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Weinberg L, Johnston S, Fletcher L, Caragata R, Hazard RH, Le P, Karp J, Carp B, Sean Yip SW, Walpole D, Shearer N, Neal-Williams T, Nicolae R, Armellini A, Matalanis G, Seevanayagam S, Bellomo R, Makar T, Pillai P, Warrillow S, Ansari Z, Koshy AN, Lee DK, Yii M. Methadone in combination with magnesium, ketamine, lidocaine, and dexmedetomidine improves postoperative outcomes after coronary artery bypass grafting: an observational multicentre study. J Cardiothorac Surg 2024; 19:375. [PMID: 38918868 PMCID: PMC11202251 DOI: 10.1186/s13019-024-02935-0] [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: 04/01/2024] [Accepted: 06/15/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND An optimal pharmacological strategy for fast-track cardiac anesthesia (FTCA) is unclear. This study evaluated the effectiveness and safety of an FTCA program using methadone and non-opioid adjuvant infusions (magnesium, ketamine, lidocaine, and dexmedetomidine) in patients undergoing coronary artery bypass grafting. METHODS This retrospective, multicenter observational study was conducted across private and public teaching sectors. We studied patients managed by a fast-track protocol or via usual care according to clinician preference. The primary outcome was the total mechanical ventilation time in hours adjusted for hospital, body mass index, category of surgical urgency, cardiopulmonary bypass time and EuroSCORE II. Secondary outcomes included successful extubation within four postoperative hours, postoperative pain scores, postoperative opioid requirements, and the development of postoperative complications. RESULTS We included 87 patients in the fast-track group and 88 patients in the usual care group. Fast-track patients had a 35% reduction in total ventilation hours compared with usual care patients (p = 0.007). Thirty-five (40.2%) fast-track patients were extubated within four hours compared to 10 (11.4%) usual-care patients (odds ratio: 5.2 [95% CI: 2.39-11.08; p < 0.001]). Over 24 h, fast-track patients had less severe pain (p < 0.001) and required less intravenous morphine equivalent (22.00 mg [15.75:32.50] vs. 38.75 mg [20.50:81.75]; p < 0.001). There were no significant differences observed in postoperative complications or length of hospital stay between the groups. CONCLUSION Implementing an FTCA protocol using methadone, dexmedetomidine, magnesium, ketamine, lignocaine, and remifentanil together with protocolized weaning from a mechanical ventilation protocol is associated with significantly reduced time to tracheal extubation, improved postoperative analgesia, and reduced opioid use without any adverse safety events. A prospective randomized trial is warranted to further investigate the combined effects of these medications in reducing complications and length of stay in FTCA. TRIALS REGISTRATION The study protocol was registered in the Australian New Zealand Clinical Trials Registry ( https://www.anzctr.org.au/ACTRN12623000060640.aspx , retrospectively registered on 17/01/2023).
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Affiliation(s)
| | - Samuel Johnston
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Luke Fletcher
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | | | - Riley H Hazard
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Peter Le
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Jadon Karp
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Bradly Carp
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | | | - Dominic Walpole
- Department of Cardiac Surgery, Epworth Eastern Hospital, Melbourne, Australia
| | | | | | - Robert Nicolae
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | | | - George Matalanis
- Department of Cardiac Surgery, Austin Hospital, Melbourne, Australia
| | - Siven Seevanayagam
- Department of Cardiac Surgery, Epworth Eastern Hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, Australia
| | - Timothy Makar
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Param Pillai
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Stephen Warrillow
- Department of Intensive Care, Epworth Eastern Hospital, Melbourne, Australia
| | - Ziauddin Ansari
- Department of Intensive Care, Epworth Eastern Hospital, Melbourne, Australia
| | - Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Michael Yii
- Department of Cardiac Surgery, Epworth Eastern Hospital, Melbourne, Australia
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Laudanski K, Liu D, Okeke T, Restrepo M, Szeto WY. Persistent Depletion of Neuroprotective Factors Accompanies Neuroinflammatory, Neurodegenerative, and Vascular Remodeling Spectra in Serum Three Months after Non-Emergent Cardiac Surgery. Biomedicines 2022; 10:biomedicines10102364. [PMID: 36289630 PMCID: PMC9598177 DOI: 10.3390/biomedicines10102364] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 11/24/2022] Open
Abstract
We hypothesized that the persistent depletion of neuroprotective markers accompanies neuroinflammation and neurodegeneration in patients after cardiac surgery. A total of 158 patients underwent elective heart surgery with their blood collected before surgery (tbaseline) and 24 h (t24hr), seven days (t7d), and three months (t3m) post-surgery. The patients’ serum was measured for markers of neurodegeneration (τau, τaup181–183, amyloid β1-40/β2-42, and S100), atypical neurodegeneration (KLK6 and NRGN), neuro-injury (neurofilament light/heavy, UC-HL, and GFAP), neuroinflammation (YKL-40 and TDP-43), peripheral nerve damage (NCAM-1), neuroprotection (apoE4, BDNF, fetuin, and clusterin), and vascular smoldering inflammation (C-reactive protein, CCL-28 IL-6, and IL-8). The mortality at 28 days, incidence of cerebrovascular accidents (CVA), and functional status were followed for three months. The levels of amyloid β1-40/β1-42 and NF-L were significantly elevated at all time points. The levels of τau, S100, KLK6, NRGN, and NCAM-1 were significantly elevated at 24 h. A cluster analysis demonstrated groupings around amyloids, KLK6, and NCAM-1. YKL-40, but not TDP-43, was significantly elevated across all time points. BDNF, apoE4, fetuin, and clusterin levels were significantly diminished long-term. IL-6 and IL-8 levles returned to baseline at t3m. The levels of CRP, CCL-28, and Hsp-70 remained elevated. At 3 months, 8.2% of the patients experienced a stroke, with transfusion volume being a significant variable. Cardiac-surgery patients exhibited persistent peripheral and neuronal inflammation, blood vessel remodeling, and the depletion of neuroprotective factors 3 months post-procedure.
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Affiliation(s)
- Krzysztof Laudanski
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA
- Correspondence: ; Tel.: +1-215-662-8000
| | - Da Liu
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang 110055, China
| | - Tony Okeke
- Department of Bioengineering, Drexel University, Philadelphia, PA 19104, USA
| | - Mariana Restrepo
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Wilson Y. Szeto
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA
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