Synergistic immunosuppression caused by high-dose methylprednisolone and cardiopulmonary bypass

Prophylactic corticosteroids for cardiopulmonary bypass in adult cardiac surgery

BACKGROUND

Cardiac surgery triggers a strong inflammatory reaction, which carries significant clinical consequences. Corticosteroids have been suggested as a potential perioperative strategy to reduce inflammation and help prevent postoperative complications. However, the safety and effectiveness of perioperative corticosteroid use in adult cardiac surgery is uncertain. This is an update of the 2011 review with 18 studies added.

OBJECTIVES

Primary objective: to estimate the effects of prophylactic corticosteroid use in adults undergoing cardiac surgery with cardiopulmonary bypass on the: - co-primary endpoints of mortality, myocardial complications, and pulmonary complications; and - secondary outcomes including atrial fibrillation, infection, organ injury, known complications of steroid therapy, prolonged mechanical ventilation, prolonged postoperative stay, and cost-effectiveness.

SECONDARY OBJECTIVE

to explore the role of characteristics of the study cohort and specific features of the intervention in determining the treatment effects via a series of prespecified subgroup analyses.

SEARCH METHODS

We used standard, extensive Cochrane search methods to identify randomised studies assessing the effect of corticosteroids in adult cardiac surgery. The latest searches were performed on 14 October 2022.

SELECTION CRITERIA

We included randomised controlled trials in adults (over 18 years, either with a diagnosis of coronary artery disease or cardiac valve disease, or who were candidates for cardiac surgery with the use of cardiopulmonary bypass), comparing corticosteroids with no treatments. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more endpoints.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were all-cause mortality, and cardiac and pulmonary complications. Secondary outcomes were infectious complications, gastrointestinal bleeding, occurrence of new post-surgery atrial fibrillation, re-thoracotomy for bleeding, neurological complications, renal failure, inotropic support, postoperative bleeding, mechanical ventilation time, length of stays in the intensive care unit (ICU) and hospital, patient quality of life, and cost-effectiveness. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

This updated review includes 72 randomised trials with 17,282 participants (all 72 trials with 16,962 participants were included in data synthesis). Four trials (6%) were considered at low risk of bias in all the domains. The median age of participants included in the studies was 62.9 years. Study populations consisted mainly (89%) of low-risk, first-time coronary artery bypass grafting (CABG) or valve surgery. The use of perioperative corticosteroids may result in little to no difference in all-cause mortality (risk with corticosteroids: 25 to 36 per 1000 versus 33 per 1000 with placebo or no treatment; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.75 to 1.07; 25 studies, 14,940 participants; low-certainty evidence). Corticosteroids may increase the risk of myocardial complications (68 to 86 per 1000) compared with placebo or no treatment (66 per 1000; RR 1.16, 95% CI 1.04 to 1.31; 25 studies, 14,766 participants; low-certainty evidence), and may reduce the risk of pulmonary complications (risk with corticosteroids: 61 to 77 per 1000 versus 78 per 1000 with placebo/no treatment; RR 0.88, 0.78 to 0.99; 18 studies, 13,549 participants; low-certainty evidence). Analyses of secondary endpoints showed that corticosteroids may reduce the incidence of infectious complications (risk with corticosteroids: 94 to 113 per 1000 versus 123 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.76 to 0.92; 28 studies, 14,771 participants; low-certainty evidence). Corticosteroids may result in little to no difference in incidence of gastrointestinal bleeding (risk with corticosteroids: 9 to 17 per 1000 versus 10 per 1000 with placebo/no treatment; RR 1.21, 95% CI 0.87 to 1.67; 6 studies, 12,533 participants; low-certainty evidence) and renal failure (risk with corticosteroids: 23 to 35 per 1000 versus 34 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.69 to 1.02; 13 studies, 12,799; low-certainty evidence). Corticosteroids may reduce the length of hospital stay, but the evidence is very uncertain (-0.5 days, 0.97 to 0.04 fewer days of length of hospital stay compared with placebo/no treatment; 25 studies, 1841 participants; very low-certainty evidence). The results from the two largest trials included in the review possibly skew the overall findings from the meta-analysis.

AUTHORS' CONCLUSIONS

A systematic review of trials evaluating the organ protective effects of corticosteroids in cardiac surgery demonstrated little or no treatment effect on mortality, gastrointestinal bleeding, and renal failure. There were opposing treatment effects on cardiac and pulmonary complications, with evidence that corticosteroids may increase cardiac complications but reduce pulmonary complications; however, the level of certainty for these estimates was low. There were minor benefits from corticosteroid therapy for infectious complications, but the evidence on hospital length of stay was very uncertain. The inconsistent treatment effects across different outcomes and the limited data on high-risk groups reduced the applicability of the findings. Further research should explore the role of these drugs in specific, vulnerable cohorts.

Organ damage evaluation in a temperature-controlled circulatory arrest rat model

BACKGROUND

Deep hypothermic circulatory arrest (DHCA) is commonly used in adult aortic surgery and pediatric complex congenital heart disease, and is associated with pathophysiological changes and postoperative complications. Here, a temperature-controlled circulatory arrest model in rats was established to study the suitable temperature of circulatory arrest by investigating the damage to body organs under different temperatures.

METHODS

Thirty Sprague‒Dawley rats were randomly divided into 5 equal groups for DHCA experiments: I (15-20 °C), II (20-25 °C), III (25-30 °C), IV (normothermic cardiopulmonary bypass), and V (sham operation group). Blood gas analysis, homodynamic parameters, and intervals of cardiac recovery were measured at different time points in all groups. Morphological changes in intestinal tissue were observed under light and electron microscopes. Oxidative stress was measured by MPO activity, MDA, and SOD content. Tissue damage was confirmed by serum detection of ALT, AST, BUN, Cr, and LDH. To examine the inflammatory response, cytokines, including IL-1, IL-4, IL-10, IFN-γ, and TNF-α, were detected.

RESULTS

The extracorporeal circulation technique caused damage to the body; the degree of the damage caused by the circulatory arrest technique may be related to circulating temperature, with the least amount of damage occurring at 20-25 °C compared to 15-20 °C and 25-30 °C. Ischemia and hypoxia can cause intestinal tissue damage, which manifests primarily as a loss of the intestinal mucosal barrier. Ischemic intestinal damage caused by DHCA was not associated with inflammation.

CONCLUSION

The study provides new insights into the pathophysiologic mechanisms of DHCA.

Meta-Analysis: Shouldn't Prophylactic Corticosteroids be Administered During Cardiac Surgery with Cardiopulmonary Bypass?

Background

Corticosteroids can effectively inhibit systemic inflammation induced by cardiopulmonary bypass. Recently clinical trials and meta-analyses and current guidelines for cardiac surgery do not support corticosteroids prophylaxis during cardiac surgery because of an increase in myocardial infarction and no benefit for patients. The aim of this study is to determine whether specific corticosteroids dose ranges might provide clinical benefits without increasing myocardial infarction.

Methods

The PubMed, Web of Science, Embase, Clinical Trials, and Cochrane databases were searched for randomized controlled trials (RCTs) published before August 1, 2021.

Results

88 RCTs with 18,416 patients (17,067 adults and 1,349 children) were identified. Relative to placebo and high-dose corticosteroids, low-dose corticosteroids (≤20 mg/kg hydrocortisone) during adult cardiac surgery did not increase the risks of myocardial infarction (odds ratio [OR]: 0.96, 95% confidence interval [CI]: 0.43-2.17; p = 0.93). However, low-dose corticosteroids were associated with lower risks of atrial fibrillation (OR: 0.58, 95% CI: 0.44-0.76; p < 0.0001) and kidney injury (OR: 0.29, 95% CI: 0.09-0.96; p = 0.04). Furthermore, low-dose corticosteroids significantly shortened the mechanical ventilation times (mean difference [MD]: -2.74 h, 95% CI: -4.14, -1.33; p = 0.0001), intensive care unit (ICU) stay (MD: -1.48 days, 95% CI: -2.73, -0.22; p = 0.02), and hospital stay (MD: -2.29 days, 95% CI: -4.51, -0.07; p = 0.04).

Conclusion

Low-dose corticosteroids prophylaxis during cardiac surgery provided significant benefits for adult patients, without increasing the risks of myocardial infarction and other complications.

Low dose of methylprednisolone for pain and immune function after thoracic surgery

BACKGROUND

The purpose of this study was to evaluate the effects of single low-dose preoperative methylprednisolone (MP) on the immunological function and postoperative pain of patients undergoing elective video-assisted thoracoscopic surgery under general anesthesia.

METHODS

Eighty-one patients who underwent elective video-assisted thoracoscopic surgery were randomly assigned to the MP Group or the Control Group. The T lymphocyte subsets of CD3⁺, CD4⁺, and CD8⁺, the CD4⁺/CD8⁺ ratio at T₀ (before anesthesia), T₁ (after surgery), and T₂ (24 h after surgery) were all recorded. Postoperative rest and cough pain scores, as well as postoperative adverse effects and surgery complications were also recorded.

RESULTS

Compared to T0, the levels of CD3⁺ and CD4⁺ subsets and CD4⁺/CD8⁺ were significantly decreased, the level of CD8⁺ were increased after surgery in both groups. There was no significant difference in the variation of CD3+, CD4+, CD8⁺, and CD4+/CD8+ between the MP Group and the Control Group. Both the rest and cough pain of patients in the MP Group were significantly lower as compared to the Control Group at 2, 4, 6 and 24 hours after surgery. And the incidences of nausea and vomiting and dizziness were also significantly higher in the Control Group than those in the MP Group.

CONCLUSIONS

Preoperative single low-dose of MP (1 mg/kg) has no effect on immune function. Preoperative single low dose of MP (1 mg/kg) had effective analgesic effects and could reduce the incidence of dizziness and postoperative nausea and vomiting.

Efficacy and safety of corticosteroids prophylaxis in cardiac surgery: A protocol for systematic review and meta-analysis

BACKGROUND

Although corticosteroid prophylaxis in adult cardiac surgery has been studied extensively for 40 years, its role remains controversial, and the optimal dose remains uncertain. The objective of this meta-analysis was to estimate the clinical benefits and risks of corticosteroid use in cardiopulmonary bypass.

METHODS

We will search Pubmed, Web of Science, Embase, Clinical Trials, and Cochrane Central Register of Controlled Trials for relevant clinical trials published in any language before August 1, 2020. Randomized controlled trials (RCTs) of interest which meet inclusion criteria published or unpublished will be included. We will divide the included studies into child and adult groups for analysis. If sufficient data are available, the included trials will be divided into 4 subgroups: ≤20 mg/kg (low dose), 20-40 mg/kg (slightly high dose), 40-100 mg/kg (high dose), and >100 mg/kg (ultra high dose) based on the equivalent hydrocortisone dose. INPLASY registration number: INPLASY2020100044.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

This study will compare the efficacy of tprophylactic corticosteroids for adults and children undergoing cardiac surgery with CPB. Due to the nature of the disease and intervention methods, randomized controlled trials may be inadequate, and we will carefully consider inclusion in high-quality, non-randomized controlled trials, but this may result in high heterogeneity and affect the reliability of the results.

Management Strategies for Patients After CABG Surgery in the Outbreak of the COVID-19 Pandemic

Background

The novel coronavirus 2019 pandemic (COVID-19) has quickly spread over the world and affected over 100 countries so far. Patients with pre-existing cardiovascular disease may have a higher risk of infection of COVID-19 and worse outcomes than others. To improve the outcome during the pandemic, management strategies for the patients recovering from coronary artery bypass graft (CABG) surgery need to be reconsidered.

Methods

Some precaution advices including self-protection, blood glucose and blood pressure controlling are recommended for the patients recovering from CABG during the pandemic. They are encouraged to communicate with doctors by telephone or Internet when COVID-19 related symptoms such as cough, fever and dyspnea occur. As a follow-up strategy for patients after CABG surgery, cardiac biomarkers and CTA could also be helpful to the diagnosis of COVID-19. Some medications being investigated for COVID-19 therapy may have side effects relevant to cardiovascular disease. Appropriate personal protection equipment (PPE) is necessary for cardiovascular health-care workers operating in clinical settings.

Results

There was zero out of over 300 follow-up patients after CABG surgery confirmed to be infected with COVID-19 from January to June 2020. No cardiovascular health-care workers were reported to be infected neither in the Second Xiangya Hospital during the pandemic.

Conclusion

The management strategy here we proposed could improve the outcome of patients after CABG during the pandemic and benefit both cardiovascular patients and health-care workers.

Steroids and Survival in Critically Ill Adult Patients: A Meta-analysis of 135 Randomized Trials

OBJECTIVE

Corticosteroids have important effects on intermediate outcomes in critically ill patients, but their effect on survival is unknown. The objective of this meta-analysis was to analyze the effect on mortality of corticosteroids in critical and perioperative settings.

DESIGN

A meta-analysis of randomized trials.

SETTING

PubMed, Embase, BioMed Central, Google Scholar, and the Cochrane Central Register of Controlled Trials were searched to February 1, 2018, for randomized trials comparing corticosteroids with placebo or standard care.

PARTICIPANTS

Critically ill or surgical adult patients.

INTERVENTIONS

Corticosteroids compared with placebo or standard care.

MEASUREMENTS AND MAIN RESULTS

A total of 44,553 patients from 135 studies were included. Overall, mortality in the corticosteroid group and in the control group were similar (16% v 16%; p = 0.9). Subanalyses identified a beneficial effect of corticosteroids on survival in patients with respiratory system diseases (9% v 13%; p < 0.001) and bacterial meningitis (28% v 32%; p= 0.04), and a detrimental effect on survival in patients with traumatic brain injury (22% v 19%; p < 0.001). No differences in mortality were found in patients with cardiac diseases (7% v 6%; p = 0.7), in patients undergoing cardiac surgery (2.8% v 3.2% p = 0.14), and when treatment duration or patient age were considered.

CONCLUSIONS

This meta-analysis documents the safety of corticosteroids in the overall critically ill population with the notable exception of brain injury patients, a setting where the authors confirmed their detrimental effect on survival. A possible beneficial effect of corticosteroids on survival was found among patients with respiratory diseases and in patients with bacterial meningitis.

Lactate Elevation During and After Major Cardiac Surgery in Adults: A Review of Etiology, Prognostic Value, and Management

Elevated lactate is a common occurrence after cardiac surgery. This review summarizes the literature on the complex etiology of lactate elevation during and after cardiac surgery, including considerations of oxygen delivery, oxygen utilization, increased metabolism, lactate clearance, medications and fluids, and postoperative complications. Second, the association between lactate and a variety of outcomes are described, and the prognostic role of lactate is critically assessed. Despite the fact that elevated lactate is strongly associated with many important outcomes, including postoperative complications, length of stay, and mortality, little is known about the optimal management of postoperative patients with lactate elevations. This review ends with an assessment of the limited literature on this subject.

The inflammatory response to cardiopulmonary bypass: a therapeutic overview

The demographic of cardiac surgery patients continues to evolve to include older, sicker candidates, all the while maintaining an expectation of excellent outcomes. These latter results can only be achieved by the parallel advancement and re-examination of the technology of cardiopulmonary bypass (CPB); the key tool used daily by surgical teams worldwide. In this review, we will provide an overview of integrated therapeutic strategies that can be utilized to minimize the complex and myriad changes related to inflammation after CPB with the understanding that this may abrogate the detrimental end-organ and systemic effects of blood activation. Therapeutic strategies specifically related to the technology can be classified into those targeting biomaterial dependent or independent processes. The former can be addressed by the utilization of currently available biocompatible surfaces such as with heparin-coated circuits, phosphorylcholine-coated circuits (‘biomembrane mimicry’) and circuits composed of copolymers containing surface-modifying additives. The most important strategies related to biomaterial independent activation include the modification of techniques related to cardiotomy blood management and blood filtration. Finally, all of these strategies must be integrated and tailored with complementary pharmacologic agents such as aprotinin and steroids to optimize anti-inflammatory synergism. Only if we are armed with a comprehensive knowledge of the molecular and cellular basis for these strategies will we be able to continue to evolve our treatment in parallel with our patients to achieve these goals.

Concomitant off-pump coronary artery bypass and non-cardiovascular surgery

BACKGROUND

Reports on concomitant cardiac and non-cardiovascular surgeries have noted disadvantages in the use of extracorporeal circulation. We assessed the results of concomitant off-pump coronary artery bypass (OPCAB) and non-cardiovascular surgery, and compared them with isolated OPCAB results.

METHODS

Of 2,439 patients who underwent OPCAB between 1999 and 2014, 115 patients underwent concomitant OPCAB and non-cardiovascular surgery. Combined non-cardiovascular diseases included 63 malignant and 52 benign diseases. Concomitant non-cardiovascular surgeries performed were general (n=62), thoracic (n=47), orthopedic (n=3), urologic (n=2) and otolaryngologic surgeries (n=1). Operative results were compared between the OPCAB patients who underwent concomitant non-cardiovascular surgeries (group 1, n=115) and isolated OPCAB patients (group 2, n=2,251). Because preoperative characteristics of the two groups were different, a 1:2 propensity score-matched analysis was performed and operative results of the two matched groups were compared.

RESULTS

Operative mortality rates were 0.9% (1/115) in group 1 and 1.0% (22/2,251) in group 2 (P=0.909). Although there were differences in preoperative patient characteristics, postoperative complications, including atrial fibrillation (36.5% vs. 28.8%), perioperative myocardial infarction (MI) (4.3% vs. 5.2%), acute renal failure (1.7% vs. 4.9%), mediastinitis (0.9% vs. 0.8%), bleeding reoperation (0.9% vs. 2.9%), and respiratory complications (2.6% vs. 2.1%), did not show significant differences between the two groups. After a 1:2 propensity score-matched analysis, there were no statistical differences in operative complications between the two groups.

CONCLUSIONS

Concomitant OPCAB and non-cardiovascular surgeries were not associated with increased mortality and postoperative morbidities when compared with isolated OPCAB.

The Effect of Steroid Therapy on Postoperative Inflammatory Response after Endovascular Abdominal Aortic Aneurysm Repair

Objectives: Unexpected systemic inflammatory response with high fever and increase in C-reactive protein (CRP) occurred frequently after endovascular abdominal aortic aneurysm repair (EVAR). This excessive inflammatory response affects the postoperative course. We evaluated the effects of steroid on the postoperative inflammatory response after EVAR. Methods: Steroid therapy, intravenous infusion of methylprednisolone 1000 mg just after the anesthesia induction, was started since December 2012. After induction of the steroid therapy, 25 patients underwent EVAR with steroid therapy (Group S). These patients were compared with the 65 patients who underwent EVAR without steroid therapy (Group C) in white blood cell count (WBC), CRP and maximum body temperature (BT) on postoperative day 1-5. Results: There was no significant difference in age, female gender, operation time, maximum aneurysm diameter between the two groups. There was no postoperative infective complication in the both groups. WBC did not differ between the two groups; however, CRP was significantly suppressed in Group S than in Group C on POD 1, 3 and 5. Also BT was significantly lower in Group S than Group C on POD 1, 2 and 3. Conclusions: Steroid pretreatment before implantation of the stent graft reduces the early postoperative inflammatory response after EVAR, without increasing postoperative infection. (This is a translation of Jpn J Vasc Surg 2015; 24: 861-865.).

Minor Infection Encouraged by Steroid Administration during Cardiac Surgery

The aim of this study was to investigate whether steroid administration would increase the risk of postoperative infection. Sixty adults who underwent elective cardiac surgery under cardiopulmonary bypass were prospectively randomized into two groups. Thirty-one patients received hydrocortisone (50 mg·kg−1) before and after cardiopulmonary bypass, the other 29 served as controls. Various hemodynamic and pulmonary measurements were obtained perioperatively, and the white blood cell counts and levels of C-reactive protein were checked up to the 14th postoperative day. Steroid administration did not have any favorable effects during the perioperative period. Re-administration of antibiotics was needed in 7 patients (22.6%) after the 7th postoperative day in the steroid group, and in 3 (10.3%) in the control group. The peak white cell counts and C-reactive protein levels after the 7th postoperative day were significantly higher in the steroid group. Steroid administration offered no clinical benefit to patients undergoing cardiac surgery with cardiopulmonary bypass, and it may encourage minor infections in the late postoperative period.

Effect of steroids on inflammatory markers and clinical parameters in congenital open heart surgery: a randomised controlled trial

BACKGROUND

Cardiopulmonary bypass is associated with systemic inflammatory response. Steroids suppress this response, although the therapeutic evidence remains controversial. We hypothesised that intravenous steroids in children undergoing open-heart surgery would decrease inflammation leading to better early post-operative outcomes. We conducted a randomised controlled trial to evaluate the trends in the levels of immunomodulators and their effects on clinical parameters.

OBJECTIVE

To assess the effects of intravenous steroids on early post-operative inflammatory markers and clinical parameters in children undergoing open-heart surgery.

MATERIALS AND METHODS

A randomised controlled trial involving 152 patients, from one month up to 18 years of age, who underwent open-heart surgery for congenital heart disease from April 2010-2012 was carried out. Patients were randomised and administered either three scheduled intravenous pulse doses of dexamethasone (1 mg/kg) or placebo. Blood samples were drawn at four time intervals and serum levels of inflammatory cytokines - Interleukin-6, 8, 10, 18, and tumour necrosis factor-alpha - were measured. Clinical parameters were also assessed.

RESULTS

Blood cytokine levels were compared between the dexamethasone (n=65) and placebo (n=64) groups. Interleukin-6 levels were lower at 6 and 24 hours post-operatively (p<0.001), and Interleukin-10 levels were higher 6 hours post-operatively (p<0.001) in the steroid group. Interleukin-8, 18, and tumour necrosis factor-alpha levels did not differ between the groups at any time intervals. The clinical parameters were similar in both the groups.

CONCLUSION

Dexamethasone caused quantitative suppression of Interleukin-6 and increased Interleukin-10 activation, contributing to reduced immunopathology, but it did not translate into clinical benefit in the short term.

WITHDRAWN: Prophylactic steroids for pediatric open heart surgery

The Cochrane Heart Group withdrew this review as the current author team are unable to progress to the final review stage. This title has been taken over by a new author team who are producing a review, starting with a new protocol (Corticosteroids in paediatric heart surgery).

The editorial group responsible for this previously published document have withdrawn it from publication.

Does pharmacotherapy influence the inflammatory responses during cardiopulmonary bypass in children?

Cardiopulmonary bypass (CPB) induces a systemic inflammatory response syndrome (SIRS) by factors such as contact of the blood with the foreign surface of the extracorporeal circuit, hypothermia, reduction of pulmonary blood flow during CPB and endotoxemia. SIRS is maintained in the postoperative phase, co-occurring with a counter anti-inflammatory response syndrome. Research on the effects of drugs administered before the surgery, especially in the induction phase of anesthesia, as well as drugs used during extracorporeal circulation, has revealed that they greatly influence these postoperative inflammatory responses. A better understanding of these processes may not only improve postoperative recovery but also enable tailor-made pharmacotherapy, with both health and economic benefits. In this review, we describe the pathophysiology of SIRS and counter anti-inflammatory response syndrome in the light of CPB in children and the influence of drugs used on these syndromes.

Effect of high-dose dexamethasone on perioperative lactate levels and glucose control: a randomized controlled trial

Introduction

Blood lactate levels are increasingly used to monitor patients. Steroids are frequently administered to critically ill patients. However, the effect of steroids on lactate levels has not been adequately investigated. We studied the effect of a single intraoperative high dose of dexamethasone on lactate and glucose levels in patients undergoing cardiac surgery.

Methods

The Dexamethasone for Cardiac Surgery (DECS) trial was a multicenter randomized trial on the effect of dexamethasone 1 mg/kg versus placebo on clinical outcomes after cardiac surgery in adults. Here we report a pre-planned secondary analysis of data from DECS trial participants included at the University Medical Center Groningen. The use of a computer-assisted glucose regulation protocol—Glucose Regulation for Intensive care Patients (GRIP)—was part of routine postoperative care. GRIP aimed at glucose levels of 4 to 8 mmol/L. Primary outcome parameters were area under the lactate and glucose curves over the first 15 hours of ICU stay (AUC₁₅). ICU length of stay and mortality were observed as well.

Results

The primary outcome could be determined in 497 patients of the 500 included patients. During the first 15 hours of ICU stay, lactate and glucose levels were significantly higher in the dexamethasone group than in the placebo group: lactate AUC₁₅ 25.8 (13.1) versus 19.9 (11.2) mmol/L × hour, P <0.001 and glucose AUC₁₅ 126.5 (13.0) versus 114.4 (13.9) mmol/L × hour, P <0.001. In this period, patients in the dexamethasone group required twice as much insulin compared with patients who had received placebo. Multivariate and cross-correlation analyses suggest that the effect of dexamethasone on lactate levels is related to preceding increased glucose levels. Patients in the placebo group were more likely to stay in the ICU for more than 24 hours (39.2%) compared with patients in the dexamethasone group (25.0%, P = 0.001), and 30-day mortality rates were 1.6% and 2.4%, respectively (P = 0.759).

Conclusions

Intraoperative high-dose dexamethasone increased postoperative lactate and glucose levels in the first 15 hours of ICU stay. Still, patients in the dexamethasone group had a shorter ICU length of stay and similar mortality compared with controls.

Trial registration

ClinicalTrials.gov NCT00293592. Registered 16 February 2006.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0736-9) contains supplementary material, which is available to authorized users.

'Cool and quiet' therapy for malignant hyperthermia following severe traumatic brain injury: A preliminary clinical approach

Malignant hyperthermia increases mortality and disability in patients with brain trauma. A clinical treatment for malignant hyperthermia following severe traumatic brain injury, termed ‘cool and quiet’ therapy by the authors of the current study, was investigated. Between June 2003 and June 2013, 110 consecutive patients with malignant hyperthermia following severe traumatic brain injury were treated using mild hypothermia (35–36°C) associated with small doses of sedative and muscle relaxant. Physiological parameters and intracranial pressure were monitored, and the patients slowly rewarmed following the maintenance of mild hypothermia for 3–12 days. Consecutive patients who had undergone normothermia therapy were retrospectively analyzed as the control. In the mild hypothermia group, the recovery rate was 54.5%, the mortality rate was 22.7%, and the severe and mild disability rates were 11.8 and 10.9%, respectively. The mortality rate of the patients, particularly that of patients with a Glasgow Coma Scale (GCS) score of between 3 and 5 differed significantly between the hypothermia group and the normothermia group (P<0.05). The mortality of patients with a GCS score of between 6 and 8 was not significantly different between the two groups (P> 0.05). The therapy using mild hypothermia with a combination of sedative and muscle relaxant was beneficial in decreasing the mortality of patients with malignant hyperthermia following severe traumatic brain injury, particularly in patients with a GCS score within the range 3–5 on admission. The therapy was found to be safe, effective and convenient. However, rigorous clinical trials are required to provide evidence of the effectiveness of ‘cool and quiet’ therapy for hyperthermia.

Rationale and design of the steroids in cardiac surgery trial

BACKGROUND

Steroids may improve outcomes in high-risk patients undergoing cardiac surgery with the use of cardiopulmonary bypass (CBP). There is a need\ for a large randomized controlled trial to clarify the effect of steroids in such patients.

METHODS

We plan to randomize 7,500 patients with elevated European System for Cardiac Operative Risk Evaluation who are undergoing cardiac surgery with the use of CBP to methylprednisolone or placebo. The first coprimary outcome is 30-day all-cause mortality, and the most second coprimary outcome is a composite of death, MI, stroke, renal failure, or respiratory failure within 30 days. Other outcomes include a composite of MI or mortality at 30 days, new onset atrial fibrillation, bleeding and transfusion requirements, length of intensive care unit stay and hospital stay, infection, stroke, wound complications, gastrointestinal complications, delirium, postoperative insulin use and peak blood glucose, and all-cause mortality at 6 months.

RESULTS

As of October 22, 2013, 7,034 patients have been recruited into SIRS in 82 centers from 18 countries. Patient's mean age is 67.3 years, and 60.4% are male. The average European System for Cardiac Operative Risk Evaluation is 7.0 with 22.1% having an isolated coronary artery bypass graft procedure, and 66.1% having a valve procedure.

CONCLUSIONS

SIRS will lead to a better understanding of the safety and efficacy of prophylactic steroids for cardiac surgery requiring CBP.

Steroids for surgery during cardiopulmonary bypass in adults: a meta-analysis

STUDY OBJECTIVE

To evaluate the effect of steroid administration on myocardial infarction (MI), stroke, renal insufficiency, death, intensive care (ICU) length of stay (LOS) and hospital LOS of patients undergoing cardiopulmonary bypass (CPB).

DESIGN

Meta-analysis of parallel randomized controlled trials.

SETTING

University hospital.

MEAUREMENTS

A search was conducted in PubMed, EMBASE, MEDLINE(R) and the Cochrane Central Register of Controlled Trials of studies on adults undergoing surgery with CPB who received steroid administration. Effect size (risk ratio or mean difference) for MI, stroke, renal insufficiency, death, ICU LOS, and hospital LOS were evaluated.

MAIN RESULTS

48 RCTs published between 1977 and 2012 were retained for analysis. Steroids had no effect on the MI risk ratio (RR) 0.91 (95% confidence interval [CI] 0.63, 1.32); death at 30 days RR 0.84 (0.59, 1.20); stroke RR 0.92 (0.60, 1.42) or renal insufficiency RR 0.83 (0.52, 1.32). Administration of steroids reduced ICU LOS (P = 0.00001; I(2) 87.5%) and hospital LOS (P = 0.03; I(2) 81.1%). Metaregressions showed that duration of steroid administration was correlated with the reduction in ICU LOS (P = 0.0004) and hospital LOS (P < 0.00001).

CONCLUSIONS

Increasing the duration of steroid administration may reduce ICU and hospital LOS greater than increasing the dose.

Prophylactic steroids for paediatric open-heart surgery: a systematic review

Background  The immune response to cardiopulmonary bypass in infants and children can lead to a series of post-operative morbidities and mortality, that is, hemodynamic instability, increased infection and tachyarrhythmias. Administration of prophylactic doses of corticosteroids is sometimes used to try and ameliorate this pro-inflammatory response. However, the clinical benefits and harms of this type of intervention in the paediatric patient remain unclear. Objectives  To systematically review the beneficial and harmful effects of the prophylactic administration of corticosteroids, compared with placebo, in paediatric open-heart surgery. Search strategy  The trials registry of the Cochrane Heart Group, the Cochrane Central Register of Controlled Trials in The Cochrane Library (Issue 4, 2006), MEDLINE (1966 to January 2007), EMBASE (1980 to January 2007) were searched. An additional hand-search of the EMRO database for Arabic literature was performed. Grey literature was searched, and experts in the field were contacted for any unpublished material. No language restrictions were applied. Selection criteria  All randomised and quasi-randomised controlled trials of open-heart surgery in the paediatric population that received corticosteroids pre-, peri- or post-operatively, with reported clinical outcomes in terms of morbidity and mortality. Data collection and analysis  Eligible studies were abstracted and evaluated by two independent reviewers. All meta-analyses were completed using RevMan4.2.8. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random-effects model. Main results  All cause mortality could not be assessed as the data reports were incomplete. There was weak evidence in favour of prophylactic corticosteroid administration for reducing intensive care unit stay, peak core temperature and duration of ventilation (WMD (95% confidence intervals) -0.50 h (-1.41 to 0.41); -0.20°C (-1.16 to 0.77) and -0.63 h (-4.02 to 2.75) respectively).

Point of care serum lactate levels as a prognostic marker of outcome in complex pediatric cardiac surgery patients: Can we utilize it?

BACKGROUND

Post-operative course after complex pediatric cardiac surgery is unpredictable. Although, change in arterial lactate levels has been used as a surrogate marker for many years, scientific evidence correlating the early perioperative lactate levels with outcome is still lacking.

OBJECTIVE

To evaluate the trends in lactate levels from intraoperative period to an extended post-operative period in pediatric intensive care unit (PICU) and to assess its usefulness as a prognostic marker.

DESIGN

Prospective observational study.

SETTING

Tertiary pediatric cardiac surgical unit.

PATIENTS

Thirty-five non-consecutive children aged 1-140 months who underwent surgery for congenital heart diseases (CHD) on cardiopulmonary bypass (CPB).

INTERVENTION

None.

MATERIALS AND METHODS

ARTERIAL BLOOD LACTATE LEVELS WERE OBTAINED AT THE FOLLOWING TIME POINTS: After induction of anesthesia, 15 and 45 min after institution of CPB, at the start of rewarming, after sternotomy closure, then at 1, 6, 24, and 48 h in PICU. Other hemodynamic and clinical variables, CPB variables, blood gas values, and laboratory variables were also recorded.

RESULTS

Four patients died out of 35 patients (11.4%). Non-survivors showed significant persistent elevation in lactates (>4.0 mmol/l). Peak lactates correlate significantly with longer aortic cross clamp time, CPB duration, ventilation hours and PICU stay.

CONCLUSION

Early point of care lactate can be a useful prognostic marker in post-cardiac surgery patients in adjunct with other parameters measured in PICU. This reiterates the importance of measuring lactates and timely recognition of at-risk patients, which on early intervention can help in reducing post-operative morbidity and mortality.

Left upper lobectomy with combined resection of the distal arch aorta after chemoradiotherapy for locally advanced lung cancer

We report a case of complete resection of lung cancer involving the thoracic aorta, after induction chemoradiotherapy in a 55-year-old man. The chemoradiotherapy, which consisted of two courses of platinum-based chemotherapy with concurrent radiation to a total of 40 Gy, resulted in a partial response. Left upper lobectomy with combined resection and reconstruction of the distal arch aorta and left subclavian artery was performed under cardiopulmonary bypass. The patient was given two courses of platinum-based adjuvant chemotherapy, and there has been no sign of recurrence in the 34 months since his operation.

Prophylactic corticosteroids for cardiopulmonary bypass in adults

BACKGROUND

High-dose prophylactic corticosteroids are often administered during cardiac surgery. Their use, however, remains controversial, as no trials are available that have been sufficiently powered to draw conclusions on their effect on major clinical outcomes.

OBJECTIVES

The objective of this meta-analysis was to estimate the effect of prophylactic corticosteroids in cardiac surgery on mortality, cardiac and pulmonary complications.

SEARCH STRATEGY

Major medical databases (CENTRAL, MEDLINE, EMBASE, CINAHL and Web of Science) were systematically searched for randomised studies assessing the effect of corticosteroids in adult cardiac surgery. Database were searched for the full period covered, up to December 2009. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials comparing corticosteroid treatment to either placebo treatment or no treatment in adult cardiac surgery were selected. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more end-points.

DATA COLLECTION AND ANALYSIS

The processes of searching and selection for inclusion eligibility were performed independently by two authors. Also, quality assessment and data-extraction of selected studies were independently performed by two authors. The primary endpoints were mortality, cardiac and pulmonary complications. The main effect measure was the Peto odds ratio comparing corticosteroids to no treatment/placebo.

MAIN RESULTS

Fifty-four randomised studies, mostly of limited quality, were included. Altogether, 3615 patients were included in these studies. The pooled odds ratio for mortality was 1.12 (95% CI 0.65 to 1.92), showing no mortality reduction in patients treated with corticosteroids. The odds ratios for myocardial and pulmonary complications were 0.95, (95% CI 0.57 to 1.60) and 0.83 (95% CI 0.49 to 1.40), respectively. The use of a random effects model did not substantially influence study results. Analyses of secondary endpoints showed a reduction of atrial fibrillation and an increase in gastrointestinal bleeding in the corticosteroids group.

AUTHORS' CONCLUSIONS

This meta-analysis showed no beneficial effect of corticosteroid use on mortality, cardiac and pulmonary complications in cardiac surgery patients.

Modulation of the cellular and humoral immune response to pediatric open heart surgery by methylprednisolone

BACKGROUND

With the intention to reduce overshooting immune response, glucocorticoids are frequently administered perioperatively in children undergoing open heart surgery. In a retrospective study we investigated extensively the modulation of the humoral and cellular immune response by methylprednisolone (MP).

METHODS

This study was carried out on blood samples from two groups of children who had undergone surgical correction of atrial or ventricular septal defects, either without (MP⁻, n = 10), or with MP administration (MP+, n = 23, dose median 11 (IQR 10-16) mg kg⁻¹ body weight) before cardiopulmonary bypass (CPB, duration median 42 (IQR 36-65) min). EDTA blood was obtained 24 h preoperatively, after anesthesia, at CPB begin and end, 4, 24, and 48 h after surgery, at discharge and at out-patient follow-up (median 8.2 (IQR 3.3-12.2) months after surgery). Complex blood analysis including clinical chemistry and flow cytometry were performed to monitor humoral immune response, differential blood count, lymphocyte subsets, and the degree of activation of various leukocyte subpopulations.

RESULTS

The patients' postoperative courses and follow-up were uneventful. Release of IL-6 and IL8 was reduced and that of the anti-inflammatory cytokine IL-10 upregulated by MP. Significant increase of circulating neutrophils and monocytes as inflammatory reaction to surgery and CPB contact was detected in both groups. However, invasion of monocytes to the periphery was delayed with MP. CD4+ and CD8+ T-lymphocyte counts were lower with MP treatment. B-lymphocyte count increased significantly after surgery in MP+ but remained constant in MP⁻ group.

CONCLUSIONS

MP treatment partially decreased the pro-inflammatory effect of CPB surgery and induced anti-inflammatory effect on the cellular and humoral level.

Effect of Cardiopulmonary Bypass on Cancer Prognosis

Adverse effects of cardiopulmonary bypass on cancer prognosis are expected but have not been confirmed. Seventy-four cancer patients who underwent cardiac surgery before cancer therapy were followed up for 42 ± 37 months; 45 had cardiac surgery with cardiopulmonary bypass. There was no significant difference in cancer recurrence (40.0%) and deaths (26.7%) among patients who had cardiopulmonary bypass and those who underwent off-pump cardiac surgery (27.6% and 24.1%). There were no significant differences in freedom from cancer-related death at 2 and 5 years after cardiac surgery (78.4% and 68.5%) in the cardiopulmonary bypass group compared to the 29 off-pump group (81.8% and 58.3%). Despite some limitations, this study detected no significant adverse effects of cardiopulmonary bypass on cancer prognosis. Although these results do not verify the safety of cardiopulmonary bypass from an oncologic aspect, they suggest it can be applied in cancer patients who require cardiac surgery.

Protective effects of steroids in cardiac surgery: a meta-analysis of randomized double-blind trials

OBJECTIVE

Cardiac surgery and cardiopulmonary bypass (CPB) induce an acute inflammatory response contributing to postoperative morbidity. The use of steroids as anti-inflammatory agents in surgery using CPB has been tested in many trials and has been shown to have good anti-inflammatory effects but no clear clinical advantages for the lack of an adequately powered sample size. The aim of this study was to evaluate the effects of steroid treatment on mortality and morbidity after cardiac surgery.

DESIGN

A systematic meta-analysis of randomized double-blind trials (RDBs).

SETTING

A university hospital.

PARTICIPANTS

Adult patients who underwent cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

A trial search was performed through PubMed and Cochrane databases from 1966 to January 2009. Among 104 clinical trials reviewed, 31 RDB trials (1,974 patients) were considered suitable to be analyzed. A quality assessment of the trials was performed using the Jadad score. The types of steroid used in these trials were methylprednisolone (51.4%), dexamethasone (34.3%), hydrocortisone (5.7%), prednisolone (2.9%), or a combination of methylprednisolone and dexamethasone (5.7%). Steroid prophylaxis provided a protective effect preventing postoperative atrial fibrillation (odds ratio = 0.56; confidence interval [CI] 0.44-0.72, p < 0.0001), reducing postoperative blood loss (mean difference = -204.2 mL; CI from -287.4 to -121 mL; p < 0.0001), and reducing intensive care unit (mean difference = -6.6 hours; CI from -10.5 to -2.7 hours, p = 0.0007) and overall hospital stay (mean difference = -0.8 days; CI from -1.4 to -0.2 days, p = 0.01). Steroid prophylaxis had no effect on postoperative mortality, mechanical ventilation duration, re-exploration for bleeding, and postoperative infection.

CONCLUSIONS

A systematic review of RDB trials reveals that steroid prophylaxis may reduce morbidity after cardiac surgery and does not increase the risk of postoperative infections.

Benefits and Risks of Corticosteroid Prophylaxis in Adult Cardiac Surgery

Background— Cardiopulmonary bypass and cardiac surgery are associated with a significant systemic inflammatory response that may increase postoperative complications. This meta-analysis assessed whether the benefits and risks of corticosteroid use were dose dependent in adult cardiac surgery.

Methods and Results— Randomized controlled trials of the use of corticosteroid prophylaxis in adult cardiac surgery (>18 years of age) requiring cardiopulmonary bypass were selected from MEDLINE (1966 to August 1, 2008), EMBASE (1988 to August 1, 2008), and the Cochrane controlled trials register without any language restrictions. A total of 3323 patients from 50 randomized controlled trials were identified and subject to meta-analysis. Corticosteroid prophylaxis reduced the risk of atrial fibrillation (25.1% versus 35.1%; number needed to treat, 10; relative risk, 0.74; 95% confidence interval [CI], 0.63 to 0.86; P <0.01) and length of stay in the intensive care unit (weighted mean difference, −0.37 days; 95% CI, −0.21 to −0.52; P <0.01) and hospital (weighted mean difference, −0.66 days; 95% CI, −0.77 to −1.25; P =0.03) compared with placebo. The use of corticosteroid was not associated with an increased risk of all-cause infection (relative risk, 0.93; 95% CI, 0.61 to 1.41; P =0.73), but hyperglycemia requiring insulin infusion after corticosteroid prophylaxis was common (28.2%; relative risk, 1.49; 95% CI, 1.11 to 2.01; P <0.01). No additional benefits were found on all outcomes beyond a total dose of 1000 mg hydrocortisone, and very high doses of corticosteroid were associated with prolonged mechanical ventilation.

Conclusions— Evidence suggests that low-dose corticosteroid is as effective as high-dose corticosteroid in reducing the risk of atrial fibrillation and duration of mechanical ventilation but with fewer potential side effects in adult cardiac surgery.

Clinical benefit of steroid use in patients undergoing cardiopulmonary bypass: a meta-analysis of randomized trials

We sought to establish the efficacy and safety of prophylactic steroids in adult patients undergoing cardiopulmonary bypass (CPB). We performed a meta-analysis of randomized trials reporting the effects of prophylactic steroids on clinical outcomes after CPB. Outcomes examined were mortality, myocardial infarction, neurological events, new onset atrial fibrillation, transfusion requirements, postoperative bleeding, duration of ventilation, intensive care unit (ICU) stay, hospital stay, wound complications, gastrointestinal complications, and infectious complications. We included 44 trials randomizing 3205 patients. Steroids reduced new onset atrial fibrillation [relative risk (RR) 0.71, 95% confidence interval (CI) 0.59 to 0.87], postoperative bleeding [weighted mean difference (WMD) -99.6 mL, 95% CI -149.8 to -49.3], and duration of ICU stay (WMD -0.23 days, 95% CI -0.40 to -0.07). Length of hospital stay was also reduced (WMD -0.59 days, 95% CI -1.17 to -0.02), but this result was less robust. A trend towards reduction in mortality was observed (RR 0.73, 95% CI 0.45 to 1.18). Randomized trials suggest that perioperative steroids have significant clinical benefit in CPB patients by decreasing the risk of new onset atrial fibrillation, while results are encouraging for reducing bleeding, length of stay, and mortality. These data do not raise major safety concerns, however, a sufficiently powered trial is warranted to confirm or refute these findings.

Prophylactic steroids for paediatric open-heart surgery: a systematic review

BACKGROUND

The immune response to cardiopulmonary bypass in infants and children can lead to a series of post-operative morbidities and mortality, that is, hemodynamic instability, increased infection and tachyarrhythmias. Administration of prophylactic doses of corticosteroids is sometimes used to try and ameliorate this pro-inflammatory response. However, the clinical benefits and harms of this type of intervention in the paediatric patient remain unclear.

OBJECTIVES

To systematically review the beneficial and harmful effects of the prophylactic administration of corticosteroids, compared with placebo, in paediatric open-heart surgery.

SEARCH STRATEGY

The trials registry of the Cochrane Heart Group, the Cochrane Central Register of Controlled Trials in The Cochrane Library (Issue 4, 2006), MEDLINE (1966 to January 2007), EMBASE (1980 to January 2007) were searched. An additional hand-search of the EMRO database for Arabic literature was performed. Grey literature was searched, and experts in the field were contacted for any unpublished material. No language restrictions were applied.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials of open-heart surgery in the paediatric population that received corticosteroids pre-, peri- or post-operatively, with reported clinical outcomes in terms of morbidity and mortality.

DATA COLLECTION AND ANALYSIS

Eligible studies were abstracted and evaluated by two independent reviewers. All meta-analyses were completed using RevMan4.2.8. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random-effects model.

MAIN RESULTS

All cause mortality could not be assessed as the data reports were incomplete. There was weak evidence in favour of prophylactic corticosteroid administration for reducing intensive care unit stay, peak core temperature and duration of ventilation (WMD (95% confidence intervals) -0.50 h (-1.41 to 0.41); -0.20°C (-1.16 to 0.77) and -0.63 h (-4.02 to 2.75) respectively).

Prophylactic steroids for pediatric open heart surgery

BACKGROUND

The immune response to cardiopulmonary bypass in infants and children can lead to a series of postoperative morbidities and mortality i.e. hemodynamic instability, increased infection and tachyarrhythmias. Administration of prophylactic doses of corticosteroids is sometimes used to try and ameliorate this pro-inflammatory response. However, the clinical benefits and harms of this type of intervention in the pediatric patient remains unclear.

OBJECTIVES

To systematically review the beneficial and harmful effects of the prophylactic administration of corticosteroids, compared with placebo, in pediatric open heart surgery.

SEARCH STRATEGY

The trials registry of the Cochrane Heart Group, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 4, 2006), MEDLINE (1966 to January 2007), EMBASE (1980 to January 2007) were searched. An additional handsearch of the EMRO database for Arabic literature was performed. Grey literature was searched and experts in the field were contacted for any unpublished material. No language restrictions were applied.

SELECTION CRITERIA

All randomized and quasi-randomized controlled trials of open heart surgery in the pediatric population that received corticosteroids pre-, peri- or post-operatively, with reported clinical outcomes in terms of morbidity and mortality.

DATA COLLECTION AND ANALYSIS

Eligible studies were abstracted and evaluated by two independent reviewers. All meta-analyses were completed using RevMan4.2.8. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random-effects model.

MAIN RESULTS

All cause mortality could not be assessed as the data reports were incomplete. There was weak evidence in favor of prophylactic corticosteroid administration for reducing intensive care unit stay, peak core temperature and duration of ventilation [WMD (95% CI) -0.50 hours (-1.41 to 0.41); -0.20 degrees C (-1.16 to 0.77) and -0.63 hours (-4.02 to 2.75), respectively].

AUTHORS' CONCLUSIONS

The use of prophylactic steroids in pediatric patients to reduce postoperative complications commonly experienced following cardiopulmonary bypass surgery is not supported by the existing evidence. Further well designed and adequately powered randomized controlled trials are needed to more accurately estimate the benefit and harm of this intervention.

Cardiopulmonary and systemic effects of methylprednisolone in patients undergoing cardiac surgery

BACKGROUND

Cardiopulmonary bypass (CPB)-related inflammatory response can be attenuated by glucocorticoid treatment, but its impact on postoperative cardiopulmonary function remains controversial. It was investigated whether the systemic and myocardial antiinflammatory effects of glucocorticoids are associated with improved cardiopulmonary function in cardiac surgery patients.

METHODS

Eighty patients undergoing elective coronary artery bypass grafting were randomly assigned to receive a single shot of methylprednisolone (15 mg/kg) or placebo before CPB. Variables of myocardial and pulmonary function and systemic hemodynamics were measured before and 1, 4, 10, and 24 hours after CPB. Blood was sampled for measurement of proinflammatory (tumor necrosis factor-alpha, interleukin 6, interleukin 8) and antiinflammatory (interleukin 10) cytokines (by enzyme-linked immunoassay), troponin T, and C-reactive protein. Phosphorylation of inhibitory kappa-B alpha and p38 mitogen-activated protein kinase was determined in right atrial biopsies before and after CPB (phosphoprotein assay).

RESULTS

Preoperative and intraoperative characteristics of patients were not different between groups. Methylprednisolone attenuated postoperative tumor necrosis factor-alpha, interleukin 6, interleukin 8, and C-reactive protein levels while increasing interleukin 10 release. Myocardial inhibitory kappa-B alpha was preserved with methylprednisolone (p < 0.05 versus placebo), but p38 mitogen-activated protein kinase activation occurred in both groups after CPB (p < 0.05 versus before CPB). Methylprednisolone improved postoperative cardiac index and was associated with decreased troponin T when compared with placebo (p < 0.05). Postoperative blood glucose, oxygen delivery index, and pulmonary shunt flow were increased in the methylprednisolone group (p < 0.05). There was no difference in postoperative oxygenation index, ventilation time, and clinical outcome between treatment groups.

CONCLUSIONS

Glucocorticoid treatment before CPB attenuates perioperative release of systemic and myocardial inflammatory mediators and improves myocardial function, suggesting potential cardioprotective effects in patients undergoing cardiac surgery.

Effect of Dexamethasone on Atrial Fibrillation After Cardiac Surgery: Prospective, Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVE

The purpose of this study was to assess the effect of preoperative dexamethasone (DEX) on the occurrence of postoperative atrial fibrillation (AF).

DESIGN

Prospective, randomized, double-blind, placebo-controlled clinical trial.

SETTING

Tertiary referral center.

PARTICIPANTS

Seventy-eight adult patients undergoing combined valve and coronary artery bypass graft (CABG) surgery were randomized to receive either DEX or placebo.

INTERVENTIONS

The DEX group received dexamethasone, 0.6 mg/kg, after induction of anesthesia, and the placebo group received an equal volume of normal saline. Interleukin (IL)-6, -8, and -10; tumor necrosis factor alpha; and endothelin (ET)-1 were measured preoperatively and on postoperative days (POD) 1, 2, and 3. Complement (C-4) and C-reactive protein (CRP) were measured preoperatively and on POD 2. Exhaled nitric oxide (NO) was measured preoperatively, 15 minutes after aortic unclamping, and 1 hour after intensive care unit admission.

MEASUREMENTS AND MAIN RESULTS

No significant difference in the incidence of AF was found between the placebo (41%) and DEX groups (30%) (95% confidence interval [-11%, 34%); p = 0.31). DEX significantly reduced at least 1 postoperative level of IL-6, IL-8, IL-10, CRP, and exhaled NO. DEX did not affect ET-1 or C-4 levels. IL-10 on POD 3 was positively correlated with postoperative hospital length of stay (r = 0.30, p = 0.01). Increased levels of IL-8 and IL-10 on POD 1 were positively correlated with the intubation time (r = 0.31, p = 0.01; r = 0.30, p = 0.01, respectively). Conversely, C-4 on POD 2 was negatively correlated with the intubation time and intensive care unit length of stay (r = -0.32, p = 0.006; r = -0.30, p = 0.01, respectively).

CONCLUSIONS

DEX did not affect the incidence of AF in patients undergoing combined CABG and valve surgery. However, it did modulate the release of several inflammatory and acute-phase response mediators that are associated with adverse outcomes.

Pulse Low Dose Steroids Attenuate Post-Cardiopulmonary Bypass SIRS; SIRS I

BACKGROUND

Cardiopulmonary bypass (CPB) initiates inflammation that contributes to multiorgan dysfunction (SIRS). Steroids have been demonstrated to attenuate this response; however, resistance to use steroids remains because of potential adverse effects of the high doses used. This study examines a lower dose steroid protocol for safety and attenuation of SIRS.

METHODS

Sixty patients undergoing CPB were randomized to pulse low doses of methylprednisolone (250 mg given twice IV) or placebo in this RCT. Outcomes pertaining to hemodynamics, ventilator requirement, arrhythmia, and metabolic derangements were recorded. Post-operative glucose control and gastrointestinal prohylaxis was instituted in all patients.

RESULTS

IL-6 concentrations were lower in the steroid group at 4 and 8 h post-operatively (P < 0.0001). The steroid group demonstrated more normothermia (37.2 degrees C versus 37.6 degrees C, P = 0.002), better hemodynamic stability with less requirement for inotropes or vasopressors (0% versus 27.6%, P = 0.005), higher SVRIs (1840 versus 1340 DSm2/cm5, P = 0.002), and higher mean arterial pressures (79 versus 74 mmHg, P = 0.03). The steroid group had a shorter duration of intubation (7.7 versus 10.7 h, P = 0.02), a shorter length of ICU stay (1.0 versus 2.0 days, P = 0.03), and less blood loss (505 versus 690 ml, P = 0.04) with no difference in post-operative blood glucose levels or complications.

CONCLUSIONS

Patients undergoing cardiopulmonary bypass receiving low pulse dose steroids had better hemodynamics, shorter mechanical ventilation times, less blood loss, and required less time in the ICU compared to those receiving placebo. Therefore, this study demonstrates that prophylactic low dose steroids attenuate the SIRS response to CPB without resulting in any untoward side-effects.

Pulmonary and renal function following cardiopulmonary bypass is associated with systemic capillary leak

OBJECTIVE

The purpose of this study was to compare perioperative capillary permeability during cardiac surgery with subsequent pulmonary and renal function.

DESIGN

An observational prospective comparison of capillary permeability (microalbuminuria) during and after cardiopulmonary bypass (CPB), with postoperative pulmonary and renal function.

SETTING

A university teaching hospital.

PARTICIPANTS

Forty patients, mean (range) age 67.8 (50-85) years, undergoing elective first-time coronary artery bypass grafting (CABG).

INTERVENTIONS

Urine albumin concentration (AC) and albumin creatinine ratio (ACR) were compared with PO2 /FIO2 ratio, mechanical ventilation (intermittent positive-pressure ventilation [IPPV]) duration, and renal function.

MEASUREMENTS AND MAIN RESULTS

Median (range) AC and ACR increased from 8.3 (1.6-184.2) mg/L and 0.65 (0.1-18.8) mg/mmol preoperatively to 13.6 (1.6-267.2) mg/L and 4.80 (0.3-54.2) mg/mmol 10 minutes postbypass (p = 0.003 for ACR Wilcoxon rank test: not significant for AC). AC 2 hours postbypass was associated with mean PO2 /FIO2 ratio 0 to 2 hours postbypass and AC 4 hours postbypass was associated with mean PO2 /FIO2 ratio 0 to 2 and 2 to 12 hours postbypass (p < 0.05 Spearman). ACR 2 hours postbypass was associated with mean PO2 /FIO2 ratio 0 to 2 and 2 to 12 hours postbypass (p < 0.05 Spearman). AC 10 minutes and 2 hours postbypass and ACR 2 hours postbypass were associated with the duration of IPPV (p < 0.03). Day 1 serum creatinine was associated with pre- and 4 hours postbypass AC and ACR (p < 0.05). Day 2 serum creatinine was associated with 2 and 4 hours postbypass ACR (p < 0.05).

CONCLUSIONS

The magnitude of increase in capillary permeability during CABG is associated with later pulmonary and renal function.

The effects of steroids on the occurrence of postoperative atrial fibrillation after coronary artery bypass grafting surgery: A prospective randomized trial

OBJECTIVE

Atrial fibrillation remains one of the most common postoperative complications of coronary artery bypass grafting. Despite many clinical studies, there is still no consensus regarding the best prevention strategy for atrial arrhythmia. A randomized, double-blind, placebo-controlled trial was conducted to determine the effect of steroids on the occurrence of atrial fibrillation after elective coronary artery bypass grafting.

METHODS

Eighty-eight consecutive patients were prospectively entered in this study. No patient had documented or suspected arrhythmias before surgery. Forty-three patients received 1 g of methylprednisolone before surgery and 4 mg of dexamethasone every 6 hours for 1 day after surgery, and 43 patients received only placebo. The primary end point was the overall occurrence of postoperative atrial fibrillation.

RESULTS

Postoperative atrial fibrillation occurred in 9 (21%) of the 43 patients in the steroid group, as compared with 22 (51%) of the 43 patients in the placebo group ( P = .003). Minor postoperative complications occurred in 15 steroid patients (35%) and in 6 patients (14%) receiving placebo ( P = .01). Major complications occurred in 4 patients who received steroids (9%) and in 2 patients (5%) who received placebo ( P = .68; for all complications, P = .05).

CONCLUSIONS

Prophylactic short-term steroid administration in patients undergoing coronary artery bypass grafting significantly reduced postoperative atrial fibrillation. In this study, there was no significant difference between the steroid group and the placebo group with regard to the length of hospital stay; however, the steroid group had more complications, which may contribute to prolonged hospitalization.