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Bao Q, Lei M, Xiao D, Xie J. Comparison Between the Protective Effect of Isoflurane and Propofol on Myocardium During Coronary Artery Bypass Grafting: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Braz J Cardiovasc Surg 2024; 39:e20210424. [PMID: 38629941 PMCID: PMC11020280 DOI: 10.21470/1678-9741-2021-0424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/15/2021] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE Intravenous non-volatile anaesthetics like propofol are commonly used in cardiac surgeries across several countries. Volatile anaesthetics like isoflurane may help in protecting the myocardium and minimize ischaemia-reperfusion injury. Hence, we did this review to compare the cardioprotective effect of isoflurane and propofol among patients undergoing coronary artery bypass grafting (CABG). METHODS We conducted a search in the databases Medical Literature Analysis and Retrieval System Online (or MEDLINE), Embase, PubMed Central®, ScienceDirect, Google Scholar, and Cochrane Library from inception until April 2021. We carried out a meta-analysis with random-effects model and reported pooled risk ratio (RR) or standardized mean difference (SMD) with 95% confidence interval (CI) depending on the type of outcome. RESULTS We analysed 13 studies including 808 participants. Almost all were low-quality studies. For cardiac index, the pooled SMD was 0.14 (95% CI: -0.22 to 0.50); for cardiac troponin I, pooled SMD was 0.10 (95% CI: -0.28 to 0.48). For mortality, the RR was 3.00 (95% CI: 0.32 to 28.43); for MI, pooled RR was 1.58 (95% CI: 0.59 to 4.20); and for inotropic drug use, pooled RR was 1.04 (95% CI: 0.90 to 1.21). For length of intensive care unit stay, the pooled SMD was 0.13 (95% CI: -0.29 to 0.55), while pooled SMD for mechanical ventilation time was -0.02 (95% CI: -0.54 to 0.51). CONCLUSION Isoflurane did not have significant cardioprotective effect compared to propofol following CABG. Hence, the anaesthetists need to check some viable alternatives to manage these patients and reduce the rate of postoperative complications.
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Affiliation(s)
- Qi Bao
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of
Medicine, Zhejiang University, Zhejiang, People’s Republic of China
| | - Min Lei
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of
Medicine, Zhejiang University, Zhejiang, People’s Republic of China
| | - Dongju Xiao
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of
Medicine, Zhejiang University, Zhejiang, People’s Republic of China
| | - Junran Xie
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of
Medicine, Zhejiang University, Zhejiang, People’s Republic of China
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Xing J, Loh SKN. Perioperative acute kidney injury: Current knowledge and the role of anaesthesiologists. PROCEEDINGS OF SINGAPORE HEALTHCARE 2023. [DOI: 10.1177/20101058231163406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
Background Among the different types of perioperative organ injury, acute kidney injury (AKI) occurs frequently and is consistently associated with increased rates of mortality and mortality. Despite development of many clinical trials to assess perioperative interventions, reliable means to prevent or reverse AKI are still lacking. Objectives This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and potential directions for future research. Methods A Pubmed search with the relevant keywords was done for articles published in the last 10 years. Results New insights into preoperative identification and optimisation, intraoperative strategies, including the choice of anaesthetic, haemodynamic and fluid management, have been made, with the aim of preventing perioperative AKI. Conclusion A patient-centric multidisciplinary approach is essential to protect kidney function of patients going for surgery. Much can be done by anaesthesiologists perioperatively, to reduce the risk of development of AKI, especially in susceptible patients. There is a need for further multicentred trials to enhance the currently generic perioperative recommendations.
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Affiliation(s)
- Jieyin Xing
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Samuel Kent Neng Loh
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
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Chiari P, Desebbe O, Durand M, Fischer MO, Lena-Quintard D, Palao JC, Samson G, Varillon Y, Vaz B, Joseph P, Ferraris A, Jacquet-Lagreze M, Pozzi M, Maucort-Boulch D, Ovize M, Bidaux G, Mewton N, Fellahi JL. A Multimodal Cardioprotection Strategy During Cardiac Surgery: The ProCCard Study. J Cardiothorac Vasc Anesth 2023; 37:1368-1376. [PMID: 37202231 DOI: 10.1053/j.jvca.2023.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/03/2023] [Accepted: 04/07/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE The ProCCard study tested whether combining several cardioprotective interventions would reduce the myocardial and other biological and clinical damage in patients undergoing cardiac surgery. DESIGN Prospective, randomized, controlled trial. SETTING Multicenter tertiary care hospitals. PARTICIPANTS 210 patients scheduled to undergo aortic valve surgery. INTERVENTIONS A control group (standard of care) was compared to a treated group combining five perioperative cardioprotective techniques: anesthesia with sevoflurane, remote ischemic preconditioning, close intraoperative blood glucose control, moderate respiratory acidosis (pH 7.30) just before aortic unclamping (concept of the "pH paradox"), and gentle reperfusion just after aortic unclamping. MEASUREMENTS AND MAIN RESULTS The primary outcome was the postoperative 72-h area under the curve (AUC) for high-sensitivity cardiac troponin I (hsTnI). Secondary endpoints were biological markers and clinical events occurring during the 30 postoperative days and the prespecified subgroup analyses. The linear relationship between the 72-h AUC for hsTnI and aortic clamping time, significant in both groups (p < 0.0001), was not modified by the treatment (p = 0.57). The rate of adverse events at 30 days was identical. A non-significant reduction of the 72-h AUC for hsTnI (-24%, p = 0.15) was observed when sevoflurane was administered during cardiopulmonary bypass (46% of patients in the treated group). The incidence of postoperative renal failure was not reduced (p = 0.104). CONCLUSION This multimodal cardioprotection has not demonstrated any biological or clinical benefit during cardiac surgery. The cardio- and reno-protective effects of sevoflurane and remote ischemic preconditioning therefore remain to be demonstrated in this context.
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Affiliation(s)
- Pascal Chiari
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France; Inserm U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France..
| | - Olivier Desebbe
- Service d'Anesthésie-Réanimation, Clinique de la Sauvegarde, Ramsay Générale de Santé, Lyon, France
| | - Michel Durand
- Pole d'Anesthésie-Réanimation, Hôpital Albert Michallon, Centre Hospitalier Universitaire de Grenoble-Alpes, Grenoble, France
| | - Marc-Olivier Fischer
- Service d'Anesthésie-Réanimation, Centre Hospitalier Universitaire de Caen, Université de Normandie, UNICAEN, Caen, France
| | - Diane Lena-Quintard
- Service d'Anesthésie-Réanimation, Institut Arnault Tzanck, Saint Laurent du Var, France
| | - Jean-Charles Palao
- Service d'Anesthésie-Réanimation, Hôpital Nord, Centre Hospitalier Universitaire de Saint Etienne, Saint Etienne, France
| | - Géraldine Samson
- Centre d'Investigation Clinique de Lyon (CIC 1407 Inserm), Hospices Civils de Lyon, Lyon, France
| | - Yvonne Varillon
- Centre d'Investigation Clinique de Lyon (CIC 1407 Inserm), Hospices Civils de Lyon, Lyon, France
| | - Bernadette Vaz
- Centre d'Investigation Clinique de Lyon (CIC 1407 Inserm), Hospices Civils de Lyon, Lyon, France
| | - Pierre Joseph
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Arnaud Ferraris
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Matthias Jacquet-Lagreze
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France; Inserm U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France
| | - Matteo Pozzi
- Service de Chirurgie Cardiaque, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Delphine Maucort-Boulch
- Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France; Université de Lyon, Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS, UMR5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne France
| | - Michel Ovize
- Inserm U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France.; Centre d'Investigation Clinique de Lyon (CIC 1407 Inserm), Hospices Civils de Lyon, Lyon, France
| | - Gabriel Bidaux
- Inserm U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France
| | - Nathan Mewton
- Inserm U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France.; Centre d'Investigation Clinique de Lyon (CIC 1407 Inserm), Hospices Civils de Lyon, Lyon, France; Service d'Insuffisance Cardiaque, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France; Inserm U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France
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Milne B, Gilbey T, Kunst G. Perioperative Management of the Patient at High-Risk for Cardiac Surgery-Associated Acute Kidney Injury. J Cardiothorac Vasc Anesth 2022; 36:4460-4482. [PMID: 36241503 DOI: 10.1053/j.jvca.2022.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/27/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
Acute kidney injury (AKI) is one of the most common major complications of cardiac surgery, and is associated with increased morbidity and mortality. Cardiac surgery-associated AKI has a complex, multifactorial etiology, including numerous factors such as primary cardiac dysfunction, hemodynamic derangements of cardiac surgery and cardiopulmonary bypass, and the possibility of a large volume of blood transfusion. There are no truly effective pharmacologic therapies for the management of AKI, and, therefore, anesthesiologists, intensivists, and cardiac surgeons must remain vigilant and attempt to minimize the risk of developing renal dysfunction. This narrative review describes the current state of the scientific literature concerning the specific aspects of cardiac surgery-associated AKI, and presents it in a chronological fashion to aid the perioperative clinician in their approach to this high-risk patient group. The evidence was considered for risk prediction models, preoperative optimization, and the intraoperative and postoperative management of cardiac surgery patients to improve renal outcomes.
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Affiliation(s)
- Benjamin Milne
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research Academic Clinical Fellow, King's College London, London, United Kingdom
| | - Tom Gilbey
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research Academic Clinical Fellow, King's College London, London, United Kingdom
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine and Metabolic Medicine and Sciences, King's College London, British Heart Foundation Centre of Excellence, Faculty of Life Sciences and Medicine, London, United Kingdom.
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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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Ștefan M, Predoi C, Goicea R, Filipescu D. Volatile Anaesthesia versus Total Intravenous Anaesthesia for Cardiac Surgery—A Narrative Review. J Clin Med 2022; 11:jcm11206031. [PMID: 36294353 PMCID: PMC9604446 DOI: 10.3390/jcm11206031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 12/03/2022] Open
Abstract
Recent research has contested the previously accepted paradigm that volatile anaesthetics improve outcomes in cardiac surgery patients when compared to intravenous anaesthesia. In this review we summarise the mechanisms of myocardial ischaemia/reperfusion injury and cardioprotection in cardiac surgery. In addition, we make a comprehensive analysis of evidence comparing outcomes in patients undergoing cardiac surgery under volatile or intravenous anaesthesia, in terms of mortality and morbidity (cardiac, neurological, renal, pulmonary).
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Affiliation(s)
- Mihai Ștefan
- Department of Anaesthesiology and Intensive Care, “Prof Dr CC Iliescu” Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
- Correspondence:
| | - Cornelia Predoi
- Department of Anaesthesiology and Intensive Care, “Prof Dr CC Iliescu” Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
- Discipline of Anaesthesiology and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Raluca Goicea
- Department of Anaesthesiology and Intensive Care, “Prof Dr CC Iliescu” Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
- Discipline of Anaesthesiology and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Daniela Filipescu
- Department of Anaesthesiology and Intensive Care, “Prof Dr CC Iliescu” Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
- Discipline of Anaesthesiology and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Ritiu SA, Rogobete AF, Sandesc D, Bedreag OH, Papurica M, Popovici SE, Toma D, Ivascu RI, Velovan R, Garofil DN, Corneci D, Bratu LM, Pahontu EM, Pistol A. The Impact of General Anesthesia on Redox Stability and Epigenetic Inflammation Pathways: Crosstalk on Perioperative Antioxidant Therapy. Cells 2022; 11:cells11121880. [PMID: 35741011 PMCID: PMC9221536 DOI: 10.3390/cells11121880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 05/31/2022] [Accepted: 06/07/2022] [Indexed: 02/07/2023] Open
Abstract
Worldwide, the prevalence of surgery under general anesthesia has significantly increased, both because of modern anesthetic and pain-control techniques and because of better diagnosis and the increased complexity of surgical techniques. Apart from developing new concepts in the surgical field, researchers and clinicians are now working on minimizing the impact of surgical trauma and offering minimal invasive procedures due to the recent discoveries in the field of cellular and molecular mechanisms that have revealed a systemic inflammatory and pro-oxidative impact not only in the perioperative period but also in the long term, contributing to more difficult recovery, increased morbidity and mortality, and a negative financial impact. Detailed molecular and cellular analysis has shown an overproduction of inflammatory and pro-oxidative species, responsible for augmenting the systemic inflammatory status and making postoperative recovery more difficult. Moreover, there are a series of changes in certain epigenetic structures, the most important being the microRNAs. This review describes the most important molecular and cellular mechanisms that impact the surgical patient undergoing general anesthesia, and it presents a series of antioxidant therapies that can reduce systemic inflammation.
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Affiliation(s)
- Stelian Adrian Ritiu
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brînzeu”, 300723 Timișoara, Romania; (S.A.R.); (D.S.); (O.H.B.); (M.P.); (S.E.P.); (D.T.); (R.V.)
- Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania;
| | - Alexandru Florin Rogobete
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brînzeu”, 300723 Timișoara, Romania; (S.A.R.); (D.S.); (O.H.B.); (M.P.); (S.E.P.); (D.T.); (R.V.)
- Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania;
- Anaesthesia and Intensive Care Research Center (CCATITM), “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
- Correspondence: (A.F.R.); (D.N.G.); Tel.: +40-075-985-2479 (A.F.R.)
| | - Dorel Sandesc
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brînzeu”, 300723 Timișoara, Romania; (S.A.R.); (D.S.); (O.H.B.); (M.P.); (S.E.P.); (D.T.); (R.V.)
- Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania;
- Anaesthesia and Intensive Care Research Center (CCATITM), “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Ovidiu Horea Bedreag
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brînzeu”, 300723 Timișoara, Romania; (S.A.R.); (D.S.); (O.H.B.); (M.P.); (S.E.P.); (D.T.); (R.V.)
- Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania;
- Anaesthesia and Intensive Care Research Center (CCATITM), “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Marius Papurica
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brînzeu”, 300723 Timișoara, Romania; (S.A.R.); (D.S.); (O.H.B.); (M.P.); (S.E.P.); (D.T.); (R.V.)
- Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania;
- Anaesthesia and Intensive Care Research Center (CCATITM), “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Sonia Elena Popovici
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brînzeu”, 300723 Timișoara, Romania; (S.A.R.); (D.S.); (O.H.B.); (M.P.); (S.E.P.); (D.T.); (R.V.)
- Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania;
| | - Daiana Toma
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brînzeu”, 300723 Timișoara, Romania; (S.A.R.); (D.S.); (O.H.B.); (M.P.); (S.E.P.); (D.T.); (R.V.)
- Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania;
| | - Robert Iulian Ivascu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (R.I.I.); (D.C.); (A.P.)
- Clinic of Anaesthesia and Intensive Care, Central Military Emergency Hospital “Dr. Carol Davila”, 010242 Bucharest, Romania
| | - Raluca Velovan
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brînzeu”, 300723 Timișoara, Romania; (S.A.R.); (D.S.); (O.H.B.); (M.P.); (S.E.P.); (D.T.); (R.V.)
- Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania;
| | - Dragos Nicolae Garofil
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (R.I.I.); (D.C.); (A.P.)
- Correspondence: (A.F.R.); (D.N.G.); Tel.: +40-075-985-2479 (A.F.R.)
| | - Dan Corneci
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (R.I.I.); (D.C.); (A.P.)
- Clinic of Anaesthesia and Intensive Care, Central Military Emergency Hospital “Dr. Carol Davila”, 010242 Bucharest, Romania
| | - Lavinia Melania Bratu
- Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania;
| | - Elena Mihaela Pahontu
- Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| | - Adriana Pistol
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (R.I.I.); (D.C.); (A.P.)
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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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Shaw AD, Guinn NR, Brown JK, Arora RC, Lobdell KW, Grant MC, Gan TJ, Engelman DT. Controversies in enhanced recovery after cardiac surgery. Perioper Med (Lond) 2022; 11:19. [PMID: 35477446 PMCID: PMC9047268 DOI: 10.1186/s13741-022-00250-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 02/17/2022] [Indexed: 11/30/2022] Open
Abstract
Advances in cardiac surgical operative techniques and myocardial protection have dramatically improved outcomes in the past two decades. An unfortunate and unintended consequence is that 80% of the preventable morbidity and mortality following cardiac surgery now originates outside of the operating room. Our hope is that a renewed emphasis on evidence-based best practice and standardized perioperative care will reduce overall morbidity and mortality and improve patient-centric care. The Perioperative Quality Initiative (POQI) and Enhanced Recovery After Surgery–Cardiac Society (ERAS® Cardiac) have identified significant evidence gaps in perioperative medicine related to cardiac surgery, defined as areas in which there is significant controversy about how best to manage patients. These five areas of focus include patient blood management, goal-directed therapy, acute kidney injury, opioid analgesic reduction, and delirium.
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Affiliation(s)
- Andrew D Shaw
- Department of Intensive Care and Resuscitation, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Nicole R Guinn
- Department of Anesthesiology, Duke University Medical Center, Box 3094, 2301 Erwin Road, Durham, NC, USA
| | - Jessica K Brown
- Department of Anesthesiology and Perioperative Medicine, Division of Anesthesiology and Critical Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rakesh C Arora
- Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Michael C Grant
- Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Baltimore, MD, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Daniel T Engelman
- University of Massachusetts Medical School-Baystate, Baystate Medical Center, 759 Chestnut St, Springfield, MA, USA
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10
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Mano R, Tin AL, Silagy AW, Haywood SC, Huang C, Benfante N, Fischer GW, Vickers AJ, Russo P, Coleman JA, McCormick PJ, Mincer JS, Hakimi AA. The association between modifiable perioperative parameters and renal function after nephrectomy. BJU Int 2022; 129:380-386. [PMID: 34196093 PMCID: PMC9088019 DOI: 10.1111/bju.15531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the association between intraoperative anaesthetic parameters, primarily intraoperative hypotension, and postoperative renal function in patients undergoing nephrectomy. PATIENTS AND METHODS We reviewed data from 3240 consecutive patients who underwent nephrectomy between 2010 and 2018. Anaesthetic parameters evaluated included duration of hypotension, tachycardia, hypothermia, volatile anaesthetic use and mean arterial pressure in the post-anaesthesia care unit. Outcomes included acute kidney injury (AKI) and estimated glomerular filtration rate (eGFR) within the first year after nephrectomy. Associations between anaesthetic parameters and outcomes were evaluated with multivariable logistic regression and generalised estimating equation, respectively, adjusted for predictors of renal function after nephrectomy. RESULTS Before nephrectomy, 677 (21%) patients had moderate-severe chronic kidney disease. A quarter of patients (n = 809) had postoperative AKI and 35% (n = 746) had Stage ≥3 chronic kidney disease 12-months after surgery. Only 12% of patients (n = 386) had >5 min of intraoperative hypotension. While not statistically significant, longer duration of intraoperative hypotension was associated with slightly higher rates of AKI (odds ratio [OR] per 10-min 1.14, 95% confidence interval [CI] 0.98, 1.32). Prolonged hypothermia was associated with increased rate of AKI (OR per 10-min 1.02, 95% CI 1.00, 1.04), and decreased eGFR (change in eGFR per 10-min -0.19, 95% CI -0.27, -0.12); however, these results have limited clinical significance. CONCLUSIONS Under current practice, intraoperative anaesthetic parameters are tightly maintained, restricting the significance of their effect on postoperative renal function. Future studies should evaluate whether haemodynamic parameters during the early postoperative period, when they are monitored less frequently, are associated with renal functional outcome.
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Affiliation(s)
- Roy Mano
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York,Department of Urology, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Amy L. Tin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew W. Silagy
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York,Department of Surgery, University of Melbourne, Austin Hospital, Melbourne, Australia
| | - Samuel C. Haywood
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Chun Huang
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nicole Benfante
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gregory W. Fischer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew J. Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul Russo
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan A. Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Patrick J. McCormick
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joshua S. Mincer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York,Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - A. Ari Hakimi
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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11
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Makkad B, Heinke TL, Kertai MD. Inhalational or total intravenous anesthetic for cardiac surgery: does the debate even exist? Curr Opin Anaesthesiol 2022; 35:18-35. [PMID: 34873076 DOI: 10.1097/aco.0000000000001087] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Perioperative myocardial injury related to cardiac surgery is associated with organ dysfunction and increased mortality. Volatile anesthetics (VA) have been used during cardiac surgery for decades because of their direct and indirect preconditioning and protection against ischemia-reperfusion injury. The current review provides a summary of the latest literature comparing pharmacological preconditioning and the potential benefits of using VA versus total intravenous anesthesia (TIVA) for general anesthesia to improve outcomes after cardiac surgery. RECENT FINDINGS Recent literature reports lower mortality and better outcomes when VA is used alone or in combination with remote ischemic preconditioning compared with groups receiving TIVA. However, inconsistent research findings over the years have led to continued debate regarding the anesthetic technique considered more favorable for cardiac surgery. SUMMARY Research findings regarding the use of volatile anesthetic versus TIVA for better outcomes after cardiac surgery are inconsistent. Variability in timing, duration, dosing, and type of VA as well as surgical and patient-related factors may have influenced these results. Therefore, either technique can reasonably be adopted depending on provider and institutional preference and used safely in patients undergoing cardiac surgery.
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Affiliation(s)
- Benu Makkad
- Department of Anesthesiology, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Timothy Lee Heinke
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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12
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Vu T, Smith JA. An Update on Postoperative Cognitive Dysfunction Following Cardiac Surgery. Front Psychiatry 2022; 13:884907. [PMID: 35782418 PMCID: PMC9240195 DOI: 10.3389/fpsyt.2022.884907] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/23/2022] [Indexed: 12/14/2022] Open
Abstract
Postoperative cognitive dysfunction is extremely prevalent following cardiac surgery. The increasing patient age and comorbidity profile increases their susceptibility to cognitive impairment. The underlying pathophysiological mechanisms leading to cognitive impairment are not clearly elucidated. Using the contemporary literature (2015-present), this narrative review has three aims. Firstly, to provide an overview of postoperative cognitive impairment. Secondly, to analyse the predominant pathophysiological mechanisms leading to cognitive dysfunction following cardiac surgery such as inflammation, cerebral hypoperfusion, cerebral microemboli, glycaemic control and anaesthesia induced neurotoxicity. Lastly, to assess the current therapeutic strategies of interest to address these pathophysiological mechanisms, including the administration of dexamethasone, the prevention of prolonged cerebral desaturations and the monitoring of cerebral perfusion using near-infrared spectroscopy, surgical management strategies to reduce the neurological effects of microemboli, intraoperative glycaemic control strategies, the effect of volatile vs. intravenous anaesthesia, and the efficacy of dexmedetomidine.
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Affiliation(s)
- Tony Vu
- Department of Cardiothoracic Surgery, Monash Health, Melbourne, VIC, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Julian A Smith
- Department of Cardiothoracic Surgery, Monash Health, Melbourne, VIC, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
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14
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Volatile Anesthetics versus Propofol for Cardiac Surgery with Cardiopulmonary Bypass. Anesthesiology 2020; 132:1429-1446. [DOI: 10.1097/aln.0000000000003236] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Background
The aim of this systematic review and meta-analysis was to assess the effect of anesthesia maintenance with volatile agents compared with propofol on both short- and long-term mortality (primary outcomes) and major clinical events in adults undergoing cardiac surgery with cardiopulmonary bypass.
Methods
Randomized clinical trials on the effects of current volatile anesthetics versus propofol in adults undergoing cardiac surgery with cardiopulmonary bypass were searched (1965 to September 30, 2019) in PubMed, the Cochrane Library, and article reference lists. A random effect model on standardized mean difference for continuous outcomes and odds ratio for dichotomous outcomes were used to meta-analyze data.
Results
In total, 37 full-text articles (42 studies, 8,197 participants) were included. The class of volatile anesthetics compared with propofol was associated with lower 1-yr mortality (5.5 vs. 6.8%; odds ratio, 0.76 [95% CI, 0.60 to 0.96]; P = 0.023), myocardial infarction (odds ratio, 0.60 [95% CI, 0.39 to 0.92]; P = 0.023), cardiac troponin release (standardized mean difference, −0.39 [95% CI, −0.59 to −0.18], P = 0.0002), need for inotropic medications (odds ratio, 0.40 [95% CI, 0.24 to 0.67]; P = 0.0004), extubation time (standardized mean difference, −0.35 [95% CI, −0.68 to −0.02]; P = 0.038), and with higher cardiac index/output (standardized mean difference, 0.70 [95% CI, 0.37 to 1.04]; P < 0.0001). The class of volatile anesthetics was not associated with changes in short-term mortality (1.63 vs. 1.65%; odds ratio, 1.04 [95% CI, 0.73 to 1.49]; P = 0.820) and acute kidney injury (odds ratio, 1.25 [95% CI, 0.77 to 2.03]; P = 0.358).
Conclusions
In adults undergoing cardiac surgery with cardiopulmonary bypass, the class of volatile anesthetics was superior to propofol with regard to long-term mortality, as well as to many secondary outcomes indicating myocardial protection.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
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15
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Pisano A, Torella M, Yavorovskiy A, Landoni G. The Impact of Anesthetic Regimen on Outcomes in Adult Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 35:711-729. [PMID: 32434720 DOI: 10.1053/j.jvca.2020.03.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/18/2020] [Accepted: 03/29/2020] [Indexed: 11/11/2022]
Abstract
Despite improvements in surgical techniques and perioperative care, cardiac surgery still is burdened by relatively high mortality and frequent major postoperative complications, including myocardial dysfunction, pulmonary complications, neurologic injury, and acute kidney injury. Although the surgeon's skills and volume and patient- and procedure-related risk factors play a major role in the success of cardiac surgery, there is growing evidence that also optimizing perioperative care may improve outcomes significantly. The present review focuses on the aspects of perioperative care that are strictly related to the anesthesia regimen, with special reference to volatile anesthetics and neuraxial anesthesia, whose effect on outcome in adult cardiac surgery has been investigated extensively.
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Affiliation(s)
- Antonio Pisano
- Department of Critical Care, Cardiac Anesthesia and Intensive Care Unit, AORN Dei Colli, Monaldi Hospital, Naples, Italy
| | - Michele Torella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Andrey Yavorovskiy
- Department of Anesthesiology and Intensive Care, First Moscow State Medical University, Moscow, Russia
| | - Giovanni Landoni
- Vita-Salute San Raffaele University, Milan, Italy; Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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16
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Harky A, Joshi M, Gupta S, Teoh WY, Gatta F, Snosi M. Acute Kidney Injury Associated with Cardiac Surgery: a Comprehensive Literature Review. Braz J Cardiovasc Surg 2020; 35:211-224. [PMID: 32369303 PMCID: PMC7199993 DOI: 10.21470/1678-9741-2019-0122] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective To comprehensively understand cardiac surgeryassociated acute kidney injury (CSA-AKI) and methods of prevention of such complication in cardiac surgery patients. Methods A comprehensive literature search was performed using the electronic database to identify articles describing acute kidney injury (AKI) in patients that undergone cardiac surgery. There was neither time limit nor language limit on the search. The results were narratively summarized. Results All the relevant articles have been extracted; results have been summarized in each related section. CSA-AKI is a serious postoperative complication and it can contribute to a significant increase in perioperative morbidity and mortality rates. Optimization of factors that can reduce CSA-AKI, therefore, contributes to a better postoperative outcome. Conclusion Several factors can significantly increase the rate of AKI; identification and minimization of such factors can lead to lower rates of CSA-AKI and lower perioperative morbidity and mortality rates.
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Affiliation(s)
- Amer Harky
- Liverpool Heart and Chest Department of Cardiothoracic Surgery Liverpool UK Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
| | - Mihika Joshi
- Countess of Chester Hospital Department of Cardiology Chester UK Department of Cardiology, Countess of Chester Hospital, Chester, UK
| | - Shubhi Gupta
- University of Liverpool School of Medicine Liverpool UK School of Medicine, University of Liverpool, Liverpool, UK
| | - Wan Yi Teoh
- University of Liverpool School of Medicine Liverpool UK School of Medicine, University of Liverpool, Liverpool, UK
| | - Francesca Gatta
- Liverpool Heart and Chest Department of Cardiothoracic Surgery Liverpool UK Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
| | - Mostafa Snosi
- Liverpool Heart and Chest Department of Cardiothoracic Surgery Liverpool UK Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
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17
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Jiao XF, Lin XM, Ni XF, Li HL, Zhang C, Yang CS, Song HX, Yi QS, Zhang LL. Volatile anesthetics versus total intravenous anesthesia in patients undergoing coronary artery bypass grafting: An updated meta-analysis and trial sequential analysis of randomized controlled trials. PLoS One 2019; 14:e0224562. [PMID: 31661512 PMCID: PMC6818786 DOI: 10.1371/journal.pone.0224562] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/16/2019] [Indexed: 12/29/2022] Open
Abstract
Background The benefits of volatile anesthetics in coronary artery bypass grafting (CABG) patients remain controversial. We aimed to conduct an updated meta-analysis to assess whether the use of volatile anesthetics during CABG could reduce mortality and other outcomes. Methods We searched eight databases from inception to June 2019 and included randomized controlled trials (RCTs) comparing the effects of volatile anesthetics versus total intravenous anesthesia (TIVA) in CABG patients. The primary outcomes were operative mortality and one-year mortality. The secondary outcomes included the length of stay in the intensive care unit (ICU) and hospital and postoperative safety outcomes (myocardial infarction, heart failure, arrhythmia, stroke, delirium, postoperative cognitive impairment, acute kidney injury, and the use of intra-aortic balloon pump (IABP) or other mechanical circulatory support). Trial sequential analysis (TSA) was performed to control for random errors. Results A total of 89 RCTs comprising 14,387 patients were included. There were no significant differences between the volatile anesthetics and TIVA groups in operative mortality (relative risk (RR) = 0.92, 95% confidence interval (CI): 0.68–1.24, p = 0.59, I2 = 0%), one-year mortality (RR = 0.64, 95% CI: 0.32–1.26, p = 0.19, I2 = 51%), or any of the postoperative safety outcomes. The lengths of stay in the ICU and hospital were shorter in the volatile anesthetics group than in the TIVA group. TSA revealed that the results for operative mortality, one-year mortality, length of stay in the ICU, heart failure, stroke, and the use of IABP were inconclusive. Conclusions Conventional meta-analysis suggests that the use of volatile anesthetics during CABG is not associated with reduced risk of mortality or other postoperative safety outcomes when compared with TIVA. TSA shows that the current evidence is insufficient and inconclusive. Thus, future large RCTs are required to clarify this issue.
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Affiliation(s)
- Xue-feng Jiao
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
- West China School of Medicine, Sichuan University, Sichuan, China
| | - Xue-mei Lin
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Sichuan, China
| | - Xiao-feng Ni
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
- West China School of Medicine, Sichuan University, Sichuan, China
| | - Hai-long Li
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Chuan Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Chun-song Yang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Hao-xin Song
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Qiu-sha Yi
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
- West China School of Medicine, Sichuan University, Sichuan, China
| | - Ling-li Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
- * E-mail:
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Vives M, Hernandez A, Parramon F, Estanyol N, Pardina B, Muñoz A, Alvarez P, Hernandez C. Acute kidney injury after cardiac surgery: prevalence, impact and management challenges. Int J Nephrol Renovasc Dis 2019; 12:153-166. [PMID: 31303781 PMCID: PMC6612286 DOI: 10.2147/ijnrd.s167477] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 05/29/2019] [Indexed: 12/14/2022] Open
Abstract
Acute kidney injury (AKI) is a major medical problem that is of particular concern after cardiac surgery. Perioperative AKI is independently associated with an increase in short-term morbidity, costs of treatment, and long-term mortality. In this review, we explore the definition of cardiac surgery-associated acute kidney injury (CSA-AKI) and identify diverse mechanisms and risk factors contributing to the renal insult. Current theories of the pathophysiology of CSA-AKI and description of its clinical course will be addressed in this review. Data on the most promising renal protective strategies in cardiac surgery, from well-designed studies, will be scrutinized. Furthermore, diagnostic tools such as novel biomarkers of AKI and their potential utility will be discussed.
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Affiliation(s)
- M Vives
- Department of Anesthesiology & Critical Care, Clinical Research Lead, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Institut d´Investigació Biomédica de Girona (IDIBGI), Girona, Spain
| | - A Hernandez
- Department of Anesthesia & Critical Care, Grupo Policlinica, Ibiza, Spain
| | - F Parramon
- Department of Anesthesiology & Critical Care Chief, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
| | - N Estanyol
- Department of Anesthesiology & Critical Care Chief, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
| | - B Pardina
- Department of Anesthesiology & Critical Care Chief, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
| | - A Muñoz
- Department of Anesthesiology & Critical Care Chief, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
| | - P Alvarez
- Department of Cardiac Surgery, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
| | - C Hernandez
- Department of Anesthesiology & Critical Care Chief, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
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19
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Ren SF, Yu H, Guo YQ, Yu H. Inhalation versus intravenous anesthesia for adults undergoing heart valve surgery: a systematic review and meta-analysis. Minerva Anestesiol 2019; 85:665-675. [DOI: 10.23736/s0375-9393.19.13377-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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20
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McKinlay J, Tyson E, Forni LG. Renal complications of anaesthesia. Anaesthesia 2019; 73 Suppl 1:85-94. [PMID: 29313905 DOI: 10.1111/anae.14144] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 12/15/2022]
Abstract
Peri-operative acute kidney injury is common, accounting for 30-40% of all in-hospital cases of acute kidney injury. It is associated with clinically significant morbidity and mortality even with what was hitherto regarded as relatively trivial increases in serum creatinine, and carries over a 12-fold relative risk of death following major abdominal surgery. Comorbid conditions such as diabetes, hypertension, liver disease and particularly pre-existing chronic kidney disease, as well as the type and urgency of surgery, are major risk factors for the development of postoperative acute kidney injury. As yet, there are no specific treatment options for the injured kidney, although there are several modifiable risk factors of which the anaesthetist should be aware. As well as the avoidance of potential nephrotoxins and appropriate volume balance, optimal anaesthetic management should aim to reduce the risk of postoperative renal complications. This may include careful ventilatory management and blood pressure control, as well as appropriate analgesic strategies. The choice of anaesthetic agent may also influence renal outcomes. Rather than concentrate on the classical management of acute kidney injury, this review focuses on the potential development of acute kidney injury peri-operatively, and the means by which this may be ameliorated.
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Affiliation(s)
- J McKinlay
- Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group and Department of Intensive Care Medicine, University of Surrey, Surrey, UK
| | - E Tyson
- Department of Intensive Care Medicine, Royal Surrey County Hospital, University of Surrey, Surrey, UK
| | - L G Forni
- Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group and Department of Intensive Care Medicine, University of Surrey, Surrey, UK.,Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group and Department of Clinical and Experimental Medicine, Faculty of Health Care Sciences, University of Surrey, Surrey, UK
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21
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Hobson C, Lysak N, Huber M, Scali S, Bihorac A. Epidemiology, outcomes, and management of acute kidney injury in the vascular surgery patient. J Vasc Surg 2018; 68:916-928. [PMID: 30146038 PMCID: PMC6236681 DOI: 10.1016/j.jvs.2018.05.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 05/13/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Conventional clinical wisdom has often been nihilistic regarding the prevention and management of acute kidney injury (AKI), despite its being a frequent and morbid complication associated with both increased mortality and cost. Recent developments have shown that AKI is not inevitable and that changes in management of patients can reduce both the incidence and morbidity of perioperative AKI. The purpose of this narrative review was to review the epidemiology and outcomes of AKI in patients undergoing vascular surgery using current consensus definitions, to discuss some of the novel emerging risk stratification and prevention techniques relevant to the vascular surgery patient, and to describe a standardized perioperative pathway for the prevention of AKI after vascular surgery. METHODS We performed a critical review of the literature on AKI in the vascular surgery patient using the PubMed and MEDLINE databases and Google Scholar through September 2017 using web-based search engines. We also searched the guidelines and publications available online from the organizations Kidney Disease: Improving Global Outcomes and the Acute Dialysis Quality Initiative. The search terms used included acute kidney injury, AKI, epidemiology, outcomes, prevention, therapy, and treatment. RESULTS The reported epidemiology and outcomes associated with AKI have been evolving since the publication of consensus criteria that allow accurate identification of mild and moderate AKI. The incidence of AKI after major vascular surgery using current criteria is as high as 49%, although there are significant differences, depending on the type of procedure performed. Many tools have become available to assess and to stratify the risk for AKI and to use that information to prevent AKI in the surgical patient. We describe a standardized clinical assessment and management pathway for vascular surgery patients, incorporating current risk assessment and preventive strategies to prevent AKI and to decrease its complications. Patients without any risk factors can be managed in a perioperative fast-track pathway. Those patients with positive risk factors are tested for kidney stress using the urinary biomarker TIMP-2•IGFBP7, and care is then stratified according to the result. Management follows current Kidney Disease: Improving Global Outcomes guidelines. CONCLUSIONS AKI is a common postoperative complication among vascular surgery patients and has a significant impact on morbidity, mortality, and cost. Preoperative risk assessment and optimal perioperative management guided by that risk assessment can minimize the consequences associated with postoperative AKI. Adherence to a standardized perioperative pathway designed to reduce risk of AKI after major vascular surgery offers a promising clinical approach to mitigate the incidence and severity of this challenging clinical problem.
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Affiliation(s)
- Charles Hobson
- Department of Surgery, Malcom Randall VAMC, Gainesville, Fla; Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Fla
| | - Nicholas Lysak
- Department of Surgery, College of Medicine, University of Florida, Gainesville, Fla
| | - Matthew Huber
- Department of Medicine, College of Medicine, University of Florida, Gainesville, Fla
| | - Salvatore Scali
- Department of Surgery, Malcom Randall VAMC, Gainesville, Fla; Department of Surgery, College of Medicine, University of Florida, Gainesville, Fla
| | - Azra Bihorac
- Department of Medicine, College of Medicine, University of Florida, Gainesville, Fla; Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, Fla.
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22
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Nadim MK, Forni LG, Bihorac A, Hobson C, Koyner JL, Shaw A, Arnaoutakis GJ, Ding X, Engelman DT, Gasparovic H, Gasparovic V, Herzog CA, Kashani K, Katz N, Liu KD, Mehta RL, Ostermann M, Pannu N, Pickkers P, Price S, Ricci Z, Rich JB, Sajja LR, Weaver FA, Zarbock A, Ronco C, Kellum JA. Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group. J Am Heart Assoc 2018; 7:JAHA.118.008834. [PMID: 29858368 PMCID: PMC6015369 DOI: 10.1161/jaha.118.008834] [Citation(s) in RCA: 160] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Mitra K Nadim
- Division of Nephrology & Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Lui G Forni
- Department of Clinical & Experimental Medicine, University of Surrey, Guildford, United Kingdom.,Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom
| | - Azra Bihorac
- Division of Nephrology, Hypertension & Renal Transplantation, Department of Medicine, University of Florida, Gainesville, FL
| | - Charles Hobson
- Division of Surgical Critical Care, Department of Surgery, Malcom Randall VA Medical Center, Gainesville, FL
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, IL
| | - Andrew Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - George J Arnaoutakis
- Division of Thoracic & Cardiovascular Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Xiaoqiang Ding
- Department of Nephrology, Shanghai Institute for Kidney Disease and Dialysis, Shanghai Medical Center for Kidney Disease, Zhongshan Hospital Fudan University, Shanghai, China
| | - Daniel T Engelman
- Division of Cardiac Surgery, Department of Surgery, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Rebro, Zagreb, Croatia
| | | | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
| | - Kianoush Kashani
- Division of Nephrology & Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Nevin Katz
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Kathleen D Liu
- Divisions of Nephrology and Critical Care, Departments of Medicine and Anesthesia, University of California, San Francisco, CA
| | - Ravindra L Mehta
- Department of Medicine, UCSD Medical Center, University of California, San Diego, CA
| | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Neesh Pannu
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Peter Pickkers
- Department Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Susanna Price
- Adult Intensive Care Unit, Imperial College, Royal Brompton Hospital, London, United Kingdom
| | - Zaccaria Ricci
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Roma, Italy
| | - Jeffrey B Rich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Lokeswara R Sajja
- Division of Cardiothoracic Surgery, STAR Hospitals, Hyderabad, India
| | - Fred A Weaver
- Division of Vascular Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital International Renal Research Institute of Vicenza, Italy
| | - John A Kellum
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, PA
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Abstract
PURPOSE OF REVIEW In this review, we discuss the latest updates on perioperative acute kidney injury (AKI) and the specific considerations that are relevant to different surgeries and patient populations. RECENT FINDINGS AKI diagnosis is constantly evolving. New biomarkers detect AKI early and shed a light on the possible cause of AKI. Hypotension, even for a short duration, is associated with perioperative AKI. The debate on the deleterious effects of chloride-rich solutions is still far from conclusion. Remote ischemic preconditioning is showing promising results in the possible prevention of perioperative AKI. No definite data show a beneficiary effect of statins, fenoldepam, or sodium bicarbonate in preventing AKI. SUMMARY Perioperative AKI is prevalent and associated with significant morbidity and mortality. Considering the lack of effective preventive or therapeutic interventions, this review focuses on perioperative AKI: measures for early diagnosis, defining risks and possible mechanisms, and summarizing current knowledge for intraoperative fluid and hemodynamic management to reduce risk of AKI.
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24
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Cyclosporine before Coronary Artery Bypass Grafting Does Not Prevent Postoperative Decreases in Renal Function. Anesthesiology 2018; 128:710-717. [DOI: 10.1097/aln.0000000000002104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Abstract
Background
Acute kidney injury is a common complication after cardiac surgery, leading to increased morbidity and mortality. One suggested cause for acute kidney injury is extracorporeal circulation–induced ischemia–reperfusion injury. In animal studies, cyclosporine has been shown to reduce ischemia–reperfusion injury in the kidneys. We hypothesized that administering cyclosporine before extracorporeal circulation could protect the kidneys in patients undergoing cardiac surgery.
Methods
The Cyclosporine to Protect Renal Function in Cardiac Surgery (CiPRICS) study was an investigator-initiated, double-blind, randomized, placebo-controlled, single-center study. The primary objective was to assess if cyclosporine could reduce acute kidney injury in patients undergoing coronary artery bypass grafting surgery with extracorporeal circulation. In the study, 154 patients with an estimated glomerular filtration rate of 15 to 90 ml · min–1 · 1.73 m–2 were enrolled. Study patients were randomized to receive 2.5 mg/kg cyclosporine or placebo intravenously before surgery. The primary endpoint was relative plasma cystatin C changes from the preoperative day to postoperative day 3. Secondary endpoints included biomarkers of kidney, heart, and brain injury.
Results
All enrolled patients were analyzed. The cyclosporine group (136.4 ± 35.6%) showed a more pronounced increase from baseline plasma cystatin C to day 3 compared to placebo (115.9 ± 30.8%), difference, 20.6% (95% CI, 10.2 to 31.2%, P < 0.001). The same pattern was observed for the other renal markers. The cyclosporine group had more patients in Risk Injury Failure Loss End-stage (RIFLE) groups R (risk), I (injury), or F (failure; 31% vs. 8%, P < 0.001). There were no differences in safety parameter distribution between groups.
Conclusions
Administration of cyclosporine did not protect coronary artery bypass grafting patients from acute kidney injury. Instead, cyclosporine caused a decrease in renal function compared to placebo that resolved after 1 month.
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25
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Wagner J, Strosing KM, Spassov SG, Lin Z, Engelstaedter H, Tacke S, Hoetzel A, Faller S. Sevoflurane posttreatment prevents oxidative and inflammatory injury in ventilator-induced lung injury. PLoS One 2018; 13:e0192896. [PMID: 29470503 PMCID: PMC5823378 DOI: 10.1371/journal.pone.0192896] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/24/2018] [Indexed: 02/04/2023] Open
Abstract
Mechanical ventilation is a life-saving clinical treatment but it can induce or aggravate lung injury. New therapeutic strategies, aimed at reducing the negative effects of mechanical ventilation such as excessive production of reactive oxygen species, release of pro-inflammatory cytokines, and transmigration as well as activation of neutrophil cells, are needed to improve the clinical outcome of ventilated patients. Though the inhaled anesthetic sevoflurane is known to exert organ-protective effects, little is known about the potential of sevoflurane therapy in ventilator-induced lung injury. This study focused on the effects of delayed sevoflurane application in mechanically ventilated C57BL/6N mice. Lung function, lung injury, oxidative stress, and inflammatory parameters were analyzed and compared between non-ventilated and ventilated groups with or without sevoflurane anesthesia. Mechanical ventilation led to a substantial induction of lung injury, reactive oxygen species production, pro-inflammatory cytokine release, and neutrophil influx. In contrast, sevoflurane posttreatment time dependently reduced histological signs of lung injury. Most interestingly, increased production of reactive oxygen species was clearly inhibited in all sevoflurane posttreatment groups. Likewise, the release of the pro-inflammatory cytokines interleukin-1β and MIP-1β and neutrophil transmigration were completely prevented by sevoflurane independent of the onset of sevoflurane administration. In conclusion, sevoflurane posttreatment time dependently limits lung injury, and oxidative and pro-inflammatory responses are clearly prevented by sevoflurane irrespective of the onset of posttreatment. These findings underline the therapeutic potential of sevoflurane treatment in ventilator-induced lung injury.
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Affiliation(s)
- Julie Wagner
- Department of Anesthesiology and Critical Care Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Veterinary Clinical Sciences, Clinic for Small Animal-Surgery, Justus-Liebig-University Giessen, Giessen, Germany
| | - Karl M. Strosing
- Department of Anesthesiology and Critical Care Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sashko G. Spassov
- Department of Anesthesiology and Critical Care Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ziwei Lin
- Department of Anesthesiology and Critical Care Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Helen Engelstaedter
- Department of Anesthesiology and Critical Care Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sabine Tacke
- Department of Veterinary Clinical Sciences, Clinic for Small Animal-Surgery, Justus-Liebig-University Giessen, Giessen, Germany
| | - Alexander Hoetzel
- Department of Anesthesiology and Critical Care Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Simone Faller
- Department of Anesthesiology and Critical Care Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Abstract
BACKGROUND Volatile sedation in the intensive care unit (ICU) may reduce the number of adverse events and improve patient outcomes compared with intravenous (IV) sedation. We performed a systematic review and meta-analysis comparing the effects of volatile and IV sedation in adult ICU patients. METHODS We searched the PubMed, Embase, Cochrane Central Register, and Web of Science databases for all randomized trials comparing volatile sedation using an anesthetic-conserving device (ACD) with IV sedation in terms of awakening and extubation times, lengths of ICU and hospital stay, and pharmacologic end-organ effects. RESULTS Thirteen trials with a total of 1027 patients were included. Volatile sedation (sevoflurane or isoflurane) administered through an ACD shortened the awakening time [mean difference (MD), -80.0 minutes; 95% confidence intervals (95% CIs), -134.5 to -25.6; P = .004] and extubation time (MD, -196.0 minutes; 95% CIs, -305.2 to -86.8; P < .001) compared with IV sedation (midazolam or propofol). No differences in the lengths of ICU and hospital stay were noted between the 2 groups. In the analysis of cardiac effects of sedation from 5 studies, patients who received volatile sedation showed lower serum troponin levels 6 hours after ICU admission than patients who received IV sedation (P < .05). The effect size of troponin was largest between 12 and 24 hours after ICU admission (MD, -0.27 μg/L; 95% CIs, -0.44 to -0.09; P = .003). CONCLUSION Compared with IV sedation, volatile sedation administered through an ACD in the ICU shortened the awakening and extubation times. Considering the difference in serum troponin levels between both arms, volatile anesthetics might have a myocardial protective effect after cardiac surgery even at a subanesthetic dose. Because the included studies used small sample sizes with high heterogeneity, further large, high-quality prospective clinical trials are needed to confirm our findings.
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Affiliation(s)
- Ha Yeon Kim
- Department of Anesthesiology and Pain Medicine, Sungkyunkwan University School of Medicine
| | - Ja Eun Lee
- Department of Anesthesiology and Pain Medicine, Sungkyunkwan University School of Medicine
| | | | - Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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27
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Motayagheni N, Phan S, Eshraghi C, Nozari A, Atala A. A Review of Anesthetic Effects on Renal Function: Potential Organ Protection. Am J Nephrol 2017; 46:380-389. [PMID: 29131005 DOI: 10.1159/000482014] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Renal protection is a critical concept for anesthesiologists, nephrologists, and urologists, since anesthesia and renal function are highly interconnected and can potentially interfere with one another. Therefore, a comprehensive understanding of anesthetic drugs and their effects on renal function remains fundamental to the success of renal surgeries, especially transplant procedures. Some experimental studies have shown that some anesthetics provide protection against renal ischemia/reperfusion (IR) injury, but there is limited clinical evidence. SUMMARY The effects of anesthetic drugs on renal failure are particularly important in the context of kidney transplantation, since the conditions of preservation following removal profoundly influence the recovery of organ function. Currently, preservation procedures are typically based on the usage of a cold-storage solution. Some anesthetic drugs induce anti-inflammatory, anti-necrotic, and anti-apoptotic effects. A more thorough understanding of anesthetic effects on renal function can present a novel approach for developing organ-protective strategies. The aim of this review is to discuss the effects of different anesthetic drugs on renal function, with particular focus on IR injury. Many studies have demonstrated the organ-protective effects of some anesthetic drugs, specifically propofol, which indicate the potential of some anesthetics to introduce novel organ protective targets. This is not surprising, since lipid emulsions are major components of propofol, which accumulating data show provide organ protective effects against IR injury. Key Messages: Thorough understanding of the interaction between anesthetic drugs and renal function remains fundamental to the delivery of safe perioperative care and to optimizing outcomes after renal surgeries, particularly transplant procedures. Anesthetics can be repurposed for organ protection with more information about their effects, especially during transplant procedures. Here, we review the effects of different anesthetic drugs - specifically those that contain lipids in their structure, with special reference to IR injury.
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Affiliation(s)
- Negar Motayagheni
- Institute for Regenerative Medicine (Wake Forest Institute of Regenerative Medicine), Wake Forest School of Medicine Medical Center Boulevard, Winston-Salem, North Carolina, USA
| | - Sheshanna Phan
- Department of Anesthesiology, Division of Molecular Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Crystal Eshraghi
- Department of Anesthesiology, Division of Molecular Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Ala Nozari
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony Atala
- Institute of Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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28
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Pasqualin RC, Mostarda CT, Souza LED, Vane MF, Sirvente R, Otsuki DA, Torres MLA, Irigoyen MCC, Auler JOC. Sevoflurane preconditioning during myocardial ischemia-reperfusion reduces infarct size and preserves autonomic control of circulation in rats. Acta Cir Bras 2017; 31:338-45. [PMID: 27275856 DOI: 10.1590/s0102-865020160050000008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 04/17/2016] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To investigate the myocardial ischemia-reperfusion with sevoflurane anesthetic preconditioning (APC) would present beneficial effects on autonomic and cardiac function indexes after the acute phase of a myocardial ischemia-reperfusion. METHODS Twenty Wistar rats were allocated in three groups: control (CON, n=10), myocardial infarction with sevoflurane (SEV, n=5) and infarcted without sevoflurane (INF, n=5). Myocardial ischemia (60 min) and reperfusion were performed by temporary coronary occlusion. Twenty-one days later, the systolic and diastolic function were evaluated by echocardiography; spectral analysis of the systolic arterial pressure (SAPV) and heart rate variability (HRV) were assessed. After the recording period, the infarct size (IS) was evaluated. RESULTS The INF group presented greater cardiac dysfunction and increased sympathetic modulation of the SAPV, as well as decreased alpha index and worse vagal modulation of the HRV. The SEV group exhibited attenuation of the systolic and diastolic dysfunction and preserved vagal modulation (square root of the mean squared differences of successive R-R intervals and high frequency) of HRV, as well as a smaller IS. CONCLUSION Sevoflurane preconditioning better preserved the cardiac function and autonomic modulation of the heart in post-acute myocardial infarction period.
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Affiliation(s)
- Rubens Campana Pasqualin
- PhD, Faculdade de Medicina, Universidade de São Paulo (USP), Brazil. Conception and design of the study, analysis of data, manuscript writing., Universidade de São Paulo, Faculdade de Medicina, Universidade de São Paulo (USP), Brazil
| | - Cristiano Teixeira Mostarda
- PhD, Hypertension Unit, Experimental Division, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, USP, Sao Paulo-SP, Brazil. Conception of the study, analysis of data, manuscript writing., Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, USP, Sao Paulo SP , Brazil
| | - Leandro Ezequiel de Souza
- Graduate student, Hypertension Unit, Experimental Division, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, USP, Sao Paulo-SP, Brazil. Helped conduct the study, analysis of data., Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, USP, Sao Paulo SP , Brazil
| | - Matheus Fachini Vane
- Postgraduate student in Anesthesiology, Laboratory of Anesthesiology (LIM-08), Faculdade de Medicina, USP, Sao Paulo-SP, Brazil. Helped conduct the study, analysis of data, manuscript writing., Universidade de São Paulo, Laboratory of Anesthesiology (LIM-08), Faculdade de Medicina, USP, Sao Paulo SP , Brazil
| | - Raquel Sirvente
- PhD, Hypertension Unit, Experimental Division, Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, USP, Sao Paulo-SP, Brazil. Helped conduct the study, analysis of data., Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, USP, Sao Paulo SP , Brazil
| | - Denise Aya Otsuki
- PhD, Laboratory of Anesthesiology (LIM-08), Faculdade de Medicina, USP, Sao Paulo-SP, Brazil. Helped conduct the study, analysis of data, manuscript writing., Universidade de São Paulo, Laboratory of Anesthesiology (LIM-08), Faculdade de Medicina, USP, Sao Paulo SP , Brazil
| | - Marcelo Luís Abramides Torres
- Associate Professor, Laboratory of Anesthesiology (LIM-08), Faculdade de Medicina, USP, Sao Paulo-SP, Brazil. Manuscript writing, critical revision., Universidade de São Paulo, Laboratory of Anesthesiology (LIM-08), Faculdade de Medicina, USP, Sao Paulo SP , Brazil
| | - Maria Cláudia Costa Irigoyen
- Associate Professor, Hypertension Unit, Experimental Division, Instituto do Coração (InCor), Hospital das Clínicas, USP, Sao Paulo-SP, Brazil. Analysis of data, manuscript writing, critical revision., Universidade de São Paulo, Instituto do Coração (InCor), Hospital das Clínicas, USP, Sao Paulo SP , Brazil
| | - José Otávio Costa Auler
- Full Professor, Laboratory of Anesthesiology (LIM-08), Faculdade de Medicina, USP, Sao Paulo-SP, Brazil. Analysis of data, manuscript writing, critical revision., Universidade de São Paulo, Laboratory of Anesthesiology (LIM-08), Faculdade de Medicina, USP, Sao Paulo SP , Brazil
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29
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Zhou C, Bulluck H, Fang N, Li L, Hausenloy DJ. Age and Surgical Complexity impact on Renoprotection by Remote Ischemic Preconditioning during Adult Cardiac Surgery: A Meta analysis. Sci Rep 2017; 7:215. [PMID: 28303021 PMCID: PMC5428278 DOI: 10.1038/s41598-017-00308-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 02/16/2017] [Indexed: 01/31/2023] Open
Abstract
We aimed to conduct an up-to-date meta-analysis to comprehensively assess the renoprotective effect of remote ischemic preconditioning (RIPC) in patients undergoing adult cardiac surgery. 21 randomized controlled trials (RCTs) with a total of 6302 patients were selected and identified. Compared with controls, RIPC significantly reduced the incidence of acute kidney injury (AKI) [odds ratio (OR) = 0.79; P = 0.02; I2 = 38%], and in particular, AKI stage I (OR = 0.65; P = 0.01; I2 = 55%). RIPC significantly shortened mechanical ventilation (MV) duration [weighted mean difference (WMD) = −0.79 hours; P = 0.002; I2 = 53%), and reduced intensive care unit (ICU) stay (WMD = −0.23 days; P = 0.07; I2 = 96%). Univariate meta-regression analyses showed that the major sources of heterogeneity for AKI stage I were age (coefficient = 0.06; P = 0.01; adjusted R2 = 0.86) and proportion of complex surgery (coefficient = 0.02; P = 0.03; adjusted R2 = 0.81). Subsequent multivariate regression and subgroup analyses also confirmed these results. The present meta-analysis suggests that RIPC reduces the incidence of AKI in adults undergoing cardiac surgery and this benefit was more pronounced in younger patients undergoing non-complex cardiac surgery. RIPC may also shorten MV duration and ICU stay. Future RCTs tailored for those most likely to benefit from RIPC warrants further investigation.
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Affiliation(s)
- Chenghui Zhou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Heerajnarain Bulluck
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK.,The National Institute of Health Research University College London Hospitals Biomedical Research Centre, London, UK.,National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore, Singapore
| | - Nengxin Fang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Lihuan Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
| | - Derek J Hausenloy
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK.,The National Institute of Health Research University College London Hospitals Biomedical Research Centre, London, UK.,National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore, Singapore.,Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore, Singapore, Singapore
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30
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Anaesthetics and analgesics; neurocognitive effects, organ protection and cancer reoccurrence an update. Int J Surg 2016; 34:41-46. [DOI: 10.1016/j.ijsu.2016.08.235] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 08/15/2016] [Accepted: 08/20/2016] [Indexed: 12/17/2022]
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31
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Renoprotection by remote ischemic conditioning during elective coronary revascularization: A systematic review and meta-analysis of randomized controlled trials. Int J Cardiol 2016; 222:295-302. [PMID: 27498373 DOI: 10.1016/j.ijcard.2016.07.176] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 07/27/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Remote ischemic conditioning (RIC) has been recognized an emerging non-invasive approach for preventing acute kidney injury (AKI) in patients undergoing either elective coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI). On the other hand, accumulating evidence has indicated the involving role of pre-CABG contrast usage for coronary angiography in post-surgery AKI risk. Along with the shortening time delay of CABG after coronary angiography, and the prevalent hybrid coronary revascularization (HCR), the AKI prevention by RIC has faced challenges following coronary revascuralization. METHODS Randomized controlled trials (RCTs) were searched from Pubmed, EMBase, and Cochrane library (until May 2016). The primary outcome was postoperative AKI. The second outcomes were included the requirement for renal replacement therapy (RRT), and in-hospital or 30-day mortality. RESULTS Twenty eligible RCTs (CABG, 3357 patients; PCI, 1501 patients) were selected. RIC significantly halved the incidence of AKI following PCI when compared with controls [n=1501; odds ratio (OR)=0.51; 95% CI, 0.32 to 0.82; P=0.006; I(2)=29.6%]. However, RIC did not affect the incidence of AKI following CABG (n=1850; OR=0.94; 95% CI, 0.73 to 1.19; P=0.586; I(2)=12.4%). The requirement for RRT and in-hospital mortality was not affected by RIC in CABG (n=2049, OR=1.04, P=0.87; n=1920, OR=0.89, P=0.7; respectively). CONCLUSIONS Our meta-analysis suggests that RIC for preventing AKI following CABG has faced with challenges in terms of AKI, the requirement for RRT, and mortality. However, RIC shows a renoprotective benefit for PCI. Hence, our findings may infer the preserved renal effects of RIC in CABG with preconditioning before the coronary angiography, or in HCR.
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Effects of Volatile Anesthetics on Mortality and Postoperative Pulmonary and Other Complications in Patients Undergoing Surgery. Anesthesiology 2016; 124:1230-45. [DOI: 10.1097/aln.0000000000001120] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Abstract
Background
It is not known whether modern volatile anesthetics are associated with less mortality and postoperative pulmonary or other complications in patients undergoing general anesthesia for surgery.
Methods
A systematic literature review was conducted for randomized controlled trials fulfilling following criteria: (1) population: adult patients undergoing general anesthesia for surgery; (2) intervention: patients receiving sevoflurane, desflurane, or isoflurane; (3) comparison: volatile anesthetics versus total IV anesthesia or volatile anesthetics; (4) reporting on: (a) mortality (primary outcome) and (b) postoperative pulmonary or other complications; (5) study design: randomized controlled trials. The authors pooled treatment effects following Peto odds ratio (OR) meta-analysis and network meta-analysis methods.
Results
Sixty-eight randomized controlled trials with 7,104 patients were retained for analysis. In cardiac surgery, volatile anesthetics were associated with reduced mortality (OR = 0.55; 95% CI, 0.35 to 0.85; P = 0.007), less pulmonary (OR = 0.71; 95% CI, 0.52 to 0.98; P = 0.038), and other complications (OR = 0.74; 95% CI, 0.58 to 0.95; P = 0.020). In noncardiac surgery, volatile anesthetics were not associated with reduced mortality (OR = 1.31; 95% CI, 0.83 to 2.05, P = 0.242) or lower incidences of pulmonary (OR = 0.67; 95% CI, 0.42 to 1.05; P = 0.081) and other complications (OR = 0.70; 95% CI, 0.46 to 1.05; P = 0.092).
Conclusions
In cardiac, but not in noncardiac, surgery, when compared to total IV anesthesia, general anesthesia with volatile anesthetics was associated with major benefits in outcome, including reduced mortality, as well as lower incidence of pulmonary and other complications. Further studies are warranted to address the impact of volatile anesthetics on outcome in noncardiac surgery.
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Landoni G, Pasin L, Cabrini L, Scandroglio AM, Baiardo Redaelli M, Votta CD, Bellandi M, Borghi G, Zangrillo A. Volatile Agents in Medical and Surgical Intensive Care Units: A Meta-Analysis of Randomized Clinical Trials. J Cardiothorac Vasc Anesth 2016; 30:1005-14. [PMID: 27238433 DOI: 10.1053/j.jvca.2016.02.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To comprehensively assess published randomized peer-reviewed studies related to volatile agents used for sedation in intensive care unit (ICU) settings, with the hypothesis that volatile agents could reduce time to extubation in adult patients. DESIGN Systematic review and meta-analysis of randomized trials. SETTING Intensive care units. PARTICIPANTS Critically ill patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The BioMedCentral, PubMed, Embase, and Cochrane Central Register databases of clinical trials were searched systematically for studies on volatile agents used in the ICU setting. Articles were assessed by trained investigators, and divergences were resolved by consensus. Inclusion criteria included random allocation to treatment (volatile agents versus any intravenous comparator, with no restriction on dose or time of administration) in patients requiring mechanical ventilation in the ICU. Twelve studies with 934 patients were included in the meta-analysis. The use of halogenated agents reduced the time to extubation (standardized mean difference = -0.78 [-1.01 to -0.55] hours; p for effect<0.00001; p for heterogeneity = 0.18; I(2) = 32% in 7 studies with 503 patients). Results for time to extubation were confirmed in all subanalyses (eg, medical and surgical patients) and sensitivity analyses. No differences in length of hospital stay, ICU stay, and mortality were recorded. CONCLUSIONS In this meta-analysis of randomized trials, volatile anesthetics reduced time to extubation in medical and surgical ICU patients. The results of this study should be confirmed by large and high-quality randomized controlled studies.
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Affiliation(s)
- Giovanni Landoni
- IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University, Milan, Italy.
| | | | | | | | | | | | | | | | - Alberto Zangrillo
- IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University, Milan, Italy
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Sackey P. Isoflurane for ICU sedation - dead or alive? Eur J Anaesthesiol 2016; 33:4-5. [PMID: 26627678 DOI: 10.1097/eja.0000000000000351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Peter Sackey
- From the Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Zhou C, Gong J, Chen D, Wang W, Liu M, Liu B. Levosimendan for Prevention of Acute Kidney Injury After Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials. Am J Kidney Dis 2015; 67:408-16. [PMID: 26518388 DOI: 10.1053/j.ajkd.2015.09.015] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 09/03/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Levosimendan has been shown to confer direct renoprotection in renal endotoxemic and ischemia-reperfusion injury and could increase renal blood flow in patients with low-cardiac-output heart failure. Results from clinical trials of levosimendan on acute kidney injury (AKI) following cardiac surgery are controversial. STUDY DESIGN A random-effect meta-analysis was conducted based on evidence from PubMed, EMBASE, and Cochrane Library. SETTINGS & POPULATION Adult patients undergoing cardiac surgery. SELECTION CRITERIA FOR STUDIES Randomized controlled trials comparing the renal effect of levosimendan versus placebo or other inotropic drugs during cardiac surgery. INTERVENTION Perioperative levosimendan continuous infusion at a rate of 0.1 to 0.2μg/kg/min following a loading dose (6-24μg/kg) for 24 hours or only 1 loading dose (24μg/kg) within 1 hour. OUTCOMES AKI, need for renal replacement therapy, mechanical ventilation duration, intensive care unit stay during hospitalization, and postoperative mortality (in-hospital or within 30 days). RESULTS 13 trials with a total of 1,345 study patients were selected. Compared with controls, levosimendan reduced the incidence of postoperative AKI (40/460 vs 78/499; OR, 0.51; 95% CI, 0.34-0.76; P=0.001; I(2)=0.0%), renal replacement therapy (22/492 vs 49/491; OR, 0.43; 95% CI, 0.25-0.76; P=0.002; I(2)=0.0%), postoperative mortality (35/658 vs 94/657; OR, 0.41; 95% CI, 0.27-0.62; P<0.001; I(2)=0.0%), mechanical ventilation duration (in days; n=235; weighted mean difference, -0.34; 95% CI, -0.58 to -0.09; P=0.007], and intensive care unit stay (in days; n=500; weighted mean difference, -2.2; 95% CI, -4.21 to -0.13; P=0.04). LIMITATIONS Different definitions for AKI among studies. Small sample size for some trials. CONCLUSIONS Perioperative administration of levosimendan in patients undergoing cardiac surgery may reduce complications. Future trials are needed to determine the dose effect of levosimendan in improving outcomes, especially in patients with decreased baseline kidney function.
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Affiliation(s)
- Chenghui Zhou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junsong Gong
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Chen
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weipeng Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingzheng Liu
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Liu
- Department of Anesthesiology, Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China.
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Abstract
Perioperative acute kidney injury (AKI) is a common, morbid, and costly surgical complication. Current efforts to understand and manage AKI in surgical patients focus on prevention, mitigation of further injury when AKI has occurred, treatment of associated conditions, and facilitation of renal recovery. Lesser severity AKI is now understood to be much more common, and more morbid, than was previously thought. The ability to detect AKI within hours of onset would be helpful in protecting the kidney and in preserving renal function, and several imaging and biomarker modalities are currently being evaluated.
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Affiliation(s)
- Charles Hobson
- Department of Surgery, Malcom Randall VA Medical Center, NF/SG VAMC, Gainesville, FL 32608, USA; Department of Health Services Research, Management, and Policy, University of Florida, Gainesville, FL, USA
| | - Girish Singhania
- Department of Medicine, University of Florida, PO Box 100254, Gainesville, FL 32610-0254, USA
| | - Azra Bihorac
- Department of Medicine, University of Florida, PO Box 100254, Gainesville, FL 32610-0254, USA; Department of Anesthesiology, University of Florida, PO Box 100254, Gainesville, FL 32610-0254, USA.
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Ray EC, Abdel-Kader K, Bircher N, Rondon-Berrios H. Case report: proximal tubule impairment following volatile anesthetic exposure. Physiol Rep 2015; 3:3/9/e12560. [PMID: 26416976 PMCID: PMC4600399 DOI: 10.14814/phy2.12560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The safety of contemporary volatile anesthetic agents with respect to kidney function is well established, and growing evidence suggests that volatile anesthetics even protect against ischemic nephropathy. However, studies examining effects of volatile anesthetics on kidney function frequently demonstrate transient proteinuria and glycosuria following exposure to these agents, although the cause of these findings has not been thoroughly examined. We describe the case of a patient who underwent a neurosurgical procedure, then experienced glycosuria without hyperglycemia that resolved within days. Following a second neurosurgical procedure, the patient again developed glycosuria, now associated with ketonuria. Further examination demonstrated nonalbuminuric proteinuria in conjunction with urinary wasting of phosphate and potassium, indicative of proximal tubule impairment. We suggest that transient proximal tubule impairment may play a role in the proteinuria and glycosuria described following volatile anesthetic exposure and discuss the relationship between these observations and the ability of these agents to protect against ischemic nephropathy.
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Affiliation(s)
- Evan C Ray
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University, Nashville, Tennessee
| | - Nicholas Bircher
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Helbert Rondon-Berrios
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Andersen ND. Volatile anesthetics in cardiac surgery: renoprotective, cardioprotective, neither, or both? J Thorac Cardiovasc Surg 2014; 148:3137-8. [PMID: 25433889 DOI: 10.1016/j.jtcvs.2014.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 10/02/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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