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Yang X, Zhu L, Pan H, Yang Y. Cardiopulmonary bypass associated acute kidney injury: better understanding and better prevention. Ren Fail 2024; 46:2331062. [PMID: 38515271 PMCID: PMC10962309 DOI: 10.1080/0886022x.2024.2331062] [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: 10/17/2023] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
Cardiopulmonary bypass (CPB) is a common technique in cardiac surgery but is associated with acute kidney injury (AKI), which carries considerable morbidity and mortality. In this review, we explore the range and definition of CPB-associated AKI and discuss the possible impact of different disease recognition methods on research outcomes. Furthermore, we introduce the specialized equipment and procedural intricacies associated with CPB surgeries. Based on recent research, we discuss the potential pathogenesis of AKI that may result from CPB, including compromised perfusion and oxygenation, inflammatory activation, oxidative stress, coagulopathy, hemolysis, and endothelial damage. Finally, we explore current interventions aimed at preventing and attenuating renal impairment related to CPB, and presenting these measures from three perspectives: (1) avoiding CPB to eliminate the fundamental impact on renal function; (2) optimizing CPB by adjusting equipment parameters, optimizing surgical procedures, or using improved materials to mitigate kidney damage; (3) employing pharmacological or interventional measures targeting pathogenic factors.
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Affiliation(s)
- Xutao Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Li Zhu
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
- The Jinhua Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, China
| | - Hong Pan
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Yi Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
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2
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Sun Q, Wu W. Effect of near-infrared spectroscopy on postoperative delirium in cardiac surgery with cardiopulmonary bypass: a systematic review and meta-analysis. Front Cardiovasc Med 2024; 11:1404210. [PMID: 38962088 PMCID: PMC11221214 DOI: 10.3389/fcvm.2024.1404210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 06/07/2024] [Indexed: 07/05/2024] Open
Abstract
Background Postoperative delirium (POD) is a common anesthetic side effect in cardiac surgery. However, the role of oxygen saturation monitoring in reducing postoperative delirium has been controversial. Therefore, this meta-analysis aimed to analyze whether NIRS monitoring during cardiac surgery under cardiopulmonary bypass could reduce the incidence of postoperative delirium. Methods PubMed, Web of Science, Cochrane Library, Embase and China National Knowledge Infrastructure (CNKI) databases were systematically searched using the related keywords for randomized-controlled trials (RCTs) published from their inception to March 16, 2024. This review was conducted by the Preferred Reporting Project and Meta-Analysis Statement (PRISMA) guidelines for systematic review. The primary outcome was postoperative delirium, and the second outcomes included the length of ICU stay, the incidence of kidney-related adverse outcomes, and the incidence of cardiac-related adverse outcomes. Results The incidence of postoperative delirium could be reduced under the guidance of near-infrared spectroscopy monitoring (OR, 0.657; 95% CI, 0.447-0.965; P = 0.032; I2 = 0%). However, there were no significant differences in the length of ICU stay (SMD, 0.005 days; 95% CI, -0.135-0.146; P = 0.940; I2 = 39.3%), the incidence of kidney-related adverse outcomes (OR, 0.761; 95% CI, 0.386-1.500; P = 0.430; I2 = 0%), and the incidence of the cardiac-related adverse outcomes (OR, 1.165; 95% CI, 0.556-2.442; P = 0.686; I2 = 0%) between the two groups. Conclusion Near-infrared spectroscopy monitoring in cardiac surgery with cardiopulmonary bypass helps reduce postoperative delirium in patients. Systematic Review Registration PROSPERO, identifier, CRD42023482675.
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Affiliation(s)
| | - Weiguo Wu
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
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3
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Ghia S, Savadjian A, Shin D, Diluozzo G, Weiner MM, Bhatt HV. Hypothermic Circulatory Arrest in Adult Aortic Arch Surgery: A Review of Hypothermic Circulatory Arrest and its Anesthetic Implications. J Cardiothorac Vasc Anesth 2023; 37:2634-2645. [PMID: 37723023 DOI: 10.1053/j.jvca.2023.08.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 09/20/2023]
Abstract
Diseases affecting the aortic arch often require surgical intervention. Hypothermic circulatory arrest (HCA) enables a safe approach during open aortic arch surgeries. Additionally, HCA provides neuroprotection by reducing cerebral metabolism and oxygen requirements. However, HCA comes with significant risks (eg, neurologic dysfunction, stroke, and coagulopathy), and the cardiac anesthesiologist must completely understand the surgical techniques, possible complications, and management strategies.
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Affiliation(s)
- Samit Ghia
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andre Savadjian
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC
| | - DaWi Shin
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gabriele Diluozzo
- Department of Cardiovascular Surgery, Yale School of Medicine, Bridgeport, CT
| | - Menachem M Weiner
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Himani V Bhatt
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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4
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Ho R, McDonald C, Pauls JP, Li Z. Improving Trendelenburg position effectiveness by varying cardiopulmonary bypass flow. Perfusion 2023; 38:1213-1221. [PMID: 35703549 DOI: 10.1177/02676591221108810] [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] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Trendelenburg position (TP) is used to transport gaseous emboli away from the cerebral region during cardiac surgery. However, TP effectiveness has not been fully considered when combined with varying the cardiopulmonary bypass (CPB) flow. This study simulated the supine and TP at different pump flows and assessed the trapped emboli and embolic load entering the aortic arch branch arteries (AABA). METHODS A computational fluid dynamics (CFD) approach used a centrally cannulated adult patient-specific aorta model replicating a CPB circuit. Air emboli of 0.1 mm, 0.5 mm, and 1.0 mm (n = 700 each) were injected into the aorta placed in the supine position (0°) and the TP (-20°) at 2 L/min and 5 L/min. The number of emboli entering the AABA were compared. An aortic phantom flow experiment was performed to validate air bubble behaviour. RESULTS TP at 5 L/min had the lowest 0.1 mm mean (±SD) embolic load compared to the supine 2 L/min (55.3 ± 30.8 vs 64.3 ± 35.4). For both the supine and TP, the lower flow of 2 L/min had the highest number of simulated trapped emboli in higher elevated regions than at 5 L/min (541 ± 185 and 548 ± 191 vs 520 ± 159 and 512 ± 174), respectively. The flow experiment demonstrated that 2 L/min promoted bubble coalescence and high amounts of trapped emboli and 5 L/min transported air emboli away from the AABA. CONCLUSIONS TP effectiveness was improved by using CPB flow to manage air emboli. These results provide insights for predicting emboli behaviour and improving emboli de-airing procedures.
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Affiliation(s)
- Raymond Ho
- School of Mechanical, Medical and Process Engineering, Faculty of Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Innovative Cardiovascular Engineering and Technology Laboratory (ICETLAB), Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Charles McDonald
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital. Chermside, QLD, Australia
| | - Jo P Pauls
- Innovative Cardiovascular Engineering and Technology Laboratory (ICETLAB), Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Engineering and Built Environment, Griffith University, Southport, QLD, Australia
| | - Zhiyong Li
- School of Mechanical, Medical and Process Engineering, Faculty of Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia
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Paal P, Pasquier M, Darocha T, Lechner R, Kosinski S, Wallner B, Zafren K, Brugger H. Accidental Hypothermia: 2021 Update. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:501. [PMID: 35010760 PMCID: PMC8744717 DOI: 10.3390/ijerph19010501] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 12/13/2022]
Abstract
Accidental hypothermia is an unintentional drop of core temperature below 35 °C. Annually, thousands die of primary hypothermia and an unknown number die of secondary hypothermia worldwide. Hypothermia can be expected in emergency patients in the prehospital phase. Injured and intoxicated patients cool quickly even in subtropical regions. Preventive measures are important to avoid hypothermia or cooling in ill or injured patients. Diagnosis and assessment of the risk of cardiac arrest are based on clinical signs and core temperature measurement when available. Hypothermic patients with risk factors for imminent cardiac arrest (temperature < 30 °C in young and healthy patients and <32 °C in elderly persons, or patients with multiple comorbidities), ventricular dysrhythmias, or systolic blood pressure < 90 mmHg) and hypothermic patients who are already in cardiac arrest, should be transferred directly to an extracorporeal life support (ECLS) centre. If a hypothermic patient arrests, continuous cardiopulmonary resuscitation (CPR) should be performed. In hypothermic patients, the chances of survival and good neurological outcome are higher than for normothermic patients for witnessed, unwitnessed and asystolic cardiac arrest. Mechanical CPR devices should be used for prolonged rescue, if available. In severely hypothermic patients in cardiac arrest, if continuous or mechanical CPR is not possible, intermittent CPR should be used. Rewarming can be accomplished by passive and active techniques. Most often, passive and active external techniques are used. Only in patients with refractory hypothermia or cardiac arrest are internal rewarming techniques required. ECLS rewarming should be performed with extracorporeal membrane oxygenation (ECMO). A post-resuscitation care bundle should complement treatment.
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Affiliation(s)
- Peter Paal
- Department of Anesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, 5020 Salzburg, Austria
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
| | - Mathieu Pasquier
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
- Department of Emergency Medicine, Lausanne University Hospital, 1011 Lausanne, Switzerland
| | - Tomasz Darocha
- Department of Anesthesiology and Intensive Care, Medical University of Silesia, 40-001 Katowice, Poland;
| | - Raimund Lechner
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Military Hospital, 89081 Ulm, Germany;
| | - Sylweriusz Kosinski
- Faculty of Health Sciences, Jagiellonian University Medical College, 34-500 Krakow, Poland;
| | - Bernd Wallner
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Ken Zafren
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
- Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, AK 99508, USA
- Department of Emergency Medicine, Stanford University Medical Center, Stanford University, Palo Alto, CA 94304, USA
| | - Hermann Brugger
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
- Institute of Mountain Emergency Medicine, Eurac Research, 39100 Bolzano, Italy
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria
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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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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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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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9
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Regiroli G, Loi B, Fortas F, Centorrino R, Mosca F, De Luca D. Effect of inspired gas temperature on lung mechanics and gas exchange in neonates in normothermia or therapeutic hypothermia. Resuscitation 2021; 163:116-123. [PMID: 33895234 DOI: 10.1016/j.resuscitation.2021.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/27/2021] [Accepted: 04/12/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Respiratory critical care guidelines suggest heating the air/oxygen mixture but do not recommend a specific temperature target. We aimed to clarify if the inspired gas temperature influences lung mechanics and gas exchange in intubated patients treated with whole body hypothermia (WBH) or normothermia (NT). METHODS Prospective cohort study enrolling neonates ventilated for perinatal asphyxia resuscitation (no lung disease) or acute hypoxemic respiratory failure. Patients were divided between those ventilated in NT or WBH. Compliance (Cdyn), airway resistances (Raw), oxygenation index (OI), PaO2/FiO2, A-a gradient, a/A ratio, estimated alveolar dead space (VDalv), ventilatory index (VI) and CO2 production (VCO2) were registered at the study beginning (inspired gas at 37°C). Then, gas temperature was decreased (32 °C) and variables were recorded again after 1 and 3 h. Data were analysed with univariate and multivariate repeated measures-ANOVA. RESULTS Cdyn, Raw, OI, PaO2/FiO2, A-a gradient, a/A ratio, VDalv, VI and VCO2 are similar between WBH and NT at any timepoint (between-subjects effect); these results do not change adjusting for the presence of respiratory failure. When this is considered in multivariate ANOVA (within-subjects effect), Cdyn (p = 0.016), Raw (p = 0.034) and VDalv (p < 0.001) were worse in patients with respiratory failure than in those without lung disease. CONCLUSIONS Decreasing the gas temperature from 37 °C to 32 °C for 3 h does not change lung mechanics and gas exchange, neither in neonates with, nor in those without respiratory failure and in those treated in NT or WBH. These findings fill a knowledge gap regarding the effect of inspired gas temperature during WBH: they may inform future respiratory critical care guidelines.
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Affiliation(s)
- Giulia Regiroli
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France; Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Barbara Loi
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Feriel Fortas
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France; Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
| | - Roberta Centorrino
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France; Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France; Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France.
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Qu JZ, Kao LW, Smith JE, Kuo A, Xue A, Iyer MH, Essandoh MK, Dalia AA. Brain Protection in Aortic Arch Surgery: An Evolving Field. J Cardiothorac Vasc Anesth 2020; 35:1176-1188. [PMID: 33309497 DOI: 10.1053/j.jvca.2020.11.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/10/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
Despite advances in cardiac surgery and anesthesia, the rates of brain injury remain high in aortic arch surgery requiring circulatory arrest. The mechanisms of brain injury, including permanent and temporary neurologic dysfunction, are multifactorial, but intraoperative brain ischemia is likely a major contributor. Maintaining optimal cerebral perfusion during cardiopulmonary bypass and circulatory arrest is the key component of intraoperative management for aortic arch surgery. Various brain monitoring modalities provide different information to improve cerebral protection. Electroencephalography gives crucial data to ensure minimal cerebral metabolism during deep hypothermic circulatory arrest, transcranial Doppler directly measures cerebral arterial blood flow, and near-infrared spectroscopy monitors regional cerebral oxygen saturation. Various brain protection techniques, including hypothermia, cerebral perfusion, pharmacologic protection, and blood gas management, have been used during interruption of systemic circulation, but the optimal strategy remains elusive. Although deep hypothermic circulatory arrest and retrograde cerebral perfusion have their merits, there have been increasing reports about the use of antegrade cerebral perfusion, obviating the need for deep hypothermia. With controversy and variability of surgical practices, moderate hypothermia, when combined with unilateral antegrade cerebral perfusion, is considered safe for brain protection in aortic arch surgery performed with circulatory arrest. The neurologic outcomes of brain protection in aortic arch surgery largely depend on the following three major components: cerebral temperature, circulatory arrest time, and cerebral perfusion during circulatory arrest. The optimal brain protection strategy should be individualized based on comprehensive monitoring and stems from well-executed techniques that balance the major components contributing to brain injury.
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Affiliation(s)
- Jason Z Qu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lee-Wei Kao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jennifer E Smith
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alexander Kuo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Albert Xue
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing, China
| | - Manoj H Iyer
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH
| | - Michael K Essandoh
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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11
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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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12
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Kunst G, Milojevic M, Boer C, De Somer FM, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Puis L, Wahba A, Alston P, Fitzgerald D, Nikolic A, Onorati F, Rasmussen BS, Svenmarker S. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Br J Anaesth 2019; 123:713-757. [DOI: 10.1016/j.bja.2019.09.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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13
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Li LQ, Wang C, Fang MD, Xu HY, Lu HL, Zhang HZ. Effects of dexamethasone on post-operative cognitive dysfunction and delirium in adults following general anaesthesia: a meta-analysis of randomised controlled trials. BMC Anesthesiol 2019; 19:113. [PMID: 31253079 PMCID: PMC6599229 DOI: 10.1186/s12871-019-0783-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 06/11/2019] [Indexed: 02/08/2023] Open
Abstract
Background Several studies have investigated the effects of dexamethasone on post-operative cognitive dysfunction (POCD) or post-operative delirium (POD); however, their conclusions have been inconsistent. Thus, we conducted a meta-analysis to determine the effects of dexamethasone on POCD and POD in adults following general anaesthesia. Methods The Cochrane Central Register of Controlled Trials (2018, Issue 11 of 12) in the Cochrane Library (searched 17 November 2018), MEDLINE OvidSP (1946 to 16 November 2018) and Embase OvidSP (1974 to 16 November 2018) were searched for randomised controlled trials that evaluated the incidence of POCD and POD following dexamethasone administration in adults (age ≥ 18 years) under general anaesthesia. We used the Grading of Recommendations, Assessment, Development and Evaluations framework to assess the quality of the evidence. Results Five studies were included (three studies with 855 participants in the dexamethasone group and 538 participants in the placebo group for the incidence of POCD, and two studies with 410 participants in the dexamethasone group and 420 participants in the placebo group for the incidence of POD). There was no significant difference between the dexamethasone group and the placebo group in terms of the incidence of POCD 30 days after surgery (RR [relative risk] 1.00; 95% CI [confidence interval: 0.51, 1.96], P = 1.00, I2 = 77%) or the incidence of POD (RR 0.96; 95% CI [0.68, 1.35], P = 0.80, I2 = 0%). However, both analyses had some limitations because of limited evidence and clinical heterogeneity, and we considered the quality of the evidence for the post-operative incidence of POCD and POD to be very low. Conclusions This meta-analysis revealed that prophylactic dexamethasone did not reduce the incidence of POCD and POD. Trials of alternative preventive strategies for POCD and POD, as well as a better understanding of the pathophysiology of those complex syndromes, are still needed to make progress in this field. Trial registrationr This study is registered with PROSPERO, 23 October 2018, number CRD42018114552. Available from https://www.crd.york.ac.uk/PROSPERO/#recordDetails. Electronic supplementary material The online version of this article (10.1186/s12871-019-0783-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Li-Qin Li
- Department of Anesthesiology, Jilin University Second Hospital, No. 218 Ziqiang street, Changchun, Jilin, 130021, People's Republic of China
| | - Cong Wang
- Department of Anesthesiology, Jilin University Second Hospital, No. 218 Ziqiang street, Changchun, Jilin, 130021, People's Republic of China
| | - Mei-Dan Fang
- Department of Anesthesiology, Jilin University Second Hospital, No. 218 Ziqiang street, Changchun, Jilin, 130021, People's Republic of China
| | - Hong-Yu Xu
- Department of Anesthesiology, Jilin University Second Hospital, No. 218 Ziqiang street, Changchun, Jilin, 130021, People's Republic of China
| | - Hong-Liu Lu
- Department of Anesthesiology, Jilin University Second Hospital, No. 218 Ziqiang street, Changchun, Jilin, 130021, People's Republic of China
| | - Hou-Zhong Zhang
- Department of Anesthesiology, Jilin University Second Hospital, No. 218 Ziqiang street, Changchun, Jilin, 130021, People's Republic of China.
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Manetta F, Mullan CW, Catalano MA. Neuroprotective Strategies in Repair and Replacement of the Aortic Arch. Int J Angiol 2018; 27:98-109. [PMID: 29896042 PMCID: PMC5995688 DOI: 10.1055/s-0038-1649512] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Aortic arch surgery is a technical challenge, and cerebral protection during distal anastomosis is a continued topic of controversy and discussion. The physiologic effects of hypothermic arrest and adjunctive cerebral perfusion have yet to be fully defined, and the optimal strategies are still undetermined. This review highlights the historical context, physiological rationale, and clinical efficacy of various neuroprotective strategies during arch operations.
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Affiliation(s)
- Frank Manetta
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Clancy W. Mullan
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Michael A. Catalano
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
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Perioperative Research into Memory (PRiMe): Cognitive impairment following a severe burn injury and critical care admission, part 1. Burns 2018; 44:1167-1178. [PMID: 29752016 DOI: 10.1016/j.burns.2018.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 03/20/2018] [Accepted: 04/10/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION An investigation into long-term cognitive impairment and Quality of Life (QoL) after severe burns. METHODS A proof of principle, cohort design, prospective, observational clinical study. Patients with severe burns (>15% TBSA) admitted to Burns ICU for invasive ventilation were recruited for psychocognitive assessment with a convenience sample of age and sex-matched controls. Participants completed psychological and QoL questionnaires, the Cogstate® electronic battery, Hopkins Verbal Learning, Verbal Fluency and Trail making tasks. RESULTS 15 patients (11M, 4F; 41±14 years; TBSA 38.4%±18.5) and comparators (11M, 4F; 40±13 years) were recruited. Burns patients reported worse QoL (Neuro-QoL Short Form v2, patient 30.1±8.2, control 38.7±3.2, p=0.0004) and cognitive function (patient composite z-score 0.01, IQR -0.11 to 0.33, control 0.13, IQR 0.47-0.73, p=0.02). Compared to estimated premorbid FSIQ, patients dropped an equivalent of 8 IQ points (p=0.002). Cognitive function negatively correlated with burn severity (rBaux score, p=0.04). QoL strongly correlated with depressive symptoms (Rho=-0.67, p=0.009) but not cognitive function. CONCLUSIONS Severe burns injuries are associated with a significant, global, cognitive deficit. Patients also report worse QoL, depression and post-traumatic stress. Perceived QoL from cognitive impairment was more closely associated with depression than cognitive impairment.
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Abstract
Accidental hypothermia causes profound changes to the body's physiology. After an initial burst of agitation (e.g., 36-37°C), vital functions will slow down with further cooling, until they vanish (e.g. <20-25°C). Thus, a deeply hypothermic person may appear dead, but may still be able to be resuscitated if treated correctly. The hospital use of minimally invasive rewarming for nonarrested, otherwise healthy patients with primary hypothermia and stable vital signs has the potential to substantially decrease morbidity and mortality for these patients. Extracorporeal life support (ECLS) has revolutionized the management of hypothermic cardiac arrest, with survival rates approaching 100%. Hypothermic patients with risk factors for imminent cardiac arrest (i.e., temperature <28°C, ventricular arrhythmia, systolic blood pressure <90 mmHg), and those who have already arrested, should be transferred directly to an ECLS center. Cardiac arrest patients should receive continuous cardiopulmonary resuscitation (CPR) during transfer. If prolonged transport is required or terrain is difficult, mechanic CPR can be helpful. Intermittent CPR may be appropriate in hypothermic arrest when continuous CPR is impossible. Modern postresuscitation care should be implemented following hypothermic arrest. Structured protocols should be in place to optimize prehospital triage, transport, and treatment as well as in-hospital management, including detailed criteria and protocols for the use of ECLS and postresuscitation care.
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Affiliation(s)
- Peter Paal
- Department of Anaesthesia and Intensive Care Medicine, Hospitallers Brothers Hospital, Salzburg, Austria.
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
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Paal P, Gordon L, Strapazzon G, Brodmann Maeder M, Putzer G, Walpoth B, Wanscher M, Brown D, Holzer M, Broessner G, Brugger H. Accidental hypothermia-an update : The content of this review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). Scand J Trauma Resusc Emerg Med 2016; 24:111. [PMID: 27633781 PMCID: PMC5025630 DOI: 10.1186/s13049-016-0303-7] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/07/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND This paper provides an up-to-date review of the management and outcome of accidental hypothermia patients with and without cardiac arrest. METHODS The authors reviewed the relevant literature in their specialist field. Summaries were merged, discussed and approved to produce this narrative review. RESULTS The hospital use of minimally-invasive rewarming for non-arrested, otherwise healthy, patients with primary hypothermia and stable vital signs has the potential to substantially decrease morbidity and mortality for these patients. Extracorporeal life support (ECLS) has revolutionised the management of hypothermic cardiac arrest, with survival rates approaching 100 % in some cases. Hypothermic patients with risk factors for imminent cardiac arrest (temperature <28 °C, ventricular arrhythmia, systolic blood pressure <90 mmHg), and those who have already arrested, should be transferred directly to an ECLS-centre. Cardiac arrest patients should receive continuous cardiopulmonary resuscitation (CPR) during transfer. If prolonged transport is required or terrain is difficult, mechanical CPR can be helpful. Delayed or intermittent CPR may be appropriate in hypothermic arrest when continuous CPR is impossible. Modern post-resuscitation care should be implemented following hypothermic arrest. Structured protocols should be in place to optimise pre-hospital triage, transport and treatment as well as in-hospital management, including detailed criteria and protocols for the use of ECLS and post-resuscitation care. CONCLUSIONS Based on new evidence, additional clinical experience and clearer management guidelines and documentation, the treatment of accidental hypothermia has been refined. ECLS has substantially improved survival and is the treatment of choice in the patient with unstable circulation or cardiac arrest.
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Affiliation(s)
- Peter Paal
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck University Hospital, Anichstr. 35, 6020 Innsbruck, Austria
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, Barts Health NHS Trust, Queen Mary University of London, KGV Building, Office 10, 1st floor, West Smithfield, London, EC1A 7BE UK
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
| | - Les Gordon
- Department of Anaesthesia, University hospitals, Morecambe Bay Trust, Lancaster, UK
- Langdale Ambleside Mountain Rescue Team, Ambleside, UK
| | - Giacomo Strapazzon
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, Bozen/Bolzano, Italy
| | - Monika Brodmann Maeder
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, Bozen/Bolzano, Italy
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Gabriel Putzer
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck University Hospital, Anichstr. 35, 6020 Innsbruck, Austria
| | - Beat Walpoth
- Department of Surgery, Cardiovascular Research, Service of Cardiovascular Surgery, University Hospital Geneva, Geneva, Switzerland
| | - Michael Wanscher
- Department of Cardiothoracic Anaesthesia and Intensive Care 4142, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Doug Brown
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Gregor Broessner
- Department of Neurology, Neurologic Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - Hermann Brugger
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck University Hospital, Anichstr. 35, 6020 Innsbruck, Austria
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, Bozen/Bolzano, Italy
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Abstract
Strategies for basic and advanced neuromonitoring techniques are reviewed. Cerebral hyperthermia during rewarming and unrecognized jugular venous obstruction are associated with cerebral compromise and can be readily detected and avoided. The strengths and limitations of transcranial Doppler and electroencephalographic monitoring are reviewed, as is use of noninvasive cerebral optical spectroscopy and jugular venous oximetry. The potential for reduction in perioperative stroke by using epiaortic scanning to detect and avoid otherwise nonpalpable atherosclerotic plaque, is also reviewed.
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Affiliation(s)
- John M. Murkin
- University Hospital Campus-LHSC, University of Western Ontario, London, Ontario, Canada; Department of Anesthesiology and Perioperative Medicine, University Hospital Campus-LHSC, 339 Windermere Rd., London, Ontario, Canada N6A 5A5
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Dorotta I, Kimball-Jones P, Applegate R. Deep Hypothermia and Circulatory Arrest in Adults. Semin Cardiothorac Vasc Anesth 2016; 11:66-76. [PMID: 17484175 DOI: 10.1177/1089253206297482] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Brain protection during cardiopulmonary bypass has been the subject of intense research. Deep hypothermic circulatory arrest (DHCA) continues to be used for that goal during complex aortic arch and large intracranial aneurysm surgeries. The anesthetic management for adult patients undergoing these types of procedures requires specific knowledge and expertise. Based on our experience and review of the current literature, the authors highlight the key areas of the anesthetic plan, discussing the risk factors associated with adverse neurologic outcome as well as the rationale for decisions regarding specific monitors and medications. In the conclusion an anesthetic protocol for adult patients undergoing DHCA is suggested.
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Affiliation(s)
- Ihab Dorotta
- Department of Anesthesiology, Loma Linda University Medical Center, CA 92354, USA.
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20
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Murkin JM. Pathophysiological Basis of CNS Injury in Cardiac Surgical Patients: Detection and Prevention. Perfusion 2016; 21:203-8. [PMID: 16939113 DOI: 10.1191/0267659106pf869oa] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The current understanding of adverse central nervous system (CNS) events following cardiac surgery involves several identifiable, evidence-based mechanisms: athero-sclerotic emboli, microgaseous and microparticulate emboli, and hypoperfusion.1 Secondary factors, including patient co-morbidities and inherent genetic susceptibilities, as well as systemic inflammatory processes and a suboptimal metabolic milieu may interact to potentiate the extent of injury.2 In this review a number of these factors and their potential interactions will be explored with a view towards developing a comprehensive management strategy to minimize CNS injury.
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Durandy Y. Rationale for Implementation of Warm Cardiac Surgery in Pediatrics. Front Pediatr 2016; 4:43. [PMID: 27200324 PMCID: PMC4858514 DOI: 10.3389/fped.2016.00043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 04/21/2016] [Indexed: 02/03/2023] Open
Abstract
Cardiac surgery was developed thanks to the introduction of hypothermia and cardiopulmonary bypass in the early 1950s. The deep hypothermia protective effect has been essential to circulatory arrest complex cases repair. During the early times of open-heart surgery, a major concern was to decrease mortality and to improve short-term outcomes. Both mortality and morbidity dramatically decreased over a few decades. As a consequence, the drawbacks of deep hypothermia, with or without circulatory arrest, became more and more apparent. The limitation of hypothermia was particularly evident for the brain and regional perfusion was introduced as a response to this problem. Despite a gain in popularity, the results of regional perfusion were not fully convincing. In the 1990s, warm surgery was introduced in adults and proved to be safe and reliable. This option eliminates the deleterious effect of ischemia-reperfusion injuries through a continuous, systemic coronary perfusion with warm oxygenated blood. Intermittent warm blood cardioplegia was introduced later, with impressive results. We were convinced by the easiness, safety, and efficiency of warm surgery and shifted to warm pediatric surgery in a two-step program. This article outlines the limitations of hypothermic protection and the basic reasons that led us to implement pediatric warm surgery. After tens of thousands of cases performed across several centers, this reproducible technique proved a valuable alternative to hypothermic surgery.
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Affiliation(s)
- Yves Durandy
- Perfusion Department, CCML, Le Plessis Robinson, France
- Intensive Care Department, CCML, Le Plessis Robinson, France
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22
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Alpha-stat, beach chair, cerebral autoregulation… But who is at risk? Can J Anaesth 2016; 63:513-8. [DOI: 10.1007/s12630-016-0605-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/14/2015] [Accepted: 01/27/2016] [Indexed: 11/27/2022] Open
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23
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Liebold A. Extrakorporale Zirkulation. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2015. [DOI: 10.1007/s00398-015-0032-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Risk Factors Associated with Cognitive Decline after Cardiac Surgery: A Systematic Review. Cardiovasc Psychiatry Neurol 2015; 2015:370612. [PMID: 26491558 PMCID: PMC4605208 DOI: 10.1155/2015/370612] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 09/15/2015] [Indexed: 12/20/2022] Open
Abstract
Modern day cardiac surgery evolved upon the advent of cardiopulmonary bypass machines (CPB) in the 1950s. Following this development, cardiac surgery in recent years has improved significantly. Despite such advances and the introduction of new technologies, neurological sequelae after cardiac surgery still exist. Ischaemic stroke, delirium, and cognitive impairment cause significant morbidity and mortality and unfortunately remain common complications. Postoperative cognitive decline (POCD) is believed to be associated with the presence of new ischaemic lesions originating from emboli entering the cerebral circulation during surgery. Cardiopulmonary bypass was thought to be the reason of POCD, but randomised controlled trials comparing with off-pump surgery show contradictory results. Attention has now turned to the growing evidence that perioperative risk factors, as well as patient-related risk factors, play an important role in early and late POCD. Clearly, identifying the mechanism of POCD is challenging. The purpose of this systematic review is to discuss the literature that has investigated patient and perioperative risk factors to better understand the magnitude of the risk factors associated with POCD after cardiac surgery.
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Seco M, Edelman JJB, Van Boxtel B, Forrest P, Byrom MJ, Wilson MK, Fraser J, Bannon PG, Vallely MP. Neurologic injury and protection in adult cardiac and aortic surgery. J Cardiothorac Vasc Anesth 2015; 29:185-95. [PMID: 25620144 DOI: 10.1053/j.jvca.2014.07.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Michael Seco
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - J James B Edelman
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Benjamin Van Boxtel
- Columbia University Medical Center-New York Presbyterian Hospital, New York, New York
| | - Paul Forrest
- Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael J Byrom
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael K Wilson
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Paul G Bannon
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael P Vallely
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia.
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Esper SA, Subramaniam K, Tanaka KA. Pathophysiology of Cardiopulmonary Bypass. Semin Cardiothorac Vasc Anesth 2014; 18:161-76. [DOI: 10.1177/1089253214532375] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The techniques and equipment of cardiopulmonary bypass (CPB) have evolved over the past 60 years, and numerous numbers of cardiac surgical procedures are conducted around the world using CPB. Despite more widespread applications of percutaneous coronary and valvular interventions, the need for cardiac surgery using CPB remains the standard approach for certain cardiac pathologies because some patients are ineligible for percutaneous procedures, or such procedures are unsuccessful in some. The ageing patient population for cardiac surgery poses a number of clinical challenges, including anemia, decreased cardiopulmonary reserve, chronic antithrombotic therapy, neurocognitive dysfunction, and renal insufficiency. The use of CPB is associated with inductions of systemic inflammatory responses involving both cellular and humoral interactions. Inflammatory pathways are complex and redundant, and thus, the reactions can be profoundly amplified to produce a multiorgan dysfunction that can manifest as capillary leak syndrome, coagulopathy, respiratory failure, myocardial dysfunction, renal insufficiency, and neurocognitive decline. In this review, pathophysiological aspects of CPB are considered from a practical point of view, and preventive strategies for hemodilutional anemia, coagulopathy, inflammation, metabolic derangement, and neurocognitive and renal dysfunction are discussed.
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Zierer A, Risteski P, El-Sayed Ahmad A, Moritz A, Diegeler A, Urbanski PP. The impact of unilateral versus bilateral antegrade cerebral perfusion on surgical outcomes after aortic arch replacement: A propensity-matched analysis. J Thorac Cardiovasc Surg 2014; 147:1212-7; discussion 1217-8. [DOI: 10.1016/j.jtcvs.2013.12.022] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 10/04/2013] [Accepted: 12/04/2013] [Indexed: 11/28/2022]
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Grocott HP, Davie SN. Future uncertainties in the development of clinical cerebral oximetry. Front Physiol 2013; 4:360. [PMID: 24385967 PMCID: PMC3866380 DOI: 10.3389/fphys.2013.00360] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 11/22/2013] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hilary P Grocott
- Department of Anesthesia & Perioperative Medicine, University of Manitoba Winnipeg, MB, Canada ; Department of Surgery, University of Manitoba Winnipeg, MB, Canada
| | - Sophie N Davie
- Department of Anesthesia & Perioperative Medicine, University of Manitoba Winnipeg, MB, Canada
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Urbanski PP, Lenos A, Kolowca M, Bougioukakis P, Keller G, Zacher M, Diegeler A. Near-infrared spectroscopy for neuromonitoring of unilateral cerebral perfusion. Eur J Cardiothorac Surg 2012; 43:1140-4. [DOI: 10.1093/ejcts/ezs557] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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van Harten AE, Scheeren TWL, Absalom AR. A review of postoperative cognitive dysfunction and neuroinflammation associated with cardiac surgery and anaesthesia. Anaesthesia 2012; 67:280-93. [DOI: 10.1111/j.1365-2044.2011.07008.x] [Citation(s) in RCA: 188] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Pappas A, Shankaran S, Laptook AR, Langer JC, Bara R, Ehrenkranz RA, Goldberg RN, Das A, Higgins RD, Tyson JE, Walsh MC. Hypocarbia and adverse outcome in neonatal hypoxic-ischemic encephalopathy. J Pediatr 2011; 158:752-758.e1. [PMID: 21146184 PMCID: PMC3229432 DOI: 10.1016/j.jpeds.2010.10.019] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2010] [Revised: 09/10/2010] [Accepted: 10/15/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate the association between early hypocarbia and 18- to 22-month outcome among neonates with hypoxic-ischemic encephalopathy. STUDY DESIGN Data from the National Institute of Child Health and Human Development Neonatal Research Network randomized, controlled trial of whole-body hypothermia for neonatal hypoxic-ischemic encephalopathy were used for this secondary observational study. Infants (n = 204) had multiple blood gases recorded from birth to 12 hours of study intervention (hypothermia versus intensive care alone). The relationship between hypocarbia and outcome (death/disability at 18 to 22 months) was evaluated by unadjusted and adjusted analyses examining minimum PCO(2) and cumulative exposure to PCO(2) <35 mm Hg. The relationship between cumulative PCO(2) <35 mm Hg (calculated as the difference between 35 mm Hg and the sampled PCO(2) multiplied by the duration of time spent <35 mm Hg) and outcome was evaluated by level of exposure (none-high) using a multiple logistic regression analysis with adjustments for pH, level of encephalopathy, treatment group (± hypothermia), and time to spontaneous respiration and ventilator days; results were expressed as odds ratios and 95% confidence intervals. Alternative models of CO(2) concentration were explored to account for fluctuations in CO(2). RESULTS Both minimum PCO(2) and cumulative PCO(2) <35 mm Hg were associated with poor outcome (P < .05). Moreover, death/disability increased with greater cumulative exposure to PCO(2) <35 mm Hg. CONCLUSIONS Hypocarbia is associated with poor outcome after hypoxic-ischemic encephalopathy.
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Affiliation(s)
- Athina Pappas
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI 48201, USA.
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University School of Medicine, Detroit MI
| | - Abbot R. Laptook
- Department of Pediatrics, Women and Infants’ Hospital, Brown University, Providence RI
| | - John C. Langer
- Statistics and Epidemiology, RTI International, Research Triangle Park, NC
| | - Rebecca Bara
- Department of Pediatrics, Wayne State University School of Medicine, Detroit MI
| | | | | | - Abhik Das
- Statistics and Epidemiology, RTI International, Research Triangle Park, NC
| | - Rosemary D. Higgins
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health
| | - Jon E. Tyson
- Department of Pediatrics, University of Texas Medical School at Houston
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland OH
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Effect of deep hypothermic circulatory arrest followed by low-flow cardiopulmonary bypass on brain metabolism in newborn piglets: comparison of pH-stat and α-stat management. Pediatr Crit Care Med 2011; 12:e79-86. [PMID: 20601925 PMCID: PMC2951487 DOI: 10.1097/pcc.0b013e3181e89e91] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the effects of pH-stat and α-stat management before deep hypothermic circulatory arrest followed by a period of low-flow (two rates) cardiopulmonary bypass on cortical oxygenation and selected regulatory proteins: Bax, Bcl-2, Caspase-3, and phospho-Akt. DESIGN Piglets were placed on cardiopulmonary bypass, cooled with pH-stat or α-stat management to 18 °C over 30 mins, subjected to 30-min deep hypothermic circulatory arrest and 1-hr low flow at 20 mL/kg/min (LF-20) or 50 mL/kg/min (LF-50), rewarmed to 37 °C, separated from cardiopulmonary bypass, and recovered for 6 hrs. SUBJECTS Newborn piglets, 2-5 days old, assigned randomly to experimental groups. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Cortical oxygen was measured by oxygen-dependent quenching of phosphorescence; proteins were measured by Western blots. The means from six experiments ± sem are presented as % of α-stat. Significance was determined by Student's t test. For LF-20, cortical oxygenation was similar for α-stat and pH-stat, whereas for LF-50, it was significantly better using pH-stat. For LF-20, the measured proteins were not different except for Bax in the cortex (214 ± 24%, p = .006) and hippocampus (118 ± 6%, p = .024) and Caspase 3 in striatum (126% ± 7%, p = .019). For LF-50, in pH-stat group: In cortex, Bax and Caspase-3 were lower (72 ± 8%, p = .001 and 72 ± 10%, p = .004, respectively) and pAkt was higher (138 ± 12%, p = .049). In hippocampus, Bcl-2 and Bax were not different but pAkt was higher (212 ± 37%, p = .005) and Caspase 3 was lower (84 ± 4%, p = .018). In striatum, Bax and pAkt did not differ, but Bcl-2 increased (146 ± 11%, p = .001) and Caspase-3 decreased (81 ± 11%, p = .042). CONCLUSIONS In this deep hypothermic circulatory arrest-LF model, when flow was 20 mL/kg/min, there was little difference between α-stat and pH-stat management. However, for LF-50, pH-stat management resulted in better cortical oxygenation during recovery and Bax, Bcl-2, pAk, and Caspase-3 changes were consistent with lesser activation of proapoptotic signaling with pH-stat than with α-stat.
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Rudolph JL, Schreiber KA, Culley DJ, McGlinchey RE, Crosby G, Levitsky S, Marcantonio ER. Measurement of post-operative cognitive dysfunction after cardiac surgery: a systematic review. Acta Anaesthesiol Scand 2010; 54:663-77. [PMID: 20397979 DOI: 10.1111/j.1399-6576.2010.02236.x] [Citation(s) in RCA: 146] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Post-operative cognitive dysfunction (POCD) is a decline in cognitive function from pre-operative levels, which has been frequently described after cardiac surgery. The purpose of this study was to examine the variability in the measurement and definitions for POCD using the framework of a 1995 Consensus Statement on measurement of POCD. Electronic medical literature databases were searched for the intersection of the search terms 'thoracic surgery' and 'cognition, dementia, and neuropsychological test.' Abstracts were reviewed independently by two reviewers. English articles with >50 participants published since 1995 that performed pre-operative and post-operative psychometric testing in patients undergoing cardiac surgery were reviewed. Data relevant to the measurement and definition of POCD were abstracted and compared with the recommendations of the Consensus Statement. Sixty-two studies of POCD in patients undergoing cardiac surgery were identified. Of these studies, the recommended neuropsychological tests were carried out in less than half of the studies. The cognitive domains measured most frequently were attention (n=56; 93%) and memory (n=57; 95%); motor skills were measured less frequently (n=36; 60%). Additionally, less than half of the studies examined anxiety and depression, performed neurological exam, or accounted for learning. Four definitions of POCD emerged: per cent decline (n=15), standard deviation decline (n=14), factor analysis (n=13), and analysis of performance on individual tests (n=12). There is marked variability in the measurement and definition of POCD. This heterogeneity may impede progress by reducing the ability to compare studies on the causes and treatment of POCD.
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Affiliation(s)
- J L Rudolph
- Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02130, USA.
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Abdul Aziz KA, Meduoye A. Is pH-stat or alpha-stat the best technique to follow in patients undergoing deep hypothermic circulatory arrest? Interact Cardiovasc Thorac Surg 2010; 10:271-82. [DOI: 10.1510/icvts.2009.214130] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Mackensen GB, McDonagh DL, Warner DS. Perioperative hypothermia: use and therapeutic implications. J Neurotrauma 2009; 26:342-58. [PMID: 19231924 DOI: 10.1089/neu.2008.0596] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Perioperative cerebral ischemic insults are common in some surgical procedures. The notion that induced hypothermia can be employed to improve outcome in surgical patients has persisted for six decades. Its principal application has been in the context of cardiothoracic and neurosurgery. Mild (32-35 degrees C) and moderate (26-31 degrees C) hypothermia have been utilized for numerous procedures involving the heart, but intensive research has found little or no benefit to outcome. This may, in part, be attributable to confounding effects associated with rewarming and lack of understanding of the mechanisms of injury. Evidence of efficacy of mild hypothermia is absent for cerebral aneurysm clipping and carotid endarterectomy. Deep hypothermia (18-25 degrees C) during circulatory arrest has been practiced in the repair of congenital heart disease, adult thoracic aortas, and giant intracranial aneurysms. There is little doubt of the protective efficacy of deep hypothermia, but continued efforts to refine its application may serve to enhance its utility. Recent evidence that mild hypothermia is efficacious in out-of-hospital cardiac arrest has implications for patients incurring anoxic or global ischemic brain insults during anesthesia and surgery, or perioperatively. Advances in preclinical models of ischemic/anoxic injury and cardiopulmonary bypass that allow definition of optimal cooling strategies and study of cellular and subcellular events during perioperative ischemia can add to our understanding of mechanisms of hypothermia efficacy and provide a rationale basis for its implementation in humans.
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Affiliation(s)
- G Burkhard Mackensen
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Groenendaal F, De Vooght KMK, van Bel F. Blood gas values during hypothermia in asphyxiated term neonates. Pediatrics 2009; 123:170-2. [PMID: 19117878 DOI: 10.1542/peds.2008-1955] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Floris Groenendaal
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Department of Neonatology, Utrecht, Netherlands.
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Markowitz SD, Mendoza-Paredes A, Liu H, Pastuszko P, Schultz SP, Schears GJ, Greeley WJ, Wilson DF, Pastuszko A. Response of brain oxygenation and metabolism to deep hypothermic circulatory arrest in newborn piglets: comparison of pH-stat and alpha-stat strategies. Ann Thorac Surg 2007; 84:170-6. [PMID: 17588406 PMCID: PMC2782723 DOI: 10.1016/j.athoracsur.2007.02.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Revised: 01/30/2007] [Accepted: 02/05/2007] [Indexed: 11/21/2022]
Abstract
BACKGROUND To determine the effect of pH-stat as compared with alpha-stat management on brain oxygenation, level of striatal extracellular dopamine, phosphorylation, and levels of protein kinase B (Akt) and cyclic adenosine 3', 5'-monophosphate response element-binding protein (CREB), and levels of extracellular signal-regulated kinase (ERK)1/2, Bcl-2, and Bax in a piglet model of deep hypothermic circulatory arrest (DHCA). METHODS The piglets were placed on cardiopulmonary bypass (CPB), cooled with pH-stat or alpha-stat to 18 degrees C, subjected to 90 minutes of DHCA, rewarmed, weaned from CPB, and maintained for two hours recovery. The cortical oxygen was measured by: quenching of phosphorescence; dopamine by microdialysis; phosphorylation of CREB (p-CREB), ERK (p-ERK) 1/2, Akt (p-Akt), and level of Bcl-2, Bax by Western blots. RESULTS Oxygen pressure histograms for the microvasculature of the cortex show substantially higher oxygen levels during cooling and during the oxygen depletion period after cardiac arrest (up to 15 minutes) when using pH-stat compared with alpha-stat management. Significant increases in dopamine occurred at 45 minutes and 60 minutes of DHCA in the alpha-stat and pH-stat groups, respectively. The p-CREB and p-Akt in the pH-stat group were significantly higher than in the alpha-stat group (140 +/- 9%, p < 0.05 and 125 +/- 6%, p < 0.05, respectively). There was no significant difference in p-ERK1/2 and Bax. The Bcl-2 increased in the pH-stat group to 121 +/- 4% (p < 0.05) compared with the alpha-stat group. The ratio Bcl-2:Bax increased in the pH-stat group compared with the alpha-stat group. CONCLUSIONS The increase in p-CREB, p-Akt, Bcl-2, Bcl-2/Bax, and delay in increase of dopamine indicated that pH-stat, in the piglet model, prolongs "safe" time of DHCA and provides some brain protection against ischemic injury.
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Affiliation(s)
- Scott D Markowitz
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Ballweg JA, Wernovsky G, Gaynor JW. Neurodevelopmental outcomes following congenital heart surgery. Pediatr Cardiol 2007; 28:126-33. [PMID: 17265108 DOI: 10.1007/s00246-006-1450-9] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Accepted: 09/05/2006] [Indexed: 10/23/2022]
Abstract
Advances in both surgical techniques and perioperative care have led to improved survival outcomes in infants and children undergoing surgery for complex congenital heart disease. An awareness is emerging that early and late neurological morbidities complicate the outcome of these operations. Adverse neurological outcomes after neonatal and infant cardiac surgery are related to both fixed and modifiable mechanisms. Fixed factors include many variables specific to the individual patient, including genetic predisposition, gender, race, socioeconomic status, and in utero central nervous system development. Modifiable factors include not only intraoperative variables (cardiopulmonary bypass, deep hypothermic circulatory arrest, and hemodilution) but also such variables as hypoxemia, hypotension, and low cardiac output. The purpose of this review is to examine these mechanisms as they relate to available outcome data.
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Affiliation(s)
- Jean A Ballweg
- The Cardiac Center at The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA
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Hogue CW, Palin CA, Arrowsmith JE. Cardiopulmonary bypass management and neurologic outcomes: an evidence-based appraisal of current practices. Anesth Analg 2006; 103:21-37. [PMID: 16790619 DOI: 10.1213/01.ane.0000220035.82989.79] [Citation(s) in RCA: 167] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Neurologic complications after cardiac surgery are of growing importance for an aging surgical population. In this review, we provide a critical appraisal of the impact of current cardiopulmonary bypass (CPB) management strategies on neurologic complications. Other than the use of 20-40 microm arterial line filters and membrane oxygenators, newer modifications of the basic CPB apparatus or the use of specialized equipment or procedures (including hypothermia and "tight" glucose control) have unproven benefit on neurologic outcomes. Epiaortic ultrasound can be considered for ascending aorta manipulations to avoid atheroma, although available clinical trials assessing this maneuver are limited. Current approaches for managing flow, arterial blood pressure, and pH during CPB are supported by data from clinical investigations, but these studies included few elderly or high-risk patients and predated many other contemporary practices. Although there are promising data on the benefits of some drugs blocking excitatory amino acid signaling pathways and inflammation, there are currently no drugs that can be recommended for neuroprotection during CPB. Together, the reviewed data highlight the deficiencies of the current knowledge base that physicians are dependent on to guide patient care during CPB. Multicenter clinical trials assessing measures to reduce the frequency of neurologic complications are needed to develop evidence-based strategies to avoid increasing patient morbidity and mortality.
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Affiliation(s)
- Charles W Hogue
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University Medical School, 600 North Wolfe Street, Tower 711, Baltimore, MD 21205, USA.
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Shann KG, Likosky DS, Murkin JM, Baker RA, Baribeau YR, DeFoe GR, Dickinson TA, Gardner TJ, Grocott HP, O'Connor GT, Rosinski DJ, Sellke FW, Willcox TW. An evidence-based review of the practice of cardiopulmonary bypass in adults: A focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response. J Thorac Cardiovasc Surg 2006; 132:283-90. [PMID: 16872951 DOI: 10.1016/j.jtcvs.2006.03.027] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Revised: 01/10/2006] [Accepted: 03/13/2006] [Indexed: 01/04/2023]
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Dueck MH, Paul M, Wiesner RH, Boerner U. [Why does blood have a pH-value of 7.4? The theory of acid-base management]. Anaesthesist 2005; 53:1046-53. [PMID: 15565420 DOI: 10.1007/s00101-004-0757-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aim of the present paper is to discuss the physiologic principles of the acid-base status, in particular those of the pH value. The alpha-stat theory of acid-base management interprets the normal value of arterial pH, usually thought of as being 7.40, as a value derived from the intracellular pH, which is close to neutrality. This appears to have offered an evolutionary advantage, since most of the intermediates in biosynthetic pathways are ionized at neutrality resulting in a decreased rate of penetration across biological membranes of these compounds thus producing a benefit for the economy of a cell. Finally, we present the clinical implications of both the alpha-stat and the pH-stat strategy of acid-base management.
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Affiliation(s)
- M H Dueck
- Klinik für Anaesthesiologie und Operative Intensivmedizin, Klinikum der Universität zu Köln.
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Yao FSF, Tseng CCA, Ho CYA, Levin SK, Illner P. Cerebral oxygen desaturation is associated with early postoperative neuropsychological dysfunction in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2004; 18:552-8. [PMID: 15578464 DOI: 10.1053/j.jvca.2004.07.007] [Citation(s) in RCA: 248] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the relationship between cerebral oxygen saturation and neuropsychological dysfunction after cardiac surgery. DESIGN Prospective and observational study. SETTING Operating room and cardiac floor of a university hospital. PARTICIPANTS One hundred one patients undergoing elective cardiac surgery with cardiopulmonary bypass INTERVENTION Bilateral noninvasive cerebral oxygen saturations were monitored over the forehead. The anesthetic and surgical techniques were performed as usual, and no interventions were attempted based on the monitor. Neuropsychological outcome was assessed by the Mini-Mental State Examination (MMSE) and the antisaccadic eye movement test (ASEM). MEASUREMENTS AND MAIN RESULTS Preoperative baseline values of cerebral oxygen saturation (rSO(2)) were 58.6% +/- 10.2%. Patients with the nadir rSO(2) <35% had significantly higher incidences of postoperative ASEM and MMSE impairments than those with rSO(2) always above 35% (44% and 33% v 12% and 9%, respectively). Patients with areas of rSO(2) <40% for more than 10 minutes . % presented with a significantly higher incidence of postoperative ASEM and MMSE impairments than those with areas of rSO(2) <40% for less than 10 minutes . % (42% and 32% v 13% and 10%, respectively). Patients with postoperative ASEM or MMSE impairment had significantly lower nadir rSO(2) and significantly larger areas of rSO(2) <40%, <45%, and <50% than those with normal postoperative neuropsychological outcome. However, multivariate logistic regression analysis showed that areas of rSO(2) <40% were the only predictor for both postoperative ASEM and MMSE impairments. CONCLUSIONS Intraoperative cerebral oxygen desaturation is associated with early postoperative neuropsychological dysfunction in patients undergoing cardiac surgery with cardiopulmonary bypass. However, it remains to be determined whether interventions to maintain adequate cerebral oxygenation may improve neuropsychological outcome.
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Affiliation(s)
- Fun-Sun F Yao
- Department of Anesthesiology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, NY, USA.
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Ohkura K, Kazui T, Yamamoto S, Yamashita K, Terada H, Washiyama N, Suzuki T, Suzuki K, Fujie M, Ohishi K. Comparison of pH management during antegrade selective cerebral perfusion in canine models with old cerebral infarction. J Thorac Cardiovasc Surg 2004; 128:378-85. [PMID: 15354095 DOI: 10.1016/j.jtcvs.2003.11.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We sought to examine the influence on the brain, with or without old infarction, of pH management during antegrade selective cerebral perfusion in a canine model. METHODS A cerebral infarct canine model was created by injecting a cylindrical silicone embolus. Dogs that had obvious neurologic deficits and had survived for 4 weeks or more were included in the model. Deep hypothermia with antegrade selective cerebral perfusion was performed in intact mongrel dogs (alpha-stat: group A, n = 6; pH-stat: group B, n = 6) and mongrel dogs with infarctions (alpha-stat: group C, n = 6; pH-stat: group D, n = 6). Maxillary vein saturation of oxygen, venous-arterial lactate difference, and serum concentrations of malondialdehyde and glutamate were measured and central conduction times and amplitude in somatosensory evoked potentials were assessed during the operation. RESULTS During the experimental procedure, the maxillary vein saturation of oxygen was significantly less (P <.05), whereas the venous-arterial lactate difference was significantly greater (P <.05) in the cooling phase to 28 degrees C in group C than in the other groups. The pH-stat group showed significantly greater arterial Paco(2) and lower pH than the alpha-stat group during the period between the cooling to 28 degrees C and the rewarming to 28 degrees C (P <.05). Other intraoperative parameters did not show any difference among the groups. In group C the serum concentrations of malondialdehyde and glutamate significantly increased, as did the central conduction time, whereas in both groups C and D the amplitude ratio decreased significantly. CONCLUSIONS This experiment suggests that pH-stat management during antegrade selective cerebral perfusion provides more effective protection for a brain with old infarction than alpha-stat management.
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Affiliation(s)
- Kazuhiro Ohkura
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Abstract
Despite remarkable progress in surgical, cardiopulmonary bypass and anaesthetic techniques during the last three decades, brain damage remains an important complication of adult cardiac surgery. Effective brain protection strategies are already implemented today, but ongoing research is needed to meet the challenges faced in operating on increasingly old and disabled patients. The incidence of brain injury may be reduced by modifying the surgical procedure according to carotid duplex scanning and epiaortic echocardiography, by using techniques to reduce microembolization during cardiopulmonary bypass and by optimizing patient temperature during and after surgery. Increased knowledge will aid in choosing the best procedure or combination of procedures in each case to ensure that risks do not outweigh benefits.
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Affiliation(s)
- J Ahonen
- Department of Anaesthesia and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland.
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Murkin JM. Retrograde cerebral perfusion: more risk than benefit? J Thorac Cardiovasc Surg 2003; 126:631-3. [PMID: 14502131 DOI: 10.1016/s0022-5223(03)00810-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Nagy ZL, Collins M, Sharpe T, Mirsadraee S, Guerrero RR, Gibbs J, Watterson KG. Effect of two different bypass techniques on the serum troponin-T levels in newborns and children: does pH-Stat provide better protection? Circulation 2003; 108:577-82. [PMID: 12874184 DOI: 10.1161/01.cir.0000081779.88132.74] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac troponin-T is a sensitive marker of myocardial damage. In a prospective study, the effect of 2 different pH strategies during cardiopulmonary bypass on ischemic myocardial injury and clinical outcome was measured in a pediatric population. METHODS AND RESULTS One hundred one patients (31 neonates 13.2+/-8.3 days and 70 children 34.5+/-44.1 months of age) undergoing open-heart surgery were selected to either alpha-stat (n=51) or pH-stat (n=50) acid-based management protocol. Serum troponin-T levels were measured before and 30 minutes after bypass and then 4 and 24 hours postoperatively. Surgical procedure, bypass details, inotropic support requirement, and postoperative recovery were recorded. Baseline troponin-T level was higher in neonates than in children (0.18+/-0.22 versus 0.04+/-0.05 microg/L, P=0.02). Also, a higher baseline level was found in patients with pulmonary hypertension (0.13+/-0.21 versus 0.04+/-0.05 microg/L, P=0.04). Cyanotic children showed a higher peak troponin-T level (3.76+/-3.11 versus 1.67+/-1.33 microg/L, P=0.04). Peak troponin levels showed a correlation with the length of circulatory arrest and aortic cross-clamp time. Postoperative levels remained high at 24 hours in patients requiring inotropic support. Peak troponin-T levels were significantly lower in the pH-stat group in patients with pulmonary hypertension (P=0.03) and in cases where circulatory arrest (P=0.01) or inotropic support (P=0.01) was necessary during operation than in those with alpha-stat technique. Postoperative ventilation time and length of intensive care unit stay were also significantly longer with alpha-stat than with pH-stat technique (P=0.005 and P=0.006, respectively). CONCLUSIONS Cardiac troponin-T sensitively reflects myocardial damage in children. Our results suggest that pH-stat acid-based management protocol may provide better protection against ischemic myocardial damage than alpha-stat technique.
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Affiliation(s)
- Zsolt L Nagy
- Yorkshire Heart Centre, Leeds Teaching Hospitals, Calverley St, Leeds LS1 3EX, UK
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Washiyama N, Kazui T, Bashar AHM. Reply. J Thorac Cardiovasc Surg 2002. [DOI: 10.1016/s0022-5223(02)70004-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Borowicz L, Royall R, Grega M, Selnes O, Lyketsos C, McKhann G. Depression and cardiac morbidity 5 years after coronary artery bypass surgery. PSYCHOSOMATICS 2002; 43:464-71. [PMID: 12444229 DOI: 10.1176/appi.psy.43.6.464] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to determine whether depression 1 month after coronary artery bypass surgery would be associated with greater cardiac morbidity in patients 5 years later. The cardiac symptom most affected by depression was the recurrence of angina. Factors associated with a return of angina at 5 years were depression measured preoperatively, at 1 month, at 1 year, and at 5 years. Additional significant factors were male sex and a preoperative history of smoking, percutaneous transluminal coronary angioplasty, or cerebrovascular accident. When these factors were combined in multiple logistic regression analyses, the score on the Center for Epidemiologic Studies Depression Scale at 1 month was the most significant of all factors. The depression score at 1 month after coronary artery bypass surgery is an important indicator of cardiac morbidity up to 5 years later.
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Affiliation(s)
- Louis Borowicz
- Zanvyl Krieger Mind/Brain Institute, Department of Neurology, Johns Hopkins School of Public Health, Baltimore, MD 21287, USA.
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Bartels C, Gerdes A, Babin-Ebell J, Beyersdorf F, Boeken U, Doenst T, Feindt P, Heiermann M, Schlensak C, Sievers HH. Cardiopulmonary bypass: Evidence or experience based? J Thorac Cardiovasc Surg 2002; 124:20-7. [PMID: 12091804 DOI: 10.1067/mtc.2002.121506] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Evidence-based medicine is emerging as a new paradigm for medical practice. The purpose of this study was to evaluate the amount and quality of scientific evidence supporting principles that are currently applied for cardiopulmonary bypass performance. METHODS A survey of all German departments of cardiac surgery regarding cardiopulmonary bypass performance disclosed major differences. Consequently, for 48 major principles of cardiopulmonary bypass performance, relevant Medical Subject Headings were identified, and a literature search of the Medline database was performed. Two sequentially applied sets of inclusion-exclusion criteria were selected to assess the best available evidence. RESULTS Thirty-three thousand articles relating to the subject were identified. Among these, 1500 fulfilled the first set of inclusion criteria: meta-analysis of (randomized) controlled clinical trials and in vitro and animal studies. Rigorous methodological criteria were then applied to further select remaining publications. Ultimately, 225 articles referring to major cardiopulmonary bypass principles were identified as providing the best available evidence. These were graded according to their methodological rigor (susceptibility to bias). The scientific evidence on the investigated cardiopulmonary bypass principles did not prove to be of a high enough level to allow general recommendations to be made. CONCLUSIONS The scientific data concerning the effectiveness and safety of key principles of cardiopulmonary bypass are insufficient in both amount and quality of scientific evidence to serve as a basis for practical, evidence-based guidelines.
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Affiliation(s)
- Claus Bartels
- Clinic for Cardiac Surgery, Medical University of Luebeck, Germany
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