Low-Dose Sevoflurane May Reduce Blood Loss and Need for Blood Products After Cardiac Surgery: A Prospective, Randomized Pilot Study

Appraisal of Postoperative Outcomes of Volatile and Intravenous Anesthetics: A Network Meta-Analysis of Patients Undergoing Cardiac Surgery

OBJECTIVES

To determine the relative efficacy of specific regimens used as primary anesthetics, as well as the potential combination of volatile and intravenous anesthetics among patients undergoing cardiac, thoracic, and vascular surgery.

DESIGN

This frequentist, random-effects network meta-analysis was registered prospectively (CRD42022316328) and conducted according to the PRISMA-NMA framework. Literature searches were conducted up to April 1, 2022 across relevant databases. Risk of bias (RoB) and confidence of evidence were assessed by RoB-2 and CINeMA, respectively. Pooled treatment effects were compared with propofol monotherapy.

SETTING

Fifty-three randomized controlled trials (N = 8,085) were included, of which 46 trials (N = 6,604) enrolled patients undergoing cardiac surgery.

PARTICIPANTS

Trials enrolling adults (≥18) undergoing cardiac, thoracic, and vascular surgery, using the same induction regimens, and comparing volatile and/or total intravenous anesthesia for the maintenance of anesthesia. Given that the majority of trials focused on those undergoing cardiac surgery and the heterogeneity, analyses were restricted to this population.

MEASUREMENT AND MAIN RESULTS

Outcomes of interest included intensive care unit (ICU) length of stay (LOS), myocardial infarction, in-hospital and 30-day mortality, stroke, and delirium. Across 19 trials (N = 1,821; 9 arms; I2 = 64.5%), sevoflurane combined with propofol decreased ICU LOS (mean difference [MD] -18.26 hours; 95% CI -34.78 to -1.73 hours), whereas midazolam with propofol (MD 17.51 hours; 95% CI 2.78-32.25 hours) was associated with a significant increase in ICU LOS, when compared with propofol monotherapy. Among 27 trials (N = 4,080; 10 arms; I2 = 0%), midazolam was associated with significantly greater risk of myocardial infarction versus propofol (risk ratio 1.94; 95% CI 1.01-3.71). There were no significant differences across other outcomes.

CONCLUSION

In patients undergoing cardiac surgery, sevoflurane with propofol was associated with decreased ICU LOS compared with propofol monotherapy. Midazolam with propofol increased ICU LOS compared with propofol alone. The combined use of intravenous and volatile anesthetics should be explored further. Future trials in thoracic and vascular surgery are warranted.

A Mysterious Bleed

Spontaneous spinal epidural hematoma is an extraordinarily rare condition for which there are only a few hundred documented cases, none in relation to cardiac ablation procedures. This case describes a 71-year-old woman who develops lower extremity numbness and weakness due to spontaneous spinal epidural hematoma after an atrial fibrillation ablation. (Level of Difficulty: Intermediate.).

Association of intraoperative hyperglycemia with postoperative composite infection after cardiac surgery with cardiopulmonary bypass: A retrospective cohort study

Background

The association between intraoperative hyperglycemia (IH) and postoperative infections in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) is inadequately studied.

Methods

A total of 3,428 patients who underwent cardiac surgery with CPB at our institution between June 1, 2019 and July 30, 2021 were enrolled to evaluate the association of IH (blood glucose ≥ 180 mg/dL) with postoperative infection in patients. The new onset of any type of infection and the optimal cutoff values of intraoperative glucose to predict in-hospital infection were determined.

Results

The composite outcome occurred in 497 of 3,428 (14.50%) patients. IH was associated with an increased risk of postoperative composite infection [adjusted odds ratio: 1.39, (95% confidence interval), 1.06-1.82, P = 0.016]. Restricted cubic splines were applied to flexibly model and visualize the association of intraoperative peak glucose with infection, and a J-shaped association was revealed. Besides, it was demonstrated that the possibility of infection was relatively flat till 150 mg/dL glucose levels which started to rapidly increase afterward.

Conclusion

We summarize that IH is associated with an elevated risk of postoperative new-onset composite infections and perioperative blood glucose management should be more stringent, i.e., lesser than 150 mg/dL in patients undergoing cardiac surgery.

Transfusion of Red Blood Cells, Fresh Frozen Plasma, or Platelets Is Associated With Mortality and Infection After Cardiac Surgery in a Dose-Dependent Manner

BACKGROUND

It is unclear whether transfusion of platelets or fresh frozen plasma, in addition to red blood cells, is associated with an increased risk of mortality and infection after cardiac surgery.

METHODS

Patients who underwent valve surgery and/or coronary artery bypass grafting from January 1, 2011 to June 30, 2017 and September 1, 2013 to June 30, 2017 at 2 centers performing cardiac surgery were included in this retrospective study. After stratifying patients based on propensity score matching, we compared rates of mortality and infection between patients who transfused red blood cells, fresh frozen plasma, or platelets with those who did not receive such transfusions. We also compared outcomes between patients who received any of the 3 blood products and patients who received no transfusions at all. Multivariable logistic regression was used to assess associations between transfusion and outcomes.

RESULTS

Of 8238 patients in this study, 109 (1.3%) died, 812 (9.9%) experienced infection, and 4937 (59.9%) received at least 1 type of blood product. Transfusion of any blood type was associated with higher rates of mortality (2.0% vs 0.18%; P < .01) and infection (13.3% vs 4.8%; P < .01). Each of the 3 blood products was independently associated with an increase in mortality per unit transfused (red blood cells, odds ratio 1.18, 95% confidence interval [CI], 1.14-1.22; fresh frozen plasma, odds ratio 1.24, 95% CI, 1.18-1.30; platelets, odds ratio 1.12, 95% CI, 1.07-1.18). Transfusing 3 units of any of the 3 blood products was associated with a dose-dependent increase in the incidence of mortality (odds ratio 1.88, 95% CI, 1.70-2.08) and infection (odds ratio 1.50, 95% CI, 1.43-1.57).

CONCLUSIONS

Transfusion of red blood cells, fresh frozen plasma, or platelets is an independent risk factor of mortality and infection, and combination of the 3 blood products is associated with adverse outcomes after cardiac surgery in a dose-dependent manner.

Risk of massive blood product requirement in cardiac surgery: A large retrospective study from 2 heart centers

Cardiac surgery under cardiopulmonary bypass (CPB) accounts for most consumption of red blood cells (RBCs). Identifying risk factors for massive red blood cell transfusion (MRT) in cardiac surgery may help to reduce this consumption.We retrospectively analyzed 8238 patients who underwent valve surgery and/or coronary artery bypass grafting (CABG) under CPB at 2 major heart centers in China. Uni- and multivariate logistic regression was carried out to assess whether risk factors for MRT (defined as receiving at least 4 units RBCs) varied with type of cardiac surgery.A total of 1691 patients (21%) received at least 4 units RBCs (6.77 ± 4.78 units per person). This MRT group consumed 70% of the total units of allogeneic RBCs in the study. MRT incidence was 2-fold higher among patients undergoing CABG with or without valve surgery than among patients undergoing valve surgery alone. Multivariate logistic analysis identified the following MRT risk factors common to valve surgery alone, CABG alone, and their combination: female sex, older age, renal dysfunction, lower body mass index, lower preoperative hemoglobin, and longer CPB. Several independent MRT risk factors were also identified specific to valve surgery: active endocarditis, nonatrial fibrillation, smaller left atrium diameter, abnormal international normalized ratio, and repeat surgery.Different types of cardiac surgery share several, but not all, MRT risk factors. This study may help guide the prediction and management of patients at higher MRT risk.