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D'Amico F, Pruna A, Putowski Z, Dormio S, Ajello S, Scandroglio AM, Lee TC, Zangrillo A, Landoni G. Low Versus High Blood Pressure Targets in Critically Ill and Surgical Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2024:00003246-990000000-00330. [PMID: 38656245 DOI: 10.1097/ccm.0000000000006314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVES Hypotension is associated with adverse outcomes in critically ill and perioperative patients. However, these assumptions are supported by observational studies. This meta-analysis of randomized controlled trials aims to compare the impact of lower versus higher blood pressure targets on mortality. DATA SOURCES We searched PubMed, Cochrane, and Scholar from inception to February 10, 2024. STUDY SELECTION Randomized trials comparing lower versus higher blood pressure targets in the management of critically ill and perioperative settings. DATA EXTRACTION The primary outcome was all-cause mortality at the longest follow-up available. This review was registered in the Prospective International Register of Systematic Reviews, CRD42023452928. DATA SYNTHESIS Of 2940 studies identified by the search string, 28 (12 in critically ill and 16 in perioperative settings) were included totaling 15,672 patients. Patients in the low blood pressure target group had lower mortality (23 studies included: 1019/7679 [13.3%] vs. 1103/7649 [14.4%]; relative risk 0.93; 95% CI, 0.87-0.99; p = 0.03; I2 = 0%). This corresponded to a 97.4% probability of any increase in mortality with a Bayesian approach. These findings were mainly driven by studies performed in the ICU setting and with treatment lasting more than 24 hours; however, the magnitude and direction of the results were similar in the majority of sensitivity analyses including the analysis restricted to low risk of bias studies. We also observed a lower rate of atrial fibrillation and fewer patients requiring transfusion in low-pressure target groups. No differences were found in the other secondary outcomes. CONCLUSIONS Based on pooled randomized trial evidence, a lower compared with a higher blood pressure target results in a reduction of mortality, atrial fibrillation, and transfusion requirements. Lower blood pressure targets may be beneficial but there is ongoing uncertainty. However, the present meta-analysis does not confirm previous findings and recommendations. These results might inform future guidelines and promote the study of the concept of protective hemodynamics.
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Affiliation(s)
- Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Zbigniew Putowski
- Department of Intensive Care and Perioperative Medicine, Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Sara Dormio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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Jian B, Liu H, Zhang Y, Li G, Yang S, Fu G, Huang S, Huang Y, Zhou Z, Wu Z, Liang M. Postoperative Dipping Patterns of Mean Arterial Pressure and Mortality After Coronary Artery Bypass Grafting. J Cardiovasc Transl Res 2024; 17:287-297. [PMID: 38196010 DOI: 10.1007/s12265-023-10475-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 12/18/2023] [Indexed: 01/11/2024]
Abstract
Blood pressure dipping patterns have long been considered to be associated with adverse events. We aimed to investigate whether dipping patterns of postoperative MAP were related to 90-day and hospital mortality in patients undergoing CABG. Four thousand three hundred ninety-one patients were classified into extreme dippers (night-to-day ratio of MAP ≤ 0.8), dippers (0.8 < night-to-day ratio of MAP ≤ 0.9), non-dippers (0.9 < night-to-day ratio of MAP ≤ 1), and reverse dippers (> 1). Compared with non-dippers, reverse dippers were at a higher risk of 90-day mortality (aHR = 1.58; 95% CI, 1.10-2.27) and hospital mortality (aOR = 1.97; 95% CI, 1.12-3.47). A significant interaction was observed between hypertension and dipping patterns (P for interaction = 0.02), with a significant increased risk of 90-day mortality in non-hypertensive reverse dippers (aHR = 1.90; 95% CI, 1.17-3.07) but not in hypertensive reverse dippers (aHR = 1.26; 95% CI, 0.73-2.19).
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Affiliation(s)
- Bohao Jian
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Haoliang Liu
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yi Zhang
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Gang Li
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Song Yang
- Department of Cardiothoracic Surgical ICU, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Guangguo Fu
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Suiqing Huang
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yang Huang
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Zhuoming Zhou
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
| | - Zhongkai Wu
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
| | - Mengya Liang
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
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Francica A, Mazzeo G, Galeone A, Linardi D, San Biagio L, Luciani GB, Onorati F. Mean Arterial Pressure (MAP) Trial: study protocol for a multicentre, randomized, controlled trial to compare three different strategies of mean arterial pressure management during cardiopulmonary bypass. Trials 2024; 25:191. [PMID: 38491507 PMCID: PMC10941373 DOI: 10.1186/s13063-024-07992-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 02/16/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND One of the main goals of cardiopulmonary bypass (CPB) is targeting an adequate mean arterial pressure (MAP) during heart surgery, in order to maintain appropriate perfusion pressures in all end-organs. As inheritance of early studies, a value of 50-60 mmHg has been historically accepted as the "gold standard" MAP. However, in the last decades, the CPB management has remarkably changed, thanks to the evolution of technology and the availability of new biomaterials. Therefore, as highlighted by the latest European Guidelines, the current management of CPB can no longer refer to those pioneering studies. To date, only few single-centre studies have compared different strategies of MAP management during CPB, but with contradictory findings and without achieving a real consensus. Therefore, what should be the ideal strategy of MAP management during CPB is still on debate. This trial is the first multicentre, randomized, controlled study which compares three different strategies of MAP management during the CPB. METHODS We described herein the methodology of a multicentre, randomized, controlled trial comparing three different approaches to MAP management during CPB in patients undergoing elective cardiac surgery: the historically accepted "standard MAP" (50-60 mmHg), the "high MAP" (70-80 mmHg) and the "patient-tailored MAP" (comparable to the patient's preoperative MAP). It is the aim of the study to find the most suitable management in order to obtain the most adequate perfusion of end-organs during cardiac surgery. For this purpose, the primary endpoint will be the peak of serum lactate (Lmax) released during CPB, as index of tissue hypoxia. The secondary outcomes will include all the intraoperative parameters of tissue oxygenation and major postoperative complications related to organ malperfusion. DISCUSSION This trial will assess the best strategy to target the MAP during CPB, thus further improving the outcomes of cardiac surgery. TRIAL REGISTRATION NCT05740397 (retrospectively registered; 22/02/2023).
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Affiliation(s)
- Alessandra Francica
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy.
| | - Gina Mazzeo
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Antonella Galeone
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Daniele Linardi
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Livio San Biagio
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Giovanni Battista Luciani
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
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Payne T, Moran B. Intraoperative hypotension is not associated with reduced atrial fibrillation or hospital length of stay. Comment on Br J Anaesth 2023; 131: 823-31. Br J Anaesth 2024; 132:181-183. [PMID: 37996276 DOI: 10.1016/j.bja.2023.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 11/25/2023] Open
Affiliation(s)
- Thomas Payne
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
| | - Benjamin Moran
- Critical Care Program, The George Institute of Global Health, Sydney, NSW, Australia; Department of Intensive Care, Gosford Hospital, Gosford, NSW, Australia; Department of Anaesthesia and Pain Medicine, Gosford Hospital, Gosford, NSW, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
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Molina-Andujar A, Rios J, Piñeiro GJ, Sandoval E, Ibañez C, Quintana E, Matute P, Andrea R, Lopez-Sobrino T, Mercadal J, Reverter E, Rovira I, Villar AM, Fernandez S, Castellà M, Poch E. Assessment of Individualized Mean Perfusion Pressure Targets for the Prevention of Cardiac Surgery-Associated Acute Kidney Injury-The PrevHemAKI Randomized Controlled Trial. J Clin Med 2023; 12:7746. [PMID: 38137815 PMCID: PMC10743963 DOI: 10.3390/jcm12247746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/06/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Retrospective studies support that mean perfusion pressure (MPP) deficit in cardiac surgery patients is associated with a higher incidence of acute kidney injury (CS-AKI). The aim of our study was to apply an algorithm based on MPP in the postoperative period to determine whether management with an individualized target reduces the incidence of CS-AKI. METHODS Randomized controlled trial of patients undergoing cardiac surgery with extracorporeal circulation. Adult patients submitted to valve replacement and/or bypass surgery with a high risk of CS-AKI evaluated by a Leicester score >30 were randomized to follow a target MPP of >75% of the calculated baseline or a standard hemodynamic management during the first postoperative 24 h. RESULTS Ninety-eight patients with an eGFR of 54 mL/min were included. There were no differences in MAP and MPP in the first 24 h between the randomized groups, although a higher use of noradrenaline was found in the intervention arm (38.78 vs. 63.27, p = 0.026). The percentage of time with MPP < 75% of measured baseline was similar in both groups (10 vs. 12.7%, p = 0.811). MAP during surgery was higher in the intervention group (73 vs. 77 mmHg, p = 0.008). The global incidence of CS-AKI was 36.7%, being 38.6% in the intervention group and 34.6% in the control group (p = 0.40). There were no differences in extrarenal complications between groups as well. CONCLUSION An individualized hemodynamic management based on MPP compared to standard treatment in cardiac surgery patients was safe but did not reduce the incidence of CS-AKI in our study.
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Affiliation(s)
- Alicia Molina-Andujar
- Nephrology and Kidney Transplantation Department, Hospital Clinic, 08036 Barcelona, Spain; (A.M.-A.); (G.J.P.)
| | - José Rios
- Department of Clinical Farmacology, Hospital Clinic and Medical Statistics Core Facility, 08036 Barcelona, Spain;
- Institut d’investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.A.); (T.L.-S.)
- Faculty of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
| | - Gaston J. Piñeiro
- Nephrology and Kidney Transplantation Department, Hospital Clinic, 08036 Barcelona, Spain; (A.M.-A.); (G.J.P.)
- Institut d’investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.A.); (T.L.-S.)
| | - Elena Sandoval
- Cardiovascular Surgery Department, Hospital Clinic, 08036 Barcelona, Spain; (E.S.); (E.Q.); (M.C.)
| | - Cristina Ibañez
- Anesthesiology Department, Hospital Clínic, 08036 Barcelona, Spain; (C.I.); (P.M.); (J.M.); (I.R.)
| | - Eduard Quintana
- Cardiovascular Surgery Department, Hospital Clinic, 08036 Barcelona, Spain; (E.S.); (E.Q.); (M.C.)
| | - Purificación Matute
- Anesthesiology Department, Hospital Clínic, 08036 Barcelona, Spain; (C.I.); (P.M.); (J.M.); (I.R.)
| | - Rut Andrea
- Institut d’investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.A.); (T.L.-S.)
- Cardiology Department, Hospital Clínic, 08036 Barcelona, Spain
| | - Teresa Lopez-Sobrino
- Institut d’investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.A.); (T.L.-S.)
- Cardiology Department, Hospital Clínic, 08036 Barcelona, Spain
| | - Jordi Mercadal
- Anesthesiology Department, Hospital Clínic, 08036 Barcelona, Spain; (C.I.); (P.M.); (J.M.); (I.R.)
| | - Enric Reverter
- Liver and Digestive ICU, Liver Unit, Hospital Clínic, 08036 Barcelona, Spain;
| | - Irene Rovira
- Anesthesiology Department, Hospital Clínic, 08036 Barcelona, Spain; (C.I.); (P.M.); (J.M.); (I.R.)
| | | | - Sara Fernandez
- Medical Intensive Care Unit, Hospital Clínic, 08036 Barcelona, Spain;
| | - Manel Castellà
- Cardiovascular Surgery Department, Hospital Clinic, 08036 Barcelona, Spain; (E.S.); (E.Q.); (M.C.)
| | - Esteban Poch
- Nephrology and Kidney Transplantation Department, Hospital Clinic, 08036 Barcelona, Spain; (A.M.-A.); (G.J.P.)
- Institut d’investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.A.); (T.L.-S.)
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6
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D'Amico F, Fominskiy EV, Turi S, Pruna A, Fresilli S, Triulzi M, Zangrillo A, Landoni G. Intraoperative hypotension and postoperative outcomes: a meta-analysis of randomised trials. Br J Anaesth 2023; 131:823-831. [PMID: 37739903 DOI: 10.1016/j.bja.2023.08.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 09/24/2023] Open
Abstract
INTRODUCTION Intraoperative hypotension is associated with adverse postoperative outcomes; however these findings are supported only by observational studies. The aim of this meta-analysis of randomised trials was to compare the postoperative effects permissive management with targeted management of intraoperative blood pressure. METHODS We searched PubMed, Cochrane, and Embase up to June 2023 for studies comparing permissive (mean arterial pressure ≤60 mm Hg) with targeted (mean arterial pressure >60 mm Hg) intraoperative blood pressure management. Primary outcome was all-cause mortality at the longest follow-up available. Secondary outcomes were atrial fibrillation, myocardial infarction, acute kidney injury, delirium, stroke, number of patients requiring transfusion, time on mechanical ventilation, and length of hospital stay. RESULTS We included 10 randomised trials including a total of 9359 patients. Mortality was similar between permissive and targeted blood pressure management groups (89/4644 [1.9%] vs 99/4643 [2.1%], odds ratio 0.88, 95% confidence interval [CI], 0.65-1.18, P=0.38, I2=0% with nine studies included). Atrial fibrillation (102/3896 [2.6%] vs 130/3887 [3.3%] odds ratio 0.71, 95% CI 0.53-0.96, P=0.03, I2=0%), and length of hospital stay (mean difference -0.20 days, 95% CI -0.26 to -0.13, P<0.001, I2=0%) were reduced in the permissive management group. No significant differences were found in subgroup analysis for cardiac and noncardiac surgery. CONCLUSION Pooled randomised evidence shows that a target intraoperative mean arterial pressure ≤60 mm Hg is not associated with increased mortality; nevertheless it is surprisingly associated with a reduced rate of atrial fibrillation and of length of hospital stay. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42023393725.
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Affiliation(s)
- Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evgeny V Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Fresilli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Margherita Triulzi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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Descamps R, Amour J, Besnier E, Bougle A, Charbonneau H, Charvin M, Cholley B, Desebbe O, Fellahi JL, Frasca D, Labaste F, Lena D, Mahjoub Y, Mertes PM, Molliex S, Moury PH, Moussa MD, Oilleau JF, Ouattara A, Provenchere S, Rozec B, Parienti JJ, Fischer MO. Perioperative individualized hemodynamic optimization according to baseline mean arterial pressure in cardiac surgery patients: Rationale and design of the OPTIPAM randomized trial. Am Heart J 2023; 261:10-20. [PMID: 36934980 DOI: 10.1016/j.ahj.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 03/02/2023] [Accepted: 03/11/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Postoperative morbidity and mortality after cardiac surgery with cardiopulmonary bypass (CPB) remain high despite recent advances in both anesthesia and perioperative management. Among modifiable risk factors for postoperative complications, optimal arterial pressure during and after surgery has been under debate for years. Recent data suggest that optimizing arterial pressure to the baseline of the patient may improve outcomes. We hypothesize that optimizing the mean arterial pressure (MAP) to the baseline MAP of the patient during cardiac surgery with CPB and during the first 24 hours postoperatively may improve outcomes. STUDY DESIGN The OPTIPAM trial (NCT05403697) will be a multicenter, randomized, open-label controlled trial testing the superiority of optimized MAP management as compared with a MAP of 65 mm Hg or more during both the intraoperative and postoperative periods in 1,100 patients scheduled for cardiac surgery with CPB. The primary composite end point is the occurrence of acute kidney injury, neurological complications including stroke or postoperative delirium, and death. The secondary end points are hospital and intensive care unit lengths of stay, Day 7 and Day 90 mortality, postoperative cognitive dysfunction on Day 7 and Day 90, and quality of life at Day 7 and Day 90. Two interim analyses will assess the safety of the intervention. CONCLUSION The OPTIPAM trial will assess the effectiveness of an individualized target of mean arterial pressure in cardiac surgery with CPB in reducing postoperative morbidity. CLINICAL TRIAL REGISTRATION NCT05403697.
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Affiliation(s)
- Richard Descamps
- Department of Anesthesiology and Critical Care Medicine, Caen University Hospital, Caen, France.
| | - Julien Amour
- Institute of Perfusion, Critical Care Medicine and Anesthesiology in Cardiac Surgery (IPRA), Hôpital Privé Jacques Cartier, Massy, France
| | - Emmanuel Besnier
- Normandie Univ, UNIROUEN, INSERM U1096, CHU Rouen, Department of Anesthesiology and Critical Care, Rouen, France
| | - Adrien Bougle
- Sorbonne Université, GRC 29, Assistance Publique - Hôpitaux de Paris, DMU DREAM, Département d'Anesthésie et Réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Hélène Charbonneau
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, France
| | - Martin Charvin
- CHU Clermont-Ferrand, Médecine Péri-Opératoire (MC, FL, PJ, A-LC, EF); Université Clermont-Auvergne (EF), France
| | | | - Olivier Desebbe
- Department of Anesthesiology and Intensive Care, Ramsay Sante Sauvegarde Clinic, Lyon, France
| | - Jean-Luc Fellahi
- Service d'anesthésie-Réanimation, Hôpital Louis Pradel, Boulevard Pinel, Bron Cedex, France
| | - Denis Frasca
- Department of Anaesthesia and Intensive Care, University Hospital of Poitiers, France
| | - François Labaste
- Anesthesiology and Intensive Care Department, University Hospital of Toulouse, Toulouse, France
| | - Diane Lena
- Institut Arnault Tzanck, Cardiologie Médico-chirurgicale, Saint Laurent du Var, France
| | - Yazine Mahjoub
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, Amiens, France
| | - Paul-Michel Mertes
- Service d'Anesthésie-Réanimation, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Serge Molliex
- Department of Anaesthesiology and Critical Care Medicine, Hôpital Nord, Saint Etienne, France
| | | | | | - Jean-Ferreol Oilleau
- Department of Anaesthesia and Critical Care, Brest University Hospital, Brest, France
| | - Alexandre Ouattara
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medical Surgical Centre, Bordeaux, France
| | - Sophie Provenchere
- Anesthesiology and surgical critical care department, DMU PARABOL, AP-HP, Bichat Hospital, Paris, France
| | - Bertand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Nantes France
| | - Jean-Jacques Parienti
- Department of Biostatistics and Clinical Research, Caen University Hospital, Caen, France
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Rengel KF, Boncyk CS, DiNizo D, Hughes CG. Perioperative Neurocognitive Disorders in Adults Requiring Cardiac Surgery: Screening, Prevention, and Management. Semin Cardiothorac Vasc Anesth 2023; 27:25-41. [PMID: 36137773 DOI: 10.1177/10892532221127812] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neurocognitive changes are the most common complication after cardiac surgery, ranging from acute postoperative delirium to prolonged postoperative neurocognitive disorder. Changes in cognition are distressing to patients and families and associated with worse outcomes overall. This review outlines definitions and diagnostic criteria, risk factors for, and mechanisms of Perioperative Neurocognitive Disorders and offers strategies for preoperative screening and perioperative prevention and management of neurocognitive complications.
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Affiliation(s)
- Kimberly F Rengel
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina S Boncyk
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniella DiNizo
- Scope Anesthesia of North Carolina, Charlotte, NC, USA.,Pulmonary and Critical Care Consultants, Carolinas Medical Center, 2351Atrium Health, Charlotte, NC, USA
| | - Christopher G Hughes
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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9
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Hypotension and Cardiac Surgical Outcomes: Reply. Anesthesiology 2023; 138:336-337. [PMID: 36652594 DOI: 10.1097/aln.0000000000004417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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10
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Predictive Value of Multimodality Intraoperative Neurophysiological Monitoring During Cardiac Surgery. J Clin Neurophysiol 2023; 40:180-186. [PMID: 34510090 DOI: 10.1097/wnp.0000000000000875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION This study aimed to determine the ability of multimodality intraoperative neurophysiologic monitoring, including somatosensory evoked potentials (SSEP) and EEG, to predict perioperative clinical stroke and stroke-related mortality after open-heart surgery in high-risk patients. METHODS The records of all consecutive patients who underwent coronary artery bypass grafting, and cardiac valve repair/replacement with high risk for stroke who underwent both SSEP and EEG recording at the University of Pittsburgh Medical Center between 2009 and 2015 were reviewed. Sensitivity and specificity of these modalities to predict in-hospital clinical strokes and stroke-related mortality were calculated. RESULTS A total of 531 patients underwent open cardiac procedures monitored using SSEP and EEG. One hundred thirty-one patients (24.67%) experienced significant changes in either modality. Fourteen patients (2.64%) suffered clinical strokes within 24 hours after surgery, and eight patients (1.50%) died during their hospitalization. The incidence of in-hospital clinical stroke and stroke-related mortality among patients who experienced a significant change in monitoring compared with those with no significant change was 11.45% versus 1.75%. The sensitivity and specificity of significant changes in either SSEP or EEG to predict in-hospital major stroke and stroke-related mortality were 0.93 and 0.77, respectively. CONCLUSIONS Intraoperative neurophysiologic monitoring with SSEP and EEG has high sensitivity and specificity in predicting perioperative stroke and stroke-related mortality after open cardiac procedures. These results support the benefits of multimodality neuromonitoring during cardiac surgery.
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Ranucci M, Cotza M, Di Dedda U. The Conundrum of Systemic Arterial Pressure Management on Cardiopulmonary Bypass. J Clin Med 2023; 12:jcm12030806. [PMID: 36769463 PMCID: PMC9918189 DOI: 10.3390/jcm12030806] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
The recently released EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass (CPB) in adult cardiac surgery [...].
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12
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Predicting Risk Factors of Acute Kidney Injury in the First 7 Days after Admission: Analysis of a Group of Critically Ill Patients. Cardiovasc Ther 2022; 2022:1407563. [PMID: 36628120 PMCID: PMC9797299 DOI: 10.1155/2022/1407563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/22/2022] [Accepted: 12/03/2022] [Indexed: 12/24/2022] Open
Abstract
Background Acute kidney injury (AKI) is a common complication in critically ill patients. Some predictive models have been reported, but the conclusions are controversial. The aim of this study was the formation of nomograms to predict risk factors for AKI in critically ill patients within the first 7 days after admission to the intensive care unit (ICU). Methods Data were extracted from the Medical Information Mart for Intensive Care- (MIMIC-) III database. The random forest method was used to fill in the missing values, and least absolute shrinkage and selection operator (Lasso) regression analysis was performed to screen for possible risk factors. Results A total of 561 patients were enrolled. Complication with AKI is significantly associated with a longer length of stay (LOS). For all patients, the predictors contained in the prediction nomogram included hypertension, coronary artery disease (CAD), cardiopulmonary bypass (CPB), coronary artery bypass grafting (CABG), Simplified Acute Physiology Score II (SAPS II), central venous pressure (CVP) measured for the first time after admission, and maximum and minimum mean artery pressure (MAP). The model showed good discrimination (C - index = 0.818, 95% CI: 0.779-0.857). In the subgroup of patients with well-controlled blood glucose levels, the significant predictors included hypertension, CABG, CPB, SAPS II, and maximum and minimum MAP. Good discrimination was also present before (C - index = 0.785, 95% CI: 0.736-0.834) and after adjustment (adjusted C - index = 0.770). Conclusion Hypertension, CAD, CPB, CABG, SAPS II, CVP measured for the first time after admission, and maximum and minimum MAP were independent risk factors for AKI in critically ill patients.
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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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Kotani Y, Kataoka Y, Izawa J, Fujioka S, Yoshida T, Kumasawa J, Kwong JS. High versus low blood pressure targets for cardiac surgery while on cardiopulmonary bypass. Cochrane Database Syst Rev 2022; 11:CD013494. [PMID: 36448514 PMCID: PMC9709767 DOI: 10.1002/14651858.cd013494.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Cardiac surgery is performed worldwide. Most types of cardiac surgery are performed using cardiopulmonary bypass (CPB). Cardiac surgery performed with CPB is associated with morbidities. CPB needs an extracorporeal circulation that replaces the heart and lungs, and performs circulation, ventilation, and oxygenation of the blood. The lower limit of mean blood pressure to maintain blood flow to vital organs increases in people with chronic hypertension. Because people undergoing cardiac surgery commonly have chronic hypertension, we hypothesised that maintaining a relatively high blood pressure improves desirable outcomes among the people undergoing cardiac surgery with CPB. OBJECTIVES To evaluate the benefits and harms of higher versus lower blood pressure targets during cardiac surgery with CPB. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search of databases was November 2021 and trials registries in January 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing a higher blood pressure target (mean arterial pressure 65 mmHg or greater) with a lower blood pressure target (mean arterial pressure less than 65 mmHg) in adults undergoing cardiac surgery with CPB. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Primary outcomes were 1. acute kidney injury, 2. cognitive deterioration, and 3. all-cause mortality. Secondary outcomes were 4. quality of life, 5. acute ischaemic stroke, 6. haemorrhagic stroke, 7. length of hospital stay, 8. renal replacement therapy, 9. delirium, 10. perioperative transfusion of blood products, and 11. perioperative myocardial infarction. We used GRADE to assess certainty of evidence. MAIN RESULTS We included three RCTs with 737 people compared a higher blood pressure target with a lower blood pressure target during cardiac surgery with CPB. A high blood pressure target may result in little to no difference in acute kidney injury (risk ratio (RR) 1.30, 95% confidence interval (CI) 0.81 to 2.08; I² = 72%; 2 studies, 487 participants; low-certainty evidence), cognitive deterioration (RR 0.82, 95% CI 0.45 to 1.50; I² = 0%; 2 studies, 389 participants; low-certainty evidence), and all-cause mortality (RR 1.33, 95% CI 0.30 to 5.90; I² = 49%; 3 studies, 737 participants; low-certainty evidence). No study reported haemorrhagic stroke. Although a high blood pressure target may increase the length of hospital stay slightly, we found no differences between a higher and a lower blood pressure target for the other secondary outcomes. We also identified one ongoing RCT which is comparing a higher versus a lower blood pressure target among the people who undergo cardiac surgery with CPB. AUTHORS' CONCLUSIONS A high blood pressure target may result in little to no difference in patient outcomes including acute kidney injury and mortality. Given the wide CIs, further studies are needed to confirm the efficacy of a higher blood pressure target among those who undergo cardiac surgery with CPB.
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Affiliation(s)
- Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Yuki Kataoka
- Department of Internal Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, Japan
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Junichi Izawa
- Division of Critical Care Medicine, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Okinawa, Japan
- Department of Preventive Services, Kyoto University Graduate School of Public Health, Kyoto, Japan
| | - Shoko Fujioka
- Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Jikei University Kashiwa Hospital, Department of Emergency Medicine, Jikei University School of Medicine, Tokyo, Japan
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Japan
| | - Junji Kumasawa
- Department of Critical Care Medicine, Sakai City Medical Center, Sakai City, Japan
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Joey Sw Kwong
- Global Health Nursing, Graduate School of Nursing Science, St Luke's International University, Tokyo, Japan
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Processed Electroencephalographic Use During Anesthesia and Outcomes: Analysis of The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg 2022; 114:1688-1694. [PMID: 34717905 DOI: 10.1016/j.athoracsur.2021.09.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 08/12/2021] [Accepted: 09/20/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND This study assessed associations between processed electroencephalographic (pEEG) use during anesthesia, surgery- and anesthesia-related risk factors, and neurologic outcomes and mortality after cardiac surgery. METHODS Drawing from The Society of Thoracic Surgeons Adult Cardiac Surgery Database and its Adult Cardiac Anesthesiology Section, we identified 42 932 records for elective, urgent, and emergency cardiac surgical procedures between July 1, 2017 and December 31, 2019. Using propensity score-weighted regression analysis, we analyzed the associations between pEEG use during anesthesia on the primary outcome, postoperative delirium (POD), and secondary outcomes of stroke, encephalopathy, coma, and operative mortality. RESULTS The rate of pEEG use during anesthesia use was 32.8% (n = 14 086), and its use was not associated with decreased odds for POD (odds ratio [OR], 0.88; 95% CI, 0.78-1.02) or encephalopathy (OR, 0.85; 95% CI, 0.70-1.03). Intraoperative pEEG monitoring use was also not associated with increased odds for stroke (OR, 1.17; 95% CI, 0.97-1.42) or coma (OR, 1.44; 95% CI, 0.82-2.52). In contrast, pEEG use during anesthesia was associated with higher odds for operative mortality (OR, 1.23; 95% CI, 1.05-1.44). This association remained significant after adjusting for POD (OR, 1.21; 95% CI, 1.03-1.41), stroke (OR, 1.21; 95% CI, 1.04-1.42), and encephalopathy (OR, 1.28; 95% CI, 1.07-1.52). CONCLUSIONS This large retrospective database study found no association between pEEG use during cardiac surgery and postoperative neurologic outcomes such as POD, stroke, encephalopathy, or coma. However, patients who underwent pEEG monitoring during anesthesia experienced higher mortality, even after adjustment for neurologic outcomes.
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Song Q, Li J, Jiang Z. Provisional Decision-Making for Perioperative Blood Pressure Management: A Narrative Review. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:5916040. [PMID: 35860431 PMCID: PMC9293529 DOI: 10.1155/2022/5916040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
Blood pressure (BP) is a basic determinant for organ blood flow supply. Insufficient blood supply will cause tissue hypoxia, provoke cellular oxidative stress, and to some extent lead to organ injury. Perioperative BP is labile and dynamic, and intraoperative hypotension is common. It is unclear whether there is a causal relationship between intraoperative hypotension and organ injury. However, hypotension surely compromises perfusion and causes harm to some extent. Because the harm threshold remains unknown, various guidelines for intraoperative BP management have been proposed. With the pending definitions from robust randomized trials, it is reasonable to consider observational analyses suggesting that mean arterial pressures below 65 mmHg sustained for more than 15 minutes are associated with myocardial and renal injury. Advances in machine learning and artificial intelligence may facilitate the management of hemodynamics globally, including fluid administration, rather than BP alone. The previous mounting studies concentrated on associations between BP targets and adverse complications, whereas few studies were concerned about how to treat and multiple factors for decision-making. Hence, in this narrative review, we discussed the way of BP measurement and current knowledge about baseline BP extracting for surgical patients, highlighted the decision-making process for BP management with a view to providing pragmatic guidance for BP treatment in the clinical settings, and evaluated the merits of an automated blood control system in predicting hypotension.
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Affiliation(s)
- Qiliang Song
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Jipeng Li
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Zongming Jiang
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
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Komatsu K, Mikami T, Kimura Y, Akiyama Y, Kawaharada N, Mikuni N. Validity of preoperative screening before open-heart surgery in reduction of perioperative ischemic stroke. J Stroke Cerebrovasc Dis 2022; 31:106584. [PMID: 35661543 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 05/13/2022] [Accepted: 05/24/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Cerebrovascular event after open-heart surgery is a critical complication and contributes to poor prognosis, including increased mortality. The purpose of this study is to investigate the appropriate preoperative risk assessment and monitoring for reducing the risk of ischemic stroke after open-heart surgery. MATERIALS AND METHODS 184 patients who underwent surgery for valvular heart disease were included in this study. Near-infrared oxygen saturation monitoring (INVOS system) was performed during open-heart surgery. For the purpose of perioperative stroke risk assessment, we evaluated the clinical and radiological factors of the group that underwent preoperative consultation and the group that did not, and of the patients with and without postoperative ischemic stroke. RESULTS Preoperative consultation was performed in 60 cases. Large vessel steno-occlusive disease was found in nine cases, of which three had undergone revascularization surgery. Cerebral infarction developed in four cases, all of which had no large vessel steno-occlusive disease. There was no significant association between the development of postoperative ischemic stroke and presence of large vessel steno-occlusive disease. Preoperative baseline INVOS value was significantly low in the ischemic stroke group (49.5 ± 12.5) compared to the non-ischemic stroke group (66.8 ± 10.0), (P = 0.012). CONCLUSIONS In open-heart surgery for valvular heart disease, low preoperative baseline INVOS values were associated with cerebral ischemic stroke after surgery. The combination of appropriate preoperative screening for large vessel steno-occlusive disease and measurement of INVOS could be used as a simple and useful method in screening for the risk of ischemic stroke after open-heart surgery.
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Affiliation(s)
- Katsuya Komatsu
- Department of Neurosurgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
| | - Takeshi Mikami
- Department of Neurosurgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
| | - Yusuke Kimura
- Department of Neurosurgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
| | - Yukinori Akiyama
- Department of Neurosurgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
| | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
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Hu R, Yanase F, McCall P, Evans R, Raman J, Bellomo R. The effects of targeted changes in systemic blood flow and mean arterial pressure on urine oximetry during cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2022; 36:3551-3560. [DOI: 10.1053/j.jvca.2022.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/11/2022]
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19
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McEwen CC, Amir T, Qiu Y, Young J, Kennedy K, Grocott HP, Kessani H, Mazer D, Brudney S, Kavosh M, Jacobsohn E, Vedel A, Wang E, Whitlock RP, Belley-Coté EP, Spence J. Morbidity and mortality in patients managed with high compared with low blood pressure targets during on-pump cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 2022; 69:374-386. [PMID: 35014001 DOI: 10.1007/s12630-021-02171-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Many believe that blood pressure management during cardiac surgery is associated with postoperative outcomes. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the impact of high compared with low intraoperative blood pressure targets on postoperative morbidity and mortality in adults undergoing cardiac surgery on cardiopulmonary bypass (CPB). Our primary objective was to inform the design of a future large RCT. SOURCE We searched MEDLINE, EMBASE, Web of Science, CINAHL, and CENTRAL for RCTs comparing high with low intraoperative blood pressure targets in adult patients undergoing any cardiac surgical procedure on CPB. We screened reference lists, grey literature, and conference proceedings. PRINCIPAL FINDINGS We included eight RCTs (N =1,116 participants); all examined the effect of blood pressure management only during the CPB. Trial definitions of high compared with low blood pressure varied and, in some, there was a discrepancy between the target and achieved mean arterial pressure. We observed no difference in delirium, cognitive decline, stroke, acute kidney injury, or mortality between high and low blood pressure targets (very-low to low quality evidence). Higher blood pressure targets may have increased the risk of requiring a blood transfusion (three trials; n = 456 participants; relative risk, 1.4; 95% confidence interval, 1.1 to 1.9; P = 0.01; moderate quality evidence) but this finding was based on a small number of trials. CONCLUSION Individual trial definitions of high and low blood pressure targets varied, limiting inferences. The effect of high (compared with low) blood pressure targets on other morbidity and mortality after cardiac surgery remains unclear because of limitations with the body of existing evidence. Research to determine the optimal management of blood pressure during cardiac surgery is required. STUDY REGISTRATION PROSPERO (CRD42020177376); registered: 5 July 2020.
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Affiliation(s)
- Charlotte C McEwen
- Department of Surgery (Cardiac Surgery), McMaster University, Hamilton, ON, Canada
| | - Takhliq Amir
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Yuan Qiu
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Jack Young
- Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | - Kevin Kennedy
- Department of Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Hilary P Grocott
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Hesham Kessani
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Scott Brudney
- Departments of Medicine (Critical Care) and Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Morvarid Kavosh
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Eric Jacobsohn
- Departments of Medicine (Critical Care) and Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Anne Vedel
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eugene Wang
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada.,Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada
| | - Emilie P Belley-Coté
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada.,Departments of Medicine (Cardiology and Critical Care) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jessica Spence
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada. .,Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada.
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Soliman R, Saad D, Abukhudair W, Abdekdayem S. The neurocognitive outcomes of hemodilution in adult patients undergoing coronary artery bypass grafting using cardiopulmonary bypass. Ann Card Anaesth 2022; 25:133-140. [PMID: 35417957 PMCID: PMC9244259 DOI: 10.4103/aca.aca_206_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: The study aimed to evaluate the effect of mild and moderate hemodilution during CPB on the neurocognitive dysfunction in patients undergoing coronary artery bypass grafting. Design: A randomized clinical study. Setting: Cardiac center. Patients: 186 patients scheduled for cardiac surgery with cardiopulmonary bypass. Intervention: The patients were classified into 2 groups (each = 93), Mild hemodilution group: The hematocrit value was maintained >25% by transfusion of packed-red blood cells plus hemofiltration during CPB. Moderate hemodilution group: the hematocrit value was maintained within the range of 21-25%. Measurements: The monitors included the hemofiltrated volume, number of transfused packed red blood cells, and the incidence of postoperative cognitive dysfunction. Main Results: The hemofiltrated volume during CPB was too much higher with mild hemodilution compared to the moderate hemodilution (p = 0.001). The number of the transfused packed red blood cells during CPB was higher with mild hemodilution compared to the moderate hemodilution (p = 0.001), but after CPB, the number of the transfused packed red blood cells was lower with the mild hemodilution group than the moderate hemodilution (p = 0.001). The incidence of total postoperative neurological complications was significantly lower with the mild hemodilution group than moderate hemodilution (p = 0.033). The incidence of neurocognitive dysfunction was significantly lower with mild hemodilution group than moderate hemodilution (p = 0.042). Conclusions: The mild hemodilution was associated with a significant decrease in the incidence of neurocognitive dysfunction compared to moderate hemodilution in patients undergoing coronary artery bypass grafting. Also, the transfused packed red blood cells increased during CPB and decreased after CPB with the mild hemodilution than moderate hemodilution.
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Augoustides JG. Protecting the Central Nervous System During Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Vu T, Smith JA. An Update on Postoperative Cognitive Dysfunction Following Cardiac Surgery. Front Psychiatry 2022; 13:884907. [PMID: 35782418 PMCID: PMC9240195 DOI: 10.3389/fpsyt.2022.884907] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/23/2022] [Indexed: 12/14/2022] Open
Abstract
Postoperative cognitive dysfunction is extremely prevalent following cardiac surgery. The increasing patient age and comorbidity profile increases their susceptibility to cognitive impairment. The underlying pathophysiological mechanisms leading to cognitive impairment are not clearly elucidated. Using the contemporary literature (2015-present), this narrative review has three aims. Firstly, to provide an overview of postoperative cognitive impairment. Secondly, to analyse the predominant pathophysiological mechanisms leading to cognitive dysfunction following cardiac surgery such as inflammation, cerebral hypoperfusion, cerebral microemboli, glycaemic control and anaesthesia induced neurotoxicity. Lastly, to assess the current therapeutic strategies of interest to address these pathophysiological mechanisms, including the administration of dexamethasone, the prevention of prolonged cerebral desaturations and the monitoring of cerebral perfusion using near-infrared spectroscopy, surgical management strategies to reduce the neurological effects of microemboli, intraoperative glycaemic control strategies, the effect of volatile vs. intravenous anaesthesia, and the efficacy of dexmedetomidine.
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Affiliation(s)
- Tony Vu
- Department of Cardiothoracic Surgery, Monash Health, Melbourne, VIC, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Julian A Smith
- Department of Cardiothoracic Surgery, Monash Health, Melbourne, VIC, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
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Newman MF, Berger M, Mathew JP. Postoperative Cognitive Dysfunction and Delirium. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00042-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Mullen MT, Messé SR. Stroke Related to Surgery and Other Procedures. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00034-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Jufar AH, Lankadeva YR, May CN, Cochrane AD, Marino B, Bellomo R, Evans RG. Renal and Cerebral Hypoxia and Inflammation During Cardiopulmonary Bypass. Compr Physiol 2021; 12:2799-2834. [PMID: 34964119 DOI: 10.1002/cphy.c210019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cardiac surgery-associated acute kidney injury and brain injury remain common despite ongoing efforts to improve both the equipment and procedures deployed during cardiopulmonary bypass (CPB). The pathophysiology of injury of the kidney and brain during CPB is not completely understood. Nevertheless, renal (particularly in the medulla) and cerebral hypoxia and inflammation likely play critical roles. Multiple practical factors, including depth and mode of anesthesia, hemodilution, pump flow, and arterial pressure can influence oxygenation of the brain and kidney during CPB. Critically, these factors may have differential effects on these two vital organs. Systemic inflammatory pathways are activated during CPB through activation of the complement system, coagulation pathways, leukocytes, and the release of inflammatory cytokines. Local inflammation in the brain and kidney may be aggravated by ischemia (and thus hypoxia) and reperfusion (and thus oxidative stress) and activation of resident and infiltrating inflammatory cells. Various strategies, including manipulating perfusion conditions and administration of pharmacotherapies, could potentially be deployed to avoid or attenuate hypoxia and inflammation during CPB. Regarding manipulating perfusion conditions, based on experimental and clinical data, increasing standard pump flow and arterial pressure during CPB appears to offer the best hope to avoid hypoxia and injury, at least in the kidney. Pharmacological approaches, including use of anti-inflammatory agents such as dexmedetomidine and erythropoietin, have shown promise in preclinical models but have not been adequately tested in human trials. However, evidence for beneficial effects of corticosteroids on renal and neurological outcomes is lacking. © 2021 American Physiological Society. Compr Physiol 11:1-36, 2021.
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Affiliation(s)
- Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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26
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Miao Q, Wu DJ, Chen X, Xu M, Sun L, Guo Z, He B, Wu J. Target blood pressure management during cardiopulmonary bypass improves lactate levels after cardiac surgery: a randomized controlled trial. BMC Anesthesiol 2021; 21:309. [PMID: 34879822 PMCID: PMC8653567 DOI: 10.1186/s12871-021-01537-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 12/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background Hyperlactatemia is associated with a poor prognosis in cardiac surgery patients. This study explored the impact of target blood pressure management during cardiopulmonary bypass (CPB) on blood lactate levels after cardiac surgery. Methods Adult patients undergoing cardiac valve surgery between 20/1/2020 and 30/6/2020 at Shanghai Chest Hospital were enrolled. The patients were randomized into a low mean arterial pressure (L-MAP) group (target MAP between 50 and 60 mmHg) or a high mean arterial pressure (H-MAP) group (target MAP between 70 and 80 mmHg), n = 20 for each. Norepinephrine was titrated only during CPB to maintain MAP at the target level. Blood lactate levels in the two groups were detected before the operation (T0), at the end of CPB (T1), at the end of the operation (T2), 1 h after the operation (T3), 6 h after the operation (T4) and 24 h after the operation (T5). The primary outcome was the blood lactate level at the end of the operation (T2). The secondary outcomes included the blood lactate level at T1, T3, T4, and T5 and the dose of epinephrine and dopamine within 24 h after the operation, time to extubation, length of stay in the ICU, incidence of readmission within 30 days, and mortality within 1 year. Results Forty patents were enrolled and analyzed in the study. The lactate level in the H-MAP group was significantly lower than that in the L-MAP group at the end of the operation (3.1 [IQR 2.1, 5.0] vs. 2.1 [IQR 1.7, 2.9], P = 0.008) and at the end of CPB and 1 hour after surgery. The dose of epinephrine within 24 h after the operation, time to extubation and length of stay in the ICU in the L-MAP group were significantly higher than those in the H-MAP group. Conclusions Maintaining a relatively higher MAP during CPB deceased the blood lactate level at the end of surgery, reduced epinephrine consumption, and shortened the time to extubation and length of stay in the ICU after surgery. Trial registration This single-center, prospective, RCT has completed the registration of the Chinese Clinical Trial Center at 8/1/2020 with the registration number ChiCTR2000028941. It was conducted from 20/1/2020 to 30/6/2020 as a single, blinded trial in Shanghai Chest Hospital.
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Affiliation(s)
- Qing Miao
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China
| | - Dong Jin Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China
| | - Xu Chen
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China
| | - Meiying Xu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China
| | - Lin Sun
- Department of Cardiopulmonary Bypass, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhen Guo
- Department of Cardiopulmonary Bypass, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Bin He
- Department of Intensive Care Unit, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China.
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27
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Targeted temperature management in cardiac surgery: a systematic review and meta-analysis on postoperative cognitive outcomes. Br J Anaesth 2021; 128:11-25. [PMID: 34862000 DOI: 10.1016/j.bja.2021.09.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Postoperative cognitive decline occurs commonly after cardiac surgery. The available literature is inconclusive on the role of intraoperative causal or protective factors. METHODS We systematically reviewed studies evaluating delayed neurocognitive recovery (DNR), postoperative neurocognitive disorder (NCD), stroke, and the mortality rates among patients undergoing hypothermic or normothermic cardiopulmonary bypass (CPB). We further performed a subgroup analysis for age, surgery type (coronary artery bypass grafting [CABG], valve surgery, or combined), and the mean arterial blood pressure (MAP) during CPB, and conducted a proportion meta-analysis after calculation of single proportions and confidence intervals (CIs). RESULTS We included a total of 58 studies with 9609 patients in our analysis. Among these, 1906 of 4010 patients (47.5%) had DNR, and 2071 of 7160 (28.9%) had postoperative NCD. Ninety of 4625 patients (2.0%) had a stroke, and 174 of 7589 (2.3%) died. There was no statistically significant relationship between the considered variables and DNR, NCD, stroke, and mortality. In the subgroup analysis comparing hypothermic with normothermic CPB, we found higher NCD rates after combined surgery; for normothermic CPB cases only, the rates of DNR and NCD were lower after combined surgery compared with CABG surgery. A MAP >70 mm Hg compared with MAP=50-70 mm Hg during CPB was associated with a lower rate of DNR. CONCLUSIONS Temperature, MAP during cardiopulmonary bypass age, and surgery type were not associated with neurocognitive disorders, stroke, and mortality in cardiac surgery. Normothermic cardiopulmonary bypass, particularly when performed with MAP >70 mm Hg, may reduce the risk of postoperative neurocognitive decline after cardiac surgery. PROSPERO REGISTRATION NUMBER CRD42019140844.
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28
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Baer BR, Fremes SE, Gaudino M, Charlson M, Wells MT. On clinical trial fragility due to patients lost to follow up. BMC Med Res Methodol 2021; 21:254. [PMID: 34800976 PMCID: PMC8606097 DOI: 10.1186/s12874-021-01446-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 10/19/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Clinical trials routinely have patients lost to follow up. We propose a methodology to understand their possible effect on the results of statistical tests by altering the concept of the fragility index to treat the outcomes of observed patients as fixed but incorporate the potential outcomes of patients lost to follow up as random and subject to modification. METHODS We reanalyse the statistical results of three clinical trials on coronary artery bypass grafting (CABG) to study the possible effect of patients lost to follow up on the treatment effect statistical significance. To do so, we introduce the LTFU-aware fragility indices as a measure of the robustness of a clinical trial's statistical results with respect to patients lost to follow up. RESULTS The analyses illustrate that clinical trials can either be completely robust to the outcomes of patients lost to follow up, extremely sensitive to the outcomes of patients lost to follow up, or in an intermediate state. When a clinical trial is in an intermediate state, the LTFU-aware fragility indices provide an interpretable measure to quantify the degree of fragility or robustness. CONCLUSIONS The LTFU-aware fragility indices allow researchers to rigorously explore the outcomes of patients who are lost to follow up, when their data is the appropriate kind. The LTFU-aware fragility indices are sensitivity measures in a way that the original fragility index is not.
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Affiliation(s)
- Benjamin R. Baer
- Department of Statistics and Data Science, Cornell University, Ithaca, NY US
| | - Stephen E. Fremes
- Schulich Heart Centre, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON Canada
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY US
| | - Mary Charlson
- Department of Medicine, Weill Cornell Medicine, Weill Cornell Medicine, New York, NY US
| | - Martin T. Wells
- Department of Statistics and Data Science, Cornell University, Ithaca, NY US
- Department of Medicine, Weill Cornell Medicine, Weill Cornell Medicine, New York, NY US
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29
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Heterogeneous impact of hypotension on organ perfusion and outcomes: a narrative review. Br J Anaesth 2021; 127:845-861. [PMID: 34392972 DOI: 10.1016/j.bja.2021.06.048] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/08/2021] [Accepted: 06/25/2021] [Indexed: 12/20/2022] Open
Abstract
Arterial blood pressure is the driving force for organ perfusion. Although hypotension is common in acute care, there is a lack of accepted criteria for its definition. Most practitioners regard hypotension as undesirable even in situations that pose no immediate threat to life, but hypotension does not always lead to unfavourable outcomes based on experience and evidence. Thus efforts are needed to better understand the causes, consequences, and treatments of hypotension. This narrative review focuses on the heterogeneous underlying pathophysiological bases of hypotension and their impact on organ perfusion and patient outcomes. We propose the iso-pressure curve with hypotension and hypertension zones as a way to visualize changes in blood pressure. We also propose a haemodynamic pyramid and a pressure-output-resistance triangle to facilitate understanding of why hypotension can have different pathophysiological mechanisms and end-organ effects. We emphasise that hypotension does not always lead to organ hypoperfusion; to the contrary, hypotension may preserve or even increase organ perfusion depending on the relative changes in perfusion pressure and regional vascular resistance and the status of blood pressure autoregulation. Evidence from RCTs does not support the notion that a higher arterial blood pressure target always leads to improved outcomes. Management of blood pressure is not about maintaining a prespecified value, but rather involves ensuring organ perfusion without undue stress on the cardiovascular system.
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30
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Wahba A, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Puis L. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Eur J Cardiothorac Surg 2021; 57:210-251. [PMID: 31576396 DOI: 10.1093/ejcts/ezz267] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav's University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
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31
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Vedel AG, Holmgaard F, Danielsen ER, Langkilde A, Paulson OB, Ravn HB, Rasmussen LS, Nilsson JC. Blood pressure and brain injury in cardiac surgery: a secondary analysis of a randomized trial. Eur J Cardiothorac Surg 2021; 58:1035-1044. [PMID: 32840297 DOI: 10.1093/ejcts/ezaa216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/27/2020] [Accepted: 05/14/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Brain dysfunction is a serious complication after cardiac surgery. In the Perfusion Pressure Cerebral Infarcts trial, we allocated cardiac surgery patients to a mean arterial pressure of either 70-80 or 40-50 mmHg during cardiopulmonary bypass (CPB). In this secondary analysis, we compared selected cerebral metabolites using magnetic resonance spectroscopy hypothesizing that a postoperative decrease in occipital grey matter (GM) N-acetylaspartate-to-total-creatine ratio, indicative of ischaemic injury, would be found in the high-target group. METHODS Of the 197 patients randomized in the Perfusion Pressure Cerebral Infarcts trial, 55 and 42 patients had complete and useful data from GM and white matter (WM), respectively. Spectroscopies were done preoperatively and on postoperative days 3-6. Cognitive function was assessed prior to surgery, at discharge and at 3 months. We predefined the statistical significance level to be 0.01. RESULTS A postoperative decrease was found in GM N-acetylaspartate-to-total-creatine ratio in the high-target group [mean difference -0.09 (95% confidence interval -0.14 to -0.04), P = 0.014]. No significant differences were found in other metabolite ratios investigated in GM or WM. No significant association was found between changes in metabolite ratios and new cerebral infarcts, WM lesion score or cognitive dysfunction. CONCLUSIONS A higher mean arterial pressure during CPB was associated with signs of impaired cerebral metabolism, though not at the predefined significance level of 0.01. No significant association was found between metabolite ratio changes and neuroradiological pathology or change in cognitive function. CLINICAL TRIAL REGISTRATION NUMBER Clinicaltrials.gov: NCT02185885.
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Affiliation(s)
- Anne G Vedel
- D epartment of Cardiothoracic Anaesthesiology, Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,D epartment of Anaesthesia, Center of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Frederik Holmgaard
- D epartment of Cardiothoracic Anaesthesiology, Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Else R Danielsen
- D epartment of Radiology, Diagnostic Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Annika Langkilde
- D epartment of Radiology, Diagnostic Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Olaf B Paulson
- Neurobiology Research Unit, Neuroscience Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hanne B Ravn
- D epartment of Cardiothoracic Anaesthesiology, Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars S Rasmussen
- D epartment of Anaesthesia, Center of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens C Nilsson
- D epartment of Cardiothoracic Anaesthesiology, Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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32
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van Zuylen ML, Gribnau A, Admiraal M, Ten Hoope W, Veelo DP, Hollmann MW, Preckel B, Hermanides J. The role of intraoperative hypotension on the development of postoperative cognitive dysfunction: a systematic review. J Clin Anesth 2021; 72:110310. [PMID: 33932723 DOI: 10.1016/j.jclinane.2021.110310] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/09/2021] [Accepted: 04/11/2021] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE To clarify whether intraoperative hypotension contributes to the development of postoperative cognitive dysfunction. DESIGN A systematic review of prospective studies reporting on intraoperative hypotension and postoperative cognitive dysfunction in elective, non-cognitive impaired, adult surgical patients. PubMed, EMBASE and the Cochrane Library were searched up to the 1st of January 2021. SETTING Studies had to use a clear definition of hypotension, although differing definitions were accepted. Neurocognitive tests to determine postoperative cognitive dysfunction had to be done pre- and postoperatively, with a minimum follow-up of seven days postoperatively. MEASUREMENTS Risk of bias was assessed using the Cochrane Risk of Bias Tool 2.0 for randomized controlled trials and the Newcastle-Ottawa Scale for cohort studies. MAIN RESULTS Out of 941 studies screened, five randomized controlled trials and four cohort studies were included for qualitative analysis. Extensive methodological differences between studies were present hindering proper quantitive analysis. No studies reported statistically significant differences in incidence of postoperative cognitive dysfunction in hypo- compared to normotensive patients. Five studies reported exact incidences of postoperative cognitive dysfunction. CONCLUSIONS This systematic review showed no conclusive association between intraoperative hypotension and the development of postoperative cognitive dysfunction. Given the vast methodological differences of the included studies, the role of intraoperative hypotension in the development of postoperative cognitive dysfunction remains uncertain. Future research into the association between intraoperative hypotension and postoperative cognitive dysfunction should be conducted in a standardized manner.
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Affiliation(s)
- Mark L van Zuylen
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef, Amsterdam, the Netherlands.
| | - Annerixt Gribnau
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef, Amsterdam, the Netherlands.
| | - Manouk Admiraal
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef, Amsterdam, the Netherlands.
| | - Werner Ten Hoope
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef, Amsterdam, the Netherlands; Department of Anaesthesiology, Rijnstate Hospital, Arnhem, the Netherlands.
| | - Denise P Veelo
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef, Amsterdam, the Netherlands.
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef, Amsterdam, the Netherlands.
| | - Benedikt Preckel
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef, Amsterdam, the Netherlands.
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef, Amsterdam, the Netherlands.
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33
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Lankadeva YR, Evans RG, Cochrane AD, Marino B, Hood SG, McCall PR, Iguchi N, Bellomo R, May CN. Reversal of renal tissue hypoxia during experimental cardiopulmonary bypass in sheep by increased pump flow and arterial pressure. Acta Physiol (Oxf) 2021; 231:e13596. [PMID: 34347356 DOI: 10.1111/apha.13596] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/17/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022]
Abstract
AIM Renal tissue hypoxia during cardiopulmonary bypass could contribute to the pathophysiology of acute kidney injury. We tested whether renal tissue hypoxia can be alleviated during cardiopulmonary bypass by the combined increase in target pump flow and mean arterial pressure. METHODS Cardiopulmonary bypass was established in eight instrumented sheep under isoflurane anaesthesia, at a target continuous pump flow of 80 mL·kg-1 min-1 and mean arterial pressure of 65 mmHg. We then tested the effects of simultaneously increasing target pump flow to 104 mL·kg-1 min-1 and mean arterial pressure to 80 mmHg with metaraminol (total dose 0.25-3.75 mg). We also tested the effects of transitioning from continuous flow to partially pulsatile flow (pulse pressure ~15 mmHg). RESULTS Compared with conscious sheep, at the lower target pump flow and mean arterial pressure, cardiopulmonary bypass was accompanied by reduced renal blood flow (6.8 ± 1.2 to 1.95 ± 0.76 mL·min-1 kg-1) and renal oxygen delivery (0.91 ± 0.18 to 0.24 ± 0.11 mL·O2 min-1 kg-1). There were profound reductions in cortical oxygen tension (PO2) (33 ± 13 to 6 ± 6 mmHg) and medullary PO2 (31 ± 12 to 8 ± 8 mmHg). Increasing target pump flow and mean arterial pressure increased renal blood flow (to 2.6 ± 1.0 mL·min-1 kg-1) and renal oxygen delivery (to 0.32 ± 0.13 mL·O2 min-1kg-1) and returned cortical PO2 to 58 ± 60 mmHg and medullary PO2 to 28 ± 16 mmHg; levels similar to those of conscious sheep. Partially pulsatile pump flow had no significant effects on renal perfusion or oxygenation. CONCLUSIONS Renal hypoxia during experimental CPB can be corrected by increasing target pump flow and mean arterial pressure within a clinically feasible range.
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Affiliation(s)
- Yugeesh R. Lankadeva
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental HealthUniversity of Melbourne Melbourne VIC Australia
| | - Roger G. Evans
- Cardiovascular Disease Program Biomedicine Discovery Institute and Department of Physiology Monash University Melbourne VIC Australia
| | - Andrew D. Cochrane
- Department of Cardiothoracic Surgery Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health) Monash University Melbourne VIC Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources Melbourne VIC Australia
| | - Sally G. Hood
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental HealthUniversity of Melbourne Melbourne VIC Australia
| | - Peter R. McCall
- Department of Anaesthesia Austin Health Heidelberg VIC Australia
| | - Naoya Iguchi
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental HealthUniversity of Melbourne Melbourne VIC Australia
| | - Rinaldo Bellomo
- Department of Intensive Care Austin Health Heidelberg VIC Australia
| | - Clive N. May
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental HealthUniversity of Melbourne Melbourne VIC Australia
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34
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Manual Carotid Compression is a Viable Alternative for Reduction of Cerebral Microemboli. Cardiovasc Eng Technol 2021; 12:353-360. [PMID: 33686541 DOI: 10.1007/s13239-021-00528-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/10/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Stroke is a devastating complication of cardiovascular surgeries, and the risk is particularly high for those requiring cardiopulmonary bypass (CPB). Embolic particles generated during the unclamping of the aortic cross-clamp may enter the cerebral circulation, lodging in small vessels. External manual compression of the carotid arteries is a non-invasive technique that has been proposed for cerebral protection during CPB procedures but is not widely deployed. METHODS The aim of this study is to assess the potential for cerebral emboli reduction with carotid compression using an in vitro model. Experiments were performed with a glass aortic arch model in a mock cardiovascular circuit. Small fluorescent particles were released into the circulation with and without carotid compression, and the particles visualized in the aortic midplane. The number of particles in the aorta and arch branch vessels were counted from the images before, during and following the release of carotid compression for durations of 10, 15 and 20 s. A gamma variate function was fit to the data to describe the bolus dynamics. RESULTS Carotid compression for 10 s reduces the number of embolic articles entering the carotid arteries by over 75%. A compression duration of 15-20 s does not result in greater particle reduction than one of 10 s. CONCLUSION Brief compression of the common carotid arteries during cardiovascular interventions has the potential to dramatically reduce the number of cerebral emboli and should be investigated further.
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35
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Wiberg S, Holmgaard F, Blennow K, Nilsson JC, Kjaergaard J, Wanscher M, Langkilde AR, Hassager C, Rasmussen LS, Zetterberg H, Vedel AG. Associations between mean arterial pressure during cardiopulmonary bypass and biomarkers of cerebral injury in patients undergoing cardiac surgery: secondary results from a randomized controlled trial. Interact Cardiovasc Thorac Surg 2021; 32:229-235. [PMID: 33221914 PMCID: PMC8906782 DOI: 10.1093/icvts/ivaa264] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/15/2020] [Accepted: 10/04/2020] [Indexed: 08/26/2023] Open
Abstract
OBJECTIVES Cardiac surgery is associated with risk of cerebral injury and mean arterial pressure (MAP) during cardiopulmonary bypass (CPB) is suggested to be associated with cerebral injury. The 'Perfusion Pressure Cerebral Infarcts' (PPCI) trial randomized patients undergoing coronary artery bypass grafting (CABG) and/or aortic valve replacement to a MAP of 40-50 or 70-80 mmHg during CPB and found no difference in clinical or imaging outcomes between the groups. We here present PPCI trial predefined secondary end points, consisting of biomarkers of brain injury. METHODS Blood was collected from PPCI trial patients at baseline, 24 and 48 h after induction of anaesthesia and at discharge from the surgical ward. Blood was analysed for neuron-specific enolase, tau, neurofilament light and the glial marker glial fibrillary acidic protein. Linear mixed models were used to analyse differences in biomarker value changes from baseline between the 2 MAP allocation groups. RESULTS A total of 193 (98%) patients were included. We found no differences in biomarker levels over time from baseline to discharge between the 2 MAP allocation groups (PNSE = 0.14, PTau = 0.46, PNFL = 0.21, PGFAP = 0.13) and the result did not change after adjustment for age, sex and type of surgery. CONCLUSIONS We found no significant differences in levels of biomarkers of neurological injury in patients undergoing elective or subacute CABG and/or aortic valve replacement randomized to either a target MAP of 40-50 mmHg or a target MAP of 70-80 mmHg during CBP.
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Affiliation(s)
- Sebastian Wiberg
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Frederik Holmgaard
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Jens C Nilsson
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Michael Wanscher
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Annika R Langkilde
- Department of Radiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars S Rasmussen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anesthesia, Center of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
- UK Dementia Research Institute at UCL, London, UK
| | - Anne Grønborg Vedel
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Postoperative Neurocognitive Disorders in Cardiac Surgery: Investigating the Role of Intraoperative Hypotension. A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18020786. [PMID: 33477713 PMCID: PMC7831914 DOI: 10.3390/ijerph18020786] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/09/2021] [Accepted: 01/15/2021] [Indexed: 12/19/2022]
Abstract
Perioperative neurocognitive disorders remain a challenging obstacle in patients after cardiac surgery, as they significantly contribute to postoperative morbidity and mortality. Identifying the modifiable risk factors and mechanisms for postoperative cognitive decline (POCD) and delirium (POD) would be an important step forward in preventing such adverse events and thus improving patients’ outcome. Intraoperative hypotension is frequently discussed as a potential risk factor for neurocognitive decline, due to its significant impact on blood flow and tissue perfusion, however the studies exploring its association with POCD and POD are very heterogeneous and present divergent results. This review demonstrates 13 studies found after structured systematic search strategy and discusses the possible relationship between intraoperative hypotension and postoperative neuropsychiatric dysfunction.
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Hogue CW, Brown CH, Hori D, Ono M, Nomura Y, Balmert LC, Srdanovic N, Grafman J, Brady K. Personalized Blood Pressure Management During Cardiac Surgery With Cerebral Autoregulation Monitoring: A Randomized Trial. Semin Thorac Cardiovasc Surg 2021; 33:429-438. [DOI: 10.1053/j.semtcvs.2020.09.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/08/2020] [Indexed: 01/12/2023]
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Affiliation(s)
- Susana Vacas
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA.
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA
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Gaudino M, Benesch C, Bakaeen F, DeAnda A, Fremes SE, Glance L, Messé SR, Pandey A, Rong LQ. Considerations for Reduction of Risk of Perioperative Stroke in Adult Patients Undergoing Cardiac and Thoracic Aortic Operations: A Scientific Statement From the American Heart Association. Circulation 2020; 142:e193-e209. [DOI: 10.1161/cir.0000000000000885] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Perioperative stroke is one of the most severe and feared complications of cardiac surgery. Based on the timing of onset and detection, perioperative stroke can be classified as intraoperative or postoperative. The pathogenesis of perioperative stroke is multifactorial, which makes prediction and prevention challenging. However, information on its incidence, mechanisms, diagnosis, and treatment can be helpful in minimizing the perioperative neurological risk for individual patients. We herein provide suggestions on preoperative, intraoperative, and postoperative strategies aimed at reducing the risk of perioperative stroke and at improving the outcomes of patients who experience a perioperative stroke.
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Rajaram A, Milej D, Suwalski M, Yip LCM, Guo LR, Chu MWA, Chui J, Diop M, Murkin JM, St. Lawrence K. Optical monitoring of cerebral perfusion and metabolism in adults during cardiac surgery with cardiopulmonary bypass. BIOMEDICAL OPTICS EXPRESS 2020; 11:5967-5981. [PMID: 33149999 PMCID: PMC7587277 DOI: 10.1364/boe.404101] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/03/2020] [Accepted: 09/03/2020] [Indexed: 05/23/2023]
Abstract
During cardiac surgery with cardiopulmonary bypass (CPB), adequate maintenance of cerebral blood flow (CBF) is vital in preventing postoperative neurological injury - i.e. stroke, delirium, cognitive impairment. Reductions in CBF large enough to impact cerebral energy metabolism can lead to tissue damage and subsequent brain injury. Current methods for neuromonitoring during surgery are limited. This study presents the clinical translation of a hybrid optical neuromonitor for continuous intraoperative monitoring of cerebral perfusion and metabolism in ten patients undergoing non-emergent cardiac surgery with non-pulsatile CPB. The optical system combines broadband near-infrared spectroscopy (B-NIRS) to measure changes in the oxidation state of cytochrome c oxidase (oxCCO) - a direct marker of cellular energy metabolism - and diffuse correlation spectroscopy (DCS) to provide an index of cerebral blood flow (CBFi). As the heart was arrested and the CPB-pump started, increases in CBFi (88.5 ± 125.7%) and significant decreases in oxCCO (-0.5 ± 0.2 µM) were observed; no changes were noted during transitions off CPB. Fifteen hypoperfusion events, defined as large and sustained reductions in CPB-pump flow rate, were identified across all patients and resulted in significant decreases in perfusion and metabolism when mean arterial pressure dropped to 30 mmHg or below. The maximum reduction in cerebral blood flow preceded the corresponding metabolic reduction by 18.2 ± 15.0 s. Optical neuromonitoring provides a safe and non-invasive approach for assessing intraoperative perfusion and metabolism and has potential in guiding patient management to prevent adverse clinical outcomes.
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Affiliation(s)
- Ajay Rajaram
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Daniel Milej
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
| | - Marianne Suwalski
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Lawrence C. M. Yip
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Linrui R. Guo
- Division of Cardiac Surgery, London Health Science Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Michael W. A. Chu
- Division of Cardiac Surgery, London Health Science Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Jason Chui
- Department of Anesthesiology and Perioperative Medicine, London Health Science Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Mamadou Diop
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - John M. Murkin
- Department of Anesthesiology and Perioperative Medicine, London Health Science Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Keith St. Lawrence
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
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Temporal improvements in perioperative stroke rates following coronary artery bypass grafting. Curr Opin Cardiol 2020; 35:679-686. [DOI: 10.1097/hco.0000000000000798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Feng X, Hu J, Hua F, Zhang J, Zhang L, Xu G. The correlation of intraoperative hypotension and postoperative cognitive impairment: a meta-analysis of randomized controlled trials. BMC Anesthesiol 2020; 20:193. [PMID: 32758153 PMCID: PMC7409718 DOI: 10.1186/s12871-020-01097-5] [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] [Received: 05/01/2020] [Accepted: 07/15/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND There is no consensus on whether intraoperative hypotension is associated with postoperative cognitive impairment. Hence, we performed a meta-analysis to evaluate the correlation of intraoperative hypotension and the incidence of postoperative delirium (POD) or postoperative cognitive dysfunction (POCD). METHODS We searched PubMed, Embase, and Cochrane Library databases to find randomized controlled trials (RCTs) in which reported the relationship between intraoperative hypotension and POD or POCD. The retrieval time is up to January 2020, without language restrictions. Quality assessment of the eligible studies was conducted by two researchers independently with the Cochrane evaluation system. RESULTS We analyzed five eligible RCTs. Based on the relative mean arterial pressure (MAP), participants were divided into low-target and high-target groups. For the incidence of POD, there were two studies with 99 participants in the low-target group and 94 participants in the high-target pressure group. For the incidence of POCD, there were four studies involved 360 participants in the low-target group and 341 participants in the high-target group, with a study assessed both POD and POCD. No significant difference between the low-target and the high-target group was observed in the incidence of POD (RR = 3.30, 95% CI 0.80 to 13.54, P = 0.10), or POCD (RR = 1.26, 95% CI 0.76 to 2.08, P = 0.37). Furthermore, it also demonstrates that intraoperative hypotension prolonged the length of ICU stay, but did not increased the mortality, the length of hospital stay, and mechanical ventilation (MV) time. CONCLUSIONS There is no significant correlation between intraoperative hypotension and the incidence of POD or POCD.
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Affiliation(s)
- Xiaojin Feng
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Jialing Hu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Fuzhou Hua
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Jing Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Lieliang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Guohai Xu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China.
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Coskun C, Borulu F, Emir I, Hanedan M, Mataraci I. Investigation of the Relationship between Cerebral Near-Infrared Spectroscopy Measurements and Cerebrovascular Event in Coronary Artery Bypass Grafting Operation in Patients without Carotid Stenosis and Patients with Carotid Stenosis below Surgical Margins. Braz J Cardiovasc Surg 2020; 35:465-470. [PMID: 32864925 PMCID: PMC7454614 DOI: 10.21470/1678-9741-2019-0050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Stroke is an important cause of mortality and morbidity in surgery. In the present study, we examined the cerebral oximetry values of patients with carotid artery stenosis who did not present surgical indications and those who did not present carotid artery stenosis in coronary artery bypass grafting (CABG) surgery by comparing their cerebral oximetry values with cerebrovascular disease (CVD). METHODS Between January and May 2014, 40 patients who underwent isolated CABG were included in the study. Cerebral oximetry probes were placed prior to induction of anesthesia. Cerebral oximetry values were recorded before induction, in the pump (cardiopulmonary bypass) inlet period, in the post-clamp period, in the pump outlet period, and in the intensive care unit and neurological complications. RESULTS There was no difference between the groups in terms of demographic data and routine follow-up parameters. Intraoperative surgical data and early postoperative results were similar in both groups. When comparing the groups, there were no statistically significant results in cerebral oximetry values and CVD development. Only one patient in group 2 had postoperative CVD and this patient was discharged from the hospital with right hemiplegia. Mean arterial pressure (MAP)levels were significantly higher in Group 2 (P<0.05). CONCLUSION The follow-up of cerebral perfusion with a method like near-infrared spectroscopy (NIRS) will ensure that MAP is adjusted with interventions that will be made according to changes in NIRS. Thus, it will be possible to avoid unnecessary medication and flow-rate increase with cerebral oxygen saturation (rSO2) follow-up.
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Affiliation(s)
| | - Ferhat Borulu
- Atatürk University, Medical Faculty, Cardiovascular Surgery Department, Erzurum, Turkey
| | - Izzet Emir
- Erzincan University, Medical Faculty, Cardiovascular Surgery Department, Erzincan, Turkey
| | - Muhammed Hanedan
- Ahi Evren Thoracic Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey
| | - Ilker Mataraci
- Ahi Evren Thoracic Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey
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Li Y, Kim J, Simpson D, Aagaard-Kienitz B, Niemann D, Esene IN, Ahmed A. Difference in imaging biomarkers between transient and permanent neurological deficits after endovascular treatment of cerebrovascular aneurysms. J Neurosurg 2020; 134:1861-1870. [PMID: 32559747 DOI: 10.3171/2020.4.jns192718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 04/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The literature suggests that blood-brain barrier disruption (BBBD) plays a significant role in the development of neurological events in patients with diffusion-weighted imaging (DWI) that is negative for lesions. In this prospective, single-center cohort study, the authors compared the imaging characteristics of patients suffering transient neurological events (TNEs) with those in patients suffering permanent neurological events (PNEs) after having undergone elective embolization of unruptured intracranial aneurysms. METHODS This prospective cohort study was conducted between July 2016 and June 2019. Inclusion criteria were adults undergoing elective neuroendovascular procedures and the absence of contraindications to MRI. All subjects underwent brain MRI including postcontrast FLAIR (pcFLAIR) sequences for evaluation of BBBD within 24 hours postprocedure. RESULTS In total, 128 patients harboring 133 unruptured aneurysms were enrolled, 109 of whom (85.2%) showed some degree of BBBD on pcFLAIR MRI and 50 of whom (39.1%) suffered an ischemic insult per DWI. In total, 23 patients (18%) suffered neurological complications, 16 of which (12.5%) were TNEs and 7 of which (5.5%) were PNEs. The median extent of BBBD was focal in asymptomatic patients as compared to hemispheric and lobar in the TNE and PNE groups, respectively (p < 0.001). The American Society of Anesthesiologists physical status classification predicted the extent of BBBD (p = 0.046). Lesions on DWI were noted in 34 asymptomatic patients (32.4%) compared to 9 patients (56.3%) with TNEs and all 7 patients (100%) with PNEs (p < 0.001). The median number of DWI lesions was 0 (range 0-18 lesions) in the asymptomatic group compared to 1.5 (range 0-8 lesions) and 8 (range 1-13 lesions) in the TNE and PNE groups, respectively (p < 0.001). Smoking (p = 0.008), older age (p = 0.002), and longer surgery (p = 0.006) were positively associated with the number of lesions on DWI. On multivariate analysis, intraarterial verapamil (p = 0.02, OR 8.01, 95% CI 1.35-47.43) and extent of BBBD (p < 0.001, OR 58.58, 95% CI 9.48-361.84) were positively associated with the development of TNEs, while intravenous infusion of midazolam during surgery (p = 0.02, OR 6.03, 95% CI 1.29-28.20) was negatively associated. An increased number of lesions on DWI was the only significant predictor for the development of PNEs (p < 0.001, OR 49.85, 95% CI 5.56-447.10). CONCLUSIONS An increasing extent of BBBD was associated with the development of TNEs, whereas an increasing number of lesions on DWI was significantly associated with the development of PNEs. BBBD imaging using pcFLAIR may serve as a valuable biomarker for detecting subtle cerebral ischemia and stratifying the risk for ischemic events.
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Affiliation(s)
- Yiping Li
- Departments of1Neurological Surgery and
| | - Jason Kim
- Departments of1Neurological Surgery and
| | | | - Beverly Aagaard-Kienitz
- Departments of1Neurological Surgery and.,2Radiology, University of Wisconsin Medical School, Madison, Wisconsin
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What Is the Optimal Blood Pressure on Veno-Arterial Extracorporeal Membrane Oxygenation? Impact of Mean Arterial Pressure on Survival. ASAIO J 2020; 65:336-341. [PMID: 29762229 DOI: 10.1097/mat.0000000000000824] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Blood pressure management is crucial for patients on veno-arterial extracorporeal membrane oxygenation (VA ECMO). Lower pressure can lead to end-organ malperfusion, whereas higher pressure may compete with ECMO flow and cardiac output. The impact of mean arterial pressure (MAP) on outcomes of patients on VA ECMO was evaluated. Patients who were supported on VA ECMO from September 2010 to March 2016 were retrospectively analyzed for average MAP throughout their course on ECMO, excluding the first and last day. Survival and complications observed during ECMO were investigated by classifying patients into groups based on their average MAP. A total of 116 patients were identified. Average MAP was significantly higher in patients who survived to discharge (82 ± 5.6 vs. 78 ± 5.5 mm Hg, p = 0.0003). There was a positive association between MAP and survival. Survival was best with MAP higher than 90 mm Hg (71%) and worst with MAP less than 70 mm Hg, where no patient survived. MAP was an independent predictor of survival to discharge by multivariate analysis (odds ratio 1.17, p = 0.013). Vasopressors were used more frequently in patients with lower pressure (coefficient -3.14, p = 0.005) without affecting survival (odds ratio 0.95, p = 0.95). Although the MAP did not affect the probability of strokes or bleeding complications, patients with a higher MAP had a lower incidence of kidney injury (p = 0.007). In conclusion, survival of patients on VA ECMO was significantly greater with a higher MAP, without being affected by prolonged vasopressor use.
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Decreased mean perfusion pressure as an independent predictor of acute kidney injury after cardiac surgery. Heart Vessels 2020; 35:1154-1163. [PMID: 32200414 PMCID: PMC7332480 DOI: 10.1007/s00380-020-01578-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/28/2020] [Indexed: 12/19/2022]
Abstract
Acute kidney injury after cardiac surgery (AKICS) is common. Previous studies examining the role that mean arterial pressure (MAP) during cardiopulmonary bypass (CPB) may have on AKICS have not taken into account how baseline central venous pressure (CVP) and mean perfusion pressure (MPP) (i.e. MAP − CVP) can influence its evolution. To assess whether the change in MPP to the kidneys (i.e. delta MPP or DMPP) during CPB compared to baseline is an independent predictor of AKICS. After ethical approval, a retrospective observational study was performed on all patients undergoing CPB between October 2013 and June 2015 at a university-affiliated hospital. Known risk factors for the development of AKICS were recorded, as were the MPP values at baseline and during CPB. From this, statistical modelling was performed to identify predictors of postoperative AKICS. 664 patients were identified. Analysis was performed on 513 patients after exclusion. On logistic regression, significant and independent predictors of AKICS included: d20DMPP (cumulative duration of MPP values during CPB that were 20% below baseline and exceeded three consecutive minutes) (P = 0.010); baseline CVP; age; pre-operative creatinine level; and left ventricular (LV) dysfunction (ejection fraction (EF) < 45%). On alternative modelling, the cumulative number of MPP values during CPB that were 10% below baseline was also independently associated with AKICS (P = 0.003). Modelling without taking into account CVP also supported this association. The duration of differences in perfusion pressure to the kidneys during CPB compared to baseline is an independent predictor of AKICS.
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Neurological complications after cardiac surgery: anesthetic considerations based on outcome evidence. Curr Opin Anaesthesiol 2020; 32:563-567. [PMID: 31145196 PMCID: PMC6735528 DOI: 10.1097/aco.0000000000000755] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Neurological complications after cardiac surgery remain prevalent. This review aims to discuss the modifiable and outcome-relevant risk factors based on an up-to-date literature review, with a focus on interventions that may improve outcomes.
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Puis L, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Wahba A. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Interact Cardiovasc Thorac Surg 2020; 30:161-202. [PMID: 31576402 PMCID: PMC10634377 DOI: 10.1093/icvts/ivz251] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav s University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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Sacli H, Kara I. Are Standard Follow-Up Parameters Sufficient to Protect Neurocognitive Functions in Patients with Diabetes Mellitus who Underwent Coronary Artery Bypass Grafting? Braz J Cardiovasc Surg 2020; 35:75-81. [PMID: 32270963 PMCID: PMC7089738 DOI: 10.21470/1678-9741-2019-0160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE We aimed to compare the effectiveness of cognitive function protection between the standard follow-up parameters and advanced neuromonitoring methods in diabetic patients who underwent coronary artery bypass grafting during cardiopulmonary bypass. METHODS Study design was prospective and observational. Patients were separated into two groups, treated only with standard follow-up parameters (Group 1) and followed up with the change of regional cerebral tissue oxygenation (rSO2) by near-infrared spectroscopy (Group 2). Neurocognitive functions were evaluated preoperatively and postoperatively before discharge in all patients using the Montreal Cognitive Assessment (MoCA) test. RESULTS Cognitive functions of Group 2 patients in the postoperative period were significantly higher than Group 1 patients (P=0.001). The mean postoperative MoCA score of patients was significantly lower than the mean preoperative MoCA score in Group 1 (24.8±2.2 vs. 23.6±2.6, P=0.02). However, mild cognitive dysfunction was significantly lower in Group 2, compared to Group 1 (P=0.02). CONCLUSION In patients followed up with standard parameters, a significant decrease in cognitive function was observed in the early period. However, the use of advanced neuromonitoring methods can significantly prevent this decrease in cognitive functions.
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Affiliation(s)
- Hakan Sacli
- Sakarya University Medical Faculty Department of Cardiovascular Surgery Sakarya Turkey Department of Cardiovascular Surgery, Sakarya University Medical Faculty, Sakarya, Turkey
| | - Ibrahim Kara
- Sakarya University Medical Faculty Department of Cardiovascular Surgery Sakarya Turkey Department of Cardiovascular Surgery, Sakarya University Medical Faculty, Sakarya, Turkey
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