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Gregory A, Ender J, Shaw AD, Denault A, Ibekwe S, Stoppe C, Alli A, Manning MW, Brodt JL, Galhardo C, Sander M, Zarbock A, Fletcher N, Ghadimi K, Grant MC. ERAS/STS 2024 Expert Consensus Statement on Perioperative Care in Cardiac Surgery: Continuing the Evolution of Optimized Patient Care and Recovery. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00399-9. [PMID: 39004570 DOI: 10.1053/j.jvca.2024.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/16/2024]
Affiliation(s)
- Alexander Gregory
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | - Joerg Ender
- Department of Anesthesiology and Intensive Care Medicine, Heartcenter Leipzig GmbH, Leipzig, Germany
| | - Andrew D Shaw
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH
| | - André Denault
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Stephanie Ibekwe
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX
| | - Christian Stoppe
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Ahmad Alli
- Department of Anesthesiology & Pain Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Jessica L Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto CA
| | - Carlos Galhardo
- Department of Anesthesia, McMaster University, Ontario, Canada
| | - Michael Sander
- Anesthesiology and Intensive Care Medicine, Justus Liebig University Giessen, University Hospital Giessen, Giessen, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Nick Fletcher
- Institute of Anaesthesia and Critical Care, Cleveland Clinic London, London, UK
| | | | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Labmayr V, Rief M, Reinbacher P, Gebauer D, Smigaj J, Sandner-Kiesling A, Papamargaritis V, Michaeli K, Bornemann-Cimenti H, Schittek GA. Simplified Pain Management Including Fentanyl TTS in PACU Patients With Hip Fracture Surgery to Improve Patients' Well-Being: A Double-Blind Randomized Trial. J Perianesth Nurs 2024; 39:461-467. [PMID: 38085188 DOI: 10.1016/j.jopan.2023.10.004] [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: 02/27/2023] [Revised: 08/16/2023] [Accepted: 10/10/2023] [Indexed: 06/03/2024]
Abstract
PURPOSE Adequate pain management is eminently relevant for elderly and more vulnerable patients with hip fractures in the setting of pre and postoperative pain. This study compares postoperative hip fracture patients treated with standard pain management with a variety of medications or an approach with only one option in each medication category (nonopioid: acetaminophen; opioid: fentanyl TTS 12,5 mcg/hour; rescue medication: piritramide) to simplify the treatment algorithm for nurses and improve patient well-being. DESIGN Double-blind randomized controlled trial. METHODS The sample was cognitively intact patients (N = 141) with hip fractures in a tertiary university hospital. Administration of fentanyl 12 mcg/hour transdermal therapeutic system was administered by the nurses in the postanesthesia care unit (PACU) to address basal wound pain to improve patient well-being and patient treatment in the PACU for 24 hours to better control for early complications. FINDINGS Well-being was equally increased in both groups in comparison to our preintervention data from 35.7% to over 60% and did not differ significantly between the intervention and control group. No statistically significant differences in numeric rating scale scores, rescue opioid dosage (piritramide i.v.) or in complications were present. CONCLUSIONS This one-size-fits-all simplified pain management approach did not improve patient well-being or any other outcome but highlighted the importance of adequate pain management and a sufficient nurse-to-patient ratio.
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Affiliation(s)
- Viktor Labmayr
- Department of Orthopedic Surgery, Medical University of Graz, Graz, Austria
| | - Martin Rief
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Patrick Reinbacher
- Department of Orthopedic Surgery, Medical University of Graz, Graz, Austria
| | - David Gebauer
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Jana Smigaj
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Andreas Sandner-Kiesling
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Vasileios Papamargaritis
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Kristina Michaeli
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Helmar Bornemann-Cimenti
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Gregor A Schittek
- Department of Anaesthesiology, Division of General Anaesthesiology, Emergency, and Intensive Care Medicine, Medical University of Graz, Graz, Austria.
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Seubert ME, Goeijenbier M. Controlled Mechanical Ventilation in Critically Ill Patients and the Potential Role of Venous Bagging in Acute Kidney Injury. J Clin Med 2024; 13:1504. [PMID: 38592687 PMCID: PMC10934139 DOI: 10.3390/jcm13051504] [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: 01/18/2024] [Revised: 02/29/2024] [Accepted: 03/02/2024] [Indexed: 04/10/2024] Open
Abstract
A very low incidence of acute kidney injury (AKI) has been observed in COVID-19 patients purposefully treated with early pressure support ventilation (PSV) compared to those receiving mainly controlled ventilation. The prevention of subdiaphragmatic venous congestion through limited fluid intake and the lowering of intrathoracic pressure is a possible and attractive explanation for this observed phenomenon. Both venous congestion, or "venous bagging", and a positive fluid balance correlate with the occurrence of AKI. The impact of PSV on venous return, in addition to the effects of limiting intravenous fluids, may, at least in part, explain this even more clearly when there is no primary kidney disease or the presence of nephrotoxins. Optimizing the patient-ventilator interaction in PSV is challenging, in part because of the need for the ongoing titration of sedatives and opioids. The known benefits include improved ventilation/perfusion matching and reduced ventilator time. Furthermore, conservative fluid management positively influences cognitive and psychiatric morbidities in ICU patients and survivors. Here, it is hypothesized that cranial lymphatic congestion in relation to a more positive intrathoracic pressure, i.e., in patients predominantly treated with controlled mechanical ventilation (CMV), is a contributing risk factor for ICU delirium. No studies have addressed the question of how PSV can limit AKI, nor are there studies providing high-level evidence relating controlled mechanical ventilation to AKI. For this perspective article, we discuss studies in the literature demonstrating the effects of venous congestion leading to AKI. We aim to shed light on early PSV as a preventive measure, especially for the development of AKI and ICU delirium and emphasize the need for further research in this domain.
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Affiliation(s)
- Mark E. Seubert
- Department of Intensive Care, HagaZiekenhuis, 2725 NA Zoetermeer, The Netherlands
| | - Marco Goeijenbier
- Department of Intensive Care, Spaarne Gasthuis, 2035 RC Haarlem, The Netherlands;
- Department of Intensive Care, Erasmus MC, 3015 CN Rotterdam, The Netherlands
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4
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Koga T, Yoshida T, Kotani Y. Association between the intraoperative fluid balance during cardiac surgery and postoperative sequential organ failure assessment score: a post hoc analysis of the BROTHER study, a retrospective multicenter cohort study. Heart Vessels 2024; 39:57-64. [PMID: 37596414 DOI: 10.1007/s00380-023-02306-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/09/2023] [Indexed: 08/20/2023]
Abstract
Although intraoperative intravenous fluids are commonly administered to reverse intraoperative hypotension during cardiac surgery, the appropriate volume remains unclear. This study aimed to evaluate the relationship between the intraoperative fluid balance and sequential organ failure assessment (SOFA) score in patients undergoing cardiac surgery to determine the impact of intraoperative intravenous fluids on their organs. This was a post hoc analysis using data from a multicenter, retrospective, observational study across 14 intensive care units (ICUs) in Japan. Adult patients admitted to ICUs after elective coronary artery bypass grafting or valve surgery from January 1 to December 31, 2018 were enrolled. We compared patients with intraoperative fluid balance < 20 ml/kg to those with fluid balance ≥ 20 ml/kg and conducted a multiple regression analysis for the SOFA score within 24 h of ICU admission. Of the 1567 included patients, 870 met the eligibility criteria. A total of 725 patients (83%) had an intraoperative fluid balance of ≥ 20 ml/kg. In the univariate analysis, the SOFA score (interquartile range) was 7 (6-8) and 7 (6-9) in the intraoperative fluid balance < 20 ml/kg and ≥ 20 ml/kg groups, respectively (p = 0.017). Multiple regression analysis showed a positive association between intraoperative fluid balance and SOFA score within 24 h of ICU admission [standardized coefficient 0.0065 (95% confidence interval 0.0036-0.0095), p < 0.001]. Intraoperative fluid balance in patients undergoing cardiac surgery was significantly associated with higher SOFA scores within 24 h of ICU admission.
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Affiliation(s)
- Takahiro Koga
- Department of Emergency Medicine, Ishikawa Prefectural Central Hospital, 2-1, Kuratsuki higashi, Kanazawa, 920-8530, Japan.
| | - Takuo Yoshida
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2, Seto, Kanazawa, Yokohama, 236-0027, Japan
- Intensive Care Unit, Department of Emergency Medicine, Jikei University School of Medicine, 3-19-18, Nishi-shinbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, 929, Higashimachi, Kamogawa, Chiba, 296-8602, Japan
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy
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Jenkins DP, Martinez G, Salaunkey K, Reddy SA, Pepke-Zaba J. Perioperative Management in Pulmonary Endarterectomy. Semin Respir Crit Care Med 2023; 44:851-865. [PMID: 37487525 DOI: 10.1055/s-0043-1770123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH), provided lesions are proximal enough in the pulmonary vasculature to be surgically accessible and the patient is well enough to benefit from the operation in the longer term. It is a major cardiothoracic operation, requiring specialized techniques and instruments developed over several decades to access and dissect out the intra-arterial fibrotic material. While in-hospital operative mortality is low (<5%), particularly in high-volume centers, careful perioperative management in the operating theater and intensive care is mandatory to balance ventricular performance, fluid balance, ventilation, and coagulation to avoid or treat complications. Reperfusion pulmonary edema, airway hemorrhage, and right ventricular failure are the most problematic complications, often requiring the use of extracorporeal membrane oxygenation to bridge to recovery. Successful PEA has been shown to improve both morbidity and mortality in large registries, with survival >70% at 10 years. For patients not suitable for PEA or with residual PH after PEA, balloon pulmonary angioplasty and/or PH medical therapy may prove beneficial. Here, we describe the indications for PEA, specific surgical and perioperative strategies, postoperative monitoring and management, and approaches for managing residual PH in the long term.
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Affiliation(s)
- David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Guillermo Martinez
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Kiran Salaunkey
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - S Ashwin Reddy
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
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Kontar L, Beaubien-Souligny W, Couture EJ, Jacquet-Lagrèze M, Lamarche Y, Levesque S, Babin D, Denault AY. Prolonged cardiovascular pharmacological support and fluid management after cardiac surgery. PLoS One 2023; 18:e0285526. [PMID: 37167244 PMCID: PMC10174538 DOI: 10.1371/journal.pone.0285526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/25/2023] [Indexed: 05/13/2023] Open
Abstract
OBJECTIVE To identify potentially modifiable risk factors related to prolonged cardiovascular pharmacological support after weaning from cardiopulmonary bypass (CPB). METHODS This is a secondary analysis of two prospective cohort study in a specialized cardiac surgery institution in adult patients undergoing cardiac surgery with the use of CPB between August 2016 and July 2017. Prolonged cardiovascular pharmacological support was defined by the need for at least one vasopressor or one inotropic agent 24 hours after separation from CPB. Risk factors were identified among baseline characteristics and peri-operative events through multivariable logistic regression. RESULTS A total of 247 patients were included and 98 (39.7%) developed prolonged pharmacological support. In multivariable analysis, left ventricular ejection fraction ≤ 30% (OR 9.52, 95% confidence interval (CI) 1.14; 79.25), elevated systolic pulmonary artery pressure (sPAP) > 30 and ≤ 55 mmHg (moderate) (OR 2.52, CI 1.15; 5.52) and sPAP > 55 mmHg (severe) (OR 8.12, CI 2.54; 26.03), as well as cumulative fluid balance in the first 24 hours after surgery (OR 1.76, CI 1.32; 2.33) were independently associated with the development of prolonged pharmacological support. CONCLUSIONS Prolonged cardiovascular pharmacological support is frequent after cardiac surgery on CPB. Severe LV systolic dysfunction, preoperative pulmonary hypertension and postoperative fluid overload are risk factors. Further studies are required to explore if those risk factors could be modified or not.
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Affiliation(s)
- Loay Kontar
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
- Division of Intensive Care Unit, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
- Medical Intensive Care Unit, Centre Hospitalier Universitaire d'Amiens, Amiens, France
| | - William Beaubien-Souligny
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
- Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Etienne J Couture
- Department of Anesthesiology and Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec, Quebec, Canada
| | - Matthias Jacquet-Lagrèze
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Yoan Lamarche
- Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Sylvie Levesque
- Montreal Health Innovations Coordinating Centre, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Denis Babin
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - André Y Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
- Division of Intensive Care Unit, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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Ushio M, Egi M, Fujimoto D, Obata N, Mizobuchi S. Timing, Threshold, and Duration of Intraoperative Hypotension in Cardiac Surgery: Their Associations With Postoperative Delirium. J Cardiothorac Vasc Anesth 2022; 36:4062-4069. [PMID: 35915006 DOI: 10.1053/j.jvca.2022.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/04/2022] [Accepted: 06/15/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To study the timing, threshold, and duration of intraoperative hypotension (IOH) associated with the risk of postoperative delirium (POD). DESIGN A single-center retrospective observational study. SETTING University teaching hospital. PARTICIPANTS A total of 503 adult patients who underwent cardiac valvular surgery that required cardiopulmonary bypass (CPB). MEASUREMENTS AND MAIN RESULTS The authors predefined the following 4 periods: (1) during surgery, (2) pre-CPB, (3) during CPB, and (4) post-CPB, and 8 thresholds of mean arterial pressure for IOH according to every 5 mmHg between 50 mmHg and 85 mmHg. The authors calculated the cumulative duration below the 8 thresholds in each period. The primary outcome was delirium defined as a score of ≥4 for at least one Intensive Care Delirium Screening Checklist assessment during 48 h after the surgery. Among 503 patients, POD occurred in 95 patients (18.9%). There was no significant association of POD with all of the thresholds of IOH in the periods of pre-CPB, during CPB, and during surgery. However, in the post-CPB period, the patients with POD had a significantly longer cumulative duration of IOH according to all of the thresholds of mean arterial pressure. In multivariate analyses, 4 IOH thresholds in the post-CPB period were associated independently with POD: <60 mmHg (odds ratio [OR] =1.84 [95% CI 1.10-3.10]), <65 mmHg (OR = 1.72 [1.01-2.92]), <70 mmHg (OR = 1.83 [1.03-3.26]), and <75 mmHg (OR = 1.94 [1.02-3.69]). CONCLUSIONS A longer cumulative duration of IOH with the threshold between <60 and <75 mmHg that occurred after CPB was independently associated with the risk of POD.
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Affiliation(s)
- Masahiro Ushio
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan.
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan
| | - Daichi Fujimoto
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan
| | - Norihiko Obata
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan
| | - Satoshi Mizobuchi
- Department of Anesthesiology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo 650-0017, Japan
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Hammoud A, Saade E, Jarry S, Baelen S, Couture EJ, Beaubien-Souligny W, Denault AY. Pulsatile Femoral Vein Doppler and Congestive Delirium, What Is the Relationship?: A Case Report. A A Pract 2022; 16:e01627. [PMID: 36599030 DOI: 10.1213/xaa.0000000000001627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Delirium is common in patients undergoing cardiac surgery, and venous congestion has been reported as an important risk factor. We report a 69-year-old patient who developed postoperative delirium in the intensive care unit following aortic valve replacement surgery. The postoperative course was complicated by delirium for which echographic signs of venous congestion on the portal and the renal but also the femoral veins and their resolution correlated with the course of delirium. The use of common femoral vein Doppler as a simple bedside technique to predict and identify congestive delirium has not been reported before.
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Affiliation(s)
- Ali Hammoud
- From the Department of Nursing, Université de Montréal, Montreal, Quebec, Canada.,Department of Medicine, Intensive Care Unit and Research Centre, Montreal Heart Institute, Montreal, Quebec, Canada.,Biomedical Science Program
| | - Elena Saade
- Biomedical Science Program.,Department of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.,Pharmacology Program, Université de Montréal, Montreal, Quebec, Canada
| | - Sophie Baelen
- From the Department of Nursing, Université de Montréal, Montreal, Quebec, Canada.,Department of Medicine, Intensive Care Unit and Research Centre, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Etienne J Couture
- Division of Intensive Care Medicine, Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
| | - William Beaubien-Souligny
- Department of Medicine, Nephrology Division, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - André Y Denault
- Department of Medicine, Intensive Care Unit and Research Centre, Montreal Heart Institute, Montreal, Quebec, Canada.,Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.,Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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Huang H, Han J, Li Y, Yang Y, Shen J, Fu Q, Chen Y. Early Serum Metabolism Profile of Post-operative Delirium in Elderly Patients Following Cardiac Surgery With Cardiopulmonary Bypass. Front Aging Neurosci 2022; 14:857902. [PMID: 35754961 PMCID: PMC9226449 DOI: 10.3389/fnagi.2022.857902] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background Cardiac surgery with cardiopulmonary bypass (CPB) is considered to be one of the surgical types with the highest incidence of post-operative delirium (POD). POD has been associated with a prolonged intensive care and hospital stay, long-term neurocognitive deterioration, and increased mortality. However, the specific pathogenesis of POD is still unclear. Untargeted metabolomics techniques can be used to understand the changes of serum metabolites in early POD to discover the relationship between serum metabolites and disease. Materials and Methods The present study recruited 58 elderly patients undergoing cardiac surgery with CPB. Serum was collected within the first 24 h after surgery. The Confusion Assessment Method (CAM) and ICU-CAM assessments were used to identify patients who experienced POD. All patients with normal post-operative cognitive assessment were included in the non-POD groups. Moreover, we collected serum from 20 healthy adult volunteers. We performed untargeted analyses of post-operative serum metabolites in all surgical groups, as well as serum metabolites in healthy non-surgical adults by using liquid chromatography mass spectrometry (LC/MS) and analyzed metabolic profiles and related metabolites. Results The probability of POD after cardiac surgery were 31%. There were statistically significant differences in post-operative mechanical ventilation time, ICU stay time and post-operative hospital stay between POD and non-POD group (P < 0.05). And ICU stay time was an independent risk factor for POD. The analysis revealed that a total of 51 differentially expressed metabolites (DEMs) were identified by comparing the POD and non-POD group, mostly lipids and lipid-like molecules. Three phosphatidylinositol (PI) were down-regulated in POD group, i.e., PI [18:0/18:2 (9Z, 12Z)], PI [20:4 (8Z, 11Z, 14Z, 17Z)/18:0], and PI [18:1 (9Z)/20:3 (8Z, 11Z, 14Z)]. The receiver operating characteristic (ROC) curve analysis showed that three kinds of PI metabolites had the highest area under the curve (AUC), which were 0.789, 0.781, and 0.715, respectively. Correlation analysis showed that the expression of three PIs was negatively correlated with the incidence of POD. Conclusion Our findings suggest that lipid metabolism plays an important role in the serum metabolic profile of elderly patients with POD in the early post-operative period. Low serum lipid metabolic PI was associated with incidence of POD in elderly following cardiac bypass surgery, which may provide new insights into the pathogenesis of POD.
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Affiliation(s)
- He Huang
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jingjing Han
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yan Li
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yonglin Yang
- Division of Infectious Diseases, Taizhou Clinical Medical School of Nanjing Medical University (Taizhou People's Hospital), Taizhou, China
| | - Jian Shen
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qiang Fu
- Nanjing Red Cross Blood Center, Nanjing, China
| | - Yu Chen
- Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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10
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Mailhot T, Cossette S, Lavoie P, Maheu‐Cadotte M, Fontaine G, Bourbonnais A, Côté J. The development of the MENTOR_D nursing intervention: Supporting family involvement in delirium management. Int J Older People Nurs 2022; 17:e12462. [DOI: 10.1111/opn.12462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 02/15/2022] [Accepted: 03/08/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Tanya Mailhot
- Faculté des Sciences Infirmières Université de Montréal Montréal QC Canada
- Research Centre of the Institut de Cardiologie de Montréal Montréal QC Canada
| | - Sylvie Cossette
- Faculté des Sciences Infirmières Université de Montréal Montréal QC Canada
- Research Centre of the Institut de Cardiologie de Montréal Montréal QC Canada
| | - Patrick Lavoie
- Faculté des Sciences Infirmières Université de Montréal Montréal QC Canada
- Research Centre of the Institut de Cardiologie de Montréal Montréal QC Canada
- Centre d’innovation en Formation Infirmière Université de Montréal Montréal QC Canada
| | - Marc‐André Maheu‐Cadotte
- Faculté des Sciences Infirmières Université de Montréal Montréal QC Canada
- Research Centre of the Institut de Cardiologie de Montréal Montréal QC Canada
- Research Centre of the Centre Hospitalier de l’Université de Montréal Montréal QC Canada
| | - Guillaume Fontaine
- Faculté des Sciences Infirmières Université de Montréal Montréal QC Canada
- Research Centre of the Institut de Cardiologie de Montréal Montréal QC Canada
| | - Anne Bourbonnais
- Faculté des Sciences Infirmières Université de Montréal Montréal QC Canada
- Research Centre of the Institut Universitaire de Gériatrie de Montréal Montréal QC Canada
| | - José Côté
- Faculté des Sciences Infirmières Université de Montréal Montréal QC Canada
- Research Centre of the Centre Hospitalier de l’Université de Montréal Montréal QC Canada
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Wang DD, Li Y, Hu XW, Zhang MC, Xu XM, Tang J. Comparison of restrictive fluid therapy with goal-directed fluid therapy for postoperative delirium in patients undergoing spine surgery: a randomized controlled trial. Perioper Med (Lond) 2021; 10:48. [PMID: 34906235 PMCID: PMC8672598 DOI: 10.1186/s13741-021-00220-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 09/10/2021] [Indexed: 11/10/2022] Open
Abstract
Background Postoperative delirium (POD) is a common phenomenon after spinal surgery. Intraoperative fluid management may affect POD. The aim of this study was to compare the effects of restrictive fluid therapy (RF) with those of goal-directed fluid therapy (GDT) on POD. Methods A total of 195 patients aged ≥ 50 years who underwent spinal surgery were randomly divided into two groups: the RF group and the GDT group. In group RF, a bolus of lactated Ringer’s solution was administered at a dose of 5 mL·kg-1 before the induction of anesthesia, followed by a dose of 5 mL·kg-1·h-1 until the end of surgery. For patients in the GDT group, in addition to the initial administration of lactated Ringer’s solution at 5 mL·kg-1, the subsequent fluid therapy was adjusted by using a continuous noninvasive arterial pressure (CNAP) monitoring system to maintain pulse pressure variation (PPV) ≤ 14%. The primary endpoint was the incidence of POD, assessed once daily with the Confusion Assessment Method-Chinese Reversion (CAM-CR) scale at 1–3 days postoperatively. The secondary endpoints were intraoperative fluid infusion volume, urine volume, mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), regional cerebral oxygen saturation (rSO2) value, lactic acid value, and visual analog scale (VAS) pain score at 1–3 days after surgery. Moreover, postoperative complications and the length of hospital stay were recorded. Results The incidence of POD was lower in the GDT group than in the RF group (12.4% vs 4.1%; P = 0.035) in the first 3 days after spine surgery. Compared to group RF, group GDT exhibited a significantly increased volume of intraoperative lactated Ringer’s solution [1500 (interquartile range: 1128 to 1775) mL vs 1000 (interquartile range: 765 to 1300) mL, P < 0.001] and urine volume [398 (interquartile range: 288 to 600) mL vs 300 (interquartile range: 200 to 530) mL, P = 0.012]. Intraoperative MAP, CI and rSO2 values were higher in the GDT group than in the RF group (P < 0.05). Moreover, the length of hospital stay [17.0 (14 to 20) days versus 14.5 (13 to 17.0) days, P = 0.001] was shorter in the GDT group than in the RF group. Conclusions GDT reduced the incidence of POD in middle- and old-aged patients undergoing spinal surgery possibly by stabilizing perioperative hemodynamic and improving the supply and demand of oxygen. Trial registration ChiCTR2000032603; Registered on May 3, 2020.
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Affiliation(s)
- Duo Duo Wang
- Department of Anesthesiology, The Second Hospital of Anhui Medical University, 678 Furong Road, Economic Development Zone, Hefei City, 230032, Anhui Province, China.,Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei city, 230032, Anhui, China
| | - Yun Li
- Department of Anesthesiology, The Second Hospital of Anhui Medical University, 678 Furong Road, Economic Development Zone, Hefei City, 230032, Anhui Province, China.,Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei city, 230032, Anhui, China
| | - Xian Wen Hu
- Department of Anesthesiology, The Second Hospital of Anhui Medical University, 678 Furong Road, Economic Development Zone, Hefei City, 230032, Anhui Province, China. .,Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei city, 230032, Anhui, China.
| | - Mu Chun Zhang
- Department of Anesthesiology, The Second Hospital of Anhui Medical University, 678 Furong Road, Economic Development Zone, Hefei City, 230032, Anhui Province, China.,Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei city, 230032, Anhui, China
| | - Xing Mei Xu
- Department of Anesthesiology, The Second Hospital of Anhui Medical University, 678 Furong Road, Economic Development Zone, Hefei City, 230032, Anhui Province, China.,Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei city, 230032, Anhui, China
| | - Jia Tang
- Department of Anesthesiology, The Second Hospital of Anhui Medical University, 678 Furong Road, Economic Development Zone, Hefei City, 230032, Anhui Province, China.,Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei city, 230032, Anhui, China
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Breit H, Bleck TP, Koffman L. Delirium in Cardiac and Cardiovascular Surgical Intensive Care Units. Semin Neurol 2021; 41:453-462. [PMID: 33851391 DOI: 10.1055/s-0041-1726283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Delirium is a common occurrence in cardiac and cardiovascular surgical intensive care units. Due to multiple confounding factors, this diagnosis remains challenging for medical professionals. Multiple theories exist regarding the pathophysiology of delirium, which include disruption of neurotransmitters as well as inflammation. Delirium has been associated with prolonged hospitalizations and an increase in mortality. Although there are widely used screening tools for delirium, none have been validated in this particular patient population. Limited treatments exist for delirium, so: both pharmacologic and nonpharmacologic preventative measures should be employed in this patient population.
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Affiliation(s)
- Hannah Breit
- Section of Neurocritical Care, Rush University Medical Center, Chicago, Illinois
| | - Thomas P Bleck
- Department of Neurology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Lauren Koffman
- Section of Neurocritical Care, Rush University Medical Center, Chicago, Illinois
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Subsyndromal Delirium in Cardiac Surgery Patients: Risk Factors and Outcomes of the Different Trajectories. J Cardiovasc Nurs 2021; 37:41-49. [PMID: 33657067 DOI: 10.1097/jcn.0000000000000793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Subsyndromal delirium (SSD), a subthreshold form of delirium, is related to longer length of stay and increased mortality rates among older adults. Risk factors and outcomes of SSD in cardiac surgery patients are not fully understood. OBJECTIVE The aim of this study was to assess and describe the characteristics and outcomes related to trajectories of SSD and delirium in cardiac surgery patients. METHODS In this secondary analysis of a retrospective case-control (1:1) cohort study, SSD was defined as a score between 1 and 3 on the Intensive Care Delirium Screening Checklist paired with an absence of diagnosis of delirium on the day of assessment. Potential risk factors (eg, age) and outcomes (eg, mortality) were identified from existing literature. Patients were grouped into 4 trajectories: (1) without SSD or delirium, (2) SSD only, (3) both, and (4) delirium only. These trajectories were contrasted using analysis of variance or χ2 test. RESULTS Among the cohort of 346 patients, 110 patients did not present with SSD or delirium, 62 presented with only SSD, 69 presented with both, and 105 presented with only delirium. In comparison with patients without SSD or delirium, patients with SSD presented preoperative risk factors known for delirium (ie, older age, higher European System for Cardiac Operative Risk Evaluation II) but underwent less complicated surgical procedures, received fewer transfusions postoperatively, and had a lower positive fluid balance postoperatively than patients who presented with delirium. Patients with both SSD and delirium had worse outcomes in comparison with those with delirium only. CONCLUSION This study stresses the importance for healthcare professionals to identify SSD and prevent its progression to delirium.
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Saller T, Peterss S, Scheiermann P, Eser-Valeri D, Ehler J, Bruegger D, Chappell D, Kofler O, Hagl C, Hofmann-Kiefer K. Natriuretic Peptides as a Prognostic Marker for Delirium in Cardiac Surgery-A Pilot Study. ACTA ACUST UNITED AC 2020; 56:medicina56060258. [PMID: 32471143 PMCID: PMC7353880 DOI: 10.3390/medicina56060258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Delirium is a common and major complication subsequent to cardiac surgery. Despite scientific efforts, there are no parameters which reliably predict postoperative delirium. In delirium pathology, natriuretic peptides (NPs) interfere with the blood–brain barrier and thus promote delirium. Therefore, we aimed to assess whether NPs may predict postoperative delirium and long-term outcomes. Materials and Methods: To evaluate the predictive value of NPs for delirium we retrospectively analyzed data from a prospective, randomized study for serum levels of atrial natriuretic peptide (ANP) and the precursor of C-type natriuretic peptide (NT-proCNP) in patients undergoing coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass (off-pump coronary bypass grafting; OPCAB). Delirium was assessed by a validated chart-based method. Long-term outcomes were assessed 10 years after surgery by a telephone interview. Results: The overall incidence of delirium in the total cohort was 48% regardless of the surgical approach (CABG vs. OPCAB). Serum ANP levels > 64.6 pg/mL predicted delirium with a sensitivity (95% confidence interval) of 100% (75.3–100) and specificity of 42.9% (17.7–71.1). Serum NT-proCNP levels >1.7 pg/mL predicted delirium with a sensitivity (95% confidence interval) of 92.3% (64.0–99.8) and specificity of 42.9% (17.7–71.1). Both NPs could not predict postoperative survival or long-term cognitive decline. Conclusions: We found a positive correlation between delirium and preoperative plasma levels of ANP and NT-proCNP. A well-powered and prospective study might identify NPs as biomarkers indicating the risk of delirium and postoperative cognitive decline in patients at risk for postoperative delirium.
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Affiliation(s)
- Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (P.S.); (D.B.); (O.K.); (K.H.-K.)
- Correspondence: ; Tel.: +49-89-4400-73410
| | - Sven Peterss
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (S.P.); (C.H.)
| | - Patrick Scheiermann
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (P.S.); (D.B.); (O.K.); (K.H.-K.)
| | - Daniela Eser-Valeri
- Department of Psychiatry, University Hospital, LMU Munich, 80336 Munich, Germany;
| | - Johannes Ehler
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center, 18057 Rostock, Germany;
| | - Dirk Bruegger
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (P.S.); (D.B.); (O.K.); (K.H.-K.)
| | - Daniel Chappell
- Clinic for Anaesthesia, Surgical Intensive Care, Emergency Medicine and Pain Therapy, Klinikum Frankfurt Hoechst, 65929 Frankfurt/Main, Germany;
| | - Othmar Kofler
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (P.S.); (D.B.); (O.K.); (K.H.-K.)
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (S.P.); (C.H.)
| | - Klaus Hofmann-Kiefer
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (P.S.); (D.B.); (O.K.); (K.H.-K.)
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Kunst G, Gauge N, Salaunkey K, Spazzapan M, Amoako D, Ferreira N, Green DW, Ballard C. Intraoperative Optimization of Both Depth of Anesthesia and Cerebral Oxygenation in Elderly Patients Undergoing Coronary Artery Bypass Graft Surgery—A Randomized Controlled Pilot Trial. J Cardiothorac Vasc Anesth 2020; 34:1172-1181. [DOI: 10.1053/j.jvca.2019.10.054] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 10/26/2019] [Accepted: 10/31/2019] [Indexed: 11/11/2022]
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Russell MD, Pinkerton C, Sherman KA, Ebert TJ, Pagel PS. Predisposing and Precipitating Factors Associated With Postoperative Delirium in Patients Undergoing Cardiac Surgery at a Veterans Affairs Medical Center: A Pilot Retrospective Analysis. J Cardiothorac Vasc Anesth 2020; 34:2103-2110. [PMID: 32127274 DOI: 10.1053/j.jvca.2020.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 01/31/2020] [Accepted: 02/02/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Patients treated at Veterans Affairs (VA) medical centers are in poorer health, experience more medical and psychiatric conditions, and make greater use of medical resources than do patients in the general population. In the present pilot study, the authors examined their recent experience at a VA medical center to determine the incidence and risk factors associated with the development of postoperative delirium in VA patients after cardiac surgery and hypothesized that the risk factors for postoperative delirium after cardiac surgery are different between VA and non-VA patients. DESIGN Retrospective cohort study. SETTING Clement J. Zablocki Veterans Affairs Medical Center. PARTICIPANTS The study comprised 250 consecutive patients undergoing cardiac surgery from July 2014 to March 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographics, coexisting diseases, and medications were obtained from the VA electronic medical record. The European System for Cardiac Operative Evaluation II mortality risk index was calculated for each patient. The type and duration of the procedure and the duration of bypass were recorded. Intraoperative crystalloid, colloid, cell saver, and blood product volumes were compiled. Progress notes and International Classification of Diseases, Tenth Revision, Clinical Modification codes were searched for documentation of postoperative delirium. Thirty-eight patients (15.2%) developed postoperative delirium. Stepwise logistic regression analysis demonstrated that the European System for Cardiac Operative Evaluation II mortality risk index (odds ratio [OR] 1.036, 95% confidence interval [CI] [1.003-1.070]; p = 0.0344), congestive heart failure (OR 2.223 [95% CI 1.046-4.722]; p = 0.0377), pre-existing cognitive impairment (OR 5.147 [95% CI 1.994-13.28]; p = 0.0007), and the presence of a neuropsychiatric disorder (OR 2.015 [95% CI 1.004-4.043]; p = 0.0487) were predisposing factors associated with higher odds of postoperative delirium. The duration of surgery; transfusion of blood products (including packed red blood cells, fresh frozen plasma, and platelets); the durations of mechanical ventilation and conscious sedation (using either propofol or dexmedetomidine); and the length of intensive care unit stay were precipitating factors associated with higher odds of postoperative delirium. CONCLUSIONS The results demonstrate that congestive heart failure, pre-existing cognitive impairment, and the presence of a neuropsychiatric disorder are predisposing risk factors for postoperative delirium after cardiac surgery in VA patients, whereas the duration of surgery, transfusion of blood products, durations of mechanical ventilation and conscious sedation, and length of intensive care unit stay are precipitating factors for postoperative delirium. These findings in VA patients generally are similar to those observed in the civilian population despite the differences between these cohorts.
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Affiliation(s)
- Matthew D Russell
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - Carolyn Pinkerton
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - Katherine A Sherman
- Office of Research Administration, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - Thomas J Ebert
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI.
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Denault A, Shaaban Ali M, Couture EJ, Beaubien-Souligny W, Bouabdallaoui N, Brassard P, Mailhot T, Jacquet-Lagrèze M, Lamarche Y, Deschamps A. A Practical Approach to Cerebro-Somatic Near-Infrared Spectroscopy and Whole-Body Ultrasound. J Cardiothorac Vasc Anesth 2019; 33 Suppl 1:S11-S37. [DOI: 10.1053/j.jvca.2019.03.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Portal Vein Pulsatility After Cardiac Surgery-Who Cares? Can J Cardiol 2019; 35:1088-1090. [PMID: 31472807 DOI: 10.1016/j.cjca.2019.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/02/2019] [Accepted: 06/03/2019] [Indexed: 11/23/2022] Open
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