurol 2015; 2015:370612. [PMID: 26491558 PMCID: PMC4605208 DOI: 10.1155/2015/370612] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 09/15/2015] [Indexed: 12/20/2022] Open
Abstract
Modern day cardiac surgery evolved upon the advent of cardiopulmonary bypass machines (CPB) in the 1950s. Following this development, cardiac surgery in recent years has improved significantly. Despite such advances and the introduction of new technologies, neurological sequelae after cardiac surgery still exist. Ischaemic stroke, delirium, and cognitive impairment cause significant morbidity and mortality and unfortunately remain common complications. Postoperative cognitive decline (POCD) is believed to be associated with the presence of new ischaemic lesions originating from emboli entering the cerebral circulation during surgery. Cardiopulmonary bypass was thought to be the reason of POCD, but randomised controlled trials comparing with off-pump surgery show contradictory results. Attention has now turned to the growing evidence that perioperative risk factors, as well as patient-related risk factors, play an important role in early and late POCD. Clearly, identifying the mechanism of POCD is challenging. The purpose of this systematic review is to discuss the literature that has investigated patient and perioperative risk factors to better understand the magnitude of the risk factors associated with POCD after cardiac surgery.
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Ramakrishna H, Gutsche JT, Evans AS, Patel PA, Weiner M, Morozowich ST, Gordon EK, Riha H, Shah R, Ghadimi K, Zhou E, Fernadno R, Yoon J, Wakim M, Atchley L, Weiss SJ, Stein E, Silvay G, Augoustides JGT. The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2015. J Cardiothorac Vasc Anesth 2015; 30:1-9. [PMID: 26847747 DOI: 10.1053/j.jvca.2015.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Indexed: 12/14/2022]
Affiliation(s)
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adam S Evans
- Icahn School of Medicine, Mount Sinai Hospital, New York, NY
| | - Prakash A Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Menachem Weiner
- Icahn School of Medicine, Mount Sinai Hospital, New York, NY
| | | | - Emily K Gordon
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Hynek Riha
- Department of Anesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ronak Shah
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kamrouz Ghadimi
- Department of Anesthesiology and Critical Care, Duke University, Durham, NC
| | - Elizabeth Zhou
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rohesh Fernadno
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jeongae Yoon
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mathew Wakim
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lance Atchley
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stuart J Weiss
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Erica Stein
- Department of Anesthesiology, Ohio State University, Columbus, OH
| | - George Silvay
- Icahn School of Medicine, Mount Sinai Hospital, New York, NY
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Otto KA. Therapeutic hypothermia applicable to cardiac surgery. Vet Anaesth Analg 2015; 42:559-69. [PMID: 26361886 DOI: 10.1111/vaa.12299] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 03/19/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To review the beneficial and adverse effects of therapeutic hypothermia (TH) applicable to cardiac surgery with cardiopulmonary bypass (CPB) in the contexts of various temperature levels and techniques for achieving TH. DATABASES USED Multiple electronic literature searches were performed using PubMed and Google for articles published from June 2012 to December 2014. Relevant terms (e.g. 'hypothermia', 'cardiopulmonary bypass', 'cardiac surgery', 'neuroprotection') were used to search for original articles, letters and reviews without species limitation. Reviews were included despite potential publication bias. References from the studies identified were also searched to find other potentially relevant citations. Abstracts, case reports, conference presentations, editorials and expert opinions were excluded. CONCLUSIONS Therapeutic hypothermia is an essential measure of neuroprotection during cardiac surgery that may be achieved most effectively by intravascular cooling using hypothermic CPB. For most cardiac surgical procedures, mild to modest (32-36 °C) TH will be sufficient to assure neuroprotection and will avoid most of the adverse effects of hypothermia that occur at lower body core temperatures.
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Affiliation(s)
- Klaus A Otto
- Central Laboratory Animal Facility, Hannover Medical School, Hannover, Germany
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Engelman R, Baker RA, Likosky DS, Grigore A, Dickinson TA, Shore-Lesserson L, Hammon JW. The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines for Cardiopulmonary Bypass—Temperature Management During Cardiopulmonary Bypass. Ann Thorac Surg 2015; 100:748-57. [DOI: 10.1016/j.athoracsur.2015.03.126] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 03/25/2015] [Accepted: 03/27/2015] [Indexed: 11/29/2022]
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Engelman R, Baker RA, Likosky DS, Grigore A, Dickinson TA, Shore-Lesserson L, Hammon JW. The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines for Cardiopulmonary Bypass—Temperature Management During Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2015; 29:1104-13. [DOI: 10.1053/j.jvca.2015.07.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Fink HA, Hemmy LS, MacDonald R, Carlyle MH, Olson CM, Dysken MW, McCarten JR, Kane RL, Garcia SA, Rutks IR, Ouellette J, Wilt TJ. Intermediate- and Long-Term Cognitive Outcomes After Cardiovascular Procedures in Older Adults: A Systematic Review. Ann Intern Med 2015; 163:107-17. [PMID: 26192563 DOI: 10.7326/m14-2793] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Risks for intermediate- and long-term cognitive impairment after cardiovascular procedures in older adults are poorly understood. PURPOSE To summarize evidence about cognitive outcomes in adults aged 65 years or older at least 3 months after coronary or carotid revascularization, cardiac valve procedures, or ablation for atrial fibrillation. DATA SOURCES MEDLINE, Cochrane, and Scopus databases from 1990 to January 2015; ClinicalTrials.gov; and bibliographies of reviews and eligible studies. STUDY SELECTION English-language trials and prospective cohort studies. DATA EXTRACTION One reviewer extracted data, a second checked accuracy, and 2 independently rated quality and strength of evidence (SOE). DATA SYNTHESIS 17 trials and 4 cohort studies were included; 80% of patients were men, and mean age was 68 years. Cognitive function did not differ after the procedure between on- and off-pump coronary artery bypass grafting (CABG) (n = 6; low SOE), hypothermic and normothermic CABG (n = 3; moderate to low SOE), or CABG and medical management (n = 1; insufficient SOE). One trial reported lower risk for incident cognitive impairment with minimal versus conventional extracorporeal CABG (risk ratio, 0.34 [95% CI, 0.16 to 0.73]; low SOE). Two trials found no difference between surgical carotid revascularization and carotid stenting or angioplasty (low and insufficient SOE, respectively). One cohort study reported increased cognitive decline after transcatheter versus surgical aortic valve replacement but had large selection and outcome measurement biases (insufficient SOE). LIMITATIONS Mostly low to insufficient SOE; no pertinent data for ablation; limited generalizability to the most elderly patients, women, and persons with substantial baseline cognitive impairment; and possible selective reporting and publication bias. CONCLUSION Intermediate- and long-term cognitive impairment in older adults attributable to the studied cardiovascular procedures may be uncommon. Nevertheless, clinicians counseling patients before these procedures should discuss the uncertainty in their risk for adverse cognitive outcomes. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Affiliation(s)
- Howard A. Fink
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Laura S. Hemmy
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Roderick MacDonald
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Maureen H. Carlyle
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Carin M. Olson
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Maurice W. Dysken
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - J. Riley McCarten
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Robert L. Kane
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Santiago A. Garcia
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Indulis R. Rutks
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Jeannine Ouellette
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Timothy J. Wilt
- From Minnesota Evidence-based Practice Center, University of Minnesota, and Geriatric Research Education and Clinical Center and Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
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Oi K, Arai H. Stroke associated with coronary artery bypass grafting. Gen Thorac Cardiovasc Surg 2015; 63:487-95. [PMID: 26153474 DOI: 10.1007/s11748-015-0572-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Indexed: 01/04/2023]
Abstract
While coronary artery bypass grafting (CABG) has been playing a significant role in the revascularization for ischemic heart disease, neurological complications associated with CABG have been a primary concern. Stroke, although the incidence is low, is one of the most devastating complication of CABG. Many studies have identified the risk factors for stroke with CABG, such as prior stroke, carotid artery stenosis, aortic atherosclerosis, atrial fibrillation and cardiopulmonary bypass. Various rational approaches focusing on individual risk factor have been proposed for the stroke. Prophylactic carotid revascularization is an important strategy, and the diagnosis of carotid stenosis has to be established correctly. Prevention of emboli from aortic plaque is also an essential issue. Intraoperative monitoring with transesophageal or epiaortic ultrasound is useful to identify mobile atheromatous plaques and to select appropriate aortic manipulations. Maintenance of cerebral blood flow and blood pressure during cardiopulmonary bypass might be critical issues. Besides, there are conflicting two opinions regarding off-pump CABG; one supports an efficiency for the prevention of stroke while the other advocates no effect. This discrepancy might be explained by the difference of the risk of stroke in the population of the individual study and by the variation of the percentage of aortic clamping or aortic anastomosis in each study. Pharmaceutical therapies such as statin, preventive medication for atrial fibrillation, or antiplatelet are promising methods. Although it is hard to decrease the incidence of the stroke with any single countermeasure, sustained effort should be continued to overcome the stroke associated with CABG.
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Affiliation(s)
- Keiji Oi
- Department of Cardiovascular Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan,
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Hori D, Everett AD, Lee JK, Ono M, Brown CH, Shah AS, Mandal K, Price JE, Lester LC, Hogue CW. Rewarming Rate During Cardiopulmonary Bypass Is Associated With Release of Glial Fibrillary Acidic Protein. Ann Thorac Surg 2015; 100:1353-8. [PMID: 26163357 DOI: 10.1016/j.athoracsur.2015.04.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/27/2015] [Accepted: 04/01/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND Rewarming from hypothermia during cardiopulmonary bypass (CPB) may compromise cerebral oxygen balance, potentially resulting in cerebral ischemia. The purpose of this study was to evaluate whether CPB rewarming rate is associated with cerebral ischemia assessed by the release of the brain injury biomarker glial fibrillary acidic protein (GFAP). METHODS Blood samples were collected from 152 patients after anesthesia induction and after CPB for the measurement of plasma GFAP levels. Nasal temperatures were recorded every 15 min. A multivariate estimation model for postoperative plasma GFAP level was determined that included the baseline GFAP levels, rewarming rate, CPB duration, and patient age. RESULTS The mean rewarming rate during CPB was 0.21° ± 0.11°C/min; the maximal temperature was 36.5° ± 1.0°C (range, 33.1°C to 38.0°C). Plasma GFAP levels increased after compared with before CPB (median, 0.022 ng/mL versus 0.035 ng/mL; p < 0.001). Rewarming rate (p = 0.001), but not maximal temperature (p = 0.77), was associated with higher plasma GFAP levels after CPB. In the adjusted estimation model, rewarming rate was positively associated with postoperative plasma log GFAP levels (coefficient, 0.261; 95% confidence intervals, 0.132 to 0.390; p < 0.001). Six patients (3.9%) experienced a postoperative stroke. Rewarming rate was higher (0.3° ± 0.09°C/min versus 0.2° ± 0.11°C/min; p = 0.049) in the patients with stroke compared with those without a stroke. CONCLUSIONS Rewarming rate during CPB was correlated with evidence of brain cellular injury documented with plasma GFAP levels. Modifying current practices of patient rewarming might provide a strategy to reduce the frequency of neurologic complications after cardiac surgery.
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Affiliation(s)
- Daijiro Hori
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Allen D Everett
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Masahiro Ono
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ashish S Shah
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kaushik Mandal
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joel E Price
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laeben C Lester
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charles W Hogue
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Graber LC, Quillinan N, Marrotte EJ, McDonagh DL, Bartels K. Neurocognitive outcomes after extracorporeal membrane oxygenation. Best Pract Res Clin Anaesthesiol 2015; 29:125-35. [DOI: 10.1016/j.bpa.2015.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 03/03/2015] [Accepted: 03/20/2015] [Indexed: 01/05/2023]
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Torres J, Ishida K. Neuroprotection After Major Cardiovascular Surgery. Curr Treat Options Neurol 2015; 17:357. [DOI: 10.1007/s11940-015-0357-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ariturk C, Okten M, Ozgen ZSU, Erkek E, Uysal P, Gullu U, Senay S, Karabulut H, Alhan C, Toraman F. Utility of cerebral oxymetry for assessing cerebral arteriolar carbon dioxide reactivity during cardiopulmonary bypass. Heart Surg Forum 2015; 17:E169-72. [PMID: 25002395 DOI: 10.1532/hsf98.2014319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Our study evaluated changes in cerebral arterial oxygen saturation (rSO2) during cardiopulmonary bypass (CPB) that were caused by changes in arterial carbon dioxide tension (PaCO2). METHODS A group of 126 patients undergoing routine, elective, first-time coronary artery bypass graft surgery (CABG) was entered into a prospective study using bilateral near-infrared spectroscopy (NIRS) before anesthetic induction (T1), after anesthetic induction (T2), and continuing at 5-minute intervals during moderate hypothermic (32°C) CPB. Pump flows were set at 2.5 L/min/m(2) and adjusted to maintain mean arterial pressure (MAP) within 10 mmHg of the MAP recorded at the initial fifth minute of CPB (T3). Thirty-two patients were excluded from data collection because MAP could not be stabilized within the target range of 60-90 mmHg. In the remaining 94 patients, after obtaining steady state flow, MAP, and oxygenation, a trial period of hypocarbia (mean PaCO2 of 30 mmHg) was induced by increasing oxygenator fresh gas flow rate (FGFR) to 2.5 L/min/m(2) (T4). A reciprocal period was then measured at reduced FGFR (0.75 L/min/m(2)) (T5). RESULTS After 20 minutes of a higher (2.75 L/min/m(2)) (FGFR), mean PaCO2 decreased from a baseline of 38 ± 4 mmHg to 30 ± 2 mmHg. This was associated with a parallel decrease (-10 ± 9%) in mixed cerebral oxygen saturation without alteration of mean arterial oxygen tension (PaO2), lactate, MAP, CPB flow, or other parameters implying increased cerebral oxygen extraction. CONCLUSION Parallel changes in PaCO2 and rSO2 occur during CPB when other variables remain constant, and are due to the effects of carbon dioxide on cerebral arterioles. Cerebral oxygen saturation measured by NIRS may be a useful indirect measure of PaCO2 when continuous blood gas analysis is not possible during open-heart surgery. Cerebral oximetry values may be useful measurements for setting an optimum gas flow rate through the oxygenator.
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Affiliation(s)
- Cem Ariturk
- Department of Cardiovascular Surgery, University of Acıbadem Faculty of Medicine, Maltepe, Istanbul, Turkey
| | - Murat Okten
- Department of Cardiovascular Surgery, Acıbadem Healthcare Group, Kadikoy Hospital
| | - Zehra Serpil Ustalar Ozgen
- Department of Anesthesiology and Reanimation, University of Acıbadem Faculty of Medicine, Maltepe, Istanbul, Turkey
| | - Esin Erkek
- Department of Anesthesiology and Reanimation, Acıbadem Healthcare Group, Kadikoy Hospital
| | - Pinar Uysal
- Department of Anesthesiology and Reanimation, Acıbadem Healthcare Group, Kadikoy Hospital
| | - Umit Gullu
- Department of Cardiovascular Surgery, University of Acıbadem Faculty of Medicine, Maltepe, Istanbul, Turkey
| | - Sahin Senay
- Department of Cardiovascular Surgery, University of Acıbadem Faculty of Medicine, Maltepe, Istanbul, Turkey
| | - Hasan Karabulut
- Department of Cardiovascular Surgery, University of Acıbadem Faculty of Medicine, Maltepe, Istanbul, Turkey
| | - Cem Alhan
- Department of Cardiovascular Surgery, University of Acıbadem Faculty of Medicine, Maltepe, Istanbul, Turkey
| | - Fevzi Toraman
- Department of Anesthesiology and Reanimation, University of Acıbadem Faculty of Medicine, Maltepe, Istanbul, Turkey
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McDonagh DL, Berger M, Mathew JP, Graffagnino C, Milano CA, Newman MF. Neurological complications of cardiac surgery. Lancet Neurol 2014; 13:490-502. [PMID: 24703207 PMCID: PMC5928518 DOI: 10.1016/s1474-4422(14)70004-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
As increasing numbers of elderly people undergo cardiac surgery, neurologists are frequently called upon to assess patients with neurological complications from the procedure. Some complications mandate acute intervention, whereas others need longer term observation and management. A large amount of published literature exists about these complications and guidance on best practice is constantly changing. Similarly, despite technological advances in surgical intervention and modifications in surgical technique to make cardiac procedures safer, these advances often create new avenues for neurological injury. Accordingly, rapid and precise neurological assessment and therapeutic intervention rests on a solid understanding of the evidence base and procedural variables.
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Affiliation(s)
- David L McDonagh
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA; Department of Neurology, Duke University Medical Center, Durham, NC, USA.
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | | | - Carmelo A Milano
- Department of Surgery (Division of Cardiovascular and Thoracic Surgery), Duke University Medical Center, Durham, NC, USA
| | - Mark F Newman
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Abstract
OBJECTIVE Observational studies suggest that infections are a common complication of therapeutic hypothermia. We performed a systematic review and meta-analysis of randomized trials to examine the risk of infections in patients treated with hypothermia. DATA SOURCES PubMed, Embase, and the Cochrane Central Register of Controlled Trials were systematically searched for eligible studies up to October 1, 2012. STUDY SELECTION We included randomized controlled clinical trials of therapeutic hypothermia induced in adults for any indication, which reported the prevalence of infection in each treatment group. DATA EXTRACTION For each study, we collected information about the baseline characteristics of patients, cooling strategy, and infections. DATA SYNTHESIS Twenty-three studies were identified, which included 2,820 patients, of whom 1,398 (49.6%) were randomized to hypothermia. Data from another 31 randomized trials, involving 4,004 patients, could not be included because the occurrence of infection was not reported with sufficient detail or not at all. The risk of bias in the included studies was high because information on the method of randomization and definitions of infections lacked in most cases, and assessment of infections was not blinded. In patients treated with hypothermia, the prevalence of all infections was not increased (rate ratio, 1.21 [95% CI, 0.95-1.54]), but there was an increased risk of pneumonia and sepsis (risk ratios, 1.44 [95% CI, 1.10-1.90]; 1.80 [95% CI, 1.04-3.10], respectively). CONCLUSION The available evidence, subject to its limitations, strongly suggests an association between therapeutic hypothermia and the risk of pneumonia and sepsis, whereas no increase in the overall risk of infection was observed. All future randomized trials of hypothermia should report on this important complication.
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Zhang X, Yan X, Gorman J, Hoffman SN, Zhang L, Boscarino JA. Perioperative hyperglycemia is associated with postoperative neurocognitive disorders after cardiac surgery. Neuropsychiatr Dis Treat 2014; 10:361-70. [PMID: 24570589 PMCID: PMC3933727 DOI: 10.2147/ndt.s57761] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Neurocognitive disorders commonly occur following cardiac surgery. However, the underlying etiology of these disorders is not well understood. The current study examined the association between perioperative glucose levels and other risk factors and the onset of neurocognitive disorders in adult patients following coronary artery bypass and/or valvular surgery. METHODS Adult patients who underwent their first cardiac surgery at a large tertiary care medical center were identified and those with neurocognitive disorders prior to surgery were excluded. Demographic, perioperative, and postoperative neurocognitive outcome data were extracted from the Society for Thoracic Surgery database, and from electronic medical records, between January 2004 and June 2009. Multiple clinical risk factors and measures associated with insulin resistance, such as hyperglycemia, were assessed. Multivariable Cox competing risk survival models were used to assess hyperglycemia and postoperative neurocognitive disorders at follow up, adjusting for other risk factors and confounding variables. RESULTS Of the 855 patients included in the study, 271 (31.7%) had new onset neurocognitive disorders at follow-up. Age, sex, New York Heart Failure (NYHF) Class, length of postoperative intensive care unit stay, perioperative blood product transfusion, and other key factors were identified and assessed as potential risk factors (or confounders) for neurocognitive disorders at follow-up. Bivariate analyses suggested that new onset neurocognitive disorders were associated with NYHF Class, cardiopulmonary bypass, history of diabetes, intraoperative blood product use, and number of diseased coronary vessels, which are commonly-accepted risk factors in cardiac surgery. In addition, higher first glucose level (median =116 mg/dL) and higher peak glucose >169 mg/dL were identified as risk factors. Male sex and nonuse of intra-operative blood products appeared to be protective. Controlling for potential risk factors and confounders, multivariable Cox survival models suggested that increased perioperative first glucose measured in 20 unit increments, was significantly associated with the onset of postoperative neurocognitive disorders at follow-up (hazard ratio [HR] =1.16, P<0.001) and that women had an elevated risk for this outcome (HR =4.18, P=0.01). CONCLUSION Our study suggests that perioperative hyperglycemia was associated with new onset of postoperative neurocognitive disorders in adult patients after cardiac surgery, and that men tended to be protected from these outcomes. These findings may suggest a need for the revision of clinical protocols for perioperative insulin therapy to prevent long-term neurocognitive complications.
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Affiliation(s)
- Xiaopeng Zhang
- Department of Anesthesiology, Geisinger Medical Center, Danville, PA, USA
| | - Xiaowei Yan
- Center for Health Research, Geisinger Clinic, Danville, PA, USA
| | - Jennifer Gorman
- Center for Health Research, Geisinger Clinic, Danville, PA, USA
| | - Stuart N Hoffman
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | - Li Zhang
- Department of Anesthesiology, Geisinger Medical Center, Danville, PA, USA
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Uysal S, Reich DL. Neurocognitive Outcomes of Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:958-71. [DOI: 10.1053/j.jvca.2012.11.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Indexed: 11/11/2022]
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Hogan AM, Shipolini A, Brown MM, Hurley R, Cormack F. Fixing hearts and protecting minds: a review of the multiple, interacting factors influencing cognitive function after coronary artery bypass graft surgery. Circulation 2013; 128:162-71. [PMID: 23836829 DOI: 10.1161/circulationaha.112.000701] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Alexandra M Hogan
- MBBS, Developmental Cognitive Neuroscience Unit, UCL Institute of Child Health, 30 Guildford St, London, WC1E 6BT, United Kingdom.
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Lomivorotov VV, Shmirev VA, Efremov SM, Ponomarev DN, Moroz GB, Shahin DG, Kornilov IA, Shilova AN, Lomivorotov VN, Karaskov AM. Hypothermic versus normothermic cardiopulmonary bypass in patients with valvular heart disease. J Cardiothorac Vasc Anesth 2013; 28:295-300. [PMID: 23962460 DOI: 10.1053/j.jvca.2013.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this study was to test the hypothesis that normothermic cardiopulmonary bypass (CPB) is as effective as hypothermic CPB in terms of cardiac protection (cTnI level) and outcome in patients with valvular heart disease. DESIGN Prospective randomized study. SETTING A tertiary cardiothoracic referral center. PARTICIPANTS 140 patients who had valvular heart disease, with/without coronary artery disease, surgically treated under CPB. INTERVENTIONS The patients were allocated randomly to undergo either hypothermic (temperature [T], 31 °C-32 °C) or normothermic CPB (T>36 °C). MEASUREMENTS AND MAIN RESULTS The primary endpoint was the dynamics of troponin I. The secondary endpoints were ventilation time, the need for inotropic support, intensive care unit (ICU) and hospital stay durations, complications, and mortality. There were no significant intergroup differences in dynamics of troponin I. Ventilation time was significantly lower in the hypothermic group (6 (5-9) and 8 (5-12); p = 0.01). CONCLUSIONS Normothermic CPB in patients with valvular heart disease was as effective as hypothermic perfusion in terms of myocardial protection after the surgery assessed by cTnI release. The short ventilation duration in patients who underwent hypothermic CPB needs to be confirmed in a future investigation.
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Affiliation(s)
- Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Vladimir A Shmirev
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Sergey M Efremov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia.
| | - Dmitry N Ponomarev
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Gleb B Moroz
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Denis G Shahin
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Igor A Kornilov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Anna N Shilova
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Vladimir N Lomivorotov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Alexander M Karaskov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
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Toeg HD, Nathan H, Rubens F, Wozny D, Boodhwani M. Clinical impact of neurocognitive deficits after cardiac surgery. J Thorac Cardiovasc Surg 2013; 145:1545-9. [PMID: 23535152 DOI: 10.1016/j.jtcvs.2013.02.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 02/12/2013] [Accepted: 02/27/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Postoperative neurocognitive deficits (POCDs) have been found to occur frequently after cardiac surgery. Although POCDs have received significant attention in the medical literature and public media, the true clinical impact of these deficits on patient outcomes and quality of life (QOL) is not well defined. METHODS Neuropsychometric testing was performed on 696 patients undergoing coronary artery bypass surgery using a battery of tests divided into 4 domains; memory, attention, speed, and psychomotor function. These were performed preoperatively, at hospital discharge, and at 3 months postoperatively. POCDs were defined as a drop in scores by 1 standard deviation in 1 domain or more. QOL was assessed using Short Form 36 and clinical outcomes were recorded. RESULTS POCDs were identified in 265 (38%) patients at discharge and in 132 (19%) at 3 months. There was no observed difference in mortality or major morbidity in patients with or without POCDs. Predictors of POCDs at discharge were elevated preoperative creatinine (P = .04), increased cardiopulmonary bypass time (P = .005), and diabetes (P = .003). At 3 months, patients had improvements in both physical and mental components of QOL, independent of the occurrence of POCDs (P > .5). Independent predictors of improved QOL included younger age, severe preoperative anginal symptoms, normal left ventricular function, absence of postoperative wound infection, but not POCDs. CONCLUSIONS Neurocognitive deficits can be frequently detected on comprehensive neuropsychometric testing after cardiac surgery. However, they are not associated with any clinically important differences in patient outcome or in QOL after surgery.
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Affiliation(s)
- Hadi D Toeg
- Department of Cardiac Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
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Roman PEF, Grigore AM. Pro: hypothermic cardiopulmonary bypass should be used routinely. J Cardiothorac Vasc Anesth 2012; 26:945-8. [PMID: 22790158 DOI: 10.1053/j.jvca.2012.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Philip E F Roman
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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36
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Cerfolio RJ, Bryant AS, Skylizard L, Minnich DJ. Initial consecutive experience of completely portal robotic pulmonary resection with 4 arms. J Thorac Cardiovasc Surg 2011; 142:740-6. [DOI: 10.1016/j.jtcvs.2011.07.022] [Citation(s) in RCA: 188] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Revised: 06/01/2011] [Accepted: 07/14/2011] [Indexed: 10/17/2022]
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Belway D, Tee R, Nathan HJ, Rubens FD, Boodhwani M. Temperature management and monitoring practices during adult cardiac surgery under cardiopulmonary bypass: results of a Canadian national survey. Perfusion 2011; 26:395-400. [DOI: 10.1177/0267659111409095] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Mild to moderate systemic hypothermia is commonly used as a cerebral protective strategy during adult cardiac surgery. The benefits of this strategy for routine cardiac surgery have been questioned and the adverse effects of hyperthermia demonstrated. The purpose of the present study was to examine current temperature management and monitoring practices during adult cardiac surgery using CPB in Canada. Methods: Web-based survey referring to adult cases undergoing cardiac surgery using CPB without the use of deep hypothermic circulatory arrest. Thirty-two questionnaires were completed, representing a 100% response rate. Results: The usual management is to cool patients during CPB at 30 (94%) centers for low-risk (isolated primary CABG) cases and at 31 (97%) centers for high-risk (all other) cases. The average nadir temperature at the target site achieved on CPB is 34°C (range 28°C - 36°C). At 26 (81%) centers, patients are typically rewarmed to a target temperature between 36°C and 37°C before separation from CPB. Only 6 (19%) centers reported that thermistors and coupled devices used to monitor blood temperature are checked for accuracy or calibrated according to the product operating directive’s schedule or more often. Conclusions: Contemporary management of adult cardiac surgery under CPB still involves induction of mild to moderate systemic hypothermia. Significant practice variation exists across the country with respect to target temperatures for cooling and rewarming, as well as the site for temperature monitoring. This probably reflects the lack of definitive evidence. There is a need for well-conducted clinical trials to provide more robust evidence regarding temperature management.
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Affiliation(s)
- D Belway
- Department of Perfusion Services, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - R Tee
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - HJ Nathan
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - FD Rubens
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - M Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
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Rodriguez RA, Rubens FD, Wozny D, Nathan HJ. Cerebral Emboli Detected by Transcranial Doppler During Cardiopulmonary Bypass Are Not Correlated With Postoperative Cognitive Deficits. Stroke 2010; 41:2229-35. [DOI: 10.1161/strokeaha.110.590513] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
High-intensity transient signals (HITS) are the transcranial Doppler representation of both air and solid cerebral emboli. We studied the frequency of HITS associated with different surgical maneuvers during cardiopulmonary bypass for coronary artery bypass graft surgery and their association with postoperative cognitive dysfunction (POCD).
Methods—
We combined 356 patients undergoing coronary artery bypass graft from 2 clinical trials who had both neuropsychological testing (before, 1 week and 3 months after surgery) and transcranial Doppler during cardiopulmonary bypass. HITS were grouped into periods that included: cannulation, cardiopulmonary bypass onset, aortic crossclamp-on, aortic crossclamp-off, side clamp-on, side clamp-off, and decannulation. POCD was defined by a decreased combined Z-score of at least 2.0 or reduction in Z-scores of at least 2.0 in 20% of the individual tests.
Results—
Incidence of POCD was 47.3% and 6.3% at 1 week and 3 months after surgery. There was no association between cardiopulmonary bypass counts of HITS and POCD at 1 week (
P
=0.617) and 3 months (
P
=0.110). No differences in HITS counts were identified at any of the surgical periods between patients with and without POCD. Factors affecting HITS counts were surgical period (
P
<0.0001), blood flow velocity (
P
=0.012), cardiopulmonary bypass duration (
P
=0.040), and clinical study (
P
=0.048).
Conclusions—
Although cerebral microemboli have been implicated in the pathogenesis of POCD, in this study that included low-risk patients undergoing coronary artery bypass surgery, there was no demonstrable correlation between the counts of HITS and POCD.
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Affiliation(s)
- Rosendo A. Rodriguez
- From the Department of Surgery (R.A.R., F.D.R.), Division of Cardiac Surgery, and the Department of Anesthesia (D.W., H.J.N.), Cardiovascular Division, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Fraser D. Rubens
- From the Department of Surgery (R.A.R., F.D.R.), Division of Cardiac Surgery, and the Department of Anesthesia (D.W., H.J.N.), Cardiovascular Division, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Denise Wozny
- From the Department of Surgery (R.A.R., F.D.R.), Division of Cardiac Surgery, and the Department of Anesthesia (D.W., H.J.N.), Cardiovascular Division, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Howard J. Nathan
- From the Department of Surgery (R.A.R., F.D.R.), Division of Cardiac Surgery, and the Department of Anesthesia (D.W., H.J.N.), Cardiovascular Division, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Rudolph JL, Schreiber KA, Culley DJ, McGlinchey RE, Crosby G, Levitsky S, Marcantonio ER. Measurement of post-operative cognitive dysfunction after cardiac surgery: a systematic review. Acta Anaesthesiol Scand 2010; 54:663-77. [PMID: 20397979 DOI: 10.1111/j.1399-6576.2010.02236.x] [Citation(s) in RCA: 146] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Post-operative cognitive dysfunction (POCD) is a decline in cognitive function from pre-operative levels, which has been frequently described after cardiac surgery. The purpose of this study was to examine the variability in the measurement and definitions for POCD using the framework of a 1995 Consensus Statement on measurement of POCD. Electronic medical literature databases were searched for the intersection of the search terms 'thoracic surgery' and 'cognition, dementia, and neuropsychological test.' Abstracts were reviewed independently by two reviewers. English articles with >50 participants published since 1995 that performed pre-operative and post-operative psychometric testing in patients undergoing cardiac surgery were reviewed. Data relevant to the measurement and definition of POCD were abstracted and compared with the recommendations of the Consensus Statement. Sixty-two studies of POCD in patients undergoing cardiac surgery were identified. Of these studies, the recommended neuropsychological tests were carried out in less than half of the studies. The cognitive domains measured most frequently were attention (n=56; 93%) and memory (n=57; 95%); motor skills were measured less frequently (n=36; 60%). Additionally, less than half of the studies examined anxiety and depression, performed neurological exam, or accounted for learning. Four definitions of POCD emerged: per cent decline (n=15), standard deviation decline (n=14), factor analysis (n=13), and analysis of performance on individual tests (n=12). There is marked variability in the measurement and definition of POCD. This heterogeneity may impede progress by reducing the ability to compare studies on the causes and treatment of POCD.
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Affiliation(s)
- J L Rudolph
- Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02130, USA.
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40
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Ho KM, Tan JA. Benefits and Risks of Maintaining Normothermia during Cardiopulmonary Bypass in Adult Cardiac Surgery: A Systematic Review. Cardiovasc Ther 2009; 29:260-79. [DOI: 10.1111/j.1755-5922.2009.00114.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Impaired autoregulation of cerebral blood flow during rewarming from hypothermic cardiopulmonary bypass and its potential association with stroke. Anesth Analg 2009; 110:321-8. [PMID: 20008083 DOI: 10.1213/ane.0b013e3181c6fd12] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patient rewarming after hypothermic cardiopulmonary bypass (CPB) has been linked to brain injury after cardiac surgery. In this study, we evaluated whether cooling and then rewarming of body temperature during CPB in adult patients is associated with alterations in cerebral blood flow (CBF)-blood pressure autoregulation. METHODS One hundred twenty-seven adult patients undergoing CPB during cardiac surgery had transcranial Doppler monitoring of the right and left middle cerebral artery blood flow velocity. Eleven patients undergoing CPB who had arterial inflow maintained at >35 degrees C served as controls. The mean velocity index (Mx) was calculated as a moving, linear correlation coefficient between slow waves of middle cerebral artery blood flow velocity and mean arterial blood pressure. Intact CBF-blood pressure autoregulation is associated with an Mx that approaches 0. Impaired autoregulation results in an increasing Mx approaching 1.0. Comparisons of time-averaged Mx values were made between the following periods: before CPB (baseline), during the cooling and rewarming phases of CPB, and after CPB. The number of patients in each phase of CPB with an Mx >4.0, indicative of impaired CBF autoregulation, was determined. RESULTS During cooling, Mx (left, 0.29 +/- 0.18; right, 0.28 +/- 0.18 [mean +/- SD]) was greater than that at baseline (left, 0.17 +/- 0.21; right, 0.17 +/- 0.20; P <or= 0.0001). Mx increased during the rewarming phase of CPB (left, 0.40 +/- 0.19; right, 0.39 +/- 0.19) compared with baseline (P <or= 0.001) and the cooling phase (P <or= 0.0001), indicating impaired CBF autoregulation. After CPB, Mx (left, 0.27 +/- 0.20; right, 0.28 +/- 0.21) was higher than at baseline (left, P = 0.0004; right, P = 0.0003), no different than during the cooling phase, but lower than during rewarming (left, P <or= 0.0001; right, P <or= 0.0005). Forty-three patients (34%) had an Mx >or=0.4 during the cooling phase of CPB and 68 (53%) had an average Mx >or=0.4 during rewarming. Nine of the 11 warm controls had an average Mx >or=0.4 during the entire CPB period. There were 7 strokes and 1 TIA after surgery. All strokes were in patients with Mx >or= 0.4 during rewarming (P = 0.015). The unadjusted odds ratio for any neurologic event (stroke or transient ischemic attack) for patients with Mx >or= 0.4 during rewarming was 6.57 (95% confidence interval, 0.79 to 55.0, P < 0.08). CONCLUSIONS Hypothermic CPB is associated with abnormal CBF-blood pressure autoregulation that is worsened with rewarming. We found a high rate of strokes in patients with evidence of impaired CBF autoregulation. Whether a pressure-passive CBF state during rewarming is associated with risk for ischemic brain injury requires further investigation.
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Grigore AM, Murray CF, Ramakrishna H, Djaiani G. A Core Review of Temperature Regimens and Neuroprotection During Cardiopulmonary Bypass: Does Rewarming Rate Matter? Anesth Analg 2009; 109:1741-51. [DOI: 10.1213/ane.0b013e3181c04fea] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Mackensen GB, McDonagh DL, Warner DS. Perioperative hypothermia: use and therapeutic implications. J Neurotrauma 2009; 26:342-58. [PMID: 19231924 DOI: 10.1089/neu.2008.0596] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Perioperative cerebral ischemic insults are common in some surgical procedures. The notion that induced hypothermia can be employed to improve outcome in surgical patients has persisted for six decades. Its principal application has been in the context of cardiothoracic and neurosurgery. Mild (32-35 degrees C) and moderate (26-31 degrees C) hypothermia have been utilized for numerous procedures involving the heart, but intensive research has found little or no benefit to outcome. This may, in part, be attributable to confounding effects associated with rewarming and lack of understanding of the mechanisms of injury. Evidence of efficacy of mild hypothermia is absent for cerebral aneurysm clipping and carotid endarterectomy. Deep hypothermia (18-25 degrees C) during circulatory arrest has been practiced in the repair of congenital heart disease, adult thoracic aortas, and giant intracranial aneurysms. There is little doubt of the protective efficacy of deep hypothermia, but continued efforts to refine its application may serve to enhance its utility. Recent evidence that mild hypothermia is efficacious in out-of-hospital cardiac arrest has implications for patients incurring anoxic or global ischemic brain insults during anesthesia and surgery, or perioperatively. Advances in preclinical models of ischemic/anoxic injury and cardiopulmonary bypass that allow definition of optimal cooling strategies and study of cellular and subcellular events during perioperative ischemia can add to our understanding of mechanisms of hypothermia efficacy and provide a rationale basis for its implementation in humans.
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Affiliation(s)
- G Burkhard Mackensen
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Abstract
Therapeutic moderate hypothermia has been advocated for use in traumatic brain injury, stroke, cardiac arrest-induced encephalopathy, neonatal hypoxic-ischemic encephalopathy, hepatic encephalopathy, and spinal cord injury, and as an adjunct to aneurysm surgery. In this review, we address the trials that have been performed for each of these indications, and review the strength of the evidence to support treatment with mild/moderate hypothermia. We review the data to support an optimal target temperature for each indication, as well as the duration of the cooling, and the rate at which cooling is induced and rewarming instituted. Evidence is strongest for prehospital cardiac arrest and neonatal hypoxic-ischemic encephalopathy. For traumatic brain injury, a recent meta-analysis suggests that cooling may increase the likelihood of a good outcome, but does not change mortality rates. For many of the other indications, such as stroke and spinal cord injury, trials are ongoing, but the data are insufficient to recommend routine use of hypothermia at this time.
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Affiliation(s)
- Donald Marion
- The Children's Neurobiological Solutions Foundation, Santa Barbara, California, USA.
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45
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Bouwman NAMG, Verhagen WIM, Meulstee J. EEG abnormalities in poikilothermia suggesting Creutzfeldt-Jakob disease. Clin EEG Neurosci 2009; 40:196-9. [PMID: 19715183 DOI: 10.1177/155005940904000313] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 87-year-old woman was admitted with a rapidly progressive confusion, disorientation and myoclonus, all suggestive of sporadic Creutzfeldt-Jakob disease (sCJD). This diagnosis was initially strongly supported by the EEG, which showed slow background activity and triphasic waves, combined with the finding of an increased level of 14-3-3 protein in the cerebrospinal fluid. Remarkably, this patient had also developed hypothermia, which, after warming-up, resulted in alleviation of the mental disturbances and disappearance of myoclonus. Over time, the EEG abnormalities disappeared. She recovered clinically for which reason the diagnosis of sCJD had to be rejected; however, she kept the inability to maintain body temperature (poikilothermia). Therefore, in patients with the aforementioned symptoms body temperature should be measured and adequately managed. Our hypothesis is that she suffered from a misleading acquired encephalopathy with reversible EEG and laboratory features, mimicking sCJD. When laboratory findings suggest sCJD it remains very important to see whether or not these findings are compatible with the clinical observations.
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Affiliation(s)
- N A M G Bouwman
- Department of Neurology, Orbis Medical Centre, Sittard, The Netherlands.
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Boodhwani M, Rubens FD, Wozny D, Nathan HJ. Effects of mild hypothermia and rewarming on renal function after coronary artery bypass grafting. Ann Thorac Surg 2009; 87:489-95. [PMID: 19161766 DOI: 10.1016/j.athoracsur.2008.10.078] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2008] [Revised: 10/25/2008] [Accepted: 10/28/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hypothermia is a potential strategy for visceral organ protection during cardiopulmonary bypass (CPB). We report data from two randomized studies evaluating mild hypothermia and rewarming on postoperative renal function in cardiac surgical patients. METHODS Patients undergoing nonemergency, isolated coronary artery bypass grafting were enrolled into two studies. In the first, 223 patients were cooled to 32 degrees C during CPB and randomly assigned to rewarming to 37 degrees C (RW-37 degrees) or 34 degrees C (RW-34 degrees). The second study randomized 267 patients to sustained mild hypothermia at 34 degrees C (S-34 degrees) or normothermia (S-37 degrees) without rewarming. Serum creatinine levels were measured. Creatinine clearance was calculated. Significant renal dysfunction was defined as a 25% increase in serum creatinine or a 25% decrease in creatinine clearance postoperatively. RESULTS Postoperative serum creatinine levels were persistently higher in the RW-37 degrees patients than in the RW-34 degrees group (p < 0.01). RW-37 degrees patients had a higher incidence of renal dysfunction (17%) than RW-34 degrees patients (9%, p = 0.07). Sustained mild hypothermia had no beneficial effect on postoperative serum creatinine levels (p = 0.44) or significant renal dysfunction: S-34 degrees, 20% vs S-37 degrees, 15% (p = 0.28). Diabetes (odds ratio [OR], 1.6; 95% confidence interval [CI] 1.3 to 2.1), prolonged CPB time (OR, 1.1; 95% CI, 1.0 to 1.2), and rewarming (OR, 1.4; 95% CI, 1.0 to 1.9) were independent risk factors for significant renal dysfunction. Renal dysfunction was associated with longer hospital stay (8.4 +/- 0.8 vs 6.8 +/- 04 days, p < 0.001). CONCLUSIONS Sustained mild hypothermia does not improve renal outcome. However, rewarming on CPB is associated with increased renal injury and should be avoided.
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Affiliation(s)
- Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Sahu B, Chauhan S, Kiran U, Bisoi A, Lakshmy R, Selvaraj T, Nehra A. Neurocognitive Function in Patients Undergoing Coronary Artery Bypass Graft Surgery With Cardiopulmonary Bypass: The Effect of Two Different Rewarming Strategies. J Cardiothorac Vasc Anesth 2009; 23:14-21. [DOI: 10.1053/j.jvca.2008.07.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2008] [Indexed: 11/11/2022]
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Boodhwani M, Nathan HJ, Mesana TG, Rubens FD. Effects of Shed Mediastinal Blood on Cardiovascular and Pulmonary Function: A Randomized, Double-Blind Study. Ann Thorac Surg 2008; 86:1167-73. [DOI: 10.1016/j.athoracsur.2008.06.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Revised: 05/30/2008] [Accepted: 06/09/2008] [Indexed: 11/26/2022]
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Abstract
Increasing evidence suggests that induction of mild hypothermia (32-35 degrees C) in the first hours after an ischaemic event can prevent or mitigate permanent injuries. This effect has been shown most clearly for postanoxic brain injury, but could also apply to other organs such as the heart and kidneys. Hypothermia has also been used as a treatment for traumatic brain injury, stroke, hepatic encephalopathy, myocardial infarction, and other indications. Hypothermia is a highly promising treatment in neurocritical care; thus, physicians caring for patients with neurological injuries, both in and outside the intensive care unit, are likely to be confronted with questions about temperature management more frequently. This Review discusses the available evidence for use of controlled hypothermia, and also deals with fever control. Besides discussing the evidence, the aim is to provide information to help guide treatments more effectively with regard to timing, depth, duration, and effective management of side-effects. In particular, the rate of rewarming seems to be an important factor in establishing successful use of hypothermia in the treatment of neurological injuries.
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Affiliation(s)
- Kees H Polderman
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, Netherlands.
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